Sadistic homosexual pedophilia: treatment with cyproterone acetate: a single case study

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Organic Approaches to the Treatment of Paraphilics and Sex Offenders

Emphasizing the power and fundamental nature—comparable to the basic mammalian drive for food—of sex drives and urges in almost everybody, including paraphilics and sex offenders, this article gives an overview of biologically-based, or “organic” approaches to the treatment of paraphilics and sex offenders.

Organic treatment approaches for this population may be divided into surgical and pharmacotherapeutic categories. Surgical approaches include castration (orchiectomy), sterotactic (brain) surgery and estrogen implants, the latter two approaches are not used in the United States (U.S.). All surgical approaches act hormonally, in reducing or blocking the amount of circulating androgens in the subject. Pharmacotherapeutic approaches include: (1) Indirect-acting and direct-acting antiandrogen hormones, also intended to reduce or block the amount of circulating androgens in the subject. (2) Psychotropic medications for primary treatment of male aggressive hypersexuality, for treatment of co-occurring psychiatric symptomatology, or for both. (3) An experimental pharmacologic approach to the treatment of this population consists of the use of antiepileptic drugs, or “AED's” to stabilize the impulsivity/compulsivity of these subjects, in reducing the hypothesized “kindling” that may occur during impulsive/compulsive periods in these individuals.

Whatever organic approach may be used for paraphilics and sex offenders, such an approach alone is not sufficient treatment for this population. Psychotherapeutic and cognitive/behavioral approaches must also be included in these individuals' treatment regimens. A companion piece to this article, giving an overview of psychotherapeutic and cognitive/behavioral treatment approaches to this population will be published in a future issue of this Journal.

Psychological interventions for adults who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a legal construct that overlaps, but is not entirely congruent with, clinical constructs of disorders of sexual preference. Sexual offending is both a social and a public health issue. Victim surveys illustrate high incidence and prevalence levels, and it is commonly accepted that there is considerable hidden sexual victimisation. There are significant levels of psychiatric morbidity in survivors of sexual offences.Psychological interventions are generally based on behavioural or psychodynamic theories.Behavioural interventions fall into two main groups: those based on traditional classical conditioning and/or operant learning theory and those based on cognitive behavioural approaches. Approaches may overlap. Interventions associated with traditional classical and operant learning theory are referred to as behaviour modification or behaviour therapy, and focus explicitly on changing behaviour by administering a stimulus and measuring its effect on overt behaviour. Within sex offender treatment, examples include aversion therapy, covert sensitisation or olfactory conditioning. Cognitive behavioural therapies are intended to change internal processes - thoughts, beliefs, emotions, physiological arousal - alongside changing overt behaviour, such as social skills or coping behaviours. They may involve establishing links between offenders' thoughts, feelings and actions about offending behaviour; correction of offenders' misperceptions, irrational beliefs and reasoning biases associated with their offending; teaching offenders to monitor their own thoughts, feelings and behaviours associated with offending; and promoting alternative ways of coping with deviant sexual thoughts and desires.Psychodynamic interventions share a common root in psychoanalytic theory. This posits that sexual offending arises through an imbalance of the three components of mind: the id, the ego and the superego, with sexual offenders having temperamental imbalance of a powerful id (increased sexual impulses and libido) and a weak superego (a low level of moral probation), which are also impacted by early environment.This updates a previous Cochrane review but is based on a new protocol.

OBJECTIVES

To assess the effects of psychological interventions on those who have sexually offended or are at risk of offending.

SEARCH METHODS

In September 2010 we searched: CENTRAL, MEDLINE, Allied and Complementary Medicine (AMED), Applied Social Sciences Index and Abstracts (ASSIA), Biosis Previews, CINAHL, COPAC, Dissertation Abstracts, EMBASE, International Bibliography of the Social Sciences (IBSS), ISI Proceedings, Science Citation Index Expanded (SCI), Social Sciences Citation Index (SSCI), National Criminal Justice Reference Service Abstracts Database, PsycINFO, OpenSIGLE, Social Care Online, Sociological Abstracts, UK Clinical Research Network Portfolio Database and ZETOC. We contacted numerous experts in the field.

SELECTION CRITERIA

Randomised trials comparing psychological intervention with standard care or another psychological therapy given to adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or who are seeking treatment voluntarily for behaviours classified as illegal.

DATA COLLECTION AND ANALYSIS

At least two authors, working independently, selected studies, extracted data and assessed the studies' risk of bias. We contacted study authors for additional information including details of methods and outcome data.

MAIN RESULTS

We included ten studies involving data from 944 adults, all male.Five trials involved primarily cognitive behavioural interventions (CBT) (n = 664). Of these, four compared CBT with no treatment or wait list control, and one compared CBT with standard care. Only one study collected data on the primary outcome. The largest study (n = 484) involved the most complex intervention versus no treatment. Long-term outcome data are reported for groups in which the mean years 'at risk' in the community are similar (8.3 years for treatment (n = 259) compared to 8.4 in the control group (n = 225)). There was no difference between these groups in terms of the risk of reoffending as measured by reconviction for sexual offences (risk ratio (RR) 1.10; 95% CI 0.78 to 1.56).Four trials (n = 70) compared one behavioural programme with an alternative behavioural programme or with wait list control. No meta-analysis was possible for this comparison. For two studies (both cross-over, n = 29) no disaggregated data were available. The remaining two behavioural studies compared imaginal desensitisation with either covert sensitisation or as part of adjunctive drug therapy (n = 20 and 21, respectively). In these two studies, results for the primary outcome (being 'charged with anomalous behaviour') were encouraging, with only one new charge for the treated groups over one year in the former study, and in the latter study, only one new charge (in the drug-only group) over two years.One study compared psychodynamic intervention with probation. Results for this study (n = 231) indicate a slight trend in favour of the control group (probation) over the intervention (group therapy) in terms of sexual offending as measured by rearrest (RR 1.87; 95% CI 0.78 to 4.47) at 10-year follow-up.Data for adverse events, 'sexually anomalous urges' and for secondary outcomes thought to be 'dynamic' risk factors for reoffending, including anger and cognitive distortions, were limited.

AUTHORS' CONCLUSIONS

The inescapable conclusion of this review is the need for further randomised controlled trials. While we recognise that randomisation is considered by some to be unethical or politically unacceptable (both of which are based on the faulty premise that the experimental treatment is superior to the control - this being the point of the trial to begin with), without such evidence, the area will fail to progress. Not only could this result in the continued use of ineffective (and potentially harmful) interventions, but it also means that society is lured into a false sense of security in the belief that once the individual has been treated, their risk of reoffending is reduced. Current available evidence does not support this belief. Future trials should concentrate on minimising risk of bias, maximising quality of reporting and including follow-up for a minimum of five years 'at risk' in the community.

WITHDRAWN: Managements for people with disorders of sexual preference and for convicted sexual offenders

This review has been withdrawn (Issue 9, 2012) as it is no longer current and is to be superseded by two new reviews.

The editorial group responsible for this previously published document have withdrawn it from publication.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias

OBJECTIVES

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions.

METHODS

The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen 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.

CONCLUSIONS

An algorithm was proposed with six levels of treatment for different categories of paraphilias.

WITHDRAWN: Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

AUTHORS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Review of medical reports on pedophilia

The present report is a review of all 554 papers published on Medline on pedophilia. The first discussion is the history of the disorder from ancient Greece to the present time, especially the influence of the liberal country of the Netherlands, the North American Man-Boy Love Association, and the sexual crisis in the Catholic Church. One important question is the relationship between homosexual pedophilia and adult homosexuality. Evidence for and against this relationship is presented. Next discussed are the characteristics of the victim and the long lasting serious effects of sexual abuse. Laboratory correlations are included, especially phallometric tests in order to objectively measure the physical responses to sexual stimuli. Electrophysiological and radiographic tests are also mentioned, including electroencephalography, computed tomography, magnetic resonance imaging, and positron emission tomography scans. An important section is the characterization of pedophiles with emphasis on their frequent previous sexual abuse, their past, their present, and their anticipated future. The final topic is treatment of this disorder with surgery, medication, behavioral therapy and the combination of medication and behavioral therapy.

Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

REVIEWERS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders

Paraphilic disorders are psychiatric syndromes primarily characterized by deviant sexual thoughts, cravings, urges, and/or behaviors. Paraphilic men may engage in inappropriate sexual behaviors when cravings for socially unacceptable sexual acts become overpowering. These often chronic disorders may not only cause emotional distress and social embarrassment to the afflicted patient but also to the targets of their paraphilic focus. The primary objective of this article is to examine and review data on the efficacy and tolerability of the testosterone-lowering agents medroxprogesterone acetate, cyproterone acetate, and leuprolide acetate. The secondary goal is to review data on less conventional and more innovative pharmacological treatments, particularly the serotonin-specific reuptake inhibitors.

Managements for people with disorders of sexual preference and for convicted sexual offenders

BACKGROUND

The reviewers recognise that it may be thought that convicted sex offenders and those with disorders of sexual preference are quite different groups. In combining them within this review we have taken the view that legal process alone should not define the population. Illegal behaviours in one jurisdiction may not be considered so in others. Studies of those who are convicted of sexual offending describe reconviction rates for sexual offences of up to 40-60%. It would seem important to know if there are interventions that might reduce this high rate of re-offending. This review examines antilibidinal management of those who have been convicted of sexual offences or who have disorders of sexual preference.

OBJECTIVES

To determine the effectiveness of a range of management techniques to assist people who have disorders of sexual preference and those who have been convicted of sexual offences.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Schizophrenia Group Register of Trials, The Cochrane Library, EMBASE, MEDLINE, and PsychLIT were searched. Further references were sought from published trials and their authors. Relevant pharmaceutical manufacturers were contacted.

SELECTION CRITERIA

All relevant randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently and analysed on an intention-to-treat basis. Data were extracted for short and medium term outcomes.

MAIN RESULTS

A single trial (McConaghy 1988) found the effect of antilibidinal medication (medroxyprogesterone acetate) plus imaginal desensitisation was no better than imaginal desensitisation for problematic/anomalous sexual behaviour and desire. A relapse prevention programme was trialed by Marques (Marques 1994) and participants were followed up for an average of 3 years. What data there are suggest that although there is no discernable effect on the outcome of sex offending (OR 0.76 CI 0. 26-2.28) those treated with response prevention do have less non-sexual violent offences (OR 0.3, CI 0.1-0.89, NNT 10 CI 5-85). In addition those committing both sexual and violent offences also declined in the response prevention group (OR 0.14 CI 0.02-0.98, NNT 20 CI 10-437). A large pragmatic trial investigated the value of group therapy for sex offenders (Romero 1983). This study finds no effect on recidivism at ten years.

REVIEWER'S CONCLUSIONS

It is disappointing to find that this area lacks a strong evidence base, particularly in light of the controversial nature of the treatment and the high levels of interest in the area. The relapse prevention programme did seem to have some effect on violent reoffending but large, well-conducted randomised trials of long duration are essential if the effectiveness or otherwise of these treatments are to be established.

The paraphilias, obsessive compulsive spectrum disorder, and the treatment of sexually deviant behaviour

The paraphilias have been mostly ignored by psychiatry, even though psychiatrists are ideally suited to treat and diagnose these disorders by virtue of their medical and psychological training. The sexual deviations require an understanding of both biological and psychological causation and skills in psychological and pharmacological treatments. More recently the Supreme Court of the United States in Kansas v Hendricks (1997) upheld the constitutionality of the civil commitment of sexually deviant individuals for psychiatric treatment. As the various states adopt statutes based on Hendricks, psychiatry will be forced to take an active interest in the diagnosis and the management of the paraphilias. This paper outlines briefly where the field is in the understanding of the natural history, diagnosis, and treatment of the paraphilias.

Pharmacological treatment of paraphilias with a focus on antidepressants

This article reviews the advances in pharmacotherapy of paraphilias. Antiandrogen hormones, phenothiazines, and lithium therapy of paraphilias is briefly reviewed. Pharmacotherapy of paraphilias with serotonergic drugs such as fluoxetine, clomipramine, sertraline, and fluvoxamine is reviewed in detail. In addition, the use of buspirone hydrochloride in paraphilias is discussed. The final focus of the article is on the etiologic theories of paraphilias and some practical advice for the pharmacotherapy and management of paraphilias.

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

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

Effects of cyproterone acetate on sexual arousal patterns of pedophiles

The antiandrogen treatment of sexual offenders has been shown to reduce the recidivism rate. The mechanism of action has been assumed to be through asexualization with its secondary effects on sexual behavior. This study shows that the mechanism may be more complex and may involve a differential effect on sexual arousal patterns. Treatment responses may differ in high and low plasma testosterone groups.

Double-blind placebo crossover study of cyproterone acetate in the treatment of the paraphilias

Cyproterone acetate is a powerful antiandrogen used in the treatment of the paraphilias for at least a decade. Studies have reported it effective in reducing the recidivism rates of sexual crimes perpetrated by men. It acts through competitive inhibition of the androgen receptors blocking the effects of testosterone and dihydrotestosterone. Systematic clinical study of its effectiveness and its clinical effects on sexual behavior is lacking, however. In the current study 19 paraphilic men who had also recidivated in a variety of sexual crimes were treated with cyproterone acetate and placebo in a double-blind crossover design. The use of active drug was associated with a significant reduction of some aspects of sexual behavior, particularly sexual fantasies. There were also significant effects on levels of circulating sex hormones and some effects on physiological measurements and self-reports of sexual arousal.

Effect of a long-lasting gonadotrophin hormone-releasing hormone agonist in six cases of severe male paraphilia

Six men with severe paraphilia had been treated with depot gonadotrophin luteinizing releasing hormone analogue (GnRHa) (triptorelin 3.75 mg per month intramuscularly). In 5 cases, the treatment ended their deviant sexual behavior and markedly decreased their sexual fantasies and activities without further significant side effects than those related to hypoandrogenism. This clinical improvement was parallel to the gradual decrease of plasma testosterone level to castration values within the first month. The beneficial effect of this treatment had been maintained at follow-up varying from 7 months to 3 years. One patient interrupted the treatment at the end of the first year and relapsed within 10 weeks. GnRHa treatment, which leads to reversible castration, may constitute a promising treatment of paraphilic behavior and may favor the possibility of concurrent psychotherapy.

A double-blind placebo controlled trial of medroxyprogesterone acetate and cyproterone acetate with seven pedophiles

Seven of ten pedophiles in hospital completed a double-blind, placebo-controlled two-dose comparison of medroxyprogesterone acetate and cyproterone acetate. Sequential measures during the 28 week study were: patient self-reports, nurses' observations, phallometry, hormone levels and side-effects. The drugs, which performed equivalently, reduced sexual thoughts and fantasies, the frequency of early morning erections on awakening, the frequency and pleasure of masturbation, and level of sexual frustration. Penile responses were also reduced but to a lesser degree and were more variable. Serum testosterone FSH and LH all declined during drug administration, but by the end of the final placebo phase had essentially returned to (or exceeded) pre-drug values. Our experience suggests that only a minority of pedophiles are likely to accept libido-reducing drugs.

The management of a case of treatment-resistant paraphilia with a long-acting LHRH agonist

A patient with multiple paraphilias who had been treated for several years with sex drive reducing agents (cyproterone acetate and medroxyprogesterone acetate) with little effect on sexual activity or fantasy was offered treatment with long-acting leuprolide acetate, on LHRH agonist. This produced a marked decrease in all reported sexual thoughts and activities with no significant side-effects.

The effects of cyproterone acetate on sleeping and waking penile erections in pedophiles: possible implications for treatment

This study reports the short term effects in five pedophiles of the antiandrogenic drug cyproterone acetate (CPA) on nocturnal penile tumescence (NPT); penile responses to erotic stimuli in the laboratory; and sex hormones (testosterone, LH, FSH and prolactin). During the administration of CPA, NPT, laboratory arousal and hormone measures (except prolactin) all decreased. Waking laboratory measures were influenced less and were more variable (one subject showed greater arousal) than NPT measures. The changes in NPT closely paralleled the reduction in testosterone. The results are discussed with reference to the known psycho-neuroendocrinology of sleeping and waking erections.

Paedophilia: a cognitive/behavioural treatment approach in a single case

Our confidence in being able to offer successful treatment of paedophilia remains low. A multifaceted cognitive/behavioural treatment approach is described in the hitherto successful treatment of a man with a 13-year history of sexually interfering with young children of both sexes.