The effects of cyproterone acetate on sleeping and waking penile erections in pedophiles: possible implications for treatment

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

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

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

BACKGROUND

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

AIM

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

METHODS

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

OUTCOMES

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

RESULTS

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

CLINICAL IMPLICATIONS

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

STRENGTHS AND LIMITATIONS

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

CONCLUSIONS

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

Which factors influence the appropriateness of testosterone-lowering medications for sex offenders? A survey among clinicians from German forensic-psychiatric institutions

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.

Changed processing of visual sexual stimuli under GnRH-therapy--a single case study in pedophilia using eye tracking and fMRI

BACKGROUND

Antiandrogen therapy (ADT) has been used for 30 years to treat pedophilic patients. The aim of the treatment is a reduction in sexual drive and, in consequence, a reduced risk of recidivism. Yet the therapeutic success of antiandrogens is uncertain especially regarding recidivism. Meta-analyses and reviews report only moderate and often mutually inconsistent effects.

CASE PRESENTATION

Based on the case of a 47 year old exclusively pedophilic forensic inpatient, we examined the effectiveness of a new eye tracking method and a new functional magnetic resonance imaging (fMRI)-design in regard to the evaluation of ADT in pedophiles. We analyzed the potential of these methods in exploring the impact of ADT on automatic and controlled attentional processes in pedophiles. Eye tracking and fMRI measures were conducted before the initial ADT as well as four months after the onset of ADT. The patient simultaneously viewed an image of a child and an image of an adult while eye movements were measured. During the fMRI-measure the same stimuli were presented subliminally. Eye movements demonstrated that controlled attentional processes change under ADT, whereas automatic processes remained mostly unchanged. We assume that these results reflect either the increased ability of the patient to control his eye movements while viewing prepubertal stimuli or his better ability to manipulate his answer in a socially desirable manner. Unchanged automatic attentional processes could reflect the stable pedophilic preference of the patient. Using fMRI, the subliminal presentation of sexually relevant stimuli led to changed activation patterns under the influence of ADT in occipital and parietal brain regions, the hippocampus, and also in the orbitofrontal cortex. We suggest that even at an unconscious level ADT can lead to changed processing of sexually relevant stimuli, reflecting changes of cognitive and perceptive automatic processes.

CONCLUSION

We are convinced that our experimental designs using eye tracking and fMRI could prospectively add additional and valuable information in the evaluation of ADT in paraphilic patients and sex offenders. But with respect to the limited significance of this single case study, these first results are preliminary and further studies have to be conducted with healthy subjects and patients.

Changes in the sleep electroencephalogram (EEG) during male to female transgender therapy

Steroids, including estrogens, participate in sleep regulation. For example estrogen replacement therapy improved sleep quality in postmenopausal women. Patients, who undergo a cross-gender hormone therapy, receive high doses of estrogens. The effects of this treatment on sleep are unknown. To clarify this issue, we examined seven male to female transsexual patients (age range 31-44 years, mean±SD 35.9±4.2 years). The patients spent two nights on 2 separate occasions in our sleep laboratory. The first night of each session served for adaptation to laboratory conditions. In the second night sleep electroencephalogram [EEG] was recorded from 2300h to 0700h. The first examination was performed before and the second about 3 months after initiation of cross-gender hormone therapy with a dose of 80-100mg estrogen applied every 2 weeks. Additionally patients were treated with a starting dose of the anti-androgen cyproteronacetate of 100mg/day and after about 6 weeks with a maintenance therapy of 50mg/d in order to suppress androgenic effects. Statistical analysis was performed with the Wilcoxon rank test. Under this estrogen therapy we found a significant increase in stage 1 sleep during the whole night (at baseline [b]: 33.29±9.94min; treatment [t]: 51.57±24.26min; p<0.05) Beta activity in nonREM sleep was significantly increased (p=0.02) during hormone therapy compared to before treatment. Other sleep EEG parameters showed no significant changes. Administration of estrogen and anti-androgens in male to female transsexual patients had only a small influence on sleep EEG, with an increase in the duration of shallow sleep.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Review of medical reports on pedophilia

The present report is a review of all 554 papers published on Medline on pedophilia. The first discussion is the history of the disorder from ancient Greece to the present time, especially the influence of the liberal country of the Netherlands, the North American Man-Boy Love Association, and the sexual crisis in the Catholic Church. One important question is the relationship between homosexual pedophilia and adult homosexuality. Evidence for and against this relationship is presented. Next discussed are the characteristics of the victim and the long lasting serious effects of sexual abuse. Laboratory correlations are included, especially phallometric tests in order to objectively measure the physical responses to sexual stimuli. Electrophysiological and radiographic tests are also mentioned, including electroencephalography, computed tomography, magnetic resonance imaging, and positron emission tomography scans. An important section is the characterization of pedophiles with emphasis on their frequent previous sexual abuse, their past, their present, and their anticipated future. The final topic is treatment of this disorder with surgery, medication, behavioral therapy and the combination of medication and behavioral therapy.

[Paraphilia, sexual preference disorders. Diagnosis, etiology, epidemiology, treatment and prevention]

Hostility towards relationships is one prominent characteristic symptom for disorders of sexual preference (ICD-10) and paraphilias (DSM-IV). Paraphilic symptoms sometimes progress to obsessive or addictive- like forms leading to a loss of self-control but can occur also as single incidents or as episodic events. Besides constitutional aspects, problems in the development of close relationships to primary caregivers (attachment) play an important role in the development of these disorders. Actual relationship- and self-confidence problems often trigger the severity of disturbance, especially in the episodic forms of paraphilia. For patients who are in conflict with the law, cognitive-behavioral therapeutic approaches with the aim to minimize self-deception regarding the effects of the paraphilic behavior have become more and more relevant. Regarding the medical treatment, anti-hormonal therapy plays an important role, but also treatment with serotonergic agents and naltrexone are used. Only little can be advised in terms of prevention; general psycho-hygiene (regarding the parent-child relationship) is recommended. Beside these general measures, institutions which offer special treatment for people in danger to become delinquents may be able to prevent serious harm for possible victims of abuse.

Treatment of paraphilia with luteinizing hormone-releasing hormone agonists

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

The effects of intoxication levels of ethanol on nocturnal penile tumescence

This 12-night case study reports the effects of intoxication levels of ethanol (e.g., blood levels > 120 mg %) on Nocturnal Penile Tumescence (NPT). Several NPT variables were significantly reduced; however, the critical effect appeared to be a delayed latency to the first NPT. Integrating the present findings into relevant REM sleep data, the author argues that the uncritical extrapolation of NPT observations to sexual situations in the waking state, as an indication of "antisexual" effects of drugs (e.g., ethanol), may be misleading.