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Evidence Based Answers Could Sildenafil Cause Rape (Pdf EDUCATION • Best evidence Evidence based answers: could sildenafil cause rape? Geoff Spurling, MBBS, is a registrar, Inala Community Health Centre General Practice, Queensland. The setting would not be ethical, so the Cochrane database occurred to me that sildenafil may cause Mr LD, 48 years of age, presented with long was not likely to be helpful. Observational aggression. However, it found no empirical standing impotence. He was concerned this studies, case control studies or legal cases evidence of a causal relationship between would adversely affect the relationship with seemed to have the best chance of giving us sildenafil and rape. We did not search legal his new girlfriend of 3 weeks. Initial evalua- the information we needed. We went to the databases, although it appeared from the tion included history and physical ‘clinical queries’ page of PubMed (this link can article as though sildenafil has not been suc- examination. Relevant pathology tests did not be found on the left of the PubMed home page) cessfully used as a defence in a rape case. reveal an obvious cause for his impotence and entered the terms: ‘sildenafil’ and ‘rape’. When Mr LD returned, he expressed con- other than past depression. There was one ‘hit’. ‘Neurologic, psychological cerns about how the parole board would view ‘What about Viagra, doc?’ he asked, ‘She’s and aggressive disturbances with sildenafil’ pub- him taking sildenafil, therefore we are presently going to leave me if I don’t do something’. lished in the Annals of Pharmacotherapy.1 focussing on the relationship and psychological My concern was that I knew he was on Assessing the evidence aspects of his erectile dysfunction. parole from a 5 year prison sentence for raping The article was written in the United States to his ex-wife. Management options had to be assist the defence in the trial of a man accused Discussion discussed. I deferred this decision to give of rape, in which sildenafil was implicated. The While the search for evidence did not lead me myself time to think about the complex issues, objective was to find scientific information to research that answered my question, the and asked him to come back in 2 weeks. linking sildenafil and aggressive behaviour. process of searching clarified the issues and PubMed and Medline had been searched using expanded the scope of my thinking. It was also Asking the question specified search terms. Information was also helpful to me that our practice has a forum (the I considered the ethical and information obtained on adverse events from the Food and C-QAC) in which to discuss these difficult cases. issues – at least if I gain some evidence Drug Administration (FDA). With these data, Acknowledgment based knowledge, I should be better able to the authors proposed a pathophysiological or I would like to thank Professor Chris Del Mar for his wrestle with the ethical dilemmas. The neurochemical basis for their hypothesis that help in preparing this article. important questions seemed to be: sildenafil causes aggression. They also noted • can sildenafil cause an increased risk of rape? 13 adverse events reported to the FDA for Conflict of interest: none declared. • should this man’s prison and psychiatric rape where sildenafil was cited. The reviewers Reference history influence my prescribing? did not specify the use of other databases such 1. Milman HA, Arnold SB. Neurologic, psychologi- I raised the problem at our weekly clinical ques- as EMBASE or Current Contents and did not cal, and aggressive disturbances with sildenafil. Ann Pharmacother 2002;36:1129–1134. tion answering club (C-QAC), and it provoked an discuss how articles were considered for inclu- AFP interesting discussion. The resulting question for- sion or how they were evaluated. Finally, no mulation for a literature search was as follows: empirical evidence was presented linking silde- Rape is a heinous crime that has more to do with among impotent convicted male rapists (Patient), nafil and rape. an abuse of power than disordered sexual func- tion. The social, ethical and legal questions raised what is the chance that sildenafil (Intervention) Applying the evidence by this patient’s presentation are far more would be more likely than no impotence treat- complex than the clinical one. Legal databases ment (Comparison) to lead to rape (Outcome)? The search showed that other people had show 6 cases of erectile dysfunction treatment being proposed as a defence for rape – none has been concerned with the same issue, Accessing the information been successful in mitigating the charge. although with different motivations. Before Geoff Spurling, Steve Trumble We decided what type of research would be conducting the search, my concern was that required to answer the question. Clearly a ran- sildenafil would facilitate penile rape by Correspondence domised controlled trial on this specific PICO enabling Mr LD to gain an erection. It had not Email: [email protected] 356Reprinted from Australian Family Physician Vol. 33, No. 5, May 2004.
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