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

Changing or stopping testosterone-lowering medication in men convicted of sexual offenses: clinical evaluation of the COSTLow-R scale

BACKGROUND

Men convicted of sexual offenses (MCSO) can be treated with testosterone-lowering medications (TLM) in order to support the control of paraphilic sexual fantasies and to decrease the risk of sexual recidivism. However, due to partly severe side effects, TLM should not be a lifelong treatment.

AIM

The Change or Stop Testosterone-Lowering Medication (COSTLow)-R Scale was developed to assist forensic professionals in deciding on whether to change or stop TLM treatment in MCSO. The current study aimed to evaluate the scale in forensic outpatient aftercare practice.

METHODS

The COSTLow-R Scale was applied retrospectively in a forensic-psychiatric outpatient institution in Hesse, Germany, on 72 MCSO. TLM was stopped in 30 patients (41.7%). Moreover, 10 forensic professionals of the institution (23.3%) as well as an experienced working group within the institution focusing on the treatment of MCSO, qualitatively evaluated the COSTLow-R Scale by participating in an open designed survey.

OUTCOMES

The COSTLow-R Scale ratings as assessed by forensic professionals were collected. In addition, a survey was performed among these professionals about the usefulness of the scale and their practical experiences with it.

RESULTS

TLM stopping decisions were significantly associated with three COSTLow-R Scale items: the compliance for monitoring effects and side effects, the possibility of psychotherapy before TLM treatment, and the therapeutic alliance before starting TLM treatment. In sum, the decision towards stopping TLM was more likely for patients whose compliance was considered higher, and for those who had demonstrated a greater treatment readiness as well as therapeutic alliance before starting TLM. The forensic professionals described the scale as a good and structured tool that displays which aspects are important to consider during TLM treatment decisions.

CLINICAL IMPLICATIONS

The COSTLow-R Scale provides structure to the decision whether to change or stop TLM and should thus be implemented in the forensic treatment process of patients with TLM more frequently.

STRENGTHS & LIMITATIONS

Although the small sample size limits generalizability of the findings, the present study was conducted directly in a forensic center and, therefore, has high external validity and a strong impact on the life and health of patients treated with TLM.

CONCLUSION

The results indicate that the COSTLow-R Scale can be a useful instrument facilitating the TLM decision-making process by providing a structured compendium of criteria. Further research is still needed to evaluate the scale and to provide additional evidence for the results of the current study.

Is Stopping of Testosterone-Lowering Medication in Men Convicted of Sexual Offenses Associated With an Increase in Recidivism Risk?

There is some evidence that testosterone-lowering medications (TLM) may be an effective treatment for men convicted of sexual offenses by attenuating paraphilic sexual fantasies and behaviors and reducing the recidivism risk. To date, however, only little is known about the effects of TLM stopping on risk-relevant aspects. Therefore, the current study aimed at examining the recidivism risk as measured by Stable-2007 as well as official records of reoffenses in 29 men having stopped TLM treatment as compared to 37 men with ongoing TLM treatment. The Stable-2007 was rated retrospectively at 4 time points: committal to forensic treatment (T1), starting (T2) and stopping of TLM treatment (T3), and at reporting date (T4). There was a significant decrease in Stable-2007 scores over time, but there were no significant group differences. Within the stopped-TLM group, there were no significant differences between T3 and T4, implying that the recidivism risk remained stable over an average observation period of 4.5 years after TLM stopping. In addition, there was no significant difference in actual reoffending rates between the groups. For sexual reoffending, the percentages were 17.2% for the stopped-TLM group and 10.8% for the ongoing-TLM group. However, although the current results suggest that there is at least no increase in risk assessment (i.e., Stable-2007) after having stopped TLM, the actual reoffending rates of both groups were higher than expected. This once again demonstrates that TLM stopping decisions remain very difficult to make. Further studies are urgently needed to draw clearer conclusions.

The Treatment Needs and Experiences of Pedohebephiles: A Systematic Review

People with a sexual interest in children face significant barriers to seeking and receiving mental health treatment. This review aims to bridge the gap between the treatment needs and experiences of pedohebephiles, and the services aiming to support them. Reviewers screened 1705 database hits and extracted findings from 22 qualitative, 15 quantitative, and 3 mixed-method studies on the treatment needs and experiences of pedohebephiles. Research suggests that this population experiences significant levels of distress, depression, and anxiety related to their sexual interest. Many individuals belonging to this population would seek (median = 42.3%), or have sought (median = 46.5%), treatment to cope with their sexual interest or with potential related mental health repercussions. Their experiences in treatment have been mixed, with some reporting positive experiences with empathic therapists and others reporting rejection. Most frequently, pedohebephiles report fear of exposure and rejection as barriers to seeking treatment, in addition to fear of the legal repercussions. The current study is the first to summarize and discuss previous findings on the treatment needs and experiences of pedohebephiles. The findings indicate that the treatment needs of pedohebephiles often remain unaddressed. Suggestions to increase the fit between treatment services and the needs of pedohebephiles are put forward.

Public Stigmatizing Reactions Toward Nonoffending Pedophilic Individuals Seeking to Relieve Sexual Arousal

People with pedophilia (PWP) can deal with their sexual desires by relieving sexual arousal without sexually exploiting children. Study 1 investigated whether public reactions toward nonoffending pedophilic men are affected by their strategies to relieve sexual arousal (nonsexual pictures vs. child sex dolls) or to reduce their sex drive via testosterone lowering medication in legally nonproblematic ways. A sample of German-speaking participants (N = 143) read three vignettes describing PWP using either of these strategies. Participants' (59.4% females) mean age was 39.7 (SD = 15.6). Although no significant difference was detected between the nonsexual pictures and sex dolls conditions on cognitive (except for dangerousness), affective, and behavioral levels, both consistently elicited more stigmatizing reactions than the testosterone-lowering medication condition. To investigate if this effect was driven by disapproving any relief of sexual arousal or the use of actual child stimuli in particular, Study 2 (N = 151) added two conditions with PWP using adult child-like stimuli to relieve sexual arousal: adult-as-schoolgirl porn and adult partner with childlike appearance. Here, Participants' (57.6% females) mean age was 28.0 (SD = 13.3). Results indicate that stigmatization was driven by disapproving the use of child stimuli rather than the relief of sexual arousal in general. Individuals with a sexual interest in children face strong stigmatizing reactions, which are only alleviated when they are described as undergoing treatment lowering sex drive or - to a lesser extent - being able to mate with an adult partner or using porn with adult actors posing as schoolgirls.

"One a Day Keeps the Prison Away": Understanding the Experiences of Individuals Convicted of Sexual Offences Receiving Anti-Androgens for the Treatment of Problematic Sexual Arousal

Problematic sexual arousal (PSA) is an umbrella term to describe a range of clinical presentations related to excessive sexual thinking (e.g., sexual preoccupation) and sexual behavior (e.g., hypersexuality). Although such concepts are known to affect sexual recidivism among individuals convicted of sexual offences, PSA is not routinely or directly targeted in offending behavior programs in England and Wales. However, in recent years, there have been moves to incorporate pharmacological interventions for addressing this among people with sexual offence histories. Although some work to understand the experiences of those taking SSRI medication for this purpose has emerged, little is known about the experiences of service users taking anti-androgen medication. In this study, we interviewed all individuals in prison taking anti-androgens for the treatment of problematic sexual arousal following convictions for sexual offences in England at the time of data collection (N = 10). Using a phenomenologically oriented thematic analysis, we established themes pertaining to "Differing needs: Motivations for treatment," "Medication as a risk management strategy," and how the medication helped the men in their pursuit of "Discovering a 'new me'." This work contributes important knowledge to inform the development of ethical and effective prescribing of anti-androgen medication with this population and offer recommendations for both future research and the development of clinical practice.

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.

Rare Mental Health Disorders Affecting Urologic Care: A Comprehensive Review

Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.

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.

Media Coverage of Pedophilia and Its Impact on Help-Seeking Persons with Pedophilia in Germany-A Focus Group Study

The public stigma associated with pedophilia, the sexual attraction to prepubescent children, is tremendous. Previous research indicates that undifferentiated media coverage plays an essential role in perpetuating the public stigma by falsely equating pedophilia and child sexual abuse (CSA) and thus may stop persons suffering from a pedophilic disorder from seeking professional help. Until now, a comprehensive examination of positive as well as negative media effects on affected individuals is missing. Therefore, the present study explores if and how media coverage impacts the lives of help-seeking persons with pedophilia by conducting four qualitative focus group discussions with a clinical sample (N = 20) from the German Prevention Network "Kein Täter werden". Present results demonstrate that media coverage of pedophilia was perceived as mostly undifferentiated, even though participants observed an increase in fact-based reporting over the years. Moreover, it seems that media coverage has strong emotional and behavioral consequences for patients (e.g., negative reporting reduced self-esteem). In sum, our results highlight that differentiated media coverage could play a key role in supporting help-seeking persons with pedophilic disorder, while the impact of undifferentiated media coverage appears to be mostly negative. Therefore, our results point to the need to reframe pedophilia using differentiated media coverage to help affected persons receive treatment efficiently and thereby prevent CSA.