Pharmacological Treatments for Paraphilic Patients and Sexual Offenders

Peer Briken; Martin P. Kafka

Disclosures

Curr Opin Psychiatry. 2007;20(6):609-613. 

In This Article

Other Medications for Paraphilias and Sexual Offenders

In contrast to the slowly increasing 'current' psychiatric literature reporting treatment efficacy of testosterone-lowering 'hormonal' agents, novel clinical reports providing an empirically based rationale for and reporting prescriptive use of nonhormonal medications appear to have diminished during the past few years. Theory-based and empirically supported rationales for nonhormonal medical therapies have been proposed that are founded specifically on the ability of these treatments to ameliorate axis I comorbid diagnoses in sexual offenders or enhance serotonergic neurotransmission.[7,8,9,10] Such a theory is based upon the presence of a common putative biological substrate for both a specific axis I disorder and sexual impulsivity (e.g. unipolar and bipolar mood disorders and attention deficit hyperactivity disorder (ADHD), impulsivity associated with Asperger's syndrome). Other nonhormonal medication interventions have been proposed as general treatments for 'impulsivity', for which sexual impulsivity might be one manifestation (e.g. opiate antagonists such as naltrexone).

As is the case for hormonal agents, the prescriptive use of nonhormonal pharmacological agents to treat sexual offenders should almost always be combined with psychotherapy specific to sexual offenders. Despite there being no double-blind placebo-controlled treatments of the efficacy of SRIs for the treatment of sexual offenders, such medications have been reported to be the most commonly prescribed agents for sexual offenders in nonresidential settings (53.6% of programmes treating adult males), at least in the USA.[11]

In fact, current clinical practice in the USA favours the prescription of nonhormonally based treatments, even though the cumulative treatment outcome data are more supportive of hormonal treatments. How, then, can such pharmacological practices be clinically and ethically justified? We answer this important question in two ways. First, as mentioned above, despite their demonstrated better efficacy in terms of outcome and the sound biological rationale that markedly lowering testosterone diminishes sexually motivated behaviours, many sexual offenders refuse hormonally based medical interventions.[12] 'Chemical castration', as the prescriptive use of depo-MPA and cyproterone acetate came to be known, has a socially punitive rather than a therapeutic or ameliorative connotation. Second, the more medically intensive (and therefore much more expensive) hormonally based interventions, the need for intramuscular or subcutaneous injection, and their long-term side effect burden (e.g. liver toxicity, hypertension, weight gain, calcium loss and osteopenia) require the involvement of a dedicated psychiatric clinician, medical/endocrinological back up, and a well informed and highly motivated client. In essence, many psychiatrists and other physicians become 'gun shy' about the medical responsibility associated with the prescription of powerful testosterone-ablating drugs that have not been specifically approved by the US Food and Drug Administration for the treatment of paraphilias or sexual offenders.

Despite the absence of double-blind clinical trials, it is important to review the rationale for the prescriptive use of nonhormonal medications so that both the risks and the benefits can be considered. In addition, given the scarcity of recent literature on treatment with nonhormonal medications, these interventions must still be considered promising treatments but ones whose value in sexual offenders is not yet definitively proven.

Axis I neuropsychiatric disorders are generally associated with prefrontal cortical dysfunction, inasmuch as empathy, impulse control, social judgement and insight are commonly affected in these disorders.[13] If certain specific axis I neuropsychiatric disorders were consistently identified in male sexual offenders and if the treatment of such conditions enhanced frontal and prefrontal cortical function (or mollified limbic over-activation), then such treatments might affect 'moral' judgements and ameliorate antisocial sexual impulsivity.

Recent studies of sexual offenders, men with paraphilias and nonparaphilic expressions of 'hypersexuality' suggest that mood disorders (dysthymic disorder, major depression and bipolar spectrum disorders), certain anxiety disorders (especially social anxiety disorder and childhood-onset post-traumatic stress disorder), psychoactive substance abuse disorders (especially alcohol abuse), ADHD and neuropsychological conditions (e.g. schizophrenia, Asperger's syndrome and head injury) may occur more frequently than expected in sexually impulsive men, including sexual offenders.[14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34] Empirically established effective pharmacological treatments for unipolar and bipolar mood disorders, ADHD and impulsivity are well documented. These conditions affect prefrontal/orbital frontal executive functioning and are associated with impulsivity; therefore, amelioration of such conditions could certainly affect, if not markedly ameliorate, the propensity to be sexually impulsive.

The most comprehensive and contemporary review of the role for SRI antidepressants for sexual offenders[35] highlighted significant methodological flaws in the treatment data available, and it indicated that further investigation of treatment of sexual offenders with ective SRI antidepressants is warranted. Since that review was published, Kraus et al. [36*] reported a retrospective case series on 16 men with different paraphilias (50% paedophilia and 25% sexual sadism) who were treated with different ective SRI agents and psychotherapy. Although retrospective, this study is of interest because the length of follow up was longer than most prior reports (22 months, standard deviation 15.6 months). Masturbation with paraphilic fantasies, impulsivity and paraphilic acting-out as well as depressive symptomatology decreased significantly. Only one patient had a new criminal allegation because of a possible sexual offence. Although 75% of the patients reported that they suffered from any sexual dysfunction during treatment, 63% were satisfied with the medical intervention.

Remarkably, except for some older studies that suggested efficacy of lithium salts in sexual offenders,[37,38] literature supporting the prescriptive use of the 'newer' mood stabilizers such as limbic anticonvulsants and atypical neuroleptics for sexual offenders is lacking. Given the virtual absence of such data, I (MPK) am of the view that such medications do indeed significantly ameliorate sexual offending behaviours that are found to be comorbidly associated specifically with bipolar spectrum disorders and Asperger's syndrome, but clinical outcome treatment data are currently unpublished.

The effective use of psychostimulants to both treat ADHD and enhance SRI responsiveness in men with sexual impulsivity has also been reported,[39] but there are no specific studies on the prescriptive use of psychostimulants alone as a primary pharmacological treatment without other concomitant medications to sexual offenders.

Finally, there have been sporadic case reports of the prescriptive use of naltrexone for adults with 'compulsive sexual behaviour'[40] and adolescent persons with Tourette's syndrome,[41] and a case series with adolescent sexual offenders.[42] In the 21 adolescent offenders studied by Ryback,[42] 150-200 mg/day naltrexone was required to sustain a response in 15 offenders. Concomitant prescription of a broad range of psychotropic drugs targeting axis I comorbidity in this sample had not adequately ameliorated sexual impulsivity symptoms, but they were continued during the naltrexone trial. The presumed mechanisms of action - endogenous opiate receptor blockade, a subsequent increased accumulation of endogenous opioids, or inhibition of dopamine release in the nucleas accumbens - may account for their therapeutic benefit in a broad range of impulse control disorders. As is the case for the other nonhormonal pharmacological treatments for sexual offenders, more rigorous trials, comparison control groups and longer follow-up periods are needed.

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