Current concepts in the pharmacotherapy of paraphilias

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

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

Psychiatric and Forensic Characteristics of Sex Offenders With Child and With Adult Victims

This study presents psychiatric and forensic characteristics of people accused of a sexual crime and sent for evaluation. Data were drawn from the only institutional psychiatric forensic assessment center in Croatia, during a 9-year period, from January 1, 2010 to December 31, 2018. There were 72 cases of sex offenses: 37 with child victims and 35 with adult victims. People accused of sex offenses with child victims were more often sexually abused during childhood and treated psychiatrically as inpatients. They used alcohol less often. Sex offenders with child victims were diagnosed with narcissistic and antisocial personality disorder, dementia, and pedophilic disorder. Those with adult victims were diagnosed with antisocial personality disorder, alcohol related disorders and dementia. Due to these differences, the management of these two groups of offenders in both mental health and penal systems should be different.

Psychiatric disorders in female psychosexual disorders-a nationwide, cohort study in Taiwan : Psychiatric disorders and female psychosexual disorders

We aimed to investigate whether females with psychosexual disorders were associated with the risk of affective and other psychiatric disorders. A total of 2240 enrolled individuals, with 560 patients with psychosexual disorders and 1680 subjects without psychosexual disorders (1:3) matched for age and index year, from the Longitudinal Health Insurance Database, retrieved from the National Health Insurance Research Database (NHIRD), between 2000 and 2015 in Taiwan. The multivariate Cox regression model was used to compare the risk of developing psychiatric disorders during the 15 years of follow-up. There were 98 in the cohort with psychosexual disorders (736.07 per 100,000 person-year) and 119 in the non-cohort without psychosexual disorders (736.07 per 100,000 person-year) that developed psychiatric disorders. The multivariate Cox regression model revealed that the adjusted hazard ratio (HR) was 9.848 (95% CI = 7.298 - 13.291, p < 0.001), after the adjustment of age, monthly income, urbanization level, geographic region, and comorbidities. Female patients with psychosexual disorders were associated with the risk of psychiatric disorders. This finding could be a reminder for clinicians about the mental health problems in patients with psychosexual disorders.

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.

Profiling acquired pedophilic behavior: Retrospective analysis of 66 Italian forensic cases of pedophilia

Neurological disorders can be mis-diagnosed as psychiatric ones. This might happen to pedophilia emerging as a symptom of brain insult (i.e. acquired pedophilic behavior). This paper aims to delineate a behavioral profile that might help to identify defendants whose pedophilic behavior is likely to be the consequence of a neurological disorder. Through a systematic review of the literature, seventeen clinical and behavioral variables of the modus operandi and victimology that can distinguish between acquired and developmental pedophilic behavior have been collected. Seven of these were found to be consistent behavioral indicators (i.e. red flags) for acquired pedophilia. Cluster hierarchical analysis on the seventeen variables collected through the systematic review of the literature on cases of acquired pedophilic behavior was applied to a new dataset including 66 Italian closed cases of pedophilia. Stepwise regression and correlation analyses were carried out to further examine the differences between the clusters identified in the cluster analysis. Results revealed that the new sample was partitioned into two clusters. Individuals with ascertained acquired pedophilia were grouped together. The clusters widely differed for the prevalence of red flags (mean number of red flags in each cluster: 2.14 ± 0.79 vs 4.96 ± 0.93, p < 0.001), while no between cluster difference emerged for the other clinical and behavioral variables. Regression analysis provided a robust model that included the three most significant red flags that explain over 64.5% of the variance (absence of masking, spontaneous confession and offenders older age). An organic origin of pedophilic behavior should be suspected if red flags are present in a defendant charged with pedophilia. In those cases, an in depth trans-disciplinary neuroscientific investigation is advocated. The behavioral profile identified might help to provide a proper assessment of defendants.

Mixed Emotions: An Incentive Motivational Model of Sexual Deviance

Sexual offending behavior is a complex and multifaceted phenomenon. Most existing etiological models describe sexual offending behavior as a variant of offending behavior and mostly include factors referring to disinhibition and sexual deviance. In this article, we argue that there is additional value in describing sexual offending behavior as sexual behavior in terms of an incentive model of sexual motivation. The model describes sexual arousal as an emotion, triggered by a competent stimulus signaling potential reward, and comparable to other emotions coupled with strong bodily reactions. Consequently, we describe sexual offending behavior in terms of this new model with emphasis on the development of deviant sexual interests and preferences. Summarized, the model states that because sexual arousal itself is an emotion, there is a bidirectional relationship between sexual self-regulation and emotional self-regulation. Not only can sex be used to regulate emotional states (i.e., sexual coping), emotions can also be used, consciously or automatically, to regulate sexual arousal (i.e., sexual deviance). Preliminary support for the model is drawn from studies in the field of sex offender research as well as sexology and motivation research.

The use of cyproterone acetate in a forensic psychiatric cohort of male sex offenders and its associations with sexual activity and sexual functioning

BACKGROUND

Cyproterone acetate (CPA) is a steroidal anti-androgenic medication used in the field of psychiatry for the treatment of paraphilic disorders, hypersexuality, and inappropriate sexual behaviour which may be present in patients with disorders such as mild and major neurocognitive disorders. In the forensic psychiatric population, it is prescribed for these indications especially for patients with a history of committing a sexual offence or who are at moderate to high risk of recidivism.

OBJECTIVES

To investigate the use of CPA in a forensic psychiatric cohort of male sex offenders and its associations with sexual activity and sexual functioning.

METHODS

Seventy-six forensic psychiatric patients from Weskoppies Hospital in Pretoria, South Africa, participated in the study which measured their sexual functioning. A specifically designed questionnaire was used to capture relevant background information. The use of CPA was studied. The Changes in Sexual Functioning Questionnaire, Male Clinical Version (CSFQ-M-C) was used to measure sexual functioning of participants. The CSFQ-M-C scores, and those of all its subscales, of participants on CPA were compared to those not on the drug. Relevant statistical analyses were performed.

RESULTS

Thirteen out of the 76 participants were being treated with CPA (17.11%). In total, 53.85% of the participants on CPA and 65.08% not on CPA had scores indicating the presence of sexual dysfunction. The total CSFQ-M-C scores for participants on CPA (mean = 40.54; median = 42) were not statistically significantly lower than those not on the drug (mean = 41.22; median = 41). More notable is that the use of CPA in this population was associated with lower levels of desire, frequency of and pleasure from sexual activity. There was an association between having intellectual disability and being treated with CPA.

CONCLUSION

That all the participants were being treated with psychotropic medication could account for the high percentage of sexual dysfunction in any or all areas of sexual functioning and contribute to the small difference in CSFQ-M-C scores between the two groups. Only a tentative conclusion can be made that CPA may be more effective in decreasing levels of desire, frequency and pleasure related to sexual activity than other areas of sexual functioning. The indication for the use of CPA in this population should be assessed clinically according to patient circumstances and risk assessment.

The Biological Treatment of Paraphilic Disorders: an Updated Review

Paraphilic disorders are characterized by atypical sexual interests, fantasies, and behaviors that are subjectively distressing to patients or pose a risk of harm to others. By their very nature, some paraphilic disorders may predispose an individual to commit sexual offenses. The biological treatment of paraphilic disorders, then, is of paramount importance for psychiatry and society at large. Three categories of pharmacologic agents commonly used to treat paraphilic disorders are selective serotonin reuptake inhibitors, synthetic steroidal analogs, and gonadotropin-releasing hormone analogs. Each medication uses a different mechanism of action and has different effects on the physiological and psychological features of paraphilic disorders. In general, these medications have limited high-quality research to support their use. Despite this, some authors have proposed treatment algorithms for individuals with paraphilic disorders of varying severity. These guidelines offer clinicians potentially useful, rational approaches to assessing treatment need in individuals with paraphilic disorders. Recent neuroimaging research suggests that functional magnetic resonance imaging may offer further promise in effectively assessing paraphilic disorders to help direct treatment options.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.

Paraphilias and paraphilic disorders in Parkinson's disease: A systematic review of the literature

Paraphilias are intense urges or behaviors involving non-normative sexual interests. The newly approved diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) have established that, although paraphilias should not be regarded as inherently pathological, they ought to be qualified as paraphilic disorders if resulting in distress, impairment, or harm to the affected individual or others. Recent evidence documents that both phenomena can emerge as relatively uncommon iatrogenic consequences in Parkinson's disease (PD) patients. To outline the clinical characteristics of paraphilias and paraphilic disorders in PD patients, we summarized the available evidence on these phenomena. The review encompasses all studies on paraphilias in PD patients identified by a search on the Pubmed and Scopus online databases through May 2014. Twenty-two case reports on a total of 31 PD patients with paraphilias or paraphilic disorders were identified. These phenomena were typically associated with dopaminomimetic treatment (with a mean levodopa-equivalent daily dose of 1,303 ± 823 mg/d) in male patients with motor complications, young age at PD onset, and long disease duration. Paraphilias were highly concomitant with impulse-control disorders or dopamine dysregulation syndrome. Although evidence on paraphilias and paraphilic disorders in PD patients remains anecdotal, available data point to these phenomena as likely sequelae of high-dose dopaminomimetic treatment. Accordingly, the intensity of paraphilic urges is typically attenuated by the reduction of dopaminomimetic doses, sometimes in association with atypical antipsychotics. Failure to recognize paraphilic disorders may significantly impair the relational functioning of the affected PD patients. Practitioners should routinely inquire about paraphilias during their clinical assessment of PD patients.

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

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.

[Treatment management of sexual offenders]

In France, the Court can issue a medical treatment order only for criminally responsible persons. The nature of the treatment to be administered is at the discretion of the physician in charge of the sexual offender's care. Treatment management of sexual offenders relies essentially on psychotherapy, and preferentially cognitive behavioral therapy. For most severe sexual offenders, drug treatments, including hormonal treatment and selective serotonin reuptake inhibitors, are used to complement psychotherapy. This literature review aims at synthesizing practice changes in the treatment management of sexual offenders.

Rethinking responsibility in offenders with acquired paedophilia: punishment or treatment?

This article reviews the current neurobiological literature on the aetiology of developmental and acquired paedophilia and examines what the consequences could be in terms of responsibility and treatment for the latter. Addressing the question of responsibility and punishment of offenders with acquired paedophilia from a neurobiological perspective is controversial. Consequently it is essential to avoid hasty conclusions based strictly on neurobiological abnormality justifications. This study establishes a distinction between developmental and acquired paedophilia. The article investigates whether offenders who fulfil the diagnosis of acquired paedophilia should be held fully responsible, particularly in cases where the offender's conduct appears to result from volitionally controlled behaviour that is seemingly incompatible with a neurological cause. Moreover, the article explores how responsibility can be compromised when offenders with acquired paedophilia have (partially) preserved moral knowledge despite their sexual disorder. The article then examines the option of offering mandatory treatment as an alternative to imprisonment for offenders with acquired paedophilia. Furthermore, the article addresses the ethical issues related to offering any form of quasi-coercive treatment as a condition of release. This study concludes that decisions to fully or partially excuse an individual who fulfil the diagnosis of acquired paedophilia should take all relevant information into account, both neurobiological and other environmental evidence, and should proceed on a careful case by case analysis before sentencing or offering treatment.

A case of mental retardation with paraphilia treated with depot leuprorelin

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.

Pharmacologic treatment of paraphilias

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.

Etat des lieux sur la prise en charge pharmacologique des sujets ayant commis un délit sexuel et atteints de paraphilie–résultats préliminaires

Introduction

La prise en charge des patients paraphiles peut nécessiter la mise en place de traitement pharmacologique : antidépresseurs ou traitements anti-androgènes. Le but de notre étude est de mieux connaître cette population d’agresseurs sexuels et d’évaluer l’efficacité et la tolérance des traitements pharmacologiques dans cette indication.

Méthode

Cette étude s’appuie sur l’analyse rétrospective des dossiers médicaux. Tous les patients paraphiles ayant commis une agression sexuelle en France sont potentiellement incluables.

Résultats

Vingt-trois patients ont été inclus avec un âge moyen de 44 (± S.D.  =  12) ans. Les paraphilies retrouvées sont les suivantes : pédophilie 61 % (n = 14), exhibitionnisme 35 % (n = 8) et un violeur en série. Les comportements sexuels déviants sont décrits comme exclusifs pour 39 % (n = 9) de l’échantillon. Dix-sept pour cent (n = 4) des patients rapportent une hypersexualité associée et 39 % (n = 9) rapportent un abus sexuel durant leur enfance. Cinq patients (22 %) recevaient un traitement antidépresseur, six patients (26 %) recevaient quotidiennement de l’acétate de cyprotérone et 12 patients (52 %) une injection d’analogues de la GnRH tous les trois mois. Deux patients ont récidivé après la mise en route du traitement pharmacologique. Un patient exhibitionniste a récidivé durant le traitement par acétate de cyprotérone et un patient pédophile a récidivé durant une interruption du traitement par analogue de la GnRH due à un désir de paternité. Tous les patients décrivent une diminution de leur activité sexuelle déviante durant le traitement pharmacologique (antidépresseurs et antiandrogènes). Quatre patients (17 %) présentaient une ostéoporose, toutefois, la densité osseuse n’a pas été mesurée chez 14 patients (61 %).

Conclusion

Le traitement pharmacologique semble diminuer l’intensité des comportements et des fantasmes sexuels déviants parmi les patients paraphiles agresseurs sexuels. Notre étude permettra aux cliniciens d’avoir accès à des informations complémentaires à propos de l’efficacité et de la tolérance des traitements pharmacologiques dans cette indication.

Coercion, incarceration, and chemical castration: an argument from autonomy

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.

Pharmacologic treatment of sex offenders with paraphilic disorder

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.

Sexual disorders and crime

PURPOSE OF REVIEW

Highlighting the relationship between sexual disorders and crime, reviewing and summarizing the articles published throughout 2011 which add to the current knowledge on this subject.

RECENT FINDINGS

Studies on specific populations confirm the association between sexual disorders and crime, particularly between paraphilias and sexual crimes regarding male offenders. Female offenders are less likely to be diagnosed with a sexual disorder. Some case reports focus on unusual paraphilias and lead us to question the vast possibilities of paraphilic contents and sexual arousal patterns. The variations of paraphilic-associated sexual arousal patterns, unconventional sex behaviors or paraphilic disorders are constantly changing. In this sense, the American Psychiatric Association's DSM-5 current proposals for a sexual dysfunction diagnostic category are under intense discussion because of their important clinical and forensic consequences.

SUMMARY

Sexual violence is a theme not well understood yet. Because of its nature, researching it can raise many ethical problems. There is no possibility of clinical trials and of case-control studies. Even cohort studies may be problematic in themselves. So, most of the research involves biased samples or case reports, or is merely theoretical. Further research is needed to improve our understanding of the subject, so that preventive and rehabilitative measures can be taken.