The Use of Leuprolide Acetate in the Management of High-Risk Sex Offenders

The impact of testosterone-lowering medication on recidivism in individuals convicted of sexual offenses

INTRODUCTION

Treatment of individuals who have committed sexual offences with Testosterone-Lowering Medication (TLM) is a comparatively intrusive kind of intervention, which regularly takes place in coercive contexts. Thus, the question of efficacy, but also the question of who should be treated, when and for how long, are of great importance.

METHODS

Recidivism rates of TLM-treated high-risk individuals (+TLM; n = 54) were compared with high-risk individuals treated with psychotherapy only in the same forensic outpatient clinic (-TLM; n = 79).

RESULTS

Group differences suggested a higher initial risk of + TLM (e.g. higher ris-assessment, previous convictions). Despite the increased risk, after an average time at risk of six years, +TLM recidivated significantly less often and significantly later than - TLM (27.8% vs. 51.9%). Such an effect was also found for violent (1.9% vs. 15.2%), but not for sexual (5.6% vs. 10.1%) and serious recidivism (5.6% vs. 10.1%), which could be explained partly by the small number of cases. In the course of treatment, TLM proved to be a significant variable for a positive process, whereas a high risk-assessment score indicated a rather negative course. In total, n = 19 individuals had stopped their TLM treatment, of these 31.6% recidivated.

CONCLUSION

The results support the efficacy of TLM, particularly in the group of high-risk offenders.

Androgens, brain and androgen deprivation therapy in paraphilic disorders: A narrative review

Sexual delinquency is a global problem where those with paraphilic disorders, such as paedophiles, are more likely to commit and reoffend. Androgen deprivation therapy (ADT) has been suggested as a solution. The objective of this narrative review is to present current information on its risks, benefits and limitations as a treatment for paraphilias. The importance of testosterone in sexual function, the effect of its deficiency by age or by pharmacological treatment (anti-androgens, GnRH agonists and GnRH antagonists) and the effect of testosterone replacement therapy will be reviewed. The relationship between androgens, brain, sexual behaviour and pathophysiology of paraphilic disorders will also be explored. ADT reduces sexual urges, but has adverse effects and, because its reversible nature, it does not ensure less recidivism. Likewise, the research quality of ADT drugs is limited and not enough to support their use. Child sex offenders, and not paraphilic subjects who have not committed assaults, show signs of elevated prenatal exposure to androgens and a higher methylation state of the androgen receptor gene. Sexual behaviour is regulated by subcortical (hypothalamus, brainstem and spinal cord) and cortical structures of the brain, in addition to brain circuits (dopaminergic, serotonergic). Those with paraphilic disorders show abnormalities at these levels that could relate to the risk of sexual offences. In conclusion, androgens represent a significant part of the pathophysiology of paraphilias and therefore, ADT seems promising. Nonetheless, more studies are needed to make definite conclusions about the efficacy of long-term ADT in paraphilic patients.

Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole?

BACKGROUND

The number of individuals who sexually offended, and who are continued to be treated with pharmacological agents to reduce sex drive after their release from prison or forensic psychiatry, are not known. Furthermore, figures on the number of those who stop their sexdrive supressing antiandrogen treatment in the outpatient setting are unknown as well. This is of central importance though as it might be associated with an increased risk of recidivism.

AIM

To assess prescription patterns as well as adherence to pharmacological treatment in outpatient clinics in Germany for individuals who have sexually offended and were released from prison or forensic psychiatric hospital.

METHODS

A self-constructed online survey assessing the pharmacological treatment modalities was sent by e-mail to n = 103 forensic outpatient clinics in Germany. Thirty-three (32.0%) completed the questionnaire and reported about 834 patients.

OUTCOMES

Prevalence of the use of different pharmacological agents in the treatment of individuals convicted for sexual offenses as well as the number of patients who have discontinued testosterone-lowering medication (TLM).

RESULTS

Among all institutions, 22.4% (n = 187) of individuals received pharmacological treatment, with 40.1% receiving gonadotropin-releasing-hormone-agonists, 26.2% antipsychotics, 24.6% selective serotonin reuptake inhibitors, 6.4% cyproterone acetate, and 2.7% a combination of gonadotropin-releasing-hormone-agonists and cyproterone acetate. A significant positive correlation was found between the number of patients released from a forensic-psychiatric hospital and the number of patients treated with TLM. Within 1 year 8.6% (n = 16) stopped their TLM during or at the end of the supervision period, most of them against treatment providers advice.

CLINICAL IMPLICATIONS

Substantial regional differences indicate uncertainties regarding the prescription of pharmacological agents for outpatients who have committed sexual offences in Germany. The discontinuiation of TLM within the first year of treatment against treatment providers advise in a substantial proportion of patients could be associated with a serious risk for reoffending.

STRENGTHS & LIMITATIONS

The present survey captures prevalences of the pharmacotherapy in forensic aftercare facilities for individuals who have offended sexually, and is the first to record the number of discontinuations. This is a cross-sectional survey covering only 1 country, but includes a large number of individuals.

CONCLUSION

Even though the number of treated individuals has increased in prisons, the majority of pharmacological treatment is still provided by forensic hospitals, which then translates into the outpatient setting. The number of those who stop taking such medication is a highly relevant topic for both forensic treatment providers and legal decision makers Sauter J, Rettenberger M, Briken P, et al. Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole?. J Sex Med 2022;19:1147-1155.

Testosterone-Lowering Medication and Its Association With Recidivism Risk in Individuals Convicted of Sexual Offenses

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.

Androgen Deprivation Therapy in Pedophilic Disorder: Exploring the Physical, Psychological, and Sexual Effects From a Patient's Perspective

BACKGROUND

The use of androgen deprivation therapy (ADT) shows promising results in the treatment of paraphilic disorders. Although the side effects of ADT can be intrusive, there is no research into the experiences of patients with pedophilic disorder themselves.

AIM

This research aims to explore the psychological, physical, and sexual experiences of ADT from the perspective of sex offenders diagnosed with pedophilic disorder.

METHODS

Twelve semistructured in-depth interviews with male adults diagnosed with pedophilic disorder were conducted using a phenomenological approach. Six of the 12 respondents were on luteinizing hormone-releasing hormone agonists and the remaining on anti-androgens. Half of each group were inpatients, and the other half outpatients. The respondents were recruited in collaboration with one psychiatric hospital. The data were analyzed with help of a qualitative software application NVivo.

OUTCOMES

The respondents described experiences on the use of ADT on a physical, psychological, and sexual level.

RESULTS

The most prominent physical side effects mentioned were bone loss, weight gain, and breast formation. The respondents generally described a positive influence of the medication on their well-being. They felt more relaxed and experienced a reduction in frequency and intensity of sexual fantasies, anger, and aggressive feelings in general. In addition, all the respondents noticed a lower frequency of sexual contact and masturbation. Most of the participants experienced the use of ADT as a mandatory decision made by the treating psychiatrist.

CLINICAL IMPLICATIONS

This study recommends informing patients and their loved ones on the potential side effects of ADT. Furthermore, training forensic counselors on potential side effects of ADT and methods to alleviate them can promote the dissemination of information and will encourage the informed consent procedure.

STRENGTHS & LIMITATIONS

This is the first qualitative study about the experiences of ADT in men diagnosed with pedophilic disorder in Belgium. Future studies should include more than one treatment center.

CONCLUSION

The majority of the participants had a positive attitude towards ADT in general. Boons L, Jeandarme I, Vervaeke G. Androgen Deprivation Therapy in Pedophilic Disorder: Exploring the Physical, Psychological, and Sexual Effects From a Patient's Perspective. J Sex Med 2021;18:353-362.

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.

A narrative review of research on clinical responses to the problem of sexual offenses in the last decade

Research on the treatment and programs for people who have committed sexual offenses has greatly increased in the past decade. The aim of this review is to discuss research that has been published over that period (2010-2019) that is relevant for treatment providers. The articles included in this review were found through PsycINFO and PubMed (Medline) using the keywords "treatment or therapy" and "sex offen*". The inclusion criteria were publications that discuss treatment of persons who have committed sexual offenses (written in the English language only). Any articles that examined only special populations were excluded, such as those that examined persons who committed sexual offenses who were female, had intellectual disabilities, deafness, juveniles, etc., because these groups will likely have needs and responsivity factors that differ from the "average" natal-born male sex offender. Results showed that several meta-analyses indicate that treatment is effective in reducing sexual recidivism. The most frequently used treatment for sex offenders is cognitive behavioral therapy, which is often provided in conjunction with pharmacological treatment to reduce sexual impulsivity and/or sex drive. This review is limited to the specific key search terms. The findings of this review support the use of treatment and a community reintegration approach when treating persons who have committed sexual crimes to prevent sexual recidivism.