The Development of In Vivo Measures to Assess the Impact of Sex-Drive Reducing Medications in an Offender with an Intellectual Disability

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.

The Effectiveness of Psychological Treatment for Reducing Recidivism in Child Molesters: A Systematic Review of Randomized and Nonrandomized Studies

In this systematic review, the effectiveness of psychological treatment interventions for child molesters was examined. Studies were restricted to randomized control trials (RCTs), controlled trials, and cohort designs where recidivism had been used as the outcome variable. ASSIA, NCJRS, Medline, PsychINFO, EMBASE, Pro-requests Dissertations and Theses A&I, and the Cochrane Library were searched. Ten experts were contacted and the reference lists of 12 systematic reviews and 40 primary studies were observed. The number of hits was 3,019, of which 564 duplicates, 2,388 irrelevant references, and 38 that did not meet the inclusion criteria were removed. Fourteen studies using mixed samples had to be omitted because it was not possible to determine the recidivism rates of child molesters in the samples described. One RCT and 9 cohort studies were included in the data synthesis, providing 2,119 participants. In all, 52.1% received the intervention under investigation and 47.9% did not. The reported recidivism rates were 13.9% for the treated child molesters compared to 18.6% for the untreated child molesters. Three studies reported statistically significant lower recidivism rates for treated child molesters. Eight studies were assessed as weak. Four studies were assessed as having bias which increased the chance of finding a treatment effect and four studies were assessed as having bias which reduced the chance of finding a treatment effect. It was not possible to determine the direction of bias for two studies.

Pharmacological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a serious social problem, a public health issue, and a major challenge for social policy. Victim surveys indicate high incidence and prevalence levels and it is accepted that there is a high proportion of hidden sexual victimisation. Surveys report high levels of psychiatric morbidity in survivors of sexual offences.Biological treatments of sex offenders include antilibidinal medication, comprising hormonal drugs that have a testosterone-suppressing effect, and non-hormonal drugs that affect libido through other mechanisms. The three main classes of testosterone-suppressing drugs in current use are progestogens, antiandrogens, and gonadotropin-releasing hormone (GnRH) analogues. Medications that affect libido through other means include antipsychotics and serotonergic antidepressants (SSRIs).

OBJECTIVES

To evaluate the effects of pharmacological interventions on target sexual behaviour for people who have been convicted or are at risk of sexual offending.

SEARCH METHODS

We searched CENTRAL (2014, Issue 7), Ovid MEDLINE, EMBASE, and 15 other databases in July 2014. We also searched two trials registers and requested details of unidentified, unpublished, or ongoing studies from investigators and other experts.

SELECTION CRITERIA

Prospective controlled trials of antilibidinal medications taken by individuals for the purpose of preventing sexual offences, where the comparator group received a placebo, no treatment, or 'standard care', including psychological treatment.

DATA COLLECTION AND ANALYSIS

Pairs of authors, working independently, selected studies, extracted data, and assessed the risk of bias of included studies. We contacted study authors for additional information, including details of methods and outcome data.

MAIN RESULTS

We included seven studies with a total of 138 participants, with data available for 123. Sample sizes ranged from 9 to 37. Judgements for categories of risk of bias varied: concerns were greatest regarding allocation concealment, blinding of outcome assessors, and incomplete outcome data (dropout rates in the five community-based studies ranged from 3% to 54% and results were usually analysed on a per protocol basis).Participant characteristics in the seven studies were heterogeneous, but the vast majority had convictions for sexual offences, ranging from exhibitionism to rape and child molestation.Six studies examined the effectiveness of three testosterone-suppressing drugs: cyproterone acetate (CPA), ethinyl oestradiol (EO), and medroxyprogesterone acetate (MPA); a seventh evaluated two antipsychotics (benperidol and chlorpromazine). Five studies were placebo-controlled; in two, MPA was administered as an adjunctive treatment to a psychological therapy (assertiveness training or imaginal desensitisation). Meta-analysis was not possible due to heterogeneity of interventions, comparators, study designs, and other issues. The quality of the evidence overall was poor. In addition to methodological issues, much evidence was indirect.

PRIMARY OUTCOME

recividism. Two studies reported recidivism rates formally. One trial of intramuscular MPA plus imaginal desensitisation (ID) found no reports of recividism at two-year follow-up for the intervention group (n = 10 versus one relapse within the group treated by ID alone). A three-armed trial of oral MPA, alone or in combination with psychological treatment, reported a 20% rate of recidivism amongst those in the combined treatment arm (n = 15) and 50% of those in the psychological treatment only group (n = 12). Notably, all those in the 'oral MPA only' arm of this study (n = 5) dropped out immediately, despite treatment being court mandated.Two studies did not report recidivism rates as they both took place in one secure psychiatric facility from which no participant was discharged during the study, whilst another three studies did not appear directly to measure recividism but rather abnormal sexual activity alone.

SECONDARY OUTCOMES

The included studies report a variety of secondary outcomes. Results suggest that the frequency of self reported deviant sexual fantasies may be reduced by testosterone-suppressing drugs, but not the deviancy itself (three studies). Where measured, hormonal levels, particularly levels of testosterone, tended to correlate with measures of sexual activity and with anxiety (two studies). One study measured anxiety formally; one study measured anger or aggression. Adverse events: Six studies provided information on adverse events. No study tested the effects of testosterone-suppressing drugs beyond six to eight months and the cross-over design of some studies may obscure matters (given the 'rebound effect' of some hormonal treatments). Considerable weight gain was reported in two trials of oral MPA and CPA. Side effects of intramuscular MPA led to discontinuation in some participants after three to five injections (the nature of these side effects was not described). Notable increases in depression and excess salivation were reported in one trial of oral MPA. The most severe side effects (extra-pyramidal movement disorders and drowsiness) were reported in a trial of antipsychotic medication for the 12 participants in the study. No deaths or suicide attempts were reported in any study. The latter is important given the association between antilibidinal hormonal medication and mood changes.

AUTHORS' CONCLUSIONS

We found only seven small trials (all published more than 20 years ago) that examined the effects of a limited number of drugs. Investigators reported issues around acceptance and adherence to treatment. We found no studies of the newer drugs currently in use, particularly SSRIs or GnRH analogues. Although there were some encouraging findings in this review, their limitations do not allow firm conclusions to be drawn regarding pharmacological intervention as an effective intervention for reducing sexual offending.The tolerability, even of the testosterone-suppressing drugs, was uncertain given that all studies were small (and therefore underpowered to assess adverse effects) and of limited duration, which is not consistent with current routine clinical practice. Further research is required before it is demonstrated that their administration reduces sexual recidivism and that tolerability is maintained.It is a concern that, despite treatment being mandated in many jurisdictions, evidence for the effectiveness of pharmacological interventions is so sparse and that no RCTs appear to have been published in two decades. New studies are therefore needed and should include trials with larger sample sizes, of longer duration, evaluating newer medications, and with results stratified according to category of sexual offenders. It is important that data are collected on the characteristics of those who refuse and those who drop out, as well as those who complete treatment.

[Criminal recidivism among sexual offenders]

INTRODUCTION

No previous reports have been published on the rate, frequency and nature of long-term sexual recidivism for a large cohort of Danish sexual offenders who have been through a forensic psychiatric evaluation.

MATERIAL AND METHODS

A retrospective follow-up study of all male sexual offenders evaluated between 1st January 1978 and 31st December 1992 at the Department of Forensic Psychiatry, Aarhus University Hospital, or at the Clinic of Forensic Psychiatry, Ministry of Justice, Copenhagen (n = 441).

RESULTS

Of the followed cohort (n = 342) 30% were sentenced for a new sexual criminal offence (including severe sexual acts), 17% for severe sexual acts, 32% for nonsexual violence and 61% for general crime during follow-up (average 16.5 years). There was a low rate of repeated sexual recidivism (12%) and severe sexual recidivism (6%). Extra-familial child molesters and exhibitionists had the highest risk of sexual recidivism and repeated sexual offences. Rapists had the highest risk of severe sexual recidivism and re-offended more rapidly than the other offender subgroups. Intra-familial child molesters had a low recidivism rate. Young offenders had a higher recidivism risk than older offenders. Severely mentally ill or retarded had a statistically lower rate of sexual recidivism than less disturbed offenders.

CONCLUSION

The sexual recidivism rate varies across sexual offender types. The management and prevention of sexual recidivism need to focus on treatment of sexual offenders with the highest risk of severe and repeated sexual offences.