[Chemsex - drug use primarily orientated around a sexual experience - Patients that fall through the gaps].

INTRODUCTION: Drug use in a sexualised context provides unique challenges both in specialised clinics (psychiatric and sexual health clinics) as well as general practice. Layered onto this leads some inequalities in health care to poorer outcomes in specific groups. This article aims to provide evidence based harm reduction strategies that can easily be applied in primary care to reduce complications, identify those at higher risk and deploy appropriate treatments.

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.

Pharmacological Treatment for Pedophilic Disorder and Compulsive Sexual Behavior Disorder: A Review.

Guidelines for the pharmacological treatment of paraphilic disorders have historically been based on data from forensic settings and on risk levels for sexual crime. However, emerging treatment options are being evaluated for individuals experiencing distress because of their sexual urges and preferences, targeting both paraphilic disorders such as pedophilic disorder (PeD) and the new diagnosis of compulsive sexual behavior disorder (CSBD) included in the International Classification of Diseases, 11th Revision (ICD-11). As in other mental disorders, this may enable individualized pharmacological treatment plans, taking into account components of sexuality (e.g. high libido, compulsivity, anxiety-driven/sex as coping), medical and psychiatric comorbidity, adverse effects and patient preferences. In order to expand on previous reviews, we conducted a literature search focusing on randomized controlled trials of pharmacological treatment for persons likely to have PeD or CSBD. Our search was not restricted to studies involving forensic or criminal samples. Twelve studies conducted between 1974 and 2021 were identified regardless of setting (outpatient or inpatient), with only one study conducted during the last decade. Of a total of 213 participants included in these studies, 122 (57%) were likely to have PeD, 34 (16%) were likely to have a CSBD, and the remainder had unspecified paraphilias (40, 21%) or sexual offense (17, 8%) as the treatment indication. The diagnostic procedure for PeD and/or CSBD, as well as comorbid psychiatric symptoms, has been described in seven studies. The studies provide some empirical evidence that testosterone-lowering drugs reduce sexual activity for patients with PeD or CSBD, but the body of evidence is meager. There is a need for studies using larger samples, specific criteria for inclusion, longer follow-up periods, and standardized outcome measures with adherence to international reporting guidelines.

Sexual Sadism Disorder and Coercive Paraphilic Disorder: A Scoping Review.

BACKGROUND: Valid and reliable diagnostic criteria are essential in forensic psychiatry and sexual medicine due to the severe implications of potential misdiagnoses. One challenge in this field is the poor operationalization of sexual sadism disorder (SSD) and coercive paraphilic disorder (CP+) definitions. AIM: The aim of this scoping literature review is to provide a comprehensive overview of the key conceptual differences between SSD and CP+, as well as consider pragmatic and clinically useful approaches to their diagnostic formulation. METHODS: Arksey and O'Malley's methodological framework was followed. A literature search of Medline, PsychInfo, Web of Science, and Cumulative Index to Nursing and Allied Health Literature electronic databases was conducted. Publications in English describing the construct and/or operational definition of SSD or CP+ were included. Full-text studies were reviewed by 2 authors and data was charted and synthesized qualitatively. RESULTS: The initial search provided 1,271 records, after which 120 full-text papers were considered for eligibility and 48 studies were ultimately included. The most common sources of definitions for SSD and CP+ were the Diagnostic and Statistical Manual of Mental Disorders (n = 53) and the International Classification of Disease (n = 12). There was more variation of terms used for CP+ than SSD. Both CP+ and SSD are critiqued by reviewed literature for having low validity, reliability, and consistency, as well as being conflated with sexual crime. SSD is better described due to having diagnostic criteria and validated diagnostic tools. CLINICAL IMPLICATIONS: Currently, clinicians rely mostly on the DSM to diagnose SSD or CP+. As applications of SSD and CP+ definitions vary, interpretations may not be generalizable between clinicians. Furthermore, specific diagnoses may be practically unhelpful and unreliable. It may therefore be beneficial for treatment to be determined by risk of harm. In addition to these concerns, the stigma associated with SSD and CP+ may also impact treatment. STRENGTHS & LIMITATIONS: Strengths of this study include duplicate review and charting to increase methodological rigor, transparent reporting to minimize publication bias, and encompassing a comprehensive scope. Limitations include the weaknesses of low strength of reviewed literature and risk of publication bias. CONCLUSION: Despite their significant implications, the definitions of SSD and CP+ are inconsistent and lack reliability. Future research is necessary to develop stronger diagnostic criteria and tools. Liu A, Zhang E, Leroux EJ et al. Sexual Sadism Disorder and Coercive Paraphilic Disorder: A Scoping Review. J Sex Med 2022;000:1-11.

Effects of testosterone suppression on desire, hypersexuality, and sexual interest in children in men with pedophilic disorder.

Effects of testosterone withdrawal on significant correlates of paedophilic disorder (PeD) are largely unknown. The purpose of this study was to explore in detail the effects of testosterone suppression from degarelix as compared to placebo on desire, hypersexuality, and subjectively experienced sexual interest in participants with PeD.We compared the sexual effects of degarelix, a GnRH antagonist, on men with PeD assigned to degarelix (n = 26) or placebo (n = 26) in a double-blind randomised clinical trial. Sexual Desire Inventory scores decreased significantly at two weeks (between-group difference p = 0.001, d = -0.96 [-0.38 to -1.55) and ten weeks (p < 0.001, d = -1.30 [-0.69 to -1.91) in participants assigned degarelix, whereas HBI ratings did not differ significantly at two weeks (p = 0.07, d = -0.52 [0.05 to -1.08), but did so at ten weeks (p = 0.01, d = -0.72 [-0.15 to -1.29). Fifteen out of 26 (58%) individuals in the group assigned degarelix and 3 out of 26 (12%) in the group assigned to placebo reported no further sexual interest in children at ten weeks (Fisher's exact test, p < 0.0001), an effect unmodified by autistic, antisocial, or impulsive traits, age, age at onset of, or duration of paedophilic attraction.

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder.

OBJECTIVES: The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD. METHODS: An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews. RESULTS: Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD. CONCLUSIONS: An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.

The Paraphilias and Medical Licensure in the United States.

BACKGROUND: As part of their mission to protect the public from exploitation, state medical boards query physicians about a wide range of topics prior to licensure, including in some cases whether the applicant has been diagnosed with or been treated for paraphilias or paraphilic disorders. AIM: We investigated the prevalence of questions inquiring about the applicants' history of paraphilias and paraphilic disorders on applications for medical licensure. METHODS: The allopathic medical licensure application forms for each of the 50 United States and the District of Columbia were reviewed. Medical boards with questions pertaining to paraphilias or paraphilic disorders were asked how many affirmative responses had been obtained in the prior 5 years and how they would treat an affirmative response. OUTCOMES: Eight medical boards inquired about paraphilias or paraphilic disorders, however there was no evidence of an affirmative response to these questions in the prior 5 years. RESULTS: Of the 51 applications reviewed, 8 (16%) inquired whether the applicant had, was diagnosed with, or had been treated for a paraphilia or paraphilic disorder. The wording of the questions was variable and often failed to distinguish between paraphilias and paraphilic disorders. All but one medical board responded to requests for further information. The medical board staff members stated that an affirmative response would result in case-by-case review, including request for further information and possibly an in-person appearance before the board. None of the medical boards were willing or able to provide a formal count of affirmative responses in the last 5 years. CLINICAL IMPLICATIONS: Medical boards may be contributing to the stigma experienced by both physicians and patients with diverse sexual interests. The benefit of retaining these questions is not clear. STRENGTHS AND LIMITATIONS: This study is the first to investigate the use of paraphilias and paraphilic disorders as screening questions for medical licensure. Data regarding the number of affirmative responses were limited by the medical boards' inability or unwillingness to respond to share the information. CONCLUSIONS: Eliminating or modifying physician licensing application questions pertaining to paraphilias and paraphilic disorders may decrease the stigma encountered by persons with diverse sexual interests. Removal also may diminish the barriers to accessing health care services for both physicians and patients with diverse sexualities. If the questions are retained, they should conform to the current DSM-5 nosology, which distinguishes between the mere presence of a paraphilia and a diagnosis of a paraphilic disorder. Cranstoun LM, Moser C. The Paraphilias and Medical Licensure in the United States. J Sex Med 2021;18:1130-1133.

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 Case of Paraphilia with Osteoporosis and Administered with Depot Leuprorelin.

Paraphilia is a complex psychological and psychiatric disorder that has been difficult to treat. Leuprorelin has been used as one of the therapeutic methods for paraphilia. Leuprorelin administration could change insulin resistance and accelerate bone loss. The case study in this work was a 59-year-old man who visited a hospital with the chief complaints of frotteuristic behaviors in public places, a continuous increase in sexual desire, and sexual molestation behavior that started in 2007. We injected leuprorelin (3.6 mg) intramuscularly every month for this patient with paraphilia and comorbidities of osteoporosis and hyperthyroidism. The clinical global impression (CGI), Sex Addiction Screening Test (SAST), Wilson Sex Fantasy Questionnaire (WSFQ), physical examination, and laboratory tests were performed. After 12 months of leuprorelin injection for paraphilia, we found a significant improvement in abnormal sexual behavior/desire without aggravation of osteoporosis/hyperthyroidism. Gonadotrophin-Releasing Hormone (GnRH) analogs could be used as alternative or supplementary treatment methods for paraphilia with osteoporosis/hyperthyroidism.

The pharmacologic treatment of problematic sexual interests, paraphilic disorders, and sexual preoccupation in adult men who have committed a sexual offence.

This paper provides an international perspective on the use of medications to treat problematic sexual interests, paraphilic disorders, and sexual preoccupation in men who have committed a sexual offence. Experts from Canada, the Czech Republic (CR), Russia, the United Kingdom, and the United States met in Prague, CR in May 2017 to review and compare their treatment approaches. This report is a summary of their discussions, including empirical data from CR and Russia which have not previously been published in the English language. All participants agreed that continuing international collaboration would be very useful for the development of ethical international prescribing guidelines, as well as pooling data from studies on the efficacy and utility of pharmacological and other biological treatments for people who have committed sexual offences.

Pharmacological treatment of patients with paraphilic disorders and risk of sexual offending: An international perspective.

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.

Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts.

Guidelines for pharmacological treatment of patients with paraphilic disorders have been developed by a working group of the World Federation of Societies of Biological Psychiatry (Thibaut et al., 2010 ). With an increasing duration of experience and number of treated patients as well as aging patients, change of or withdrawal from testosterone-lowering medications (TLM) has become an important issue. The current study aimed to assess the quality of a structured professional judgment procedure that helps switching or discontinuing TLM in patients with paraphilic disorders. We used the Delphi method to estimate the quality of 10 factors originally proposed by the authors. A total of 30 experts participated in the first stage; 18 experts participated in the second stage. The experts' assessment resulted in an instrument of 15 factors that can be used to structure the process of changing or discontinuing TLM. These factors can be grouped into five broader categories: age and duration of treatment; therapeutic alliance; psychopathology and risk factors; motivation; and compliance and level of control. The developed COSTLow-R Scale provides an instrument that can be used to structure the process of changing or discontinuing TLM in patients with severe paraphilic disorders.

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

The present study investigates whether leuprolide acetate (Lupron) adds to the efficacy of traditional sex offender treatment. A group of sex offenders receiving both Lupron and cognitive behavioral therapy (CBT; n = 25) were compared with a group of sex offenders receiving only CBT (n = 22). Treated subjects were compared with norms available with reference to the Static-99R, as well as compared with a sample of untreated, nonsexual violent offenders (n = 81), to provide baseline data regarding risk of violent recidivism. Results indicated that subjects receiving Lupron were at significantly higher risk of recidivism and significantly more likely to be diagnosed with a paraphilia than subjects receiving only CBT, a priori. Both treated groups of sexual offenders recidivated at substantially lower rates than predicted by the Static-99R. Currently, this study represents the only, long-term outcome study on Lupron administration using officially recorded recidivism as the primary dependent measure.

[Review of cases of zoophilia in patients with Parkinson's disease]. / Revision de casos de zoofilia en pacientes con enfermedad de Parkinson.

INTRODUCTION: Parkinson's disease (PD) is characterized by motor symptoms such as bradykinesia, rigidity, alteration of postural reflexes and tremor at rest and other non-motor symptoms such as changes in sleep patterns and sexual behavior. However, little is known about paraphilic sexual behaviors. AIM: To summarize the number of cases of zoophilic behaviors in patients with PD between January 2000 and December 2017. DEVELOPMENT: A review was carried out in PubMed, Scopus and Virtual Health Library. Eleven articles were identified by title; six were excluded because they did not present cases related to zoophilic behavior. We found five cases of men, usually with PD of several years of course, taking dopamine agonists and who presented the zoophilic behaviors followed increasing of the dose. The zoophilic behaviors decreased with reducing doses of dopamine agonists and taking atypical antipsychotic such as clozapine or quetiapine. CONCLUSIONS: It is limited the case reports of zoophilic behaviors in patients with PD. The patients reported are men in whom the dose of dopamine agonists was increased. It is important that the clinical follow-up of patients with PD disease includes a careful review of sexual behaviors including those of the paraphilic spectrum.

TITLE: Revision de casos de zoofilia en pacientes con enfermedad de Parkinson.Introduccion. La enfermedad de Parkinson (EP) se caracteriza por sintomas motores, como bradicinesia, rigidez, alteracion de reflejos posturales y temblor en reposo, y otros sintomas no motores, como cambios en el patron de sueño y el comportamiento sexual. Sin embargo, se conoce poco sobre los comportamientos sexuales parafilicos. Objetivo. Resumir el numero de casos de comportamientos zoofilicos en pacientes con EP entre enero de 2000 y diciembre de 2017. Desarrollo. Se realizo una revision en PubMed, Scopus y la Biblioteca Virtual en Salud. Se identificaron por el titulo 11 articulos; se excluyeron seis porque no presentaban casos relacionados con un comportamiento zoofilico. Se encontraron cinco casos de hombres, generalmente con EP de varios años de curso, polimedicados con agonistas dopaminergicos, quienes presentaron los comportamientos parafilicos despues del incremento de la dosis. Los comportamientos zoofilicos cedieron con la reduccion de la dosis de los agonistas dopaminergicos y antipsicoticos atipicos, como clozapina o quetiapina. Conclusiones. Es limitada la notificacion de casos de comportamientos zoofilicos en pacientes con EP. Los pacientes notificados son hombres en quienes se incremento la dosis de agonistas dopaminergicos. Es importante que el seguimiento clinico de los pacientes con EP incluya una revision de los comportamientos sexuales, incluidos los del espectro parafilico.