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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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Turner D, Petermann J, Harrison K, Krueger R, Briken P. Pharmacological treatment of patients with paraphilic disorders and risk of sexual offending: An international perspective. World J Biol Psychiatry 2019; 20:616-625. [PMID: 29057702 DOI: 10.1080/15622975.2017.1395069] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objectives: The present study aims to evaluate existing policy and practice relating to the use of pharmacological treatments with patients suffering from paraphilic disorders who are at risk of committing further sexual offences.Methods: A systematic literature search was conducted to document current legal policies across 26 different countries. In addition, a questionnaire assessing the practice of pharmacological treatment was sent to practitioners involved in the treatment of patients with paraphilic disorders.Results: Legal policies concerning the preconditions of using pharmacological treatments differ considerably between countries, and for most jurisdictions do not exist. Drawing on the responses of 178 practitioners, pharmacological agents are a useful addition to psychotherapeutic interventions, especially with those patients classified as medium or high risk for sexually violent behaviours. It would appear that most patients are medically examined, are informed of the risks and possible side effects before treatment commences and are also obliged to sign a consent form.Conclusions: Although pharmacological agents can be seen as an intrusion into a patients' sexual self determination, results indicate that ethical and clinical standards are being met in the majority of cases. However, further promotion of current WFSBP treatment guidelines would help to standardise practice across North American and European countries.
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Affiliation(s)
- Daniel Turner
- Institute for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Julius Petermann
- Institute for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Richard Krueger
- College of Physicians and Surgeons, Department of Psychiatry, Columbia University, New York, NY, USA
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Völlm B, Craissati J, Grubin D, Skett S, Williams F. Learning from research: Adapting interventions for sexual offending to improve outcomes. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2019; 29:227-238. [PMID: 31478289 DOI: 10.1002/cbm.2122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Sexual behaviour towards another person who does not or cannot consent to it causes serious harm to its victims. Understandable tendencies towards isolating or shaming the offenders, however, may actually increase risks of recidivism and further such harms. AIM The study aims to consider evidence for the effectiveness of interventions for sex offenders, mainly in a U.K. context, across four areas: criminal justice system programmes, medication, interventions for sex offenders with personality disorder and a community-based model for the reintegration-Circles of Support and Accountability, and identify key evidence gaps. METHODS We searched for reviews in the following four strands of work-psychosocial programmes, medication, personality focused therapies, and Circles of Support and Accountability-and identified gaps in knowledge. FINDINGS Randomised controlled trials in this field are rare but have been achieved. Findings from more naturalistic outcome studies of sex offender treatment programmes are disappointing, but recidivism rates among released sex offender prisoners are low, regardless. Medication relying on substantial physiological change raises substantial ethical concerns. Not all sex offenders have a mental disorder but up to half have been diagnosed with a personality disorder, which may need specific treatment. Evidence is growing that lay work such as Circles of Support and Accountability is a valuable adjunct to other interventions. CONCLUSIONS AND IMPLICATIONS FOR FUTURE RESEARCH In this field, where tensions between attributions swing between "madness" and "badness," there is growing evidence for optimism that complexity of history and presentation can be met through cooperation between the many disciplines, integrative strategies, and wider community engagement. The need now is for large, prospective controlled trials of interventions, with long periods of follow-up. Perhaps, the most exciting developments have come from the wider public. More research into the qualities of these volunteers might inform public education and health strategies supporting wider safety.
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Affiliation(s)
- Birgit Völlm
- Hospital of Forensic Psychiatry, University of Rostock, Rostock, Germany
| | | | - Don Grubin
- Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Skett
- NHS England and HM Prison and Probation Service, London, UK
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Sauter J, Stasch J, Klemke K, Emmerling A, Voß T. Das Absetzen antiandrogener Medikation im ambulanten Setting. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2018. [DOI: 10.1007/s11757-018-0498-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wong JS, Gravel J. Do Sex Offenders Have Higher Levels of Testosterone? Results From a Meta-Analysis. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2018; 30:147-168. [PMID: 27000267 DOI: 10.1177/1079063216637857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The purpose of the current study is to review the available scientific evidence on the relationship between testosterone and sexual aggression. A systematic search for all primary studies comparing basal testosterone levels in sex offenders and non-sex offenders was undertaken across 20 electronic databases using an explicit search strategy and inclusion/exclusion criteria. A total of seven studies were identified and 11 effect sizes were computed; effects were pooled using both fixed and random effects meta-analysis models. Although individual study findings present a mix of results wherein sex offenders have higher or lower baseline levels of testosterone than non-sex offenders, pooled results indicate no overall difference between groups. Moderators of the analyses suggest possibly lower rates of testosterone in child molesters than controls; however, results are dependent on study weighting. Limitations, policy implications with respect to chemical castration laws, and future directions for research are discussed.
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Rea JA, Dixon MR, Zettle RD, Wright KL. The Development of In Vivo Measures to Assess the Impact of Sex-Drive Reducing Medications in an Offender with an Intellectual Disability. ARCHIVES OF SEXUAL BEHAVIOR 2017; 46:843-859. [PMID: 27671782 DOI: 10.1007/s10508-016-0832-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 08/06/2016] [Accepted: 08/08/2016] [Indexed: 06/06/2023]
Abstract
The ability to adequately evaluate medications in the treatment of paraphilias has been limited by reliance upon self-report as a measure of effectiveness over periods of time that may be too short to detect reoffending. One solution to this shortcoming is the development of valid, long-term, stable assessment measures. The purpose of this case study was to analyze the effects of Prozac and Provera on an array of behaviors germane to the successful treatment of paraphilias, including: (a) sexual arousal in the laboratory and natural environment, (b) sexual thoughts (deviant and nondeviant) accompanied by arousal in the natural environment, and (c) overt actions in the community associated with increased risk of reoffending over a 31-month period for an exhibitionist with an intellectual disability. Despite the ineffectiveness of the medications, the measures demonstrated long-term, differentiated significant clinical responding; further underscored the importance of assessing deviant sexual arousal and adherence to relapse-prevention procedures in the natural environment; and provided a new methodology to assess sexual preoccupations and sexual arousal. Use of these in vivo measures raises questions regarding their potential to improve the predictability of risk assessments, and serve as an aide in the analysis of whether a treatment procedure is effective for an individual.
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Affiliation(s)
- Jerry A Rea
- Parsons State Hospital and Training Center, 2601 Gabriel, Parsons, KS, 67357, USA.
- University of Kansas Life Span Institute at Parsons, Lawrence, KS, USA.
| | - Michael R Dixon
- Parsons State Hospital and Training Center, 2601 Gabriel, Parsons, KS, 67357, USA
| | - Robert D Zettle
- Department of Psychology, Wichita State University, Wichita, KS, USA
| | - Kasey L Wright
- Parsons State Hospital and Training Center, 2601 Gabriel, Parsons, KS, 67357, USA
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Abstract
This article examines one kind of conscientious refusal: the refusal of healthcare professionals to treat sexual dysfunction in individuals with a history of sexual offending. According to what I call the orthodoxy, such refusal is invariably impermissible, whereas at least one other kind of conscientious refusal—refusal to offer abortion services—is not. I seek to put pressure on the orthodoxy by (1) motivating the view that either both kinds of conscientious refusal are permissible or neither is, and (2) critiquing two attempts to buttress it.
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Abstract
Paraphilic disorders are characterized by atypical sexual interests, fantasies, and behaviors that are subjectively distressing to patients or pose a risk of harm to others. By their very nature, some paraphilic disorders may predispose an individual to commit sexual offenses. The biological treatment of paraphilic disorders, then, is of paramount importance for psychiatry and society at large. Three categories of pharmacologic agents commonly used to treat paraphilic disorders are selective serotonin reuptake inhibitors, synthetic steroidal analogs, and gonadotropin-releasing hormone analogs. Each medication uses a different mechanism of action and has different effects on the physiological and psychological features of paraphilic disorders. In general, these medications have limited high-quality research to support their use. Despite this, some authors have proposed treatment algorithms for individuals with paraphilic disorders of varying severity. These guidelines offer clinicians potentially useful, rational approaches to assessing treatment need in individuals with paraphilic disorders. Recent neuroimaging research suggests that functional magnetic resonance imaging may offer further promise in effectively assessing paraphilic disorders to help direct treatment options.
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Affiliation(s)
- Brian J Holoyda
- Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine, 2230 Stockton Blvd., Sacramento, CA, 95817, USA.
| | - Denise C Kellaher
- Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine, 2230 Stockton Blvd., Sacramento, CA, 95817, USA.
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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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Shniderman AB, Solberg LB. Cosmetic Psychopharmacology for Prisoners: Reducing Crime and Recidivism Through Cognitive Intervention. NEUROETHICS-NETH 2015. [DOI: 10.1007/s12152-015-9242-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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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Goswami GK. Castration laws: Marching towards imperfect justice. Med Leg J 2014; 82:70-79. [PMID: 24852363 DOI: 10.1177/0025817213517351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Castration is an anthropogenic procedure by which the person loses the functions of the testicles or ovaries; it can be performed by surgery or by administering chemicals. The motivation was primarily eugenic, to weed out the "unfit" from the human gene pool. In 1996, California first introduced chemical castration under s 645 of the California Penal Code for child molestation and this legal template has spread globally to counter sexual offences. The anti-androgenic pharmacotherapy used for chemical castration includes cyproterone acetate or medroxy-progesterone acetate (Depo-Provera), which reduces testosterone levels and reduces male sexual urge and fantasies. However, the associated health hazards with anti-libido drugs put a question mark on such State sponsored penal response. Castration destroys human dignity, breaches the right of privacy and procreation and attracts the cruel and unusual punishment clause. The failed Oregon castration experiment and Moldova Court verdict in July 2013 indicate that the stage is set to right this wrong.
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Affiliation(s)
- Gajendra K Goswami
- Academy of Central Bureau of Investigation, Kamla Nehru Nagar, Ghaziabad, India
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Koo KC, Ahn JH, Hong SJ, Lee JW, Chung BH. Effects of Chemical Castration on Sex Offenders in Relation to the Kinetics of Serum Testosterone Recovery: Implications for Dosing Schedule. J Sex Med 2014; 11:1316-24. [DOI: 10.1111/jsm.12492] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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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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Treatment outcomes of chemical castration on Korean sex offenders. J Forensic Leg Med 2013; 20:563-6. [DOI: 10.1016/j.jflm.2013.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/28/2013] [Accepted: 06/04/2013] [Indexed: 11/24/2022]
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Treatment with triptorelin in mentally disordered sex offenders: experience from a maximum-security hospital. J Clin Psychopharmacol 2012; 32:739-40. [PMID: 22926625 DOI: 10.1097/jcp.0b013e318266c6f5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ho DK, Ross CC. Cognitive behaviour therapy for sex offenders: too good to be true? CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2012; 22:1-13. [PMID: 22262239 DOI: 10.1002/cbm.1818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Mann RE, Carter AJ, Wakeling HC. In defence of NOMS' view about sex offending treatment effectiveness: a reply to Ho and Ross. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2012; 22:7-10. [PMID: 22262240 DOI: 10.1002/cbm.1821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Abstract
Violence is unfortunately a part of society. The causes of violence are not completely understood, but it involves sociological, genetic, financial, biological, and environmental factors. Drugs can cause aggression by altering the neurotransmitters dopamine, norepinephrine, gamma-aminobutyric acid (GABA), and serotonin. Specific drugs associated with aggression include alcohol, anabolic steroids, cocaine, amphetamines, sedatives, opiates, and hallucinogens. Aggression can be categorized into impulsive and predatory aggression. Drugs under certain conditions cause impulsive aggression. Sometimes a defense in criminal cases is that the drug caused the violence, that is drug-induced insanity. A case of insanity is more likely to be accepted if the event was unplanned and had no apparent motive. An acceptance of insanity by voluntary intoxication is rarely accepted by the criminal justice system. A more common legal strategy is to seek diminished capacity which aims to obtain a reduction in the severity of the criminal charges. We will discuss some, but not all of the pharmacological and physiological issues relating to drug-induced violence. Then some of the "big picture" forensic issues will be presented. Our goal is to present a primer on the pharmacological and forensic issues relating to drug-induced violence. No attempt was made to provide a comprehensive review of all the literature related to drug-induced violence.
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Affiliation(s)
- Peter D Anderson
- Forensic Pharmacologist, Private Practice, Adjunct Associate Professor of Pharmacy Practice, University of Rhode Island, Quincy, MA 02368, USA.
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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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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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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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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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Abstract
PURPOSE OF REVIEW This review addresses testosterone-lowering and other psychotropic medications for the treatment of paraphilic patients or sexual offenders. RECENT FINDINGS Randomized controlled studies are still lacking, and only a few new studies were reported during the past year. On the other hand, there is substantial scientific knowledge about the wide range of psychiatric comorbidity associated with paraphilias and in sexual offenders. Empirically based treatment of these patients, especially of impulsivity, anxiety and mood disorders, may also ameliorate sexual impulsivity. SUMMARY Medication interventions, either substantially lowering serum testosterone or treating axis I comorbidities, show definite promise as a significant component of the management of sexual offenders. Pharmacotherapy should be combined with other therapeutic treatment modalities, most commonly cognitive-behaviour based psychotherapy and intensive community supervision.
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