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Ågmo A, Laan E. The Sexual Incentive Motivation Model and Its Clinical Applications. JOURNAL OF SEX RESEARCH 2023; 60:969-988. [PMID: 36378887 DOI: 10.1080/00224499.2022.2134978] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Sexual motivation (desire) requires the simultaneous presence of an active central motive state and a stimulus with sexual significance. Once activated, sexual motivation leads to visceral responses and approach behaviors directed toward the emitter of the sexual stimulus. In humans, such behaviors follow cognitive evaluation of the context, including predictions of the approached individual's response. After successful approach and establishment of physical contact, manifest sexual activities may be initiated. Sexual interaction is associated with and followed by a state of positive affect in most animals, whereas aversive consequences may be experienced by humans. The affective reactions may become associated with stimuli present during sexual interaction, and these stimuli may thereby alter their incentive properties. Here we show how the incentive motivation model can be used to explain the origins and possible treatments of sexual dysfunctions, notably disorders of desire. We propose that associations formed between negative outcomes of sexual interaction and the salient stimuli, for example, the partner, underlies hypoactive desire disorder. Highly positive outcomes of sexual interaction enhance the incentive value of the stimuli present, and eventually lead to hyperactive sexual desire. Treatments aim to alter the impact of sexual incentives, mainly by modifying cognitive processes.
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Affiliation(s)
- Anders Ågmo
- Department of Psychology, University of Tromsø
| | - Ellen Laan
- Department of Sexology and Psychosomatic Gynaecology, Amsterdam UMC, University of Amsterdam
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2
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Neurochemical and Hormonal Contributors to Compulsive Sexual Behavior Disorder. CURRENT ADDICTION REPORTS 2022. [DOI: 10.1007/s40429-021-00403-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
Compulsive sexual behavior disorder has been recently included in the 11th revision of the International Classification of Diseases (ICD-11), and the possible contribution of neurochemical and hormonal factors have been reported. However, relatively little is known concerning the neurobiology underlying this disorder. The aim of this article is to review and discuss published findings in the area.
Recent Findings
Evidence suggests that the neuroendocrine systems are involved in the pathophysiology of compulsive sexual behavior. The hypothalamus-pituitary adrenal axis, the hypothalamus-pituitary–gonadal axis, and the oxytocinergic system have been implicated.
Summary
Further studies are needed to elucidate the exact involvement of neuroendocrine and hormonal systems in compulsive sexual behavior disorder. Prospective longitudinal studies are particularly needed, especially those considering co-occurring psychiatric disorders and obtaining hormonal assessments in experimental circumstances with appropriate control groups.
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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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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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5
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Briken P. An integrated model to assess and treat compulsive sexual behaviour disorder. Nat Rev Urol 2020; 17:391-406. [DOI: 10.1038/s41585-020-0343-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 12/12/2022]
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6
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Williams JM, Gallagher C, Khoury R, Grossberg GT. Inappropriate Sexual Behavior in Women with Dementia. Psychiatr Ann 2019. [DOI: 10.3928/00485713-20190807-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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7
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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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Dutta E, Naphade NM. Hypersexuality - a cause of concern: A case report highlighting the need for psychodermatology liaison. Indian J Sex Transm Dis AIDS 2018; 38:180-182. [PMID: 30148274 PMCID: PMC6085926 DOI: 10.4103/ijstd.ijstd_27_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Sexual addictions are behavioral addictions. Hypersexuality is used to describe non-paraphilic “excesses” of sexual behavior. Hypersexual disorder (HSD) can be accompanied by clinically significant social, personal distress, and medical morbidity. Common medical comorbidities seen with HSD are the sexually transmitted diseases (STDs). We present one such case with management. A psychodermatology liaison clinic would be the ideal one-stop for screening patients with STDs for HSD.
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Affiliation(s)
- Era Dutta
- Department of Mental and Behavioural Sciences, Fortis Group of Hospitals, Mumbai, Maharashtra, India
| | - Nilesh M Naphade
- Department of Psychiatry, Bharati Hospital, Bharati Vidyapeeth Medical College, Deemed University, Pune, Maharashtra, India
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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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10
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Jakubczyk A, Krasowska A, Bugaj M, Kopera M, Klimkiewicz A, Łoczewska A, Michalska A, Majewska A, Szejko N, Podgórska A, Sołowiej M, Markuszewski L, Jakima S, Płoski R, Brower K, Wojnar M. Paraphilic Sexual Offenders Do Not Differ From Control Subjects With Respect to Dopamine- and Serotonin-Related Genetic Polymorphisms. J Sex Med 2016; 14:125-133. [PMID: 27989490 DOI: 10.1016/j.jsxm.2016.11.309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/11/2016] [Accepted: 11/16/2016] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Rape and pedophilic child molestation are the most commonly convicted sexual offenses in Poland. Recent studies have suggested a possible genetic contribution toward pathologic sexual interests and behaviors. AIM To analyze and compare functional polymorphisms of genes associated with the activity of the serotonin and dopamine systems in a group of paraphilic sexual offenders and control subjects. METHODS The study sample (n = 97) consisted of two groups: paraphilic sexual offenders (65 pedophilic child molesters and 32 rapists) and controls (n = 76). Genetic polymorphisms previously associated with behavioral control, addictive behaviors, and sexual functions were chosen for analyses. Specifically, functional polymorphisms in dopamine receptors genes (DRD1, DRD2, DRD4), catechol-O-methyltransferase gene (COMT), dopamine transporter gene (DAT), serotonin transporter gene (SLC6A4), serotonin type 2A receptor gene (5HTR2A), tryptophan hydroxylase 2 gene (TPH2), monoamine oxidase A gene (MAOA), and brain-derived neurotrophic factor gene (BDNF) were analyzed. MAIN OUTCOME MEASURES An association between a history of sexual offense and the distribution of genotypes and alleles in the analyzed polymorphisms. RESULTS Our results found no association between a history of sexual offense and the distribution of genotypes or alleles in the analyzed polymorphisms. CONCLUSION Although these results are limited by the small sample and are exploratory, they highlight a novel approach to sample selection in a population that is difficult to access and study. Future research should include larger samples and other relevant polymorphisms to advance this field of study.
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Affiliation(s)
- Andrzej Jakubczyk
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | | | - Marcin Bugaj
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Kopera
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Anna Klimkiewicz
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Agata Łoczewska
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | - Aneta Michalska
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland
| | | | - Natalia Szejko
- Department of Neurology, Wolski Hospital, Warsaw, Poland; Department of Neurology, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland
| | - Anna Podgórska
- Department of Genetics, Institute of Physiology and Pathology of Hearing, Warsaw, Poland
| | | | - Leszek Markuszewski
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Sławomir Jakima
- Department of Sexology, Center of Psychotherapy Nowowiejski Hospital, Warsaw, Poland
| | - Rafał Płoski
- Department of Medical Genetics, Medical University of Warsaw, Warsaw, Poland
| | - Kirk Brower
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Marcin Wojnar
- Department of Psychiatry, Medical University of Warsaw, Warsaw, Poland; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Abstract
Sexual violence is common and can have profound effects on victims compared with other forms of violence. This violence includes unwelcome and forced sexual contact on adults or children. Assessment of individuals who perpetrate sexual violence starts with a comprehensive biopsychosocial evaluation after a finding of guilt. Clinicians should then evaluate risk. Based on this assessment, a risk management plan should be developed, directed at the specific risk of the offender. Management options include external control (eg, incarceration, probation), psychotherapeutic interventions, pharmacologic interventions, and treatment of comorbidity. This organized approach aids in reducing the risk of future sexual violence.
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Should Sexual Offending Be Considered an Addiction? Implications for Prevention and Treatment Approaches. CURRENT ADDICTION REPORTS 2016. [DOI: 10.1007/s40429-016-0120-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Emphasizing the power and fundamental nature—comparable to the basic mammalian drive for food—of sex drives and urges in almost everybody, including paraphilics and sex offenders, this article gives an overview of biologically-based, or “organic” approaches to the treatment of paraphilics and sex offenders. Organic treatment approaches for this population may be divided into surgical and pharmacotherapeutic categories. Surgical approaches include castration (orchiectomy), sterotactic (brain) surgery and estrogen implants, the latter two approaches are not used in the United States (U.S.). All surgical approaches act hormonally, in reducing or blocking the amount of circulating androgens in the subject. Pharmacotherapeutic approaches include: (1) Indirect-acting and direct-acting antiandrogen hormones, also intended to reduce or block the amount of circulating androgens in the subject. (2) Psychotropic medications for primary treatment of male aggressive hypersexuality, for treatment of co-occurring psychiatric symptomatology, or for both. (3) An experimental pharmacologic approach to the treatment of this population consists of the use of antiepileptic drugs, or “AED's” to stabilize the impulsivity/compulsivity of these subjects, in reducing the hypothesized “kindling” that may occur during impulsive/compulsive periods in these individuals. Whatever organic approach may be used for paraphilics and sex offenders, such an approach alone is not sufficient treatment for this population. Psychotherapeutic and cognitive/behavioral approaches must also be included in these individuals' treatment regimens. A companion piece to this article, giving an overview of psychotherapeutic and cognitive/behavioral treatment approaches to this population will be published in a future issue of this Journal.
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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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Abstract
Public policy has tended to treat juvenile sex offenders (JSOs) as adult sex offenders in waiting, despite research that contradicts this notion. Although as a group, JSOs are more similar to general delinquents than to adult sex offenders, atypical sexual interests and sexual victimization during childhood may be a pathway for sexual offending that differentiates some JSOs from their nonsexually delinquent peers. Developmental considerations must be considered in risk assessment evaluations of these youth. This article reviews theories of sexual offending in youth, risk factors for juvenile offending and reoffending, psychopathology in JSOs, risk assessment, and treatment.
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Affiliation(s)
- Eileen P Ryan
- Institute of Law, Psychiatry and Public Policy, University of Virginia School of Medicine, PO Box 800660, Charlottesville, VA 22903, USA.
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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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Kapfhammer HP. [Richard Freiherr v. Krafft-Ebing and Sigmund Freud--discourse on the "normality" and "perversion" of human sexuality at the close of the 19th century and the beginning of the 20th century]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2015; 29:163-78. [PMID: 26099905 DOI: 10.1007/s40211-015-0148-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
Sexuality has been defined a central feature of personal identity since the epoch of enlightenment and has gradually become a decisive issue also in societal and political terms. A major transfer from religion and religious institutions to medicine and medical experts and later on to neuropsychiatrists has to be underlined in the primary position to assess "normal" and "deviant" manifestations of sexuality. Richard Freiherr von Krafft-Ebing and Sigmund Freund play an eminent role in this "discourse on sexuality" (M. Foucault) during the nineteenth and beginning twentieth century on the way to modern sexology. Within this overarching context Krafft-Ebing's and Freud's theoretical conceptualizations of sexuality and perversion will be sketched and basic clinical and societal implications there out will be discussed.
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Affiliation(s)
- Hans-Peter Kapfhammer
- Klinik für Psychiatrie und Psychotherapeutische Medizin der Medizinischen Universität Graz, Auenbruggerplatz 31, 8036, Graz, Österreich.
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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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20
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Affiliation(s)
- John M W Bradford
- Institute of Mental Health Research, University of Ottawa, Brockville Mental Health Centre (BMHC), 1804 Highway 2 East, Brockville, Ontario, K6V 5W7, Canada.
| | - A G Ahmed
- Institute of Mental Health Research, University of Ottawa, Brockville Mental Health Centre (BMHC), 1804 Highway 2 East, Brockville, Ontario, K6V 5W7, Canada.
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21
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Abstract
Transinstitutionalization (ie, the criminalization of those with mental illness) is relevant to individuals committing sexual offenses. Mental illness can affect the treatment and risk management of individuals committing sexual offenses. In this article the current literature on mentally disordered sexual offenders is described, including how psychosis, mood disorders, anxiety disorders, attention-deficit/hyperactivity disorder, and dementing disorders may affect treatment and management.
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Affiliation(s)
- Brad D Booth
- Department of Psychiatry, University of Ottawa, 501 Smyth Road, ON K1H 8L6, Canada; Integrated Forensic Program, Royal Ottawa Mental Health Centre, Royal Ottawa Health Care Group, 2nd Floor-Forensics, 1145 Carling Avenue, Ottawa, Ontario K1Z 7K4, Canada; Sexual Behaviors Unit, St Lawrence Valley Correctional & Treatment Centre, PO Box 1050, 1804 Hwy 2 East, Brockville, ON K6V 5W7, Canada.
| | - Sanjiv Gulati
- Department of Psychiatry, University of Ottawa, 501 Smyth Road, ON K1H 8L6, Canada; Integrated Forensic Program, Royal Ottawa Mental Health Centre, Royal Ottawa Health Care Group, 2nd Floor-Forensics, 1145 Carling Avenue, Ottawa, Ontario K1Z 7K4, Canada; Assessment & Stabilization Unit, St Lawrence Valley Correctional & Treatment Centre, PO Box 1050, 1804 Hwy 2 East, Brockville, ON K6V 5W7, Canada
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22
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Abstract
Clinicians in sex offender treatment programs always encounter the need to balance the best interests of sex offenders and the safety needs of the community. The protection of the community often takes primacy, resulting in violation of traditional mental health codes of ethics. These ethical dilemmas have generated debates in the academic community. To minimize ethical dilemmas, clinicians in sex offender treatment programs need to acknowledge the conflicts, adhere to safeguards, and thoughtfully address the challenges with profession-specific ethical values and codes. This article reviews ethical principles in relation to conceptualization of sex offenders and their assessment and treatment and research involving sex offenders.
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Affiliation(s)
- Mansfield Mela
- Department of Psychiatry, Faculty of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A G Ahmed
- Divisions of Forensic Psychiatry and Addiction and Mental Health, Department of Psychiatry, University of Ottawa and the Royal Ottawa Health Care Group, Ottawa, Ontario, Canada.
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Firoz K, Nidheesh Sankar V, Rajmohan V, Manoj Kumar G, Raghuram TM. Treatment of fetishism with naltrexone: a case report. Asian J Psychiatr 2014; 8:67-8. [PMID: 24655631 DOI: 10.1016/j.ajp.2013.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 10/31/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
Fetishism is a paraphilic sexual disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving the use of nonliving objects. We describe a case of fetishism with comorbid alcohol and cannabis dependence. A 40-year-old man was presented with sexual fantasies and urges toward women's undergarments since the age of 25 years. He had fetish behavior even during prolonged period of abstinence from substance use. Our case remitted from fetishism and cannabis and alcohol use on treatment with naltrexone and maintains remission for the last 11 months. Experience with our patient suggests that naltrexone may be effective to treat fetishism with comorbid substance use. Our case is reported as it is the first reported case of successful use of naltrexone in fetishism comorbid with cannabis and alcohol dependence.
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Affiliation(s)
- K Firoz
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India.
| | - V Nidheesh Sankar
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
| | - V Rajmohan
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
| | - G Manoj Kumar
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
| | - T M Raghuram
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
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24
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Joyal CC, Beaulieu-Plante J, de Chantérac A. The neuropsychology of sex offenders: a meta-analysis. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2014; 26:149-177. [PMID: 23567470 DOI: 10.1177/1079063213482842] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Typically, neuropsychological studies of sex offenders have grouped together different types of individuals and different types of measures. This is why results have tended to be nonspecific and divergent across studies. Against this background, the authors undertook a review of the literature regarding the neuropsychology of sex offenders, taking into account subgroups based on criminological theories. They also conducted a meta-analysis of the data to demonstrate the cognitive heterogeneity of sex offenders statistically. Their main objective was to test the hypothesis to the effect that the neuropsychological deficits of sex offenders are not broad and generalized compared with specific subgroups of participants based on specific measures. In all, 23 neuropsychological studies reporting data on 1,756 participants were taken into consideration. As expected, a highly significant, broad, and heterogeneous overall effect size was found. Taking subgroups of participants and specific cognitive measures into account significantly improved homogeneity. Sex offenders against children tended to obtain lower scores than did sex offenders against adults on higher order executive functions, whereas sex offenders against adults tended to obtain results similar to those of non-sex offenders, with lower scores in verbal fluency and inhibition. However, it is concluded that neuropsychological data on sex offenders are still too scarce to confirm these trends or to test more precise hypotheses. For greater clinical relevance, future neuropsychological studies should consider specific subgroups of participants and measures to verify the presence of different cognitive profiles.
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Affiliation(s)
- Christian C Joyal
- University of Quebec at Trois-Rivières, Trois-Rivières, Quebec, Canada
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Berryessa CM. Potential implications of research on genetic or heritable contributions to pedophilia for the objectives of criminal law. RECENT ADVANCES IN DNA & GENE SEQUENCES 2014; 8:65-77. [PMID: 25557668 PMCID: PMC4393782 DOI: 10.2174/2352092209666141211233857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/30/2014] [Accepted: 12/10/2014] [Indexed: 11/22/2022]
Abstract
In recent years, there has been increasing scientific research on possible genetic or heritable influences to the etiology of pedophilia, driven by national and public concerns about better understanding the disorder in order to reduce children's vulnerabilities to pedophilic and child sex offenders. This research has corresponded to growing academic dialogue on how advances in genetic research, especially concerning the causes and development of particular mental disorders or behaviors, may affect traditional practices of criminal law and how the justice system views, manages, and adjudicates different types of criminal behavior and offenders. This paper strives to supplement this dialogue by exploring several of the many possible effects and implications of research surrounding genetic or heritable contributions to pedophilia for the five widely accepted objectives that enforce and regulate the punishment of criminal law. These include retribution, incapacitation, deterrence, rehabilitation, and restoration. Although still currently in early stages, genetic and heritability research on the etiology of pedophilia may have the potential moving forward to influence the current and established punitive methods and strategies of how the justice system perceives, adjudicates, regulates, and punishes pedophilic and sex offenders, as well as how to best prevent sexual offending against children by pedophilic offenders in the future.
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Affiliation(s)
- Colleen M Berryessa
- Stanford University, Center for Biomedical Ethics, 483 McNeil Building 3718 Locust Walk Philadelphia, PA 19104, USA.
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Brom M, Both S, Laan E, Everaerd W, Spinhoven P. The role of conditioning, learning and dopamine in sexual behavior: a narrative review of animal and human studies. Neurosci Biobehav Rev 2013; 38:38-59. [PMID: 24211372 DOI: 10.1016/j.neubiorev.2013.10.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/22/2013] [Accepted: 10/29/2013] [Indexed: 12/24/2022]
Abstract
Many theories of human sexual behavior assume that sexual stimuli obtain arousing properties through associative learning processes. It is widely accepted that classical conditioning contributes to the etiology of both normal and maladaptive human behaviors. Despite the hypothesized importance of basic learning processes in sexual behavior, research on classical conditioning of the sexual response in humans is scarce. In the present paper, animal studies and studies in humans on the role of pavlovian conditioning on sexual responses are reviewed. Animal research shows robust, direct effects of conditioning processes on partner- and place preference. On the contrast, the empirical research with humans in this area is limited and earlier studies within this field are plagued by methodological confounds. Although recent experimental demonstrations of human sexual conditioning are neither numerous nor robust, sexual arousal showed to be conditionable in both men and women. The present paper serves to highlight the major empirical findings and to renew the insight in how stimuli can acquire sexually arousing value. Hereby also related neurobiological processes in reward learning are discussed. Finally, the connections between animal and human research on the conditionability of sexual responses are discussed, and suggestions for future directions in human research are given.
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Affiliation(s)
- Mirte Brom
- Institute of Psychology, Clinical, Health and Neuropsychology Unit, Leiden University, The Netherlands; Department of Psychosomatic Gynaecology and Sexology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Stephanie Both
- Department of Psychosomatic Gynaecology and Sexology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen Laan
- Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Walter Everaerd
- Department Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Philip Spinhoven
- Institute of Psychology, Clinical, Health and Neuropsychology Unit, Leiden University, The Netherlands; Department of Psychiatry, Leiden University Medical Center, The Netherlands
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Abstract
Self-injurious behaviors are common among clinical populations, and have been associated with mood disturbance, personality pathology, and trauma histories. Such behaviors often serve to displace emotional pain, produce physical or emotional sensations, or call for attention from others. Genital self-mutilation in particular is a statistically rare phenomenon that is typically associated with psychosis, extreme religious practices, or unsophisticated attempts at sexual reassignment. The present report describes a unique case of genital self-mutilation in a nonpsychotic individual with history of chronic depression, hypersexuality, and sexual masochism. Treatment consisted of a series of 10 individual therapy sessions that used cognitive-behavioral and dialectical-behavioral techniques to reduce the frequency and severity of self-injurious behaviors, to increase distress tolerance skills, and to implement and maintain a healthy pleasurable activity schedule.
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Affiliation(s)
- Paul R. King
- VA Western New York Healthcare System, Buffalo, NY, USA
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Douglas T, Bonte P, Focquaert F, Devolder K, Sterckx S. Coercion, incarceration, and chemical castration: an argument from autonomy. JOURNAL OF BIOETHICAL INQUIRY 2013; 10:393-405. [PMID: 23813324 PMCID: PMC3824348 DOI: 10.1007/s11673-013-9465-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 01/25/2013] [Indexed: 06/02/2023]
Abstract
In several jurisdictions, sex offenders may be offered chemical castration as an alternative to further incarceration. In some, agreement to chemical castration may be made a formal condition of parole or release. In others, refusal to undergo chemical castration can increase the likelihood of further incarceration though no formal link is made between the two. Offering chemical castration as an alternative to further incarceration is often said to be partially coercive, thus rendering the offender's consent invalid. The dominant response to this objection has been to argue that any coercion present in such cases is compatible with valid consent. In this article, we take a different tack, arguing that, even if consent would not be valid, offering chemical castration will often be supported by the very considerations that underpin concerns about consent: considerations of autonomy. This is because offering chemical castration will often increase the offender's autonomy, both at the time the offer is made and in the future.
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Affiliation(s)
- Thomas Douglas
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Littlegate House, St. Ebbes Street, Oxford, OX1 1PT, United Kingdom,
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Abstract
There is an urgent need for development of methods of assessment and management of sex offenders (rapists, child sex offenders, other sexual offenders, and murderers) to mount a society-wide battle against the scourge of sexual offences in India. This paper provides an overview of theories, models, and assessment methods of rapists. It draws upon literature from psychiatry, psychology, criminology, probation, and ethics to provide a framework for understanding reasons behind rape, how mental health issues are implicated, what mental health professionals can do to contribute to crime management, and why this is ethically right and proper.
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Affiliation(s)
- Jaydip Sarkar
- Department of General and Forensic Psychiatry, Institute of Mental Health, 10 Buangkok View, Singapore
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Bradford JMW, Fedoroff P, Gulati S. Can sexual offenders be treated? INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:235-240. [PMID: 23702350 DOI: 10.1016/j.ijlp.2013.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
There are many misconceptions about sexual offender treatment. This is not only a problem in the lay press and media but is also a problem amongst mental health professionals. In part, this relates to the inadequate teaching about sexual deviation in medical schools and psychiatric residency programs and even in forensic psychiatric fellowships. Other disciplines, such as psychology, have educated mental health professionals in a more balanced way related to the assessment and treatment of sexual offenders but still the understanding, knowledge and acceptance that sexual offender treatment is available, is evidence-based, and is successful as shown in treatment outcome studies is still misunderstood. This review covers the evidence-based studies that support the efficacy of sexual offender treatment.
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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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Turner D, Basdekis‐Jozsa R, Briken P. Prescription of Testosterone‐Lowering Medications for Sex Offender Treatment in German Forensic‐Psychiatric Institutions. J Sex Med 2013; 10:570-8. [DOI: 10.1111/j.1743-6109.2012.02958.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Cross BS, DeYoung GR, Furmaga KM. High-Dose Oral Medroxyprogesterone for Inappropriate Hypersexuality in Elderly Men with Dementia: A Case Series. Ann Pharmacother 2013; 47:e1. [DOI: 10.1345/aph.1r533] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To retrospectively examine the utility of high-dose oral medroxyprogesterone (MPA) for the treatment of inappropriate hypersexuality (IH) in elderly men with dementia. CASE SUMMARY Ten men aged 65 years or older (median 79.5 years, range 65–93 years) were identified from all admissions at a 170-bed tertiary referral psychiatric hospital between December 2005 and January 2011. Admission records were used to identify subjects who received at least 100 mg daily of oral MPA. The primary outcome of successful treatment was chart documentation of a substantial decline in IH, such that subjects could return to preadmission residence. Data were collected to assess trends in dose, adverse effects, use of other symptom-modifying medications prior to MPA initiation, and successful return to preadmission placement. A trial serotoneric agent was used in 70% of subjects prior to MPA initiation. Sixty percent of subjects failed a trial of an antipsychotic, while 40% did not have response to the use of both a serotonergic agent and an antipsychotic before MPA was initiated. The average daily dose of MPA was 300 mg (range 100–400 mg/day). No adverse effects were documented from physician, nursing, or behavioral health rounding notes; however, adverse effects may not have been systematically assessed at the time of MPA administration. Seventy percent of subjects experienced favorable changes in target behaviors from MPA. DISCUSSION Few data exist on effective therapy options for treatment of IH. The minimum concentration of MPA needed to suppress IH in the male body is unknown. MPA was titrated upward, with the efficacy measure being a decrease in inappropriate behaviors. Use of MPA likely contributed to decreased IH; however, other factors involved in hospitalization could have contributed to improved behavior. CONCLUSIONS While requiring further study, high-dose (100–400 mg/day) oral MPA may represent an effective and well-tolerated treatment option for subjects displaying IH.
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Affiliation(s)
- Bethany S Cross
- Bethany S Cross PharmD, at time of writing, PGY-1 Pharmacy Practice Resident, Saint Mary's Health Care, Grand Rapids, MI; now, PGY-2 Psychiatric Pharmacy Resident, Central Texas Veterans Health Care System, Temple, TX
| | - G Robert DeYoung
- G Robert DeYoung PharmD BCPS, Clinical Pharmacist and Program Director, Pharmacy Residency (PGY-1), Advantage Health Physician Network and Saint Mary's Health Care, Grand Rapids, MI
| | - Kevin M Furmaga
- Kevin M Furmaga PharmD BCPP, Clinical Psychopharmacology Specialist, Department of Pharmacy, Pine Rest Christian Mental Health Services/Saint Mary's Health Care Grand Rapids; Adjunct Associate Professor, College of Human Medicine, Michigan State University, Grand Rapids; and Adjunct Assistant Professor, College of Pharmacy, University of Michigan, Ann Arbor
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Balon R. Controversies in the diagnosis and treatment of paraphilias. JOURNAL OF SEX & MARITAL THERAPY 2013; 39:7-20. [PMID: 23152966 DOI: 10.1080/0092623x.2012.709219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Richard Balon
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA.
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Rettenberger M, Dekker A, Klein V, Briken P. Klinische und forensische Aspekte hypersexuellen Verhaltens. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2012. [DOI: 10.1007/s11757-012-0194-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
SummaryHuman sexuality is a complex interaction of biological, social and emotional factors. When any or all of these factors are disrupted by a progressive dementia it is unsurprising that sexual ‘problems’ are identified. Most sexual behaviour ‘problems’ relate to expressions of normal sexuality complicated by changes in relationships, care needs and cognitive function, and complex ethical and legal considerations emerge. Rarely, new and severe hypersexual or paraphilic behaviours arise de novo, usually due to damage to certain brain areas, and sometimes due to medication side-effects, psychiatric disorder or delirium. Evidence and approaches to assess and to manage sexual behaviour problems in dementia are discussed.
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Prahlada Rao N, Chand PK, Murthy P. A case of late-onset pedophilia and response to sertraline. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 9:235-6. [PMID: 17632662 PMCID: PMC1911163 DOI: 10.4088/pcc.v09n0311e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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38
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Felthous AR. The "untreatability" of psychopathy and hospital commitment in the USA. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2011; 34:400-405. [PMID: 22079085 DOI: 10.1016/j.ijlp.2011.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
One argument in support of a public policy of not subjecting persons with psychopathic disorders to civil or criminal commitment is that these disorders do not improve with treatment. This article examines the relationship between the assumption of untreatability of psychopathic disorders and outpatient civil commitment, inpatient civil commitment, and insanity acquittee commitment. Research on the treatability of psychopathy is reviewed and the treatment of conditions co-morbid with psychopathy is considered. Research evidence is insufficient to support the conclusion that psychopathy is improved, worsened or not affected by treatment. Evidence does support effective treatments for conditions that can be co-morbid with psychopathic disorders including impulsive aggression which can be interpreted as a manifestation of psychopathic disorder. The absence of evidence based treatment efficacy for psychopathic disorders is a logical reason for not subjecting individuals with only a psychopathic disorder to involuntary hospitalization. This assumption should not becloud the possibility of treatable co-morbid conditions which may or may not qualify for involuntary hospitalization. Where the primary mental disorder, for which an individual is involuntarily hospitalized, results in behavioral improvement, the continued presence of a psychopathic disorder itself, should not be sufficient reason to continue coerced confinement. Even so, where the primary disorder is incompletely treated, psychopathy can be considered a risk factor when deciding upon the appropriate time for discharge and when formulating a safe and effective after care plan.
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Affiliation(s)
- Alan R Felthous
- Forensic Psychiatry Division, Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 South Grand Blvd., Saint Louis, MO 63104, USA.
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39
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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
INTRODUCTION There is some evidence that child molesters show neuropsychological abnormalities which might reflect specific structural and/or functional brain alterations, but there are also inconsistencies in the existing findings which need to be clarified. Most of the different outcomes can either be explained by the fact that different types of child molesters were examined or by not having accounted for basically confounding factors such as age, education/intelligence, or criminality. AIM The present study therefore sought to determine whether pedophilic and nonpedophilic child molesters, compared to relevant control groups, show different profiles of executive dysfunction when accounting for potentially confounding factors. METHODS The performance of 30 child molesters (15 pedophilic and 15 nonpedophilic) and 33 age- and education-matched controls (16 nonsexual offenders and 17 healthy controls) was assessed regarding several neuropsychological functions. MAIN OUTCOME MEASURES Scores on different neurocognitive tests and semistructured diagnostical interviews. RESULTS Results indicate that pedophilic child molesters exhibited less performance deficits in cognitive functioning than nonpedophilic child molesters. Compared to healthy controls and nonsexual offenders, the pedophilic child molesters only showed executive dysfunction concerning response inhibition, whereas the nonpedophilic child molesters revealed more severe dysfunction, especially on tasks associated with cognitive flexibility and verbal memory. CONCLUSIONS These results enhance our knowledge about executive dysfunction associated with criminality and/or pedophilia, as they suggest different profiles of impairment between groups. In summary, data suggest that nonpedophilic child molesters showed more severe cognitive deficits than pedophilic child molesters. However, as response inhibition is associated with prefrontal (i.e., orbitofrontal) functioning, the deficits observed in both child molester groups indicate dysfunction in the orbitofrontal cortex. This has to be further examined with functional imaging approaches in larger samples and a full-factorial approach which allows for a clear distinction between criminality and pedophilia in a factorial manner.
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Affiliation(s)
- Boris Schiffer
- Department of Forensic Psychiatry, Essen, University of Duisburg-Essen, Germany Department of Psychology, University of Muenster, Muenster, Germany.
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Saleh FM, Grudzinskas AJ, Malin HM, Dwyer RG. The management of sex offenders: perspectives for psychiatry. Harv Rev Psychiatry 2010; 18:359-68. [PMID: 21080774 DOI: 10.3109/10673229.2010.533003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In the effort to identify and manage sex offenders, the differences between legal and medical/psychiatric terminology and approaches are readily apparent. This article discusses the different definitions and approaches of the two fields and considers both the behaviors that create risk to others and the strategies for reducing that risk. Particular attention is paid to the subcategory of paraphilic sex offenders. Treatment goals, modalities, and efficacies are discussed, as are evolving legal strategies for risk control and the need for interaction between law and medicine/psychiatry in order to accomplish common goals of risk management.
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Affiliation(s)
- Fabian M Saleh
- Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA.
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42
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Winters J, Christoff K, Gorzalka BB. Dysregulated sexuality and high sexual desire: distinct constructs? ARCHIVES OF SEXUAL BEHAVIOR 2010; 39:1029-1043. [PMID: 20143148 DOI: 10.1007/s10508-009-9591-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 11/04/2009] [Accepted: 11/04/2009] [Indexed: 05/28/2023]
Abstract
The literature on dysregulated sexuality, whether theoretical, clinical or empirical, has failed to differentiate the construct from high sexual desire. In this study, we tested three hypotheses which addressed this issue. A sample of 6458 men and 7938 women, some of whom had sought treatment for sexual compulsivity, addiction or impulsivity, completed an online survey comprised of various sexuality measures. Men and women who reported having sought treatment scored significantly higher on measures of dysregulated sexuality and sexual desire. For men, women, and those who had sought treatment, dysregulated sexuality was associated with increased sexual desire. Confirmatory factor analysis supported a one-factor model, indicating that, in both male and female participants, dysregulated sexuality and sexual desire variables loaded onto a single underlying factor. The results of this study suggest that dysregulated sexuality, as currently conceptualized, labelled, and measured, may simply be a marker of high sexual desire and the distress associated with managing a high degree of sexual thoughts, feelings, and needs.
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Affiliation(s)
- Jason Winters
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada.
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43
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Garcia FD, Thibaut F. Sexual Addictions. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2010; 36:254-60. [DOI: 10.3109/00952990.2010.503823] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stickle TR, Frick PJ. Developmental pathways to severe antisocial behavior: interventions for youth with callous-unemotional traits. Expert Rev Neurother 2010; 2:511-22. [PMID: 19810948 DOI: 10.1586/14737175.2.4.511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There is an emerging body of research that has focused on understanding the different causal pathways through which children develop severe aggressive and antisocial behavior. In addition, there is a substantial body of research indicating that certain models of intervention have some demonstrated level of effectiveness for preventing and treating antisocial behavior, albeit with some significant limitations. The focus of this paper is to integrate these two bodies of research in an effort to improve the effectiveness of the next generation of interventions for antisocial youth, especially those designed to prevent and treat certain subgroups of antisocial youth who have largely been unresponsive to existing approaches to intervention. One such group consists of those antisocial youths who show a callous and unemotional interpersonal style and who seem to be at risk for showing a particularly severe and aggressive pattern of antisocial behavior.
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Affiliation(s)
- Timothy R Stickle
- Department of Psychology, University of New Orleans, New Orleans, LA 70148, USA.
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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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Bezeau SC, Bogod NM, Mateer CA. Sexually intrusive behaviour following brain injury: approaches to assessment and rehabilitation. Brain Inj 2009; 18:299-313. [PMID: 14726288 DOI: 10.1080/02699050310001617398] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Sexually intrusive behaviour, which may range from inappropriate commentary to rape, is often observed following a traumatic brain injury. It may represent novel behaviour patterns or an exacerbation of pre-injury personality traits, attitudes, and tendencies. Sexually intrusive behaviour poses a risk to staff and residents of residential facilities and to the community at large, and the development of a sound assessment and treatment plan for sexually intrusive behaviour is therefore very important. A comprehensive evaluation is best served by drawing on the fields of neuropsychology, forensic psychology, and cognitive rehabilitation. The paper discusses the types of brain damage that commonly lead to sexually intrusive behaviour, provides guidance for its assessment, and presents a three-stage treatment model. The importance of a multidisciplinary approach to both assessment and treatment is emphasized. Finally, a case example is provided to illustrate the problem and the possibilities for successful management.
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Affiliation(s)
- Scott C Bezeau
- Department of Psychology, University of Victoria, Victoria, BC, Canada.
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Winters J, Christoff K, Gorzalka BB. Conscious regulation of sexual arousal in men. JOURNAL OF SEX RESEARCH 2009; 46:330-343. [PMID: 19199141 DOI: 10.1080/00224490902754103] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The goals of this study were to examine the effectiveness of emotional reappraisal in regulating male sexual arousal and to investigate a set of variables theoretically linked to sexual arousal regulation success. Participants first completed a series of online sexuality questionnaires. Subsequently, they were assessed for their success in regulating sexual arousal in the laboratory. Results showed that the ability to regulate emotion may cross emotional domains; those men best able to regulate sexual arousal were also the most skilled at regulating their level of amusement to humorous stimuli. Participants, on average, were somewhat able to regulate their physiological and cognitive sexual arousal, although there was a wide range of regulation success. Whereas some men were very adept at regulating their sexual arousal, others became more sexually aroused while trying to regulate. Age, sexual experience, and sexual compulsivity were unrelated to sexual arousal regulation. Conversely, sexual excitation, inhibition, and desire correlated with sexual arousal regulation success. Increased sexual excitation and desire were associated with poorer regulatory performance, whereas a propensity for sexual inhibition due to fear of performance consequences was related to regulatory success.
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Affiliation(s)
- Jason Winters
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada.
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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
A unique challenge posed by advancing scientific knowledge about the biology of human behavior is how to integrate that understanding with the desire to hold ourselves--and one another--morally accountable. As human beings, we are something more than just passive agents whose behavior is the sum product of biologic determinism. Because of the existence of the mind, we are also active agents with the capacity to influence, at least to some extent, our own destinies. Behavior may be determined, but it is not predetermined. We are one of its determinants. Misconduct by a person of sound mind should not be attributed improperly to brain pathology. On the other hand, suffering, legitimate mental disorder, and associated impairments should not be trivialized. Historically, persons who once were labeled "lazy" are often more appropriately understood by modern standards as clinically depressed. Frequently they are more in need of pharmacologic treatments that alter brain chemistry than "a kick in the behind." Gluttony, one of the original cardinal sins, is often more properly understood as morbid obesity, a condition that deserves appropriate medical care. Persons who have alcoholism, once judged morally as "bums in the gutter," are more frequently referred to treatment facilities, such as The Betty Ford Clinic. One should not approach the issue of human sexual behavior without at least some appreciation of moral values and scientific research. Although clearly some persons choose to act in a sexually selfish and self-indulgent fashion with wanton disregard, others seem to be more genuinely burdened and struggle to integrate their sexual desires into an otherwise healthy and fully responsible lifestyle. When a person, whether male or female, seems to be so driven that it becomes difficult to master erotic desires and he or she experiences difficulty serving his or her own best longterm interests, the concept of sexual compulsivity seems to be relevant. Ultimately, a better understanding of any associated neuropathologies may help to facilitate future treatments and public acceptance. The possibility exists, at least in some instances, that a sexually compulsive individual is less an example of a bad person deserving of punishment than a "broken mind" in need of repair. In time, increased knowledge about the precise workings of the brain in reciprocally initiating and sustaining the sexual interests of the mind may facilitate a much clearer appreciation of the issues at hand.
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Affiliation(s)
- Fred S Berlin
- Department of Psychiatry and Behavioral Sciences, The John Hopkins University School of Medicine, Baltimore, MD, USA.
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Sajith SG, Morgan C, Clarke D. Pharmacological management of inappropriate sexual behaviours: a review of its evidence, rationale and scope in relation to men with intellectual disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2008; 52:1078-1090. [PMID: 18557968 DOI: 10.1111/j.1365-2788.2008.01097.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND The management of inappropriate sexual behaviours (ISB) including sexual offending is difficult, especially when the person treated has intellectual disabilities (ID). Psychological therapies are the accepted first line of treatment. Pharmacological treatments have also been advocated, particularly for people who have committed serious sexual offences. There is limited information on available drugs and evidence of their efficacy in the treatment of ISBs, in particular for people with ID. METHODS A literature search of electronic databases was undertaken. Pharmaceutical companies were contacted for unpublished information. Trials that included people with ID were systematically reviewed for the benefits and outcome in that population. RESULTS Androgen depleting drugs (cyproterone acetate, medroxyprogesterone acetate and luteinising hormone releasing hormone agonists) and psychotropic drugs (serotonin specific reuptake inhibitors and antipsychotics) are the two major categories of medications used in the treatment of ISBs. The majority of studies identified were open trials and most relied on self-report measures. Trials that included people with ID were few in number. Most trials indicated beneficial effects including reduction in sexually deviant fantasies and behaviours. CONCLUSION The quality of evidence base for the use of pharmacological agents in the treatment of ISBs is inadequate to justify their use in routine clinical practice. If used, they should only be a part of a comprehensive treatment programme and closely monitored. In addition, there are several clinical, ethical and legal issues to be addressed before considering pharmacological treatment of ISBs in people with ID.
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Affiliation(s)
- S G Sajith
- Olive Mount Mansion, Merseycare NHS Trust, Liverpool, UK.
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