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Sauter J, Lingenti LM, Rettenberger M, Turner D, Briken P, Voß T. The impact of testosterone-lowering medication on recidivism in individuals convicted of sexual offenses. DIALOGUES IN CLINICAL NEUROSCIENCE 2024; 26:28-37. [PMID: 38837043 PMCID: PMC11155425 DOI: 10.1080/19585969.2024.2359923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Treatment of individuals who have committed sexual offences with Testosterone-Lowering Medication (TLM) is a comparatively intrusive kind of intervention, which regularly takes place in coercive contexts. Thus, the question of efficacy, but also the question of who should be treated, when and for how long, are of great importance. METHODS Recidivism rates of TLM-treated high-risk individuals (+TLM; n = 54) were compared with high-risk individuals treated with psychotherapy only in the same forensic outpatient clinic (-TLM; n = 79). RESULTS Group differences suggested a higher initial risk of + TLM (e.g. higher ris-assessment, previous convictions). Despite the increased risk, after an average time at risk of six years, +TLM recidivated significantly less often and significantly later than - TLM (27.8% vs. 51.9%). Such an effect was also found for violent (1.9% vs. 15.2%), but not for sexual (5.6% vs. 10.1%) and serious recidivism (5.6% vs. 10.1%), which could be explained partly by the small number of cases. In the course of treatment, TLM proved to be a significant variable for a positive process, whereas a high risk-assessment score indicated a rather negative course. In total, n = 19 individuals had stopped their TLM treatment, of these 31.6% recidivated. CONCLUSION The results support the efficacy of TLM, particularly in the group of high-risk offenders.
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Affiliation(s)
- Julia Sauter
- Department of Psychology, University of Kassel, Kassel, Germany
| | - Laura M. Lingenti
- Institute of Health, Institute of Forensic Psychiatry, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
| | - Martin Rettenberger
- Department of Psychology, Johannes Gutenberg-University (JGU), Mainz, Germany
- Centre for Criminology, Kriminologische Zentralstelle (KrimZ), Wiesbaden, Germany
| | - Daniel Turner
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatjana Voß
- Institute of Health, Institute of Forensic Psychiatry, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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Baltodano-Calle MJ, Onton-Díaz M, Gonzales GF. Androgens, brain and androgen deprivation therapy in paraphilic disorders: A narrative review. Andrologia 2022; 54:e14561. [PMID: 35995581 DOI: 10.1111/and.14561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
| | - Melisa Onton-Díaz
- Faculty of Medicine, Cayetano Heredia Peruvian University., Lima, Peru
| | - Gustavo F Gonzales
- Laboratorio de Endocrinología y Reproducción, Laboratorios de Investigación y Desarrollo (LID), Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru.,Departamento de Ciencias Biológicas y Fisiológicas, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru.,Instituto de Investigaciones de la Altura, Universidad Peruana Cayetano Heredia, Lima, Peru
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Sauter J, Rettenberger M, Briken P, Turner D. Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole? J Sex Med 2022; 19:1147-1155. [PMID: 35624071 DOI: 10.1016/j.jsxm.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of individuals who sexually offended, and who are continued to be treated with pharmacological agents to reduce sex drive after their release from prison or forensic psychiatry, are not known. Furthermore, figures on the number of those who stop their sexdrive supressing antiandrogen treatment in the outpatient setting are unknown as well. This is of central importance though as it might be associated with an increased risk of recidivism. AIM To assess prescription patterns as well as adherence to pharmacological treatment in outpatient clinics in Germany for individuals who have sexually offended and were released from prison or forensic psychiatric hospital. METHODS A self-constructed online survey assessing the pharmacological treatment modalities was sent by e-mail to n = 103 forensic outpatient clinics in Germany. Thirty-three (32.0%) completed the questionnaire and reported about 834 patients. OUTCOMES Prevalence of the use of different pharmacological agents in the treatment of individuals convicted for sexual offenses as well as the number of patients who have discontinued testosterone-lowering medication (TLM). RESULTS Among all institutions, 22.4% (n = 187) of individuals received pharmacological treatment, with 40.1% receiving gonadotropin-releasing-hormone-agonists, 26.2% antipsychotics, 24.6% selective serotonin reuptake inhibitors, 6.4% cyproterone acetate, and 2.7% a combination of gonadotropin-releasing-hormone-agonists and cyproterone acetate. A significant positive correlation was found between the number of patients released from a forensic-psychiatric hospital and the number of patients treated with TLM. Within 1 year 8.6% (n = 16) stopped their TLM during or at the end of the supervision period, most of them against treatment providers advice. CLINICAL IMPLICATIONS Substantial regional differences indicate uncertainties regarding the prescription of pharmacological agents for outpatients who have committed sexual offences in Germany. The discontinuiation of TLM within the first year of treatment against treatment providers advise in a substantial proportion of patients could be associated with a serious risk for reoffending. STRENGTHS & LIMITATIONS The present survey captures prevalences of the pharmacotherapy in forensic aftercare facilities for individuals who have offended sexually, and is the first to record the number of discontinuations. This is a cross-sectional survey covering only 1 country, but includes a large number of individuals. CONCLUSION Even though the number of treated individuals has increased in prisons, the majority of pharmacological treatment is still provided by forensic hospitals, which then translates into the outpatient setting. The number of those who stop taking such medication is a highly relevant topic for both forensic treatment providers and legal decision makers Sauter J, Rettenberger M, Briken P, et al. Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole?. J Sex Med 2022;19:1147-1155.
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Affiliation(s)
- Julia Sauter
- Department of Psychology, University of Kassel, Kassel, Germany; Department of Psychology, Johannes Gutenberg-University (JGU), Mainz, Germany.
| | - Martin Rettenberger
- Department of Psychology, Johannes Gutenberg-University (JGU), Mainz, Germany; Centre for Criminology (Kriminologische Zentralstelle - KrimZ), Wiesbaden, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Turner
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
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Sauter J, Turner D, Briken P, Rettenberger M. Testosterone-Lowering Medication and Its Association With Recidivism Risk in Individuals Convicted of Sexual Offenses. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2021; 33:475-500. [PMID: 32167420 PMCID: PMC8072038 DOI: 10.1177/1079063220910723] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
For a particular subgroup of individuals with severe paraphilic disorders and a high risk of sexual recidivism, the combination of sex drive-reducing medications and psychotherapy is a promising treatment approach. The present quasi-experimental study aims at comparing differences in clinical characteristics and dynamic risk factors between persons receiving (+TLM, n = 38) versus not receiving (-TLM, n = 22) testosterone-lowering medications (TLMs). Individuals receiving TLM were more frequently diagnosed with paraphilic disorders. Neither the criminal history nor average risk scores differed between the two groups. In the +TLM, Stable-2007 scores showed a stronger decrease after TLM treatment was started. This accounted especially for the general and sexual self-regulation subscales. Individual variations in risk, however, were not predicted by TLM but were significantly related to treatment duration and Psychopathy Checklist-Revised (PCL-R) Factor I. Paraphilic patients with problems in self-regulatory abilities seem to profit most from pharmacological sex drive-reducing treatment. Furthermore, therapists seem to underestimate deviant sexual fantasies in medicated patients.
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Affiliation(s)
- Julia Sauter
- Charité–Universitätsmedizin Berlin, Germany
- Johannes Gutenberg-University Mainz, Germany
| | - Daniel Turner
- University Medical Center Mainz, Germany
- University Medical Center Hamburg-Eppendorf, Germany
| | - Peer Briken
- University Medical Center Hamburg-Eppendorf, Germany
| | - Martin Rettenberger
- Johannes Gutenberg-University Mainz, Germany
- Kriminologische Zentralstelle, Wiesbaden, Germany
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Landgren V, Malki K, Bottai M, Arver S, Rahm C. Effect of Gonadotropin-Releasing Hormone Antagonist on Risk of Committing Child Sexual Abuse in Men With Pedophilic Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2020; 77:897-905. [PMID: 32347899 PMCID: PMC7191435 DOI: 10.1001/jamapsychiatry.2020.0440] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Evidence-based treatments from randomized clinical trials for pedophilic disorder are lacking. OBJECTIVE To determine whether a gonadotropin-releasing hormone antagonist reduces dynamic risk factors for committing child sexual abuse. DESIGN, SETTING, AND PARTICIPANTS This academically initiated, double-blind, placebo-controlled, parallel-group, phase 2 randomized clinical trial was conducted at the ANOVA center in Stockholm, Sweden, from March 1, 2016, to April 30, 2019. Individuals who contacted PrevenTell, the national telephone helpline for unwanted sexuality, were recruited. Eligible participants were men seeking help aged 18 to 66 years with a pedophilic disorder diagnosis and no contraindications to the intervention. The primary end point was assessed by intent-to-treat analysis. INTERVENTIONS Randomization to receive either 2 subcutaneous injections of 120 mg of degarelix acetate or equal volume of placebo. MAIN OUTCOMES AND MEASURES The primary end point was the mean change between baseline and 2 weeks in the composite risk score of 5 domains of child sexual abuse ranging from 0 to 15 points; each domain could be rated from 0 to 3 points. Secondary end points included efficacy at 2 and 10 weeks as measured by the composite score, each risk domain, quality of life, self-reported effects, and adverse events. RESULTS A total of 52 male participants (mean [SD] age, 36 [12] years) were randomized to receive either degarelix (n = 25; with 1 withdrawal) or placebo (n = 26). At 2 weeks, the composite risk score decreased from 7.4 to 4.4 for participants in the degarelix group and from 7.8 to 6.6 for the placebo group, a mean between-group difference of -1.8 (95% CI, -3.2 to -0.5; P = .01). A decrease was seen in the composite score at 10 weeks (-2.2 [95% CI, -3.6 to -0.7]) as well as in the domains of pedophilic disorder (2 weeks: -0.7 [95% CI, -1.4 to 0.0]; 10 weeks: -1.1 [95% CI, -1.8 to -0.4]) and sexual preoccupation (2 weeks: -0.7 [95% CI, -1.2 to -0.3]; 10 weeks: -0.8 [95% CI, -1.3 to -0.3]) in the degarelix group compared with the placebo group. No difference was seen for the domains of self-rated risk (2 weeks: -0.4 [95% CI, -0.9 to 0.1]; 10 weeks: -0.5 [95% CI, -1 to 0.0]), low empathy (2 weeks: 0.2 [95% CI, -0.3 to 0.6]; 10 weeks: 0.2 [95% CI, -0.2 to 0.6]), and impaired self-regulation (2 weeks: -0.0 [95% CI, -0.7 to 0.6]; 10 weeks: 0.1 [95% CI, -0.5 to 0.8]), or quality of life (EuroQol 5 Dimensions questionnaire index score, 2 weeks: 0.06 [95% CI, -0.00 to 0.12], and 10 weeks: 0.04; 95% CI, -0.02 to 0.10; EuroQol visual analog scale, 2 weeks: 0.6 [95% CI, -9.7 to 10.9], and 10 weeks: 4.2 [95% CI, -6.0 to 14.4]). Two hospitalizations occurred from increased suicidal ideation, and more injection site reactions (degarelix: 22 of 25 [88%]; placebo: 1 of 26 [4%]) and hepatobiliary enzyme level elevations were reported by participants who received degarelix (degarelix: 11 of 25 [44%]; placebo: 2 of 26 [8%]). Among the 26 participants randomized to receive degarelix, 20 (77%) experienced positive effects (eg, improved attitude or behavior) on sexuality and 23 (89%) reported adverse effects on the body. CONCLUSION AND RELEVANCE This trial found that degarelix reduced the risk score for committing child sexual abuse in men with pedophilic disorder 2 weeks after initial injection, suggesting use of the drug as a rapid-onset treatment option. Further studies are warranted into the effects and long-term adverse effects of hormone deficiency. TRIAL REGISTRATION EU Clinical Trials Register Identifier: 2014-000647-32.
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Affiliation(s)
- Valdemar Landgren
- Institute of Neuroscience and Physiology, Gothenburg University, Gothenburg, Sweden
| | - Kinda Malki
- Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Arver
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Christoffer Rahm
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Affiliation(s)
- Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Centre, Hamburg, Germany
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Stoléru S, Moulier V, Fonteille V. Development and Preliminary Validation of the Pedophilic Fantasies, Desires, and Activities Questionnaire. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2020; 64:1134-1155. [PMID: 31658841 DOI: 10.1177/0306624x19883758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Although sexual interest in children is a risk factor for recidivism of sexual offenses against children, there is a dearth of measures for assessing its current level in patients with pedophilic disorder. The objective was to develop the Pedophilic Fantasies, Desires, and Activities Questionnaire (PFDAQ) to assess the current level of sexual interest in patients with pedophilic disorder. In total, 57 patients with pedophilic disorder and 53 controls were recruited. In addition to the PFDAQ, participants were presented with other measures of sexual interest. PFDAQ scores were significantly higher in patients than in controls and were correlated with other measures of sexual interest. Three PFDAQ scores were correlated with a phallometric index of preference for children. These results suggest that the PFDAQ may be valid and potentially useful for assessing the current level of pedophilic attraction.
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Affiliation(s)
- Serge Stoléru
- Inserm U1178, Hôpital Paul Brousse, Villejuif, France
| | - Virginie Moulier
- EPS Ville Evrard, Neuilly-sur-Marne, France
- Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
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Krueger RB. Commentary on guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry 2020; 21:409-411. [PMID: 33019868 DOI: 10.1080/15622975.2020.1823686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Richard B Krueger
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,New York Presbyterian Hospital and New York State Psychiatric Institute, New York, NY, USA.,Sexual Behavior Clinic, NYSPI, New York, NY, USA
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Thibaut F, Cosyns P, Fedoroff JP, Briken P, Goethals K, Bradford JMW. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry 2020; 21:412-490. [PMID: 32452729 DOI: 10.1080/15622975.2020.1744723] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Florence Thibaut
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin, University of Paris, INSERM U1266, Institute of Psychiatry and Neurosciences, Paris, France
| | - Paul Cosyns
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium
| | - John Paul Fedoroff
- Division of Forensic Psychiatry, The Royal Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kris Goethals
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp and University Forensic Centre, Antwerp University Hospital, Antwerp, Belgium
| | - John M W Bradford
- The Royal Institute of Mental Health Research, University of Ottawa, McMaster University, Ottawa & Hamilton, ON, Canada
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Gallo A, Abracen J, Looman J, Jeglic E, Dickey R. The Use of Leuprolide Acetate in the Management of High-Risk Sex Offenders. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2019; 31:930-951. [PMID: 30047834 DOI: 10.1177/1079063218791176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
| | | | - Jan Looman
- Providence Care, Kingston, Ontario, Canada
| | | | - Robert Dickey
- Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
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A Case of Paraphilia with Osteoporosis and Administered with Depot Leuprorelin. ACTA ACUST UNITED AC 2019; 55:medicina55100705. [PMID: 31635190 PMCID: PMC6843497 DOI: 10.3390/medicina55100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/07/2019] [Accepted: 10/17/2019] [Indexed: 11/17/2022]
Abstract
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.
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Turner D, Briken P. Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review. J Sex Med 2019; 15:77-93. [PMID: 29289377 DOI: 10.1016/j.jsxm.2017.11.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/28/2017] [Accepted: 11/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Different pharmacologic agents are used in the treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending, with luteinizing hormone-releasing hormone (LHRH) agonists being the agents introduced more recently to treatment regimens. AIM To summarize the relevant literature concerning LHRH agonist treatment of paraphilic disorders in sexual offenders and update the previously published systematic review by Briken et al (J Clin Psychiatry 2003;64:890-897). METHODS The PubMed and Google Scholar databases were searched for literature published from January 2003 through October 2017 using the following key words: LHRH agonists, GnRH agonists, antiandrogens AND paraphilia, pedophilia, sex offenders. OUTCOMES Evaluation of the effectiveness and side effects of LHRH agonist treatment of paraphilic disorders in sexual offenders. RESULTS After screening for duplicates and applying specific selection criteria, the search yielded 24 eligible studies reporting on a sample of 256 patients. There is increasing evidence that LHRH agonists are more effective than steroidal antiandrogens in lowering paraphilic sexual thoughts and behaviors. Current research also is based on methods that might be less susceptible to faking (eg, eye-tracking, brain imaging, and viewing-time measures). Side effects occurring most frequently are fatigue, hot flashes, depressive mood, weight gain, high blood pressure, diabetes, gynecomastia, loss of erectile function, and loss of bone mineral density. CLINICAL IMPLICATIONS Although LHRH agonists seem to be the most effective drugs in the treatment of paraphilic fantasies and behaviors, they should be reserved for patients with a paraphilic disorder and the highest risk of sexual offending because of their extensive side effects. STRENGTHS AND LIMITATIONS This systematic review considers all types of research on LHRH agonist treatment in patients with paraphilic disorders, thereby providing a complete overview of the current state of research. However, most studies are case reports or observational studies and randomized controlled clinical trials have not been conducted or published. CONCLUSIONS LHRH agonists are a useful treatment when combined with psychotherapy in patients with a paraphilic disorder and the highest risk of sexual offending. However, throughout treatment, close monitoring of side effects is needed and ethical concerns must always be kept in mind. Turner D, Briken P. Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review. J Sex Med 2018;15:77-93.
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Affiliation(s)
- Daniel Turner
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Fonteille V, Redouté J, Lamothe P, Straub D, Lavenne F, Le Bars D, Raverot V, Moulier V, Marchand JJ, Vittoz A, Leriche C, Pugeat M, Stoléru S. Brain processing of pictures of children in men with pedophilic disorder: A positron emission tomography study. NEUROIMAGE-CLINICAL 2019; 21:101647. [PMID: 30612938 PMCID: PMC6412007 DOI: 10.1016/j.nicl.2018.101647] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 12/11/2018] [Accepted: 12/21/2018] [Indexed: 12/14/2022]
Abstract
Although structural and functional neuroimaging techniques have recently been used to investigate the mechanisms of sexual attraction to children, a hallmark of pedophilic disorder, the differences in the processing of child sexual stimuli between men attracted to children and those attracted to adults remain unclear. Here, our purpose was to identify through positron emission tomography the brain responses of 15 male outpatients with pedophilic disorder to validated visual sexual stimuli depicting children (VSSc) and to compare them with 15 male healthy controls matched for sexual orientation (to female or male adults), age, and handedness. The patients' sample comprised both offenders and non-offenders. In response to VSSc, the between-groups analysis showed that activation in the right inferior temporal cortex [Brodmann area (BA) 20] was lower in patients than in controls. Moreover, in patients but not in controls, the presentation of VSSc induced an activation in a more caudal region of the right inferior temporal gyrus (BA 37) and in the left middle occipital gyrus (BA 19). In addition, in patients the level of activation in the caudal right inferior temporal gyrus was positively correlated with ratings of sexual arousal elicited by VSSc, whereas this correlation was negative in BA 20. These results implicate the right inferior temporal gyrus as a possible candidate area mediating sexual arousal in patients with pedophilic disorder and suggest that two of its areas play opposite, i.e., activating and inhibitory, roles. Images of children activate the pedophilic patients' right Brodmann area (BA) 37. Images of children (IC) activate the pedophilic patients' left BA 19. Right BA37 activation correlates with pedophilic patients' rating of sexual arousal. IC induce lower right BA 20 activation in pedophilic patients than in controls.
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Affiliation(s)
- Véronique Fonteille
- Hospices Civils de Lyon, Groupement Hospitalier Est, Fédération d'Endocrinologie, 59 Boulevard Pinel, Bron F-69500, France
| | - Jérôme Redouté
- CERMEP-Imagerie du Vivant, 59 Boulevard Pinel, 69677, France
| | - Pierre Lamothe
- Service Médico-Psychologique Régional, Centre Hospitalier Le Vinatier, BP 30039, 95 bd Pinel, Bron Cedex 69678, France
| | - Dominique Straub
- CRIAVS Rhône-Alpes - Délégation de St Étienne, Hôpital Bellevue, Pavillon 5 bis, Bvd Pasteur, Saint-Étienne 42055, France
| | - Frank Lavenne
- CERMEP-Imagerie du Vivant, 59 Boulevard Pinel, 69677, France
| | - Didier Le Bars
- CERMEP-Imagerie du Vivant, 59 Boulevard Pinel, 69677, France
| | - Véronique Raverot
- Centre de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, 59 Boulevard Pinel, Bron, 69677, France
| | - Virginie Moulier
- Unité de Recherche Clinique, EPS Ville Evrard, 202 avenue Jean Jaurès, Neuilly-sur-Marne 93330, France
| | - Jean-Jacques Marchand
- Hospices Civils de Lyon, Groupement Hospitalier Est, Fédération d'Endocrinologie, 59 Boulevard Pinel, Bron F-69500, France
| | - Aurélie Vittoz
- Service Médico-Psychologique Régional, Centre Hospitalier Le Vinatier, BP 30039, 95 bd Pinel, Bron Cedex 69678, France
| | - Charlotte Leriche
- Service Médico-Psychologique Régional, Centre Hospitalier Le Vinatier, BP 30039, 95 bd Pinel, Bron Cedex 69678, France
| | - Michel Pugeat
- Hospices Civils de Lyon, Groupement Hospitalier Est, Fédération d'Endocrinologie, 59 Boulevard Pinel, Bron F-69500, France
| | - Serge Stoléru
- Hospices Civils de Lyon, Groupement Hospitalier Est, Fédération d'Endocrinologie, 59 Boulevard Pinel, Bron F-69500, France; CESP, Fac. de médecine - Univ. Paris-Sud, Fac. de médecine - UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, Porte 45, 16 avenue Paul Vaillant-Couturier, Villejuif Cedex 94807, France; Corresponding author at: Inserm U1178, Hôpital Paul Brousse, Porte 45, 16 avenue Paul Vaillant-Couturier, Villejuif Cedex 94807, France..
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Briken P, Turner D, Thibaut F, Bradford J, Cosyns P, Tozdan S. Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts. JOURNAL OF SEX & MARITAL THERAPY 2018; 45:148-158. [PMID: 30040595 DOI: 10.1080/0092623x.2018.1491910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Peer Briken
- a Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Daniel Turner
- a Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
- b Department of Psychiatry , University Medical Center Mainz , Mainz , Germany
| | - Florence Thibaut
- c Centre of Psychiatry and Neurosciences, Faculty of Medicine Paris Descartes, University Hospital Cochin (site Tarnier) , Paris , France
| | - John Bradford
- d Institute of Mental Health Research , Ottawa , Canada
| | - Paul Cosyns
- e Collaborative Antwerp Psychiatric Research Institute, University Forensic Centre , Antwerp , Belgium
| | - Safiye Tozdan
- a Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Choi JH, Lee JW, Lee JK, Jang S, Yoo M, Lee DB, Hong JW, Noh IS, Lim MH. Therapeutic Effects of Leuprorelin (Leuprolide Acetate) in Sexual Offenders with Paraphilia. J Korean Med Sci 2018; 33:e231. [PMID: 30190656 PMCID: PMC6125314 DOI: 10.3346/jkms.2018.33.e231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/14/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study examined the clinical effects of leuprolide acetate in sexual offenders with paraphilic disorders evaluated by means of objective psychiatric assessment. METHODS The subjects of this study were seven sexual offenders who were being treated by means of an injection for sexual impulse control by a court order. They had been diagnosed with paraphilia by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and had been put on probation by the Ministry of Justice between January 2016 and December 2016. RESULTS After twelve months, we observed significant improvement in symptoms, as decrease of abnormal sexual interest and activity, sexual fantasy, Clinical Global Impression-Severity (CGI-S), and Clinical Global Impression-Impulsivity (GCI-I). There were a mild feminization of the body shape, feelings of fatigue, and mild hot flushes. No other adverse effect was reported. CONCLUSION These results suggested that the clinical effects of leuprolide acetate in sexual offenders might be an effective treatment and safety strategy.
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Affiliation(s)
- Jong Hyuk Choi
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Jae Woo Lee
- Department of Psychiatry, National Forensic Hospital, Bugok, Korea
| | - Jang Kyu Lee
- Sex Offenders and Treatment Center, National Forensic Hospital, Gongju, Korea
| | - Soyeong Jang
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Mi Yoo
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Dae-bo Lee
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Jeong-Won Hong
- National Institution of Probation and Parole Office, Chuncheon, Korea
| | - Il Suk Noh
- National Institution of Probation and Parole Office, Cheonan, Korea
| | - Myung Ho Lim
- Department of Psychology and Psychotherapy, College of Health Science, Dankook University, Cheonan, Korea
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Zohny H, Douglas T, Savulescu J. Biomarkers for the Rich and Dangerous: Why We Ought to Extend Bioprediction and Bioprevention to White-Collar Crime. CRIMINAL LAW AND PHILOSOPHY 2018; 13:479-497. [PMID: 31404215 PMCID: PMC6661018 DOI: 10.1007/s11572-018-9477-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
There is a burgeoning scientific and ethical literature on the use of biomarkers-such as genes or brain scan results-and biological interventions to predict and prevent crime. This literature on biopredicting and biopreventing crime focuses almost exclusively on crimes that are physical, violent, and/or sexual in nature-often called blue-collar crimes-while giving little attention to less conventional crimes such as economic and environmental offences, also known as white-collar crimes. We argue here that this skewed focus is unjustified: white-collar crime is likely far costlier than blue-collar crime in money, health, and lives lost. Moreover, attempts to biopredict and bioprevent blue-collar crime may entail adopting potentially unfair measures that target individuals who are already socio-economically disadvantaged, thus compounding pre-existing unfairness. We argue, therefore, that we ought to extend the study of bioprediction and bioprevention to white-collar crime as a means of more efficiently and fairly responding to crime. We suggest that identifying biomarkers for certain psychopathic traits, which appear to be over-represented among senior positions in corporate and perhaps political organisations, is one avenue through which this research can be broadened to include white-collar crime.
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Affiliation(s)
- Hazem Zohny
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, 16–17 St Ebbes St., Oxford, OX11PT UK
| | - Thomas Douglas
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, 16–17 St Ebbes St., Oxford, OX11PT UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, 16–17 St Ebbes St., Oxford, OX11PT UK
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Wong JS, Gravel J. Do Sex Offenders Have Higher Levels of Testosterone? Results From a Meta-Analysis. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2018; 30:147-168. [PMID: 27000267 DOI: 10.1177/1079063216637857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The purpose of the current study is to review the available scientific evidence on the relationship between testosterone and sexual aggression. A systematic search for all primary studies comparing basal testosterone levels in sex offenders and non-sex offenders was undertaken across 20 electronic databases using an explicit search strategy and inclusion/exclusion criteria. A total of seven studies were identified and 11 effect sizes were computed; effects were pooled using both fixed and random effects meta-analysis models. Although individual study findings present a mix of results wherein sex offenders have higher or lower baseline levels of testosterone than non-sex offenders, pooled results indicate no overall difference between groups. Moderators of the analyses suggest possibly lower rates of testosterone in child molesters than controls; however, results are dependent on study weighting. Limitations, policy implications with respect to chemical castration laws, and future directions for research are discussed.
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Abstract
Sexually disinhibited behaviours are quite common (prevalence 2–17%) in people with dementia, occurring with about equal frequency in men and women. Assessment of the behaviours, the contexts in which they arise and their risks is essential. It is important to manage the environment and to educate and discuss the issues with carers and families. Behavioural measures are helpful, although no specific behavioural intervention has been shown to be effective in this area. Several classes of drug may help to control the behaviours, but all are potentially harmful and none is licensed for hypersexuality in this population.
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Gordon H, Grubin D. Psychiatric aspects of the assessment and treatment of sex offenders. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.10.1.73] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Training in general and forensic psychiatry in the assessment and treatment of sex offenders is in need of considerable improvement. Although most sex offenders are not mentally ill, many are subject to substance misuse, abnormal personality traits, personality disorder, learning disability or dysphoric mood, and in some organic factors will be involved. Comprehensive assessment of sex offenders includes a full history and mental state evaluation, obtaining a collateral history from other sources, observation, psychometric testing, and psychophysiological methods of assessment, including penile plethysmography. Trials of the use of the polygraph are also under way. The treatment of sex offenders, especially those with paraphilias, may include medication with selective serotonin reuptake inhibitors or anti-libidinal agents. Ethical considerations can be problematic, but a balance can often be found between the welfare of the offender and the safety of the public.
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Rix K. Pharmacological interventions for sex offenders: A poor evidence base to guide practice. BJPSYCH ADVANCES 2017. [DOI: 10.1192/apt.bp.116.016923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryAlthough a significant proportion of prisoners and patients in secure hospitals are sex offenders and victim surveys reveal a high level of hidden sexual victimisation, the authors of this Cochrane review found only very limited support for pharmacological intervention with sex offenders. Given the nature and extent of the problem of sexual offending and the promise shown by new drugs, there is a need for clinical scientists, lawyers and ethicists to rise to the challenge of ascertaining the effectiveness and safety of drugs which are being used to treat sex offenders, some involuntarily, without the evidence base to justify confidence as to their effectiveness and safety.
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Lewis A, Grubin D, Ross CC, Das M. Gonadotrophin-releasing hormone agonist treatment for sexual offenders: A systematic review. J Psychopharmacol 2017; 31:1281-1293. [PMID: 28661259 DOI: 10.1177/0269881117714048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sexual offending is a significant international issue causing long-term consequences for victims, perpetrators and society. AIMS The purpose of this study was to review the existing research data assessing the efficacy of gonadotrophin-releasing hormone agonists for treating adult, male, sexual offenders. METHOD The method of this review involved the examination of studies involving participants prescribed at least one month of a gonadotrophin-releasing hormone agonist for the purposes of reducing sexual drive related to offending. The primary outcome measures were recidivism rates and sexual functioning. Secondary outcome measures included assessment of side effects and effects on interpersonal/psychiatric functioning. Studies in the English language that were dated 1969-2015 were included. RESULTS Twelve eligible studies (323 participants) were identified. A reduction in a variety of measures of sexual functioning and/or risk was found in all studies. Robust recidivism data was limited. Medication was rarely described as ineffectual. All studies reported side effects. Reduction in bone density and potential long-term reduction in fertility in some subjects were issues of concern. CONCLUSION Whilst identified studies showed promising results with respect to sexual functioning, challenges in performing randomised control trials in this subject group meant that included studies were methodologically limited. This review recommends that future research must be performed before the effectiveness and tolerability of gonadotrophin-releasing hormone agonists in this population can be confirmed.
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Affiliation(s)
| | - Don Grubin
- 2 Newcastle University, Newcastle upon Tyne, UK
| | | | - Mrigendra Das
- 3 Broadmoor Hospital, Crowthorne, UK.,4 Top End Mental Health Service, Darwin, Australia
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Abstract
Although the cognitively impaired are frequently included in heterogeneous studies of problematic sexual behavior, the epidemiology, etiology, and approach to assessment and treatment of persons with dementia and intellectual disability are distinct from those of the general population. The incidence of inappropriate sexual behavior among the intellectually disabled is 15-33%; however, the nature tends to be more socially inappropriate than with violative intent. Limited sociosexual education is a large contributor, and better addressing this area offers a target for prevention and treatment. A thorough clinical assessment of problematic sexual behaviors in the cognitively impaired requires understanding the patient's internal experience, which can be challenging. Assessment tools validated for the general population have not been validated for this population. Very few studies have assessed treatment approaches specifically among the cognitively impaired; however, research does suggest utility in habilitative, psychotherapeutic, and pharmacologic approaches which have been validated among the general population.
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Affiliation(s)
- Robyn P Thom
- Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Harvard Medical School, Beth Israel Deaconess Medical Center Rabb-2, Psychiatry 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Albert J Grudzinskas
- University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Fabian M Saleh
- Beth Israel Deaconess Medical Center, Harvard Medical School, Beth Israel Deaconess Medical Center Rabb-2, Psychiatry 330 Brookline Ave, Boston, MA, 02215, USA
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Briken P, Müller JL, Berner W, Bödeker RH, Vollmann J, Kasperk C, Koller M. Vom Scheitern einer Studie in Maßregelvollzugskrankenhäusern. DER NERVENARZT 2017; 88:480-485. [DOI: 10.1007/s00115-017-0301-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Khan O, Mashru A. The efficacy, safety and ethics of the use of testosterone-suppressing agents in the management of sex offending. Curr Opin Endocrinol Diabetes Obes 2016; 23:271-8. [PMID: 27032060 DOI: 10.1097/med.0000000000000257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The use of endocrine medications to reduce sexual offending recidivism is established and may involve clinicians from diverse specialities. The present review aims to outline relevant background information and note a Medical Ethics framework upon which to facilitate decision-making. RECENT FINDINGS There have been several systematic reviews in recent years. A number of problems with research in the area of the medical treatment of sex offenders have been highlighted. There remains scope for improvement in the research to answer a number of relevant clinical issues. Nonetheless, some very useful indicators of relevance to clinical practice have emerged. SUMMARY The use of medication to manage the risk of sex offending in males is appropriate under the right circumstances. These include, for example, hypersexuality with sexual deviance and psychological-treatment interfering sexual preoccupation.
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Affiliation(s)
- Omer Khan
- aChadwick Lodge, Milton Keynes bThe Wells Road Center, Nottingham, UK
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Khan O, Ferriter M, Huband N, Powney MJ, Dennis JA, Duggan C. Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Syst Rev 2015; 2015:CD007989. [PMID: 25692326 PMCID: PMC6544815 DOI: 10.1002/14651858.cd007989.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Omer Khan
- The Priory GroupChadwick Lodge, Chadwick DriveEaglestoneMilton KeynesBuckinghamshireUKMK6 5LS
| | - Michael Ferriter
- Nottinghamshire Healthcare NHS TrustForensic DivisionThe Clair Chilvers CentreRampton HospitalWoodbeckNottinghamshireUKDN22 0PD
| | - Nick Huband
- University of NottinghamInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
| | - Melanie J Powney
- The University of ManchesterDepartment of Clinical Psychology2nd Floor, Zochonis BuildingBrunswick StreetManchesterUKM13 9PL
| | - Jane A Dennis
- Queen's University Belfastc/o Cochrane Developmental, Psychosocial and Learning Problems GroupICCR6 College ParkBelfastUK
| | - Conor Duggan
- University of NottinghamInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
- Partnerships in Care2 Imperial PlaceMaxwell RoadBorehamwoodHertfordshireUKWD6 1JN
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Mohnke S, Müller S, Amelung T, Krüger TH, Ponseti J, Schiffer B, Walter M, Beier KM, Walter H. Brain alterations in paedophilia: A critical review. Prog Neurobiol 2014; 122:1-23. [DOI: 10.1016/j.pneurobio.2014.07.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 07/25/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
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Park WS, Kim KM, Jung YW, Lim MH. A case of mental retardation with paraphilia treated with depot leuprorelin. J Korean Med Sci 2014; 29:1320-4. [PMID: 25246754 PMCID: PMC4168189 DOI: 10.3346/jkms.2014.29.9.1320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 02/10/2014] [Indexed: 11/20/2022] Open
Abstract
Paraphilia is a psychiatric disease that has been difficult to cure. However, recently developed therapeutic methods hold promise. The patient was a 20-yr-old male with chief complaints of continuous masturbation, genital exposure, and aggressive behavior that started 2 yr ago. We administered leuprorelin 3.6 mg intramuscular injection per month, a depot gonadotrophin-releasing hormone analogue, to this patient who a severe mentally retardation with paraphilia. The clinical global impression (CGI)-severity, CGI-improvement and aberrant behavior checklist were performed. After one month, we observed significant improvement in symptoms, such as decreases of abnormal sexual behavior and sexual desire. The GnRH analogues are suggested to be used as an alternative or supplementary therapeutic method for sexual offenders after clinical studies.
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Affiliation(s)
- Woo Sung Park
- Department of Pediatrics, College of Medicine, Dankook University, Cheonan, Korea
| | - Kyung Min Kim
- Department of Psychiatry, College of Medicine, Dankook University, Cheonan, Korea
| | - Yong Woo Jung
- Department of Pharmacy, College of Pharmacy, Korea University, Sejong, Korea
| | - Myung Ho Lim
- Department of Psychology, College of Social Science, Dankook University, Cheonan, Korea
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Turner D, Basdekis-Jozsa R, Dekker A, Briken P. Which factors influence the appropriateness of testosterone-lowering medications for sex offenders? A survey among clinicians from German forensic-psychiatric institutions. World J Biol Psychiatry 2014; 15:472-8. [PMID: 24219802 DOI: 10.3109/15622975.2013.839052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Although testosterone-lowering medications (TLM) are a frequently used addition to psychotherapy in sex offender treatment, discord still seems to exist amongst clinicians as to in which cases administering TLM is justified. The depo-Provera scale (DPS), which was published by Maletzky and Field (Aggress Violent Behav 2003;8:391), assesses the appropriateness of TLM administration in sex offender treatment. METHODS The DPS was sent to all forensic psychiatric institutions in Germany. The clinical directors of these institutions were asked to rate the importance of each item of the DPS on a six-point Likert scale. RESULTS Twenty-nine clinicians participated. The most important reason selected for the prescription of TLM for sex offender treatment was a "history of sexual offender treatment failure". The least important item was "deviant sexual interest, by plethysmograph or Abel Screen" (neither plethysmograph nor Abel Screen is used in Germany). CONCLUSIONS Clinicians' attitudes towards the DPS correspond to the suggestions made in the current WSFBF-guidelines for the pharmacological treatment of sex offenders (Thibaut et al. 2010 ; World J Biol Psychiatry 11:604-655). Use of the DPS could therefore contribute to a more structured approach towards helping clinicians come to a decision about whether or not to treat a sex offender with TLM.
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Affiliation(s)
- Daniel Turner
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Assumpção AA, Garcia FD, Garcia HD, Bradford JMW, Thibaut F. Pharmacologic treatment of paraphilias. Psychiatr Clin North Am 2014; 37:173-81. [PMID: 24877704 DOI: 10.1016/j.psc.2014.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The treatment of paraphilias remains a challenge in the mental health field. Combined pharmacologic and psychotherapeutic treatment is associated with better efficacy. The gold standard treatment of severe paraphilias in adult males is antiandrogen treatment with cognitive behavioral therapy. Selective serotonin reuptake inhibitors have been used in mild types of paraphilia and in cases of sexual compulsions and juvenile paraphilias. Antiandrogen treatments seem to be effective in severe paraphilic subjects committing sexual offenses. In particular, gonadotropin-releasing hormone analogs have shown high efficacy working in a similar way to physical castration but being reversible at any time. Treatment recommendations, side effects, and contraindications are discussed.
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Affiliation(s)
- Alessandra Almeida Assumpção
- Department of Psychiatry, INCT-Medicina Molecular, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190 Sala 240, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Frederico Duarte Garcia
- Department of Psychiatry, INCT-Medicina Molecular, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190 Sala 240, Belo Horizonte, Minas Gerais, 30130-100, Brazil; INSERM U1073, Rouen University Hospital, Rouen University, 22 Boulevard Gambetta, Rouen Cx 76183, France.
| | - Heloise Delavenne Garcia
- Department of Psychiatry, INCT-Medicina Molecular, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190 Sala 240, Belo Horizonte, Minas Gerais, 30130-100, Brazil; INSERM U1073, Rouen University Hospital, Rouen University, 22 Boulevard Gambetta, Rouen Cx 76183, France
| | - John M W Bradford
- Institute of Mental Health Research, Brockville Mental Health Centre, University of Ottawa, 1804 Highway 2 East, Brockville, Ontario K6V 5W7, Canada
| | - Florence Thibaut
- Psychiatry and Addictive Disorders, University Hospital Cochin-Tarnier, 89 rue d'Assas, 75006 Paris, France; Department of Psychiatry and Addictive Disorders, Faculté de Médecine Paris V Descartes, 75000 Paris, France; INSERM U894, Centre des Neurosciences, 2 ter rue d'Alesia, 75000 Paris, France
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Douglas T, Bonte P, Focquaert F, Devolder K, Sterckx S. Coercion, incarceration, and chemical castration: an argument from autonomy. JOURNAL OF BIOETHICAL INQUIRY 2013; 10:393-405. [PMID: 23813324 PMCID: PMC3824348 DOI: 10.1007/s11673-013-9465-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 01/25/2013] [Indexed: 06/02/2023]
Abstract
In several jurisdictions, sex offenders may be offered chemical castration as an alternative to further incarceration. In some, agreement to chemical castration may be made a formal condition of parole or release. In others, refusal to undergo chemical castration can increase the likelihood of further incarceration though no formal link is made between the two. Offering chemical castration as an alternative to further incarceration is often said to be partially coercive, thus rendering the offender's consent invalid. The dominant response to this objection has been to argue that any coercion present in such cases is compatible with valid consent. In this article, we take a different tack, arguing that, even if consent would not be valid, offering chemical castration will often be supported by the very considerations that underpin concerns about consent: considerations of autonomy. This is because offering chemical castration will often increase the offender's autonomy, both at the time the offer is made and in the future.
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Affiliation(s)
- Thomas Douglas
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Littlegate House, St. Ebbes Street, Oxford, OX1 1PT, United Kingdom,
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Treatment outcomes of chemical castration on Korean sex offenders. J Forensic Leg Med 2013; 20:563-6. [DOI: 10.1016/j.jflm.2013.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/28/2013] [Accepted: 06/04/2013] [Indexed: 11/24/2022]
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Garcia FD, Delavenne HG, Assumpção ADFA, Thibaut F. Pharmacologic treatment of sex offenders with paraphilic disorder. Curr Psychiatry Rep 2013; 15:356. [PMID: 23572328 DOI: 10.1007/s11920-013-0356-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Sexual offending is both a social and a public health issue. Evidence demonstrates that a combination of pharmacological and psychotherapeutic approaches may reduce or even eliminate deviant sexual behavior in sex offenders with paraphilic disorders. In this article, we will review pharmacological treatment options for sex offenders with paraphilias. Both serotonin selective reuptake inhibitors (SSRIs) and antiandrogen treatments have been used with reported success in decreasing recidivism. SSRIs have been used in mild types of paraphilias and juvenile paraphilias. Antiandrogen treatments seem to be effective in severe sex offenders with paraphilic disorders in order to reduce victimization. Combined pharmacological and psychotherapeutic treatment is associated with better efficacy. Imaging studies may improve the knowledge of paraphilic disorders and the mechanisms of action of current treatments. In spite of existing evidence, there is a need for independent, large-scale and good quality studies assessing the long-term efficacy and tolerance of treatments.
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Affiliation(s)
- Frederico Duarte Garcia
- Department of Psychiatry, INCT - de Medicina Molecular, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
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Lejeune H, Huyghe É, Droupy S. [Hypoactive sexual desire and testosterone deficiency in men]. Prog Urol 2013; 23:621-8. [PMID: 23830256 DOI: 10.1016/j.purol.2013.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 01/26/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Relations between sexual desire and testosterone are more complex than previously thought particularly in ageing males. METHODS A Medline search of the existing literature utilizing terms testosterone, libido, sexual desire, hypogonadism, and andropause, was performed until January 2012. RESULTS Testosterone is a physiological stimulator of sexual desire. In case of complete hypogonadism, libido is very low and testosterone treatment restores sexual desire. In epidemiological studies, the relationship between testosterone and sexual desire is statistically significant but less strict because of interactions with other factors which decrease both sexual desire and testosterone levels. It is especially the case in ageing males: in addition to a possible late-onset hypogonadism, other etiological factors (health, partnership, socioeconomical and psychological factors) and other sexual dysfunctions (such as erectile dysfunction) must be taken into account. CONCLUSION The decrease of sexual desire is one of the symptoms seen in late-onset hypogonadism. The effect of testosterone replacement therapy is more obvious that testosterone is low and there are no other causes of impaired sexual desire. There is no evidence that testosterone therapy increases the risk of prostate cancer, benign prostatic hyperplasia or promotes the clinical expression of subclinical prostate cancer.
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Affiliation(s)
- H Lejeune
- Inserm U 846, service de médecine de la reproduction, université Claude-Bernard-Lyon-1, hôpital Femme-Mère-Enfant, CHU de Lyon, 59, boulevard Pinel, 69500 Bron, France
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Turner D, Basdekis‐Jozsa R, Briken P. Prescription of Testosterone‐Lowering Medications for Sex Offender Treatment in German Forensic‐Psychiatric Institutions. J Sex Med 2013; 10:570-8. [DOI: 10.1111/j.1743-6109.2012.02958.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Halleguen O, Baratta A. [Injunction to care. Results of a study carried out in the regions of Alsace and Lorraine]. Encephale 2013; 40:42-7. [PMID: 23351931 DOI: 10.1016/j.encep.2012.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 09/02/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The act of June 17, 1998 created a new form of compulsory treatment: the injunction to care. This is a legal measure intended to fight against recidivism of offenders and sex offenders through medical measures. The only therapies that have demonstrated partial efficacy are cognitive behavioural therapy and treatment with anti-hormone. In France, psychodynamic therapies are paramount in the treatment of perpetrators of sexual violence, although such treatments have not demonstrated effectiveness in reducing sexual recidivism. Very few studies are available regarding the implementation of court-ordered treatment in France. The recent report by the General Inspectorate of Social Affairs (IGAS) in 2011 confirms the absence of medical statistics on the implementation of court-ordered care. OBJECTIVE We conducted a study on the procedure of the injunction to care in the regions of Alsace and Lorraine. The aim of the study is to develop an inventory coordinator for practitioners (number, type of exercise) and the profile of patients undergoing the injunction of care (type of offense convicted for, psychiatric comorbidity identified for example). METHODS We first identified the practicing coordinator doctors by contacting the High Courts in the geographic area studied. We then sent out a questionnaire by post to coordinator doctors to profile their patients on care injunctions. RESULTS We identified 16 practicing coordinator doctors in two study areas: 13 are state hospital doctors and three are private practice. Of the 16 doctors contacted, six returned the completed questionnaires (38% of the sample). This allows characterizing a sample of 50 patients on care injunctions. The majority of convicted crimes are of a sexual nature (92% of cases). This is mostly for crimes or sexual offenses involving minors aged under 15 (83% of cases). Psychiatric comorbidity is the most frequently identified paedophile primary (38%) followed by mental retardation (14%), dissocial personality disorder (6%) and a borderline personality, and emotional liability (6%). Other comorbidities are divided between paranoid schizophrenia, chronic alcoholism, or other personality disorder. The follow-up is monitored by a physician in 82% of cases, while it is provided by a psychologist in 18% of cases. The management consists of a simple psychotherapy in 66% of cases. Pharmacological treatment is most often prescribed with antipsychotics (26% of cases), followed by anti-depressants (4%) and the anti-hormone (4%). CONCLUSION Our study confirms that the majority of patients on care injunctions are sexual offenders involving minors under the age of 15. The most implemented treatment is a simple psychotherapy. The pharmacological option is infrequent and generally involves the use of inappropriate treatment (neuroleptics). Suppressive libido treatment (antidepressants and anti hormone) remains an exception in France.
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Affiliation(s)
- O Halleguen
- Secteur de psychiatrie adulte 67G12, 67150 Erstein, France
| | - A Baratta
- Unité de soins intensifs psychiatriques, centre hospitalier spécialisé, 1, rue Calmette, 57200 Sarreguemines, France.
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Earp BD, Wudarczyk OA, Sandberg A, Savulescu J. If I could just stop loving you: anti-love biotechnology and the ethics of a chemical breakup. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:3-17. [PMID: 24161170 PMCID: PMC3898540 DOI: 10.1080/15265161.2013.839752] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
"Love hurts"-as the saying goes-and a certain amount of pain and difficulty in intimate relationships is unavoidable. Sometimes it may even be beneficial, since adversity can lead to personal growth, self-discovery, and a range of other components of a life well-lived. But other times, love can be downright dangerous. It may bind a spouse to her domestic abuser, draw an unscrupulous adult toward sexual involvement with a child, put someone under the insidious spell of a cult leader, and even inspire jealousy-fueled homicide. How might these perilous devotions be diminished? The ancients thought that treatments such as phlebotomy, exercise, or bloodletting could "cure" an individual of love. But modern neuroscience and emerging developments in psychopharmacology open up a range of possible interventions that might actually work. These developments raise profound moral questions about the potential uses-and misuses-of such anti-love biotechnology. In this article, we describe a number of prospective love-diminishing interventions, and offer a preliminary ethical framework for dealing with them responsibly should they arise.
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Rettenberger M, Dekker A, Klein V, Briken P. Klinische und forensische Aspekte hypersexuellen Verhaltens. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2012. [DOI: 10.1007/s11757-012-0194-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Amelung T, Kuhle LF, Konrad A, Pauls A, Beier KM. Androgen deprivation therapy of self-identifying, help-seeking pedophiles in the Dunkelfeld. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2012; 35:176-184. [PMID: 22420933 DOI: 10.1016/j.ijlp.2012.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Androgen deprivation therapy (ADT) is considered an effective strategy in sexual offender treatment. However, the evidence base concerning its effects on sexual arousal control is limited. Past research has focused almost exclusively on men in forensic contexts. The present retrospective observational study provided data on ADT in a sample of self-identifying, help-seeking pedohebephilic men applying for a one-year group therapy program. Factors possibly influencing the readiness to take up or discontinue ADT were presented. Effects of a combination of ADT and group psychotherapy program on changes in paraphilic sexual behavior and associated psychological factors were examined. The proportion of men having taken up ADT was rather small (n=15). Greater awareness of potentially risky situations to commit child sexual offenses and self-rated uncontrollability of sexual urges were identified as characterizing men resorting to ADT. Additionally, these men were initially more open to include medical treatment. Examination of the effects of ADT and psychotherapy was limited to a sample of six men providing complete data sets. Descriptive data demonstrated a reduction of paraphilic sexual behaviors, an increase of risk-awareness and self-efficacy, and a decrease of offense-supportive cognitions and self-esteem. The present study underlined the importance of careful education and monitoring of self-identifying, help-seeking pedohebephilic patients interested in ADT concerning the effects and side effects of the treatment in a clinical context.
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Affiliation(s)
- Till Amelung
- Institute of Sexology and Sexual Medicine, Charité Center for Health and Human Sciences, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Moulier V, Fonteille V, Pélégrini-Issac M, Cordier B, Baron-Laforêt S, Boriasse E, Durand E, Stoléru S. A pilot study of the effects of gonadotropin-releasing hormone agonist therapy on brain activation pattern in a man with pedophilia. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2012; 56:50-60. [PMID: 21518701 DOI: 10.1177/0306624x10392191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Gonadotropin-releasing hormone (GnRH) agonists, such as leuprorelin, are recommended in the patients with pedophilia at highest risk of offending. However, the cerebral mechanisms of the effects of these testosterone-decreasing drugs are poorly known. This study aimed to identify changes caused by leuprorelin in a pedophilic patient's brain responses to pictures representing children. Clinical, endocrine, and fMRI investigations were done of a man with pedophilia before leuprorelin therapy and 5 months into leuprorelin therapy. Patient was compared with an age-matched healthy control also assessed 5 months apart. Before therapy, pictures of boys elicited activation in the left calcarine fissure, left insula, anterior cingulate cortex, and left cerebellar vermis. Five months into therapy, all the above-mentioned activations had disappeared. No such activations and, consequently, no such decreases occurred in the healthy control. The results of this pilot study suggest that leuprorelin decreased activity in regions known to mediate the perceptual, motivational, and affective responses to visual sexual stimuli.
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Habermeyer B, Händel N, Lemoine P, Klarhöfer M, Seifritz E, Dittmann V, Graf M. LH-RH agonists modulate amygdala response to visual sexual stimulation: a single case fMRI study in pedophilia. Neurocase 2012; 18:489-95. [PMID: 22136615 DOI: 10.1080/13554794.2011.627346] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Pedophilia is characterized by a persistent sexual attraction to prepubescent children. Treatment with anti-androgen agents, such as luteinizing hormone-releasing hormone (LH-RH) agonists, reduces testosterone levels and thereby sexual drive and arousal. We used functional magnetic resonance imaging (fMRI) to compare visual erotic stimulation pre- and on-treatment with the LH-RH agonist leuprolide acetate in the case of homosexual pedophilia. The pre-treatment contrasts of the erotic pictures against the respective neutral pictures showed an activation of the right amygdala and adjacent parahippocampal gyrus that decreased significantly under treatment with leuprolide acetate. Our single case fMRI study supports the notion that anti-androgens may modify amygdala response to visual erotic stimulation, a hypothesis that should be further examined in larger studies.
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Felthous AR. The "untreatability" of psychopathy and hospital commitment in the USA. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2011; 34:400-405. [PMID: 22079085 DOI: 10.1016/j.ijlp.2011.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
One argument in support of a public policy of not subjecting persons with psychopathic disorders to civil or criminal commitment is that these disorders do not improve with treatment. This article examines the relationship between the assumption of untreatability of psychopathic disorders and outpatient civil commitment, inpatient civil commitment, and insanity acquittee commitment. Research on the treatability of psychopathy is reviewed and the treatment of conditions co-morbid with psychopathy is considered. Research evidence is insufficient to support the conclusion that psychopathy is improved, worsened or not affected by treatment. Evidence does support effective treatments for conditions that can be co-morbid with psychopathic disorders including impulsive aggression which can be interpreted as a manifestation of psychopathic disorder. The absence of evidence based treatment efficacy for psychopathic disorders is a logical reason for not subjecting individuals with only a psychopathic disorder to involuntary hospitalization. This assumption should not becloud the possibility of treatable co-morbid conditions which may or may not qualify for involuntary hospitalization. Where the primary mental disorder, for which an individual is involuntarily hospitalized, results in behavioral improvement, the continued presence of a psychopathic disorder itself, should not be sufficient reason to continue coerced confinement. Even so, where the primary disorder is incompletely treated, psychopathy can be considered a risk factor when deciding upon the appropriate time for discharge and when formulating a safe and effective after care plan.
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Affiliation(s)
- Alan R Felthous
- Forensic Psychiatry Division, Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1438 South Grand Blvd., Saint Louis, MO 63104, USA.
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Jordan K, Fromberger P, Stolpmann G, Müller JL. The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia. J Sex Med 2011; 8:3008-29. [DOI: 10.1111/j.1743-6109.2011.02393.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Concerns about paraphilia and its treatment have grown in the past few years. Although the aetiology of paraphilia disorder is still not completely understood, pharmacological treatments have been proposed for this disorder. Paraphilias are a major burden for patients and society; nevertheless, only a few individuals with paraphilias voluntarily seek treatment. Antidepressants have been used in the treatment of certain types of mild (e.g. exhibitionism) and juvenile paraphilias. Antilibidinal hormonal treatments, such as steroidal antiandrogens and gonadotrophin-releasing hormone (GnRH) analogues, have also been studied and they seem to be effective in paraphilic disorders, although caution should be taken in the prescription of these treatments in order to avoid or minimize adverse effects and the risk of victimization. The combination of psychotherapy and pharmacological therapy is associated with better efficacy compared with either treatment as monotherapy. Paraphilia is a chronic disorder and a minimal duration of treatment of 3-5 years is highly recommended for severe paraphilia with a high risk of sexual violence. In conclusion, this review of the literature provides suggestive evidence that paraphilias are well characterized disorders marked by pathological dimensions. Although further research is necessary to confirm treatment efficacy and to improve our knowledge of long-term tolerance, available data on the use of selective serotonin reuptake inhibitors, steroidal antiandrogens and GnRH analogues strongly suggest the efficacy of these treatments for paraphilic disorders.
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Affiliation(s)
- Frederico D Garcia
- ADEN Laboratory EA4311, Rouen University Hospital, Biomedical Research Institute, IFR 23, Rouen, France
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Baratta A, Morali A, Halleguen O, Milosescu GA. Prise en charge médicojudicaire des auteurs d’infractions sexuelles. MÉDECINE & DROIT 2011. [DOI: 10.1016/j.meddro.2011.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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48
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Die lange Suche nach der „richtigen“ Behandlung. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2010. [DOI: 10.1007/s11757-010-0052-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Eher R. Die antiandrogene Behandlung von Sexualstraftätern vor dem Hintergrund der aktuellen Wirksamkeitsforschung und der kriminologischen Realität. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2010. [DOI: 10.1007/s11757-010-0055-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reproduction expediting: Sexual motivations, fantasies, and the ticking biological clock. PERSONALITY AND INDIVIDUAL DIFFERENCES 2010. [DOI: 10.1016/j.paid.2010.05.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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