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.

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.

A case of familial exhibitionism in Tourette's syndrome successfully treated with haloperidol.

The authors describe a 32-year-old man with Gilles de la Tourette's syndrome whose most severe symptom was exhibitionism. Treatment with low doses of haloperidol eliminated all exhibitionistic urges. This patient's oldest son has multiple tics and his nephew has Tourette's syndrome with mild exhibitionism. The major implications of this case are that 1) all patients with compulsive-type exhibitionism should be carefully questioned about symptoms of Tourette's syndrome and, if positive, be given a trial regimen of haloperidol; 2) some patients with compulsive exhibitionism and no symptoms of Tourette's syndrome have a genetic, neurochemical disorder and respond to haloperidol.

Gonadotrophin hormone releasing hormone agonist in cases of severe paraphilia: a lifetime treatment?

Six patients with severe paraphilia were treated with a long-acting gonadotrophin hormone releasing hormone analogue (GnRH-a). In five cases, the antiandrogen treatment ended their deviant sexual behaviour and markedly decreased their sexual fantasies and activities without significant side-effects. The beneficial effects of this treatment were maintained for 7 years in the patient where there was the longest follow-up. Two patients abruptly withdrew front their antiandrogen treatment at the end of the first and third year, respectively. Both relapsed within 8-10 weeks. One of them asked for resumption of antiandrogen treatment. In another case, in order to phase out antiandrogen treatment, testosterone (T) was added to the GnRH-a. In spite of normal T levels, and of resumption of normal sexual activities and deviant fantasies, deviant sexual behaviour did not return. A smoother phasing out of GnRH-a treatment is thought to be better than an abrupt withdrawal. However, the duration of antiandrogen treatment necessary to ensure a complete disappearance of deviant sexual behaviour remains uncertain, but is at least 4 years.

Compulsive exhibitionism successfully treated with fluvoxamine: a controlled case study.

BACKGROUND: Paraphilias are psychosexual disorders that are usually conceptualized as deviant in nature. Yet in some cases, paraphilia can be conceptualized as an obsessive compulsive disorder. METHOD: We describe an exhibitionist treated under partial single-blind conditions (patient was blind to placebo but was aware he was receiving desipramine and fluvoxamine) with the serotonin selective reuptake inhibitor fluvoxamine, followed by desipramine and a placebo that looked like fluvoxamine, in an ABACA design. He was serially assessed with the Yale-Brown Obsessive Compulsive Scale. RESULTS: Fluvoxamine eliminated the undesired impulse and behavior without affecting sexual desire. Desipramine and single-blind fluvoxamine-placebo treatment were both associated with relapses. CONCLUSION: A subset of paraphiliacs may be suffering from obsessive-compulsive-related disorders and may benefit from serotonergic agents.

Three cases of paraphilias responsive to fluoxetine treatment.

Three cases are presented in which fluoxetine was employed in the apparently successful treatment of paraphilia, a disorder which has been difficult to treat pharmacologically. Therapeutic benefit may have been related to the efficacy of fluoxetine in the treatment of obsessive compulsive disorders or to direct effects on sexual activity, or both.

Pharmacotherapy of paraphilias with long-acting agonists of luteinizing hormone-releasing hormone: a systematic review.

BACKGROUND: In addition to psychotherapy, pharmacotherapy is an important treatment option for paraphilias, especially in sexual offenders. Cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA) are commonly used but can have serious side effects. Selective serotonin reuptake inhibitors (SSRIs) may also be effective in less severe cases. Recent research shows that luteinizing hormone-releasing hormone (LHRH) agonists may offer a new treatment option for treatment of paraphilic patients. METHOD: MEDLINE was searched for clinical trials, case-control studies, case reports, and other clinically and theoretically important literature published between 1980 and November 2002 on the treatment of paraphilia with LHRH agonists. Keywords included LHRH agonists, GnRH- agonists, antiandrogens, paraphilia, pedophilia, and sex offenders. RESULTS: We found 4 case reports, 1 case- control study, 7 open uncontrolled studies, and 1 study comparing patients receiving CPA with those receiving LHRH agonist treatment in forensic hospitals. In total, the studies reported on a sample of 118 treated patients with different forms of paraphilias (sadism, pedophilia, exhibitionism, voyeurism). Nearly all of the studies used self-reports to measure the effects of medication. Duration of follow-up was between 6 months and 7 years and revealed that there were no relapses if patients remained under treatment. Patients previously treated with other agents like CPA, MPA, or SSRIs reported better effects when taking LHRH agonists. CONCLUSION: Although there is a need for further research, LHRH agonists offer a treatment option for patients with severe paraphilia. We propose a differentiated pharmacologic treatment regarding side effects, symptomatology, and severity.

[Androcur (cyproterone acetate in sex offenses--follow-up of psychiatric admissions]. / Androcur (Cyproteronacetat) bei Sexualdelinquenz--Nachuntersuchung von untergebrachten psychiatrischen Patienten.

This paper presents the follow-up study of 31 sexual offenders with diminished criminal responsibility or irresponsibility who were treated with Androcur (cyproterone acetate, CPA) in depot injection form connected with psychotherapy during and after their legal psychiatric hospitalisation. There were paedophiliac, exhibitionistic, hetero-sexual aggressive, and mixed sexual deviant acts. 30 patients were visited by the author in their environment, 1 patient had died. Half of the patients had a hetero-sexual relationship. 3 patients had children. 28 of the 31 patients were free. After the treatment with CPA 2 kinds of relapses could be distinguished: homologue r. (4 pat.) and residual r. (5 pat.). As to the duration of the treatment after discharge, 2 groups of patients can be distinguished: 1 group needed Androcur for a comparatively short time (up to c. 3 years), the other group for a longer time (up to c. 5 years). The anti-androgenic treatment was accompanied by psychotherapy and social therapy as well as during the hospitalisation and after discharge. The mutual effect of Androcur and psychotherapy was successful as is to be seen by the final result of this follow-up study.

Compulsive voyeurism and exhibitionism: a clinical response to paroxetine.

The compulsive behaviors seen in sexual paraphilias may be related to those of obsessive-compulsive disorder (OCD). Based primarily upon case reports as well as studies indicating the effectiveness of serotonin reuptake inhibitors in the treatment of sexual paraphilias, it has been speculated that sexual paraphilias lie within the obsessive-compulsive spectrum. There have been no reports of the use of paroxetine in the treatment of sexual paraphilias. This is a report of two patients, the first a voyeur and the second an exhibitionist, both of whom responded to treatment with paroxetine. The discussion addresses the need for further comparative studies investigating the role of the serotonin system in the pathogenesis of sexual paraphilias and OCD as well as the effect of serotonin reuptake inhibitors in comparison to other pharmacologic modalities used in the treatment of paraphilias.

Naltrexone suppresses abnormal sexual behavior in Tourette's syndrome.

Abnormal sexual behavior occurs in 30-40% of patients with Tourette's syndrome (TS). Two patients with TS who exhibited distressing abnormal sexual behavior experienced amelioration of symptoms with administration of the oral opiate receptor antagonist naltrexone (TrexanR). Conventional anti-TS drugs including haloperidol and clonidine were ineffective. Abnormal sexual behavior may be another feature of the disease responding to opiate blockers.