The Treatment of Sexual Deviation Using a Pharmacological Approach.In a recent editorial in the New England Journal of Medicine The New England Journal of Medicine (New Engl J Med or NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It is one of the most popular and widely-read peer-reviewed general medical journals in the world. , this author decried the need for government and pharmaceutical industry support for research in the treatment of sexually deviant behavior (Bradford, 1998). There are a number of reasons for this, including the case of Kansas v. Hendricks (1997) where the U.S. Supreme Court upheld the civil commitment of sexually violent predators for treatment as constitutional. This means that the most seriously sexually deviant individuals are now to be held in psychiatric hospitals or special facilities for the treatment of their sexual deviation prior to their release. It is these individuals who need to be treated using a pharmacological approach in addition to cognitive behaviourial therapy. Further, pedophilia pedophilia, psychosexual disorder in which there is a preference for sexual activity with prepubertal children. Pedophiles are almost always males. The children are more often of the opposite sex (about twice as often) and are typically 13 years or age or younger; alone is a very severe public health problem of staggering proportions, with between 6 and 62% of girls and 10 to 30% of boys being the victims of sexual abuse in childhood according to various studies (Peters, Wyatt, & Finkelhor, 1986). Furthermore, in the United States the costs of incarcerating individuals convicted of sexually abusing children is staggering, with more than two billion dollars spent in 1990, while at the same time there is no evidence that the deterrence of incarceration Confinement in a jail or prison; imprisonment.
Police officers and other law enforcement officers are authorized by federal, state, and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes. has any impact on the problem (Pithers et al., 1995).
At this time, no one is certain of the cause of pedophilia and other sexual deviations. In addition, the actual incidence and prevalence of the paraphilias is unknown. The level of sexual abuse victimization victimization Social medicine The abuse of the disenfranchised–eg, those underage, elderly, ♀, mentally retarded, illegal aliens, or other, by coercing them into illegal activities–eg, drug trade, pornography, prostitution. of children in the general population today is fairly consistent with that reported by Kinsey (Gebhard & Johnson, 1979). In a study completed in the 1940s, 24% of 4,000 females surveyed disclosed a sexual interaction with a male at least five years older than them when they were 14 years of age or younger (Gebhard & Johnson, 1979). Sexual intercourse sexual intercourse
or coitus or copulation
Act in which the male reproductive organ enters the female reproductive tract (see reproductive system). occurred in 93% of cases, and in 31% of cases there was mild petting or fondling without involvement of the genitals. A national survey by the Federal Government of Canada The Government of Canada is the federal government of Canada. The powers and structure of the federal government are set out in the Constitution of Canada.
In modern Canadian use, the term "government" (or "federal government") refers broadly to the cabinet of the day and on sexual violence against children and adolescents found that 18.1% of children (23.5% of females and 12.8% of males) were victims of childhood sexual abuse. In only 20% of cases were the perpetrators strangers, with friends, acquaintances, parents, and other family members being the perpetrators in the majority of cases (Federal Government of Canada, 1984). The actual levels of the prevalence of pedophilia in the general population is unknown, but it could be at least at the same levels as obsessive compulsive disorder Obsessive compulsive disorder (OCD)
Disorder characterized by persistent, intrusive, and senseless thoughts (obsessions) or compulsions to perform repetitive behaviors that interfere with normal functioning.
Mentioned in: Tourette Syndrome , or most likely even higher (Bradford, 1999). Despite this convincing evidence of a serious public health problem, the support for research into the causes and treatment of pedophilia (and other sexual deviations) is very weak, with little or no pharmaceutical industry support and poor government support. In a study of sexual fantasies by Crepault and Couture (1980) it was reported that over 60% of males reported heterosexual pedophilic fantasies and 33% of males had rape fantasies. While this may be a high estimate, even if this is partially accurate the prevalence of mild cases of pedophilia in the general population is staggering. The onset of paraphilic sexual fantasies and urges is usually well established by age 18 (Abel & Rouleau rouleau /rou·leau/ (roo-lo´) pl. rouleaux´ [Fr.] an abnormal group of red blood cells adhering together like a roll of coins.
pl. rouleaux [Fr.] a roll of red blood cells resembling a pile of coins. , 1990). This means the risk of sexually acting out is present in late adolescence, yet there are only a few programs dedicated to the treatment of sexual deviation in adolescence. Generally, mental health professionals working
with this segment of the population are not aware of this serious problem, and therefore not enough is being done to treat these conditions before they are well established. In addition, there is considerable comorbidity between the various paraphilias (Bradford, Boulet, & Pawlak, 1992). This means that for a treatment to be successful it has to be able to simultaneously reduce multiple paraphilic behaviours. All of these factors strongly support a pharmacological treatment option as being the most important intervention in the treatment of paraphilias.
The treatment of paraphilias using pharmacological agents is well established (Bradford, 1991, 1994, 1995). It is a treatment approach that is effective in all types of sexual deviations, including the simultaneous presence of multiple sexual deviations. In addition, it is the treatment of choice for the most serious sexual deviations, such as sexual sadism. The paraphilias or sexual deviations are deviant sexual behaviors that have common clinical features, specifically sexual fantasies, leading to sexual urges and then, ultimately, to the deviant sexual behavior. Ideally, if a treatment were to be successful the sexually deviant behavior would be completely suppressed, while at the same time nondeviant sexual behavior (normophilic behavior) would remain intact or would even be enhanced. As outlined later in this article various pharmacological treatment approaches have been shown to have that capability. In addition an ideal treatment would be one that was able to suppress the psychological component of sexual deviation (sexual fantasies) while at the same time having an impact on physiological components of sexual deviation (sexual arousal sexual arousal Horny/horniness, randy/randiness Physiology A state of sexual 'yellow alert' which has a mental component–↑ cortical responsiveness to sensory stimulation, and physical component–↑ penile sensitivity, neural response to stimuli, ).
The success of any form of treatment is highly dependent on a detailed evaluation of the behaviour and the establishment of the appropriate diagnosis. In the case of the paraphilias, this is even more critical because of the comorbidity of the paraphilias and the associated comorbidity with other psychiatric problems such as alcoholism. In the author's sexual behaviors clinic (a research clinic that was established 20 years ago), close to 3,000 individuals with paraphilias have been assessed and treated. In specialized clinics such as this one there is a usually a standardized evaluation. This consists of a psychiatric evaluation psychiatric evaluation The assessment of a person's mental, social, psychologic functionality. See DSM-IV-table multiaxial assessment, Personality testing, Psychiatric history, Psychiatric interview. with a detailed psychiatric history psychiatric history A person's mental profile, which includes information about chief complaint, present illness, psychological adjustments made before onset of disease, individual and family Hx of psychiatric or mental disorders, and an early developmental Hx and mental status examination Mental Status Examination Definition
A mental status examination (MSE) is an assessment of a patient's level of cognitive (knowledge-related) ability, appearance, emotional mood, and speech and thought patterns at the time of evaluation. to diagnose associated psychiatric and other medical conditions. The assessment specific to sexual behaviors then consists of (a) a sex hormone sex hormone
Any of various steroid hormones, such as estrogen and androgen, affecting the growth or function of the reproductive organs and the development of secondary sex characteristics. profile, (b) sexual questionnaires, and (c) physiological testing of sexual preference. Although it is beyond the scope of this paper, a detailed evaluation is critical to establishing the appropriate treatment intervention. In brief, the sex hormone profile is used to establish a baseline level for possible future treatment with an antiandrogen antiandrogen /an·ti·an·dro·gen/ (-an´dro-jen) any substance capable of inhibiting the biological effects of androgens.
n. , as well as screening for abnormal hormone levels. The sexual questionnaires consist of computerized self-generated diagnosis based on DSM 1. DSM - Data Structure Manager.
An object-oriented language by J.E. Rumbaugh and M.E. Loomis of GE, similar to C++. It is used in implementation of CAD/CAE software. DSM is written in DSM and C and produces C as output. criteria (American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. , 1994), sexual history questionnaires, questionnaires to measure cognitive distortions in relation to rape and coercive sexual traits as well as pedophilia, questionnaires to measure types and levels of sexual fantasies, sexual drive measures as well as measures of general sexual functioning, questionnaires on aggression and impulsivity, and questionnaires on alcohol and drug abuse. Physiological measures of sexual arousal are used to measure sexual preferences such as rape proneness, pedophilia and sexual sadism. Penile penile /pe·nile/ (pe´nil) of or pertaining to the penis.
Of or relating to the penis.
of or pertaining to the penis. tumescence tumescence /tu·mes·cence/ (too-mes´ens) swelling.
1. A swelling or an enlargement.
2. A swollen condition.
3. A swollen part or organ. techniques and visual reaction time are the physiological measures used.
Sex is a basic biological drive, and understanding this helps to conceptualize con·cep·tu·al·ize
v. con·cep·tu·al·ized, con·cep·tu·al·iz·ing, con·cep·tu·al·iz·es
To form a concept or concepts of, and especially to interpret in a conceptual way: the pharmacological treatment approach to sexual deviation. In this framework the paraphilias are similar to eating disorders eating disorders, in psychology, disorders in eating patterns that comprise four categories: anorexia nervosa, bulimia, rumination disorder, and pica. Anorexia nervosa is characterized by self-starvation to avoid obesity. , where a basic biological drive is also involved. It is also well accepted how difficult it is to treat eating disorders. In eating disorders there is a basic biological drive expressed as hunger and this drive can be disturbed, leading to obesity if it is overactive o·ver·ac·tive
Active to an excessive or abnormal degree: an overactive child.
o or anorexia if it is underactive. Thoughts of certain types of food can predominate these disorders as a disturbed directional component to the drive, and the associated behaviour is very difficult to control. It is obvious from the multi-million dollar diet industry in North America how difficult it is for the average person to control their appetite. Sex is also a biological drive with sexual drive the equivalent of hunger and where it can be disturbed both in intensity and direction. Unlike hunger sex is not essential for survival, other than ensuring the procreation PROCREATION. The generation of children; it is an act authorized by the law of nature: one of the principal ends of marriage is the procreation of children. Inst. tit. 2, in pr. of the species. Nonetheless the intensity of the sexual drive is similar to hunger. If this concept is considered in relation to the sexual deviation, then the biomedical approach biomedical approach,
n medical framework that considers illness to be caused by identifiable agents. would involve reducing sexual drive (the equivalent of hunger) and redirecting the drive toward normal sexual behavior and away from deviant sexual interests. There is considerable scientific evidence that the biological components of sexual drive are hormones and neurotransmitters Neurotransmitters
Chemicals within the nervous system that transmit information from or between nerve cells.
Mentioned in: Bulimia Nervosa, Impotence, Pain, Withdrawal Syndromes (Bancroft, 1989). Using this knowledge the traditional pharmacological treatment approach has been aimed at sex drive reduction using antiandrogens or hormonal agents. This has been closely related to other biological interventions such as surgical castration surgical castration Urology Surgical removal of testes–orchiectomy or ovaries–oophorectomy to stop sex hormone production, which slows growth of certain cancers and stereotaxic stereotaxic /ster·eo·tax·ic/ (-tak´sik)
2. pertaining to or exhibiting thigmotaxis (thigmotactic).
1. neurosurgery neurosurgery /neu·ro·sur·gery/ (noor´o-sur?jer-e) surgery of the nervous system.
Surgery on any part of the nervous system. . Stereotaxic neurosurgery is of only historical interest. Surgical castration is of significant interest as it closely parallels antiandrogen treatments which are aimed at reducing plasma testosterone (Bradford, 1985). Surgical castration involves removal of the testes testes
Male reproductive organs (see reproductive system). Humans have two oval-shaped testes 1.5–2 in. (4–5 cm) long that produce sperm and androgens (mainly testosterone), contained in a sac (scrotum) behind the penis. and results in a significant reduction in plasma testosterone levels (Bradford, 1985). The effect of this intervention is seen in the long term outcome studies of surgical castration. These studies, usually involving very serious sexual offenders (mostly pedophiles and rapists) who had already shown high rates of recidivism recidivism: see criminology. resulted in follow-up rates of recidivism ranging from 1.3% to slightly over 10% with follow-up periods in some studies being over 20 years (Bremer, 1959; Cornu cornu /cor·nu/ (kor´noo) pl. cor´nua [L.] horn.
cornu ammo´nis hippocampus.
cornu cuta´neum cutaneous horn. , 1973; Heim & Hursch, 1979; Langeluddeke, 1963, Le Maire, 1956; Ortman 1980, 1984a; Sturup 1968, 1972).
Testosterone is the principle androgen androgen (ăn`drəjən): see testosterone.
Any of a group of hormones that mainly influence the development of the male reproductive system. produced by the testes of most animal species, and is also the most important androgen in influencing male sexual behavior and, to a lesser extent, female sexual behavior (Davidson, Smith, & Damassa, 1977). As the mammalian species studied become more complex, there appears to be a weakening of the direct influence of hormones on sexual behaviors, although in the male sexual behavior tends to remain androgen dependent regardless of the species, including man (Bancroft, 1989). The effects of testosterone occurs through action on the intracellular androgen receptors in various parts of the body (Liang, Tymoczko, Chan, Hung, & Liao, 1977). Testosterone may also be converted to estrogens Estrogens
Hormones produced by the ovaries, the female sex glands.
Mentioned in: Acne, Polycystic Ovary Syndrome
n. in the brain and then have an action on estrogen receptors, and in this way influence sexual drive in both males and females (Naftolin, Ryan, & Petro, 1972). It is these biological factors that are the focus of pharmacological treatments targeting hormones.
More recently the neurochemistry neurochemistry /neu·ro·chem·is·try/ (-kem´is-tre) the branch of neurology dealing with the chemistry of the nervous system.
n. of sexual behavior has been studied, and it is clear that central serotonin metabolism also has a significant effect on sexual behavior (Greenberg & Bradford, 1997). Decreased central serotonin levels in experimental animals are associated with an increase in sexual drive. Contrastingly, increased serotonin levels reduce sexual drive. In humans the role of serotonin in sexual behavior is extremely complex, and in addition there are a variety of serotonin receptors that are present (Bradford, 1999; Greenberg & Bradford, 1997).
Utilizing these factors, it has been possible to establish an algorithm for the treatment of the paraphilias. This algorithm is also based on a classification of the severity of a given paraphilia paraphilia /para·phil·ia/ (par?ah-fil´e-ah) a psychosexual disorder marked by sexual urges, fantasies, and behavior involving objects, suffering or humiliation, or children or other nonconsenting partners. . Although severity might vary according to the type of paraphilia, the following classification covers most paraphilias. In order to establish the degree and severity of a paraphilia, formal training in the assessment of treatment of the paraphilias is imperative. This scheme follows the criteria for severity of manifestations of a specific paraphilia in DSM IIIR IIIR Independent International Investment Research (UK)
IIIR Integration of Internet Information Resources , with the addition of additional category of catastrophic as the highest category of severity. (DSM IIIR 1987).
The paraphilias can be graded from mild to catastrophic as follows, based in part on the severity criteria set forth in DSM IIIR (DSM IIIR 1987).
Mild. "The person is markedly distressed by the recurrent paraphilic urges but has never acted on them" (DSM IIIR 1987). Mild cases would include deviant sexual fantasies and urges but no history of any hands-on victimization. Deviant sexual preference as measured by sexual arousal tests may show evidence of a deviation, but no evidence of severe paraphilias such as sexual sadism. Most of the hands-off paraphilias such as exhibitionism exhibitionism /ex·hi·bi·tion·ism/ (ek?si-bish´in-izm) a paraphilia marked by recurrent sexual urges for and fantasies of exposing one's genitals to an unsuspecting stranger.
n. would be classified here. Hands-on paraphilias such as pedophilia would be limited to deviant sexual fantasies and urges.
Moderate. "The person has occasionally acted on the paraphilic urges" (DSM IIIR 1987). These would be cases where victimization has occurred in terms of the hands-on paraphilias, although the numbers of victims would remain low and the degree of victimization would be confined to nonintrusive fondling (i.e., no penetration). A low number of victims would usually be classified as less than three victims. Sexual arousal would show deviant sexual preference but no arousal to coercive paraphilias or sexual sadism. The hands-off paraphilias would have problems controlling their deviant sexual urges.
Severe. "The person has repeatedly acted on the paraphilic urges" (DSM IIIR 1987). Severe cases would involve greater than three victims and there would be an increased level of intrusiveness in the victimization, where there would be penetration to some degree. Sexual arousal tests would show deviant sexual arousal with a mild coercive component to it but no frank evidence of sexual sadism. There may be mild sexually sadistic sa·dism
1. The deriving of sexual gratification or the tendency to derive sexual gratification from inflicting pain or emotional abuse on others.
2. The deriving of pleasure, or the tendency to derive pleasure, from cruelty. fantasies present. The hands-off paraphilias would have serious difficulties with control.
Catastrophic. There would be clear evidence of sexual sadism in terms of fantasies, urges, history, and behavior in these cases. There may have been victimization and, if this was the case, it would mean this is the highest level of risk in all categories. If there is no victimization, this designation would result from evidence of predatory stalking behavior with sadistic urges, homicidal hom·i·cid·al
1. Of or relating to homicide.
2. Capable of or conducive to homicide: a homicidal rage. urges, and urges to torture. It is classified as catastrophic as any acting out would result in injury and/or death to the victim. Sexual arousal testing would show evidence of sexual sadism, with high levels of arousal to coercive stimuli.
THE AIMS OF PHARMACOLOGICAL TREATMENT:
The aims of treatment in all levels of severity would be the same: (a) to suppress deviant sexual fantasies, (b) to suppress deviant sexual urges and behavior, and (c) to reduce the risk of further victimization. The treatment algorithm would then be as follows:
Level 1: Cognitive behaviourial treatment and relapse prevention treatment. This would always be given regardless of the severity of the paraphilia.
Level 2: Pharmacological treatment would start with specific serotonin reuptake reuptake /re·up·take/ (re-up´tak) reabsorption of a previously secreted substance.
n. inhibitors (SSRIs) and is indicated in most cases of mild paraphilias.
Level 3: If SSRIs are not effective in 4 to 6 weeks when at adequate dosage levels, then a small dose of an antiandrogen would be added, such as Sertraline sertraline /ser·tra·line/ (ser´trah-len) a selective serotonin reuptake inhibitor used as the hydrochloride salt in the treatment of depression, obsessive-compulsive disorder, and panic disorder. 200 mg daily and 50 mg of Medroxyprogesterone Acetate med·rox·y·pro·ges·ter·one acetate
A progestin used to treat menstrual disorders and in hormone replacement therapy, often in combination with estrogen. daily. This would be used in mild and moderate paraphilias.
Level 4: Full antiandrogen treatment or hormonal treatment given orally, e.g. 50 to 300 mg of Medroxyprogesterone Acetate per day or 50 to 300 mg of Cyproterone cy·prot·er·one
A synthetic steroid that inhibits the secretion of androgens.
a synthetic steroid that inhibits the secretion of androgens. Acetate per day. This would be used in moderate cases and in some cases of severe paraphilias.
Level 5: Full antiandrogen treatment or hormonal treatment given intramuscularly in·tra·mus·cu·lar
Within a muscle: an intramuscular injection.
in , such as 300 mg of Medroxyprogesterone Acetate given intramuscularly per week or 200 mg of Cyproterone Acetate given intramuscularly every, two weeks. This would be used in severe cases of paraphilias.
Level 6: Complete androgen suppression and sex drive suppression by giving Cyproterone intramuscularly, such as Cyproterone Acetate 200 to 400 mg intramuscularly given weekly or a luteinizing hormone-releasing hormone agonist luteinizing hormone-releasing hormone agonist LH-RH agonist Endocrinology Any substance that simulates LH-RH which, with time, result in a ↓ sex hormone secretion. See H-RH. . This is for severe cases of paraphilia and the only treatment in catastrophic cases.
The impact of this treatment algorithm on sexual behavior would be as follows:
1. Suppression of deviant sexual fantasies, urges, and behavior with a minor impact on sexual drive occurring at Level 1 and Level 2.
2. Suppression of deviant sexual fantasies, urges, and behavior with a moderate reduction in sexual drive. Normophilic behavior will occur but at a low level. This will be seen at Levels 2 and 3, but is dose dependent.
3. Suppression of deviant sexual fantasies, urges, and behavior with a severe reduction of sexual drive, so that normophilic behavior occurs but at a very low level. This would be seen at Levels 4 and 5.
4. The complete suppression of sexual drive with no paraphilic or normophilic sexual behavior, creating an asexual asexual /asex·u·al/ (a-sek´shoo-al) having no sex; not sexual; not pertaining to sex.
1. Having no evident sex or sex organs; sexless.
2. individual. This would be seen at Level 6.
In the case of the majority of paraphilias, Level 1 and Level 2 of the algorithm would be sufficient for treatment. This would cover most of the hands-off paraphilias such as exhibitionism, voyeurism Voyeurism
See also Eavesdropping.
turned into stag for watching Artemis bathe. [Gk. Myth.: Leach, 8]
elders of Babylon
watch Susanna bathe. , and others where there is not a direct physical contact involving a victim. Caution should prevail however, because of the high levels of comorbidity and crossover between hands-off paraphilias and hands-on paraphilias. This emphasizes the importance of a detailed evaluation prior to implementing treatment. In the case of hands-on paraphilias involving direct physical contacts with victims, such as frotteurism frotteurism /frot·teur·ism/ (fro-toor´izm) a paraphilia in which sexual arousal or orgasm is achieved by actual or fantasized rubbing up against another person, usually in a crowded place with an unsuspecting victim. and pedophilia, the treatment intervention would start at Levels 1 and 2, but would move quickly move to Levels 3 and 4 depending on the effectiveness of treatment outcome. For example, in the cases of mild pedophilia Level 1 and Level 2 would be sufficient treatment intervention. In contrast, for more severe cases of pedophilia Levels 3 and 4 of the algorithm would be the pharmacological treatment needed in order to reach adequate control. More serious cases and cases involving sexual sadism of various degrees would start with a Level 4 intervention would move through to Level 5 and Level 6 depending on the degree of risk and the severity of the paraphilia.
This algorithm can only be used if there is a full understanding of the pharmacology of the various agents used in the treatment. It is also important to think of the paraphilia and the type of treatment as independent variables and that the final treatment outcome can be affected by a variety of mediator variables. These mediator variables are various factors that could cause a relapse of paraphilic behavior. These include (a) abuse of substances, specifically alcohol but also nonprescription non·pre·scrip·tion
Sold legally without a physician's prescription; over-the-counter. drugs; (b) mood disorders, specifically depression but any variation of mood disorder mood disorder
Any of a group of psychiatric disorders, including depression and bipolar disorder, characterized by a pervasive disturbance of mood that is not caused by an organic abnormality. Also called affective disorder. can disinhibit dis·in·hib·it
tr.v. dis·in·hib·it·ed, dis·in·hib·it·ing, dis·in·hib·its
To free from inhibitions. sexual behavior; (c) noncompliance noncompliance
failure of the owner to follow instructions, particularly in administering medication as prescribed; a cause of a less than expected response to treatment.
noncompliance with pharmacological treatment; and (d) noncompliance with relapse prevention interventions.
THE SPECIFIC SEROTONIN REUPTAKE INHIBITORS (SSRIs)
The most recent advance in the treatment of paraphilias has been the use of drugs that affect serotonin (5HT) (Greenberg & Bradford, 1997). By decreasing brain serotonin, animal research has shown that the sexual behavior of animals is affected with an increased sexual drive and, specifically, increased mounting behavior. It is also known that increasing the brain levels of 5HT would reduce sexual drive and behavior. Although sexual behavior in humans is always regarded as being much more complicated than in animals, drugs affecting 5HT levels were seen as possibly being useful in the treatment of sexually deviant behavior by suppressing sexual drive (Greenberg & Bradford, 1997). An early report by Bianchi (1990) described an exhibitionist exhibitionist /ex·hi·bi·tion·ist/ (ek?si-bish´in-ist) a person who indulges in exhibitionism.
exhibitionist An exhibitor exhibiting exhibitionism, see there treated with fluoxetine hydrochloride flu·ox·e·tine hydrochloride
An oral antidepressant chemically unrelated to other antidepressants.
Prozac, Prozac Weekly, Prozit (UK), Sarafem
Pharmacologic class: , and reported a reduction in paraphilic fantasy and urges. Other case reports soon followed, mostly using fluoxetine hydrochloride as the pharmacological agent (Emmanuel, Lydiard, & Ballenger 1991; Lorefice 1991; Perilstein, Lipper, & Friedman 1991; Zohar, Kaplar, & Benjamin 1994). Kafka (1991) studied four patients with nondeviant hypersexuality hypersexuality
see mounting behavior. treated with fluoxetine hydrochloride and reported significant reductions in sexual drive observed clinically. He also reported on three cases of sexual deviation treated with Fluoxetine hydrochloride over a 3-month period and reported considerable improvement. Kafka and Prentky (1992) completed an outpatient study (n = 16), where 50% of the study population suffered from a sexual deviation or paraphilia and the rest suffered from nonparaphilic hypersexuality. All of the patients improved over a 12-week period with a mean dose of 39 mg of fluoxetine hydrochloride per day. Stein et al. (1992) treated five paraphilic males and in contrast reported that none had shown decreased sexual fantasies and urges or masturbation to deviant sexual fantasies when treated with fluoxetine hydrochloride. Also, Coleman, Cesnik, Moore, and Dwyer (1992) completed a retrospective study retrospective study,
a study in which a search is made for a relationship between one phenomenon or condition and another that occurred in the past (e.g. of 13 paraphilic males and reported improvement in all aspects of sexually deviant behavior when treated with fluoxetine hydrochloride. Kafka (1994) reported on an open clinical trial of both men suffering from paraphilia (n = 13) and nonparaphilic hypersexuality (n = 11). The study showed a significant reduction in sexually deviant fantasies, urges, masturbation, and sexual behavior. The specific serotonin reuptake inhibitor was Sertraline and there was about a 50% clinical response rate. The nonresponders were offered an alternative specific serotonin reuptake inhibitor, fluoxetine hydrochloride, and two thirds showed some clinical improvement. The Sertraline was used for a mean duration of treatment of 17.4 weeks (SD [+ or -] 18.6 weeks) and the mean dosage of Sertraline was approximately 100 mg per day. The mean dosage of fluoxetine hydrochloride in the second phase of the clinical study was 51.1 mg per day (SD [+ or -] 19.6) and the duration of treatment was 30.5 weeks (SD [+ or -] 16.8 weeks). Bradford, Greenberg, Gojer, Martindale, and Goldberg (1995) reported on a 12-week open label dose titrated ti·trate
tr. & intr.v. ti·trat·ed, ti·trat·ing, ti·trates
To determine the concentration of (a solution) by titration or perform the operation of titration. study of pedophilia (n = 20) using Sertraline. The mean effective dosage of Sertraline was 131 mg per day. Eighty-six percent of patients completed the study and no patients were discontinued due to an inadequate treatment response. Overall the severity of the pedophilia rated by the physicians in the study decreased dramatically over and this was a statistically significant decrease. A high proportion (86%) of patients were rated as responders. Various sexual behaviors were significantly reduced over the duration of the study while heterosexual coitus coitus /co·i·tus/ (ko´it-us) sexual connection per vaginam between male and female.co´ital
coitus incomple´tus , coitus interrup´tus actually showed a small increase during the study. Physiological measures of sexual arousal showed decreases in pedophilic arousal and improved or maintained normophilic arousal. Although this was an open label study, it did show evidence of improvement or maintenance of normophilic behavior in the treatment of pedophilia, which would be a highly desirable outcome. In another study Greenberg, Bradford, Curry, and O'Rourke (1996) completed a retrospective study of the treatment of a variety of paraphilias using three different serotonin reuptake inhibitors in a sample of paraphilic males (n = 58). The aim of the study was to see the relative efficacy of three different SSRIs in their ability to reduce deviant sexual behavior. In this particular study, the three SSRIs, sertraline hydrochloride sertraline hydrochloride
Lustral (UK), Zoloft
Pharmacologic class: Selective serotonin reuptake inhibitor (SSRI)
Therapeutic class: Antidepressant
Pregnancy risk category C
, fluoxetine hydrochloride and fluvoxamine fluvoxamine /flu·vox·amine/ (floo-vok´sah-men) a selective serotonin reuptake inhibitor, used as the maleate salt to relieve the symptoms of obsessive-compulsive disorder. hydrochloride hydrochloride /hy·dro·chlo·ride/ (-klor´id) a salt of hydrochloric acid.
A compound resulting from the reaction of hydrochloric acid with an organic base. were seen as being equally effective. Sexual fantasies were markedly reduced. Greenberg et al. (1997) completed a retrospective study of paraphilic males (n = 95) treated with SSRIs. There was a control group (n = 104) who only received psychological treatment over a 12-week period. The frequency and severity of paraphilic fantasies were significantly reduced in the sample treated with SSRIs compared to the control group.
The treatment effectiveness of SSRIs in sexually deviant behavior still requires double blind treatment studies to be completed. This is offset in part by a definitive understanding of the role of serotonin in sexual behaviour based on neurobiological neu·ro·bi·ol·o·gy
The biological study of the nervous system or any part of it.
neuro·bi studies of serotonin in animal behaviour. There is no doubt that the SSRIs have a significant impact on sexual behavior as there are now well-documented clinical studies. The success of this treatment with SSRIs has also led to speculation that the paraphilias may be part of obsessive compulsive spectrum disorders, as obsessive compulsive disorder responds to medications that alter central serotonin metabolism. The natural history of paraphilias, the similarities between paraphilic fantasies and obsessions, and deviant sexual behavior and compulsions all contribute to this hypothesis (Bradford, 1999). In fact more is known about the neurobiology Neurobiology
Study of the development and function of the nervous system, with emphasis on how nerve cells generate and control behavior. The major goal of neurobiology is to explain at the molecular level how nerve cells differentiate and develop their of sexual behavior than that of obsessive compulsive disorder at this time. Although there is considerable support for this hypothesis it remains controversial. The fact that sex is a basic biological drive and deviant sexuality involves disturbances of sexual drive as well as the direction of the drive support the paraphilias as being a different diagnostic entity to obsessive compulsive disorders. The SSRIs are recommended for use at Levels 2 and 3 of the treatment algorithm.
Historically estrogens were used for sexual drive reduction (Field, 1973; Foote, 1944; Golla & Hodge, 1949; Symmers, 1968; Whittaker, 1959). Clinical reports found this to be a successful treatment with the side effects Side effects
Effects of a proposed project on other parts of the firm. of nausea, vomiting, and feminization feminization /fem·i·ni·za·tion/ (fem?i-ni-za´shun)
1. the normal development of primary and secondary sex characters in females.
2. the induction or development of female secondary sex characters in the male. limiting its use.
Medroxyprogesterone acetate (MPA MPA
medroxyprogesterone acetate. ) has been the most important form of hormonal agent used in North America and, in particular, in the United States. This started off with studies by Heller, Laidlaw, Harvey, and Nelson (1958). Since then a number of clinical studies have been completed (Berlin & Meinecke, 1981; Cooper, Sandhu, & Losztyn, 1992; Cordoba cor·do·ba
See Table at currency.
[American Spanish córdoba, after Francisco Fernández de Córdoba (1475?-1526?), Spanish explorer.]
Noun 1. & Chapel, 1983; Gagne 1981; Gottesman & Schubert, 1993; Kiersch 1990; Langevin et al., 1979; Meyer, Collier, & Emory, 1992; Meyer, Walker, Emory, & Smith, 1985; Money, 1968; Money 1970; Money et al. 1975; Money, Wiedeking, Walker & Gain, 1976; Walker & Meyer, 1981; Wiedeking, Money, & Walker, 1979; Wincze, Bansal, & Malamud, 1986).
The mechanism of action of MPA is through the induction of testosterone-a-reductase in the liver. This increases the metabolic clearance of testosterone, and plasma testosterone is reduced. In addition, it has a progestinic effect which results in a reduction of the secretion of gonadotropins. It has been shown that it does not compete with androgen receptors at a receptor level and, therefore, by definition is not a true antiandrogen (Southren, Gordon, Vittek, & Altman, 1977). Treatment with MPA results in a number of side effects. This includes weight gain, decreased sperm production, a hypoinsulin response to a glucose load leading to potential problems with diabetes mellitus diabetes mellitus
Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia). , headaches, deep vein thrombosis A blood clot (thrombos) in a vein deep within the muscle, typically in the thigh or calf. It is caused by disease or the lack of activity such as sitting for hours at a computer screen. , hot flashes hot flashes Hot flush Gynecology A symptom afflicting 80-85% of middle-aged ♀, first occurring during the perimenopause, continuing with ↓ intensity for yrs, manifesting itself as transient waves of erythema and uncomfortable warmth beginning in the , nausea, and vomiting, all of which can be managed medically (Berlin & Meinecke, 1981; Gagne, 1981; Walker & Meyer, 1981). At the same time a significant impact on sexual behavior was observed, including a reduction in sex drive, sexual fantasy, and sexual activity (Berlin & Meinecke, 1981; Gagne, 1981; Walker & Meyer, 1981).
The clinical studies of the MPA are mostly open clinical trials, starting with the work of Money (1970, 1972). His reports involve the use of MPA in the treatment of a variety of paraphilic males (n = 9). The dosage of MPA was 300 to 400 mg per week given intramuscularly, and long term positive treatment effects were observed in some subjects 8 years later. Wiedeking, Money, and Walker (1979) reported on the treatment of XYY males (n = 11) who were seriously sexually deviant. They were followed for 12 months in treatment on MPA at a dosage level ranging from 100 to 400 mg per week given intramuscularly. Thirty percent of the patients appeared to respond positively to this treatment intervention. Langevin et al. (1979) completed a study on exhibitionists. This study had a high drop-out rate and is of questionable validity. In an ancillary study, eight of the exhibitionists were evaluated with sexual arousal tests in a placebo and in an active treatment phase using MPA. No differences between placebo and active drug phases were noted, but because of the prolonged half life of MPA this study was flawed.
The two early open clinical studies of most importance are the Berlin and Mienecke study (1981) of 20 paraphilic males and the Gagne (1981) study of 48 patients. Each study showed that MPA was an effective treatment provided the subjects were compliant with the treatment. There tended to be a significant relapse rate if treatment was discontinued. In the Berlin and Meinecke (1981) study three patients actually relapsed while on MPA. Ten out of the eleven patients relapsed after discontinuing MPA against medical advice. The dosage range was from 200 to 400 mg intramuscularly given weekly. Wincze, Bansal, and Malamud (1986) used MPA in a single case experimental design in three pedophiles. They included a double blind procedure. The results showed that self-reported arousal outside of a laboratory setting was unreliable; however, within a laboratory setting significant reduction in arousal to erotic stimuli was noted and this was statistically significant compared to the placebo phase. Nocturnal penile tumescence nocturnal penile tumescence Sexology The spontaneous erection of the penis during sleep occurring from birth to advanced old age, typically, 3 episodes/night, for a total of 2-3 hrs (!!!); NPT occurs during REM sleep and is accompanied by erotosexual dreams. was reduced in all cases. Kiersch (1990) completed a 64-week follow-up study of eight patients treated with MPA. The effectiveness of treatment outcome was self-reported sexual arousal measures, with each patient acting as his own control. MPA was given as 400 weekly depot injections for 16 weeks alternating with saline injections for a crossover period of 16 weeks. Again, the results were variable and some questions about the design of the study can be raised because of the prolonged half life of MPA.
Meyer, Collier, and Emory (1992) studied 40 men treated with MPA and with group and individual therapy. The subjects were mostly pedophiles and the treatment was 400 mg a week by depot injection for 6 months to 12 years. A control group of 21 persons who were treatment refusers were studied. They were treated with psychotherapy over the same follow-up period. In the pharmacological treatment group, 18% reoffended while on MPA and 35% reoffended after MPA was discontinued. This compared to 58% in the control group. The risk factors for reoffence were documented as raised baseline testosterone levels, head injury, and alcohol and substance abuse. Gottesman and Schubert (1993) used a low dose oral MPA treatment regime for the paraphilias. They used 60 mg of MPA a day for 15 months in an open trial involving seven subjects. This treatment regime resulted in significant drop in plasma testosterone levels when compared to baseline and a positive outcome was reported with significant reductions in paraphilic fantasies. Medroxyprogesterone acetate can be used as an intervention according to the treatment algorithm at Levels 3, 4, and 5.
luteinizing hormone-releasing hormone
LHRH Luteinizing hormone-releasing hormone, GnRH, gonadotropin-releasing hormone, LRH, LRF Endocrinology A decapeptide synthesized by hypothalamic neurons which AGONISTS
Luteinizing hormone-releasing hormone agonists (LHRH agonists) have a very specific treatment role in the paraphilias in that they produce a pharmacological "castration castration, removal of the sex glands of an animal, i.e., testes in the male, or ovaries and often the uterus in the female. Castration of the female animal is commonly referred to as spaying. ." The hypothalamic hypothalamic
pertaining to the hypothalamus.
hypothalamic-pituitary-adrenocortical axis pituitary pituitary /pi·tu·i·tary/ (pi-too´i-tar?e)
2. pituitary gland; see under gland.
anterior pituitary adenohypophysis. axis is overstimulated and exhausted, and there is a significant inhibition of gonadotropin gonadotropin /go·nado·tro·pin/ (-tro´pin) any hormone that stimulates the gonads, especially follicle-stimulating hormone and luteinizing hormone. secretion. LHRH agonists that have a prolonged action are the pharmacological agents that have a potential for the use in the treatment of the paraphilias first described by this author in 1985 (Bradford, 1985). Since that time, there have been limited clinical studies on the use of LHRH agonists in this population.
Rousseau, Dupont, Labrie, and Couture (1988) reported on the changes in sexual behavior in prostate cancer prostate cancer, cancer originating in the prostate gland. Prostate cancer is the leading malignancy in men in the United States and is second only to lung cancer as a cause of cancer death in men. patients treated with flutamide (a nonsteroidal non·ste·roi·dal or non·ster·oid
Not being or containing a steroid.
A drug or other substance not containing a steroid. antiandrogen) up to 750 mg per day in divided dosages and surgical castration. Another group of patients in the same study that did not undergo surgical castration were treated with flutamide but in addition were treated with an LHRH agonist agonist /ag·o·nist/ (ag´ah-nist)
1. one involved in a struggle or competition.
2. agonistic muscle.
3. , LHRH ethylamide, administered subcutaneously at 500 mcg for the first month and then 250 mcg after that. The pretreatment pretreatment,
n the protocols required before beginning therapy, usually of a diagnostic nature; before treatment.
n See predetermination. sexual functioning of the patients were compared to posttreatment sexual activity. In the pretreatment phase 80% of the patients were sexually active with sexual intercourse at least once a week, and 50% were able to achieve erections generated by sexual fantasy. These 50% also never had any erectile difficulties. Posttreatment more than 70% of patients had a major decrease in sexual interest, with sexual intercourse and sexual activity maintained in only 20% of cases and about 60% of cases unable to achieve an erection by sexual fantasy. Rosseau, Couture, Dupont, Labrie, and Couture (1990) in a follow-up to the study reported on a single case study treatment of an exhibitionist with the same LHRH agonist. The dosage was 50 mcg per day for four weeks, then 250 mcg per day for 22 weeks. The patient also received flutamide. The patient was followed for 1 year including 9 weeks after discontinuing treatment. The exhibitionistic ex·hi·bi·tion·ism
1. The act or practice of deliberately behaving so as to attract attention.
2. Psychiatry A psychosexual disorder marked by the compulsive exposure of the genitals in public. behavior disappeared, with a marked decrease in sexual fantasies during the active treatment phase without any significant side effects. Within nine weeks of discontinuing the treatment the patient had started to masturbate mas·tur·bate
To perform an act of masturbation. on a regular basis and once again became involved in exhibitionism.
Dickey (1992) reported on a treatment resistant case of pedophilia that had failed to respond to both MPA and CPA (Computer Press Association, Landing, NJ) An earlier membership organization founded in 1983 that promoted excellence in computer journalism. Its annual awards honored outstanding examples in print, broadcast and electronic media. The CPA disbanded in 2000. and was successfully treated with leuprolide acetate leu·pro·lide acetate
A synthetic polypeptide analog of naturally occurring gonadotropin-releasing hormone used in the treatment of advanced prostate cancer. . Thibaut, Cordier, and Kuhn (1993) reported on the treatment of six males with paraphilia treated with triptorelin 3.75 mg per month intramuscularly. These men all had a paraphilia which was mostly pedophilia. Two had failed to respond to cyproterone acetate (CPA) at 150 to 300 mg per day orally, although compliance was questionable in these cases. One patient, although successfully treated with CPA, had to stop treatment because of gynecomastia gynecomastia
Breast enlargement in a male. It usually involves only the nipple and nearby tissue of one breast. More rarely, the whole breast grows to a size normal in a female. True gynecomastia is related to an increase in estrogens. which disappeared 3 months after the CPA was discontinued. The patients were treated with triptorelin 3.75 mg per month concurrently with CPA 200 mg a day for 5.5 months. In five out of the six patients the deviant sexual behavior was markedly decreased without significant side effects in a follow-up period ranging from 7 months to 3 years. One patient interrupted treatment after 12 months and relapsed 2 to 3 months later.
The most important study to date in relation to the treatment of paraphilias with LHRH agonists was published by Rosler and Witztum (1998). This was an uncontrolled open study of the treatment of 30 men with a mean age of 32 years and who suffered from longstanding severe sexual deviation. Twenty-five of the 30 men suffered from pedophilia. They were treated with monthly injections of 3.75 mg of triptorelin and supportive psychotherapy for a follow-up period of 8 to 42 months. The treatment outcome was evaluated monthly by questionnaires. All of the men had a decrease in the number of deviant sexual fantasies and urges. Quantitatively during therapy, this was reduced to zero. There was also a significant decrease in the number of deviant sexual interests to zero while receiving triptorelin. These effects were observed for at least 1 year in all of the men (n = 24) who continued treatment for a year. The plasma testosterone levels fell to castration levels. With the triptorelin treatment, side effects were erectile failure, hot flashes, and some decrease in bone mineral density bone mineral density
See bone density.
bone mineral density A measurement of bone mass, expressed as the amount of mineral–in grams divided by the area scanned in cm2. See Bone densitometry. . LHRH analogues, specifically leuprolide acetate, triptorelin (not available in the United States and Canada) and goserilin acetate, are treatments that can be used at Level 6 of the treatment algorithm.
Cyproterone acetate (CPA) has antiandrogen, antigonadotropic, and progestinic effects and has a principle mode of action at the androgen receptors throughout the body. Its mode of action here is that it blocks intracellular testosterone uptake and the intracellular metabolism of the androgen (Bradford, 1983; Neumann, 1977). The effects of this medication are largely dose dependent. Sexual behavior decreases because of a reduction of plasma testosterone as well as the receptor blockade. This includes erections, masturbation, sexual intercourse, and deviant sexual behavior (Bradford, 1983; Neumann & Schleusener, 1980). CPA has very strong progestational progestational /pro·ges·ta·tion·al/ (pro?jes-ta´shun-al)
1. referring to that phase of the menstrual cycle just before menstruation, when the corpus luteum is active and the endometrium secreting.
2. action and is one hundred times stronger than progesterone progesterone (prōjĕs`tərōn'), female sex hormone that induces secretory changes in the lining of the uterus essential for successful implantation of a fertilized egg. in the Kleiberg test (Schering, 1983). It is designated as an antiandrogen, as it clearly acts at the level of the androgen receptor. Cyproterone and flutamide (a nonsteroidal true antiandrogen) have no antigonadotropic effects. It is the acetate radical that gives CPA its progestational action. CPA blocks or reduces LHRH secretion (Neumann & Schleusener, 1980), and the full antigonadotropic effect of CPA is only seen in females, as in males the antiandrogen and antigonadotropic effects balance out. The specific mode of action of CPA is competitive inhibition competitive inhibition
Blockage of the action of an enzyme on its substrate by replacement of the substrate with a similar but inactive compound that can combine with the active site of the enzyme but that is not acted upon or split by the enzyme. of testosterone and dihydrotestosterone dihydrotestosterone /di·hy·dro·tes·tos·te·rone/ (DHT) (-tes-tos´te-ron) an androgenic hormone formed in peripheral tissue by the action of 5 on testosterone; thought to be the androgen responsible for development of male primary sex at the androgen receptors. CPA is 100% bioavailable orally with a plasma half life of 38 HR [+ or -] 5 hours, and in the intramuscular intramuscular /in·tra·mus·cu·lar/ (-mus´ku-ler) within the muscular substance.
adj. Abbr. IM
Within a muscle. depot form reaches maximum plasma levels in 82 hours (Schering, 1983).
The theoretical risks of CPA treatment are very similar to that with MPA, although unlikely to occur at the dosage levels that are used to treat paraphilias. There is a possibility of liver dysfunction and adrenal adrenal /ad·re·nal/ (ah-dre´n'l)
2. adrenal gland.
3. pertaining to an adrenal gland.
1. suppression (Cremonocihi, Viginati, & Libroia, 1976). CPA is also the most widely studied pharmacological agent in the treatment of the paraphilias. The first clinical studies were in Germany by Laschet and Laschet (1971), who treated more than 100 sexually deviant men. The subjects were mostly exhibitionists and pedophiles, as well as sadists. Further, 50% of them were also sexual offenders. The duration of treatment in an open clinical trial varied from 6 months to longer than 4 years. It was well documented that in 80% of cases, 100 mg a day of CPA eliminated sexual drive, erections, and orgasms, whereas 50 mg a day reduced libido libido (lĭbē`dō, –bī`–) [Lat.,=lust], psychoanalytic term used by Sigmund Freud to identify instinctive energy with the sex instinct. but allowed erections to occur and, therefore, some sexual behavior could continue. CPA was administered intramuscularly at 300 mg biweekly, and in about 20% of exhibitionists there was a complete elimination of all deviant sexual behavior even after treatment was discontinued. The undesirable side effects reported in this study were fatigue, transient depression, weight gain (20% of cases), and some form of feminization including slight gynecomastia. Laschet and Laschet (1975) reported on 300 men treated for up to 8 years with an excellent treatment response. Minimal side effects in long-term management were reported. Davies (1974) completed a study on 50 patients for up to 5 years with only minimal side effects and very good treatment outcome. Bancroft, Tennent, Loucas, and Cass (1974) completed a study on 12 patients comparing CPA 100 mg a day and ethinyl estradiol eth·i·nyl estradiol
A synthetic estrogen derivative commonly used in oral contraceptives.
Ethinyl estradiol 0.2 mg a day. No significant side effects were reported although most side effects were noted with the ethinyl estradiol. Arousal to deviant erotic stimuli measured by penile tumescence was not reduced by ethinyl estradiol but was reduced on CPA.
A number of other studies (Cooper 1981; Cooper, Ismail, Phanjoo, & Love, 1972; Ortmann, 1984b; Ott & Hoffet, 1968) have all shown CPA as effective in reducing deviant sexual behavior. The largest group of sexually deviant men ever studied in pharmacological treatment was the study published by Mothes, Lehnert, Samimi, and Ufer (1971). Detailed analysis of 100 of these patients was reported, and a study of another 200 was reported by Laschet and Laschet (1975). The duration of treatment was from 2 months to 8 years and very successful outcomes were reported. The dosage ranged from 50 to 100 mg orally of CPA and depot CPA, usually from weekly or biweekly dosages ranging from 300 to 600 mg per injection. The side effects in the first 2 months were fatigue, hypersomnia, depression, negative nitrogen balance nitrogen balance
The difference between the amount of nitrogen taken into the body and the amount excreted or lost.
n , and weight gain. At about 3 months, the nitrogen balance had returned to normal and calcium and phosphate metabolism normalized. About 8 months into treatment there were signs of feminization in about 20% of cases, showing some gynecomastia and a reduction in body hair. Beneficial responses, however, were a reduction in paraphilic behavior with decreases in erections, sexual fantasies, and sexual drive reported in 80% of the cases with CPA 100 mg per day given orally. Twenty-five patients were followed up to 5 years posttreatment (i.e., after the discontinuation dis·con·tin·u·a·tion
A cessation; a discontinuance.
Noun 1. discontinuation - the act of discontinuing or breaking off; an interruption (temporary or permanent)
discontinuance of CPA) and showed no evidence of any paraphilic behavior.
A double blind placebo crossover study was completed by Bradford and Pawlak (1993a). A similar study using CPA and evaluating the effect on the sexual arousal patterns of pedophiles was also reported in 1993 by the same authors (Bradford & Pawlak 1993b). There was also a single case study by Bradford and Pawlak (1987). This showed that CPA was an effective agent in the treatment of very severe paraphilias, in this case sexual sadism and pedophilia that resulted in a sexually motivated homicide. It was also noted that in this very severe case of sadistic homosexual pedophilia with very severe temporal lobe temporal lobe
The lowest of the major subdivisions of the cortical mantle of the brain, containing the sensory center for hearing and forming the rear two thirds of the ventral surface of the cerebral hemisphere. damage, that for the first time a differential outcome on the pattern of sexual arousal was seen. What this meant was that the deviant sexual arousal was suppressed at a higher level than normophilic responses, therefore normalizing the sexual arousal patterns. In the study on the sexual arousal patterns of pedophiles (Bradford & Pawlak, 1993b), this pattern was also seen. In the double-blind placebo crossover study 19 subjects were studied, mostly pedophiles. They had high pretreatment recidivism rates with a mean of 2.5 previous convictions per subject. All of the subjects met the DSM-III-R criteria for a paraphilia. CPA was administered orally in 3-month active treatment phases with a crossover placebo design. There was a reduction in sexual arousal of responses with the active drug, but it did not quite reach statistical significance. Self-report measures of arousal were all significantly reduced. Psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.
2. abnormal, maladaptive behavior or mental activity. measured by rating scales showed significant reductions, and self-reported sexual activity was also significantly reduced. Other objective measures of sexuality including fantasies and masturbation were all significantly decreased by CPA (Bradford & Pawlak, 1993a).
Further, CPA is the one pharmacological intervention that has been subjected to research into treatment outcome and recidivism. Eight studies have shown that CPA is effective in reducing post treatment recidivism rates (Appelt & Floru, 1974; Baron & Unger, 1977; Davies, 1974; Fahndrich, 1974; Horn, 1972; Jost, 1975). All of these studies showed posttreatment recidivism rates that were significant reduced where the pretreatment rate and recidivism ranged from 50% to 100% and the posttreatment rate was 0% in follow-up periods ranging from 1 to 5 years. In only one study was there a 16.7% recidivism rate in a 1.5 year follow-up period on six patients (Appelt & Floru, 1974).
CONCLUSIONS AND RECOMMENDATIONS
There is no doubt that the pharmacological treatment of sexual deviation has a scientific basis. There is considerable knowledge of the effects of serotonin on sexual behavior in animal research and open clinical studies in men with paraphilias and hypersexuality. The antiandrogen and hormonal treatments (CPA, MPA, and LHRH agonists) have a sound scientific basis for their efficacy on the basis of androgen effects on sexual behavior. It is also very interesting that with CPA there is a differential effect on the sexual arousal patterns. An ideal treatment outcome may be available where deviant sexual behavior is suppressed and normophilic and normal arousal patterns remain intact or perhaps are even enhanced. The biggest problem in the pharmacological treatment approach has been the lack of government support by the pharmaceutical industry for research, particularly in double-blind placebo crossover design studies. Further, significant ethical barriers exist, making double-blind placebo studies in sexually deviant men very difficult and limiting this type of research in this population. There is no question, however, that this is an effective and important treatment approach, and when combined with cognitive behaviourial treatment and relapse prevention treatment provides a very powerful tool for the treatment and rehabilitation of men with sexual deviation.
Further research is clearly needed in all the pharmacological agents but particularly in the SSRIs and LHRH agonists, where research has not been as extensive as in MPA and CPA. The ethical dilemma of how to conduct placebo-controlled trials is an enormous barrier to future research. In a double-blind placebo-controlled study of CPA completed by this author, ethical approval for a fixed, alternating placebo/active drug design was approved with a proviso that the investigator would move ahead to the next phase of the study if there was a concern that a relapse of deviant sexual behaviour was possible. Bumping to the next phase did occur, and when analyzed at the completion of the study this always occurred from placebo to active drug phase. However, there is an inherent risk in switching from an active drug phase to a placebo in any of the antiandrogens or hormonal agents, as a sudden discontinuation of androgen suppression causes a rebound of hormone levels (FSH FSH follicle-stimulating hormone.
Facioscapulohumeral muscular dystrophy (FSH) , LH, and testosterone) which would increase the risk of deviant sexual behaviour occurring as sexual drive rapidly rebounds parallel to the hormone levels. This would limit studies to always starting with a placebo phase, meaning that only the subjects would be blind. This significant limitation could be only partially offset by objective measures such as hormonal levels and physiological testing of sexual arousal. Further, this does not address the ultimate ethical dilemma where withholding a potentially effective treatment under any circumstances that may result in psychological or physical harm to an innocent third party is unjustified. This means reverting to studies using treatment refusers or comparing pharmacological treatments and nonpharmacological treatments as a way of dealing with this dilemma. This author is looking at long term treatment outcome studies as an intermediate solution.
Interesting future research opportunities are likely to arise in the future when drugs highly specific to serotonin receptors are developed (e.g., the 5HT1a receptor). This could mean a clinical "mapping "of the behaviours associated with pharmacological activity at that specific receptor. This would mirror research what has occurred in animal research.
Future research opportunities are going to be highly dependent on both pharmaceutical and, even more critically, government support. In this author's opinion universities need to establish centers of excellence to promote research in all aspects of sexual behaviour.
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To form a concept or concepts of, and especially to interpret in a conceptual way: , review of treatment modalities and preliminary findings. American Journal of Psychiatry The American Journal of Psychiatry (AJP) is the most widely read psychiatric journal in the world. It covers topics on biological psychiatry, treatment innovations, forensic, ethical, economic, and social issues. , 138, 601-607.
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tr.v. cas·trat·ed, cas·trat·ing, cas·trates
1. To remove the testicles of (a male); geld or emasculate.
2. To remove the ovaries of (a female); spay.
3. sex offenders from a forensic psychiatric viewpoint]. Basel, Switzerland: Karger.
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Excessive growth of facial or body hair in women is called hirsutism.
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Male sex hormones produced by the adrenal glands and testes, the male sex glands.
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DES, diethylstilbestrol, stilbestrol, stilboestrol in the management of psychopathological psy·cho·pa·thol·o·gy
1. The study of the origin, development, and manifestations of mental or behavioral disorders.
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Selective serotonin reuptake inhibitors are medicines that relieve symptoms of depression.
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Laschet, U., & Laschet, L. (1975). Antiandrogens in the treatment of sexual deviations of men. Journal of Steroid Biochemistry, 6, 821-826.
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Liang, T., Tymoczko, J. L., Chan, K. M. B., Hung, H. C., & Liao, S. (1977). Androgen action: Receptors and rapid responses. In L. Martini & M. Motta (Eds.), Androgens and antiandrogens (pp. 77-89). New York: Raven Press.
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1. denoting behavior that violates the rights of others, societal mores, or the law.
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tr.v. a·ro·ma·tized, a·ro·ma·tiz·ing, a·ro·ma·tiz·es
1. To make aromatic or fragrant: swirled the wine to aromatize it.
2. of androstenediol in the anterior hypothalamus hypothalamus (hī'pəthăl`əməs), an important supervisory center in the brain, rich in ganglia, nerve fibers, and synaptic connections. It is composed of several sections called nuclei, each of which controls a specific function. of adult male and female rats. Endocrinology, 90, 295-298.
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Of or relating to a testicle or testis.
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Activated by or capable of liberating serotonin, especially in transmitting nerve impulses.
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A person who strongly identifies with the opposite gender and who chooses to live as a member of the opposite gender or to become one by surgery.
1. Of or relating to such a person.
2. individuals after surgical and hormonal interference with primary and secondary sex characteristics secondary sex characteristic
Any of various characteristics specific to females or males but not directly concerned with reproduction.
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Hormones that stimulate the ovary and testicles.
Mentioned in: Klinefelter Syndrome
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Walker, P. A., & Meyer, W. J. (1981). Medroxyprogesterone acetate treatment Medroxyprogesterone acetate treatment is a treatment program suggested as a possible way to dimish deviant sexual behaviour in sex offenders.
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Manuscript accepted June 18, 2000
John McDonald Wilson Bradford University of Ottawa
Address correspondence to Dr. J. M. W. Bradford, Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, Ontario, CANADA K1Z 7K4; e-mail: email@example.com.