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How to select pharmacologic treatments to manage risk in sex off enders

Consider patient factors when choosing off -label hormonal and nonhormonal agents

® Dowden Healthex offenders Media traditionally are managed by the criminal justice system, but psychiatrists are fre- Squently called on to assess and treat these indi- CopyrightFor personalviduals. use Part only of the reason is the overlap of (disorders of sexual preference) and sexual offending. Many sexual offenders do not meet DSM criteria for paraphilias,1 however, and individuals with paraphil- ias do not necessarily commit offenses or come into contact with the legal system. As clinicians, we may need to assess and treat a wide range of sexual issues, from persons with paraphilias who are self-referred and have no legal involvement, to recurrent sexual offenders who are at a high risk of repeat offending. Successfully managing sex offenders includes psychological and pharmacologic interven- 2009 © CORBIS / TIM PANNELL 2009 © CORBIS / tions and possibly incarceration and post-incarceration Bradley D. Booth, MD surveillance. This article focuses on pharmacologic in- Assistant professor terventions for male sexual offenders. Department of Director of education Integrated Forensics Program University of Ottawa Reducing sexual drive Ottawa, ON, Canada Sex offending likely is the result of a complex inter- play of environment and psychological and biologic factors. The biology of sexual function provides nu- merous targets for pharmacologic intervention, in- cluding:2 • endocrine factors, such as • neurotransmitters, such as serotonin. The use of pharmacologic treatments for sex of- fenders is off-label, and evidence is limited. In general, Current Psychiatry 60 October 2009 pharmacologic treatments are geared toward reducing

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60_CPSY1009 60 9/15/09 2:00:24 PM Table 1 Pharmacologic treatment of male sex off enders: A risk-based approach

Low-risk High-risk offenders offenders

SSRI SSRI augmented Oral CPA,* 100 to IM CPA,* 100 to GNRH agonist: with finasteride, 500 mg/d, or oral 600 mg/week,† or IM leuprolide, 5 mg/d, MPA, 100 to 600 IM MPA, 100 to 7.5 mg/month; naltrexone, 100 mg/d 700 mg/week† IM goserelin, 3.6 to 200 mg/d, mg/month; or IM methylphenidate, , 3.75 up to 1 mg/kg/d, mg/month oral MPA, 50 mg/d, or oral CPA,* 50 mg/d *Not available in the United States Clinical Point †Some authors suggest administering this dosage once every 2 weeks CPA: ; GNRH: -releasing hormone; IM: intramuscular; MPA: acetate; SSRI: selective serotonin reuptake inhibitor SSRIs may be more Source: References 3-5 appealing to patients than the ‘chemical sexual drive through nonhormonal or hor- increase in conventional sexual interests, ’ of monal means (Table 1).3-5 although this may be related to placebo or hormonal treatments halo effects—patients may have reported an increase in conventional interests be- Nonhormonal treatments cause they noticed a decrease in paraphili- SSRIs. Selective serotonin reuptake inhibi- ac interests. Negative side effects included tors act by blocking serotonin reuptake in decreased sexual desires, delayed ejacula- the synaptic cleft. Soon after the fi rst SSRIs tion, decreased , and anorgasmia. were approved in 1988, reports appeared of Adi et al11 completed a more rigor- SSRIs interfering with sexual functioning.6 ous literature evaluation that included 9 This side effect quickly was exploited to as- studies with a total of 225 patients receiv- sist the treatment of sexual offenders.7 ing fl uoxetine, fl uvoxamine, sertraline, or The may include:8 paroxetine. Eight studies showed benefi ts; • direct effects, such as general inhibi- however, Adi noted that this preliminary tion of sexual activity, reduced impulsive- evidence was “far from conclusive.” ness, and an effect on the hypothesized “ob- SSRIs generally are well tolerated and sessive-compulsive” nature of paraphilias9 may be more appealing to patients than the • indirect reduction of testosterone. “chemical castration” of hormonal treat- A growing body of literature supports ments. Dosing is similar to that used in de- SSRIs’ effectiveness in treating paraphilias pression or obsessive-compulsive disorder. and sexual offenders. Greenberg7 reviewed Although most patients notice benefi cial case studies and open drug trials of nearly effects in 2 to 4 weeks, some notice the ef- 200 patients receiving fl uoxetine, fl uvox- fect nearly immediately. , or sertraline. Most studies showed 10 response rates of 50% to 90%. Positive ef- Naltrexone. An antagonist thought ONLINE fects included decreases in: to affect the CNS processes of and ONLY • paraphiliac fantasies, urges, and sexu- pain, naltrexone has been used to treat Discuss this article at al acts dependence and pathologic gam- http://CurrentPsychiatry. • masturbation bling. A few case studies12-14 and 1 study of blogspot.com • hypersexual activity. 21 adolescent sex offenders15 have shown Some studies reported a preferential benefi ts in treating sexual offenders or para- Current Psychiatry decrease in paraphiliac interests with an philiacs. Benefi ts were seen at 50 mg/d, Vol. 8, No. 10 61 continued on page 68

61_CPSY1009 61 9/16/09 3:37:36 PM INVEGA® (paliperidone) Extended-Release Tablets continued from page 61 subjects and younger subjects, and other reported clinical experience has Table 2 not identified differences in response between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. This drug is known to be substantially excreted by the kidney and clearance Common side eff ects of is decreased in patients with moderate to severe renal impairment [see therapy Clinical Pharmacology (12.3) in full PI], who should be given reduced doses. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function [see Dosage and Administration (2.5) in full PI]. Erectile dysfunction Renal Impairment: Dosing must be individualized according to the patient’s renal function status [see Dosage and Administration (2.5) in full PI]. Fatigue Hepatic Impairment: No dosage adjustment is required in patients with mild to moderate hepatic impairment. INVEGA® has not been studied in patients with severe hepatic impairment. Hot flashes DRUG ABUSE AND DEPENDENCE ® Controlled Substance: INVEGA (paliperidone) is not a controlled substance. Hypertension Abuse: Paliperidone has not been systematically studied in animals or humans for its potential for abuse. It is not possible to predict the extent to which a Low libido CNS-active drug will be misused, diverted, and/or abused once marketed. Consequently, patients should be evaluated carefully for a history of drug Myalgia abuse, and such patients should be observed closely for signs of INVEGA® misuse or abuse (e.g., development of tolerance, increases in dose, Osteopenia drug-seeking behavior). Dependence: Paliperidone has not been systematically studied in animals or humans for its potential for tolerance or . Sweating OVERDOSAGE Human Experience: While experience with paliperidone overdose is limited, Thromboembolism among the few cases of overdose reported in pre-marketing trials, the highest estimated ingestion of INVEGA® was 405 mg. Observed signs and symptoms Weight gain included extrapyramidal symptoms and gait unsteadiness. Other potential signs and symptoms include those resulting from an exaggeration of paliperidone’s known pharmacological effects, i.e., drowsiness and somnolence, tachycardia and hypotension, and QT prolongation. with suggested dosing of 100 to 200 mg/d. Be- Paliperidone is the major of risperidone. Overdose cause data are very limited, consider naltrexone experience reported with risperidone can be found in the OVERDOSAGE section of the risperidone package insert. only on an individual basis or as a possible adjunc- Management of Overdosage: There is no specific to paliperidone, tive treatment. therefore, appropriate supportive measures should be instituted and close medical supervision and monitoring should continue until the patient recovers. Consideration should be given to the extended-release nature of the product Psychostimulants. Methylphenidate was added to when assessing treatment needs and recovery. Multiple drug involvement should also be considered. augment SSRI treatment in a study of 26 men with In case of acute overdose, establish and maintain an airway and ensure paraphilias or -related disorders.16 Results adequate oxygenation and ventilation. Gastric lavage (after intubation if patient is unconscious) and administration of activated charcoal together with included further signifi cant decreases in total sexual a laxative should be considered. outlets (orgasms per week) and average time spent The possibility of obtundation, seizures, or dystonic reaction of the head and per day in paraphilia and paraphilia-related behav- neck following overdose may create a risk of aspiration with induced emesis. Cardiovascular monitoring should commence immediately, including ior. These gains appeared to be independent of the continuous electrocardiographic monitoring for possible arrhythmias. If presence of attention-defi cit/hyperactivity disorder. antiarrhythmic therapy is administered, disopyramide, procainamide, and quinidine carry a theoretical hazard of additive QT-prolonging effects when Again, because data are very limited, consider administered in patients with an acute overdose of paliperidone. Similarly the alpha-blocking properties of bretylium might be additive to those of this strategy only on an individual basis or as a paliperidone, resulting in problematic hypotension. possible adjunctive treatment. Because sexual of- Hypotension and circulatory collapse should be treated with appropriate 17 measures, such as intravenous fluids and/or sympathomimetic agents fenders have high rates of , con- (epinephrine and dopamine should not be used, since beta stimulation may sider the potential for stimulant abuse. worsen hypotension in the setting of paliperidone-induced alpha blockade). In cases of severe extrapyramidal symptoms, anticholinergic should be administered. Inactive ingredients are carnauba wax, cellulose acetate, hydroxyethyl cellulose, propylene glycol, polyethylene glycol, polyethylene oxides, Hormonal treatments povidone, sodium chloride, stearic acid, butylated hydroxytoluene, Because testosterone is required for healthy bone hypromellose, titanium dioxide, and iron oxides. The 3 mg tablets also contain lactose monohydrate and triacetin. , the antiandrogen used in hormonal treatment can cause osteoporosis.18,19 Manufactured by: Therefore, long-term antiandrogen treatment ALZA Corporation, Vacaville, CA 95688 OR should include bone scans to monitor for osteope- Janssen Cilag Manufacturing, LLC, Gurabo, Puerto Rico 00778 Manufactured for: nia and osteoporosis. Some authors have suggested Janssen, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., that monthly doses of 25 to 50 mg of testosterone Titusville, NJ 08560 could minimize this risk.20 Bisphosphonates, vita- OROS is a registered trademark of ALZA Corporation ©Ortho-McNeil-Janssen Pharmaceuticals, Inc. 2007 Revised: July 2009 10105905B Current Psychiatry 68 October 2009

68_CPSY1009 68 9/16/09 3:37:41 PM min D, and supplements at osteo- crease deviant and recidi- porosis treatment levels might be helpful.18 vism. In a study of 100 patients receiving Other common side effects of antiandro- MPA (average 250 mg IM every 2 weeks) gen medications are listed in Table 2. for an average of 3 years, only 1 re-offended while taking MPA.4 Finasteride is approved for treating be- In a 5-year follow-up study25 of 275 nign prostatic hyperplasia and andro- men, subjects were classifi ed into high genetic alopecia. It works by preventing risk/treatment with MPA, 200 to 400 mg conversion of testosterone to dihydrotes- IM every 2 weeks, and low risk/nontreat- tosterone (DHT) by the type II isoen- ment groups. A portion of the high risk/ zyme.21 Serum DHT contributes to male treatment group did not receive MPA. No sexual behavior and predicts frequency of sexual re-offenses occurred among high- orgasms in healthy volunteers.22 Although risk subjects who received MPA, whereas there have been no studies of fi nasteride in the recidivism rate was 18% among high- sex offenders, it may be more acceptable to risk subjects who did not receive MPA. patients than other hormonal treatments Subjects in the low risk/nontreatment and have a theoretical benefi t in reducing group had a recidivism rate of 15%, which Clinical Point sexual drive. Clinically, some patients de- suggests the need for more liberal use of MPA, which reduces scribe increased control over urges with- . One major confounding testosterone levels out substantial side effects. Because there factor was that subjects in the high risk/ is no evidence supporting fi nasteride use treatment group had to report every 2 by about 50%, has in sex offenders, consider this medication weeks for injections; this may have result- been shown to only on an individual basis or as a possible ed in closer follow-up, monitoring, and decrease deviant adjunctive treatment. support, which may have contributed to sexual desire and lower recidivism. (CPA) is a synthetic recidivism that blocks receptors.3,23 Gonadotropin-releasing hormone (GNRH) Some evidence supports its use in treating agonists. The terms gonadotropin-releasing sex offenders,24 although this agent is not hormone and luteinizing-releasing hor- available in the United States. For more mone are used interchangeably. Most body information about CPA, see this article at testosterone is produced and released by CurrentPsychiatry.com. Leydig cells in the testes in response to stimulation by LH released by the pituitary Medroxyprogesterone acetate (MPA), a gland. LH release is controlled by the pul- derivative of , lowers serum satile release of GNRH from the hypothala- testosterone by inhibiting its production mus. GNRH agonists are high- through reducing pituitary luteinizing analogs of GNRH that work by causing hormone (LH).24 The typical dose range an initial surge of LH followed by down- for use in sex offenders is 100 to 600 mg/d regulation of gonadotroph cells, a drop in orally or 100 to 700 mg IM every week,3 al- LH, and a drop in testosterone to castration though some authors suggest giving simi- levels. lar doses every 2 weeks.4 The GNRH analogs leuprolide, gosere- Side effects of MPA include hypersom- lin, and triptorelin are used to treat para- nia; neurasthenia; weight gain; hot fl ashes; philiacs and sexual offenders.20 Leuprolide

gynecomastia; increased scalp hair; and typically is dosed at 7.5 mg IM every ONLINE decreased erections, ejaculate volume, month, 22.5 mg IM every 3 months, or 30 ONLY , and body and facial mg IM every 4 months. Goserelin is pro- Visit this article at hair. The drug decreases testosterone lev- vided as a subcutaneous implant/depot CurrentPsychiatry.com for els by about 50%. Positive effects include injected as 3.6 mg every month or 10.8 mg more information about reduced interest in and energy spent on every 3 months. cyproterone acetate pursuing sexual goals, but preservation of Triptorelin is FDA-approved as treat- nondeviant sexual arousal.4 ment for advanced cancer. Trip- Current Psychiatry MPA has been shown to effectively de- torelin is given in depot formulation as Vol. 8, No. 10 69

69_CPSY1009 69 9/16/09 2:43:51 PM Table 3 Monitoring patients receiving antiandrogen medications Pre-therapy workup Periodic monitoring Endocrinology or internist consultation Monthly: testosterone for the first 6 months Bone scan Every 6 months: testosterone, LH, FSH, prolactin, Weight CBC, renal function, function, fasting glucose and lipids, weight, blood pressure Sex off enders Blood pressure Yearly: bone scan Electrocardiogram CBC, renal function, liver function, fasting glucose, and lipids LH, FSH, testosterone, prolactin

CBC: complete blood count; FSH: follicle-stimulating hormone; LH: luteinizing hormone Source: References 19,27,31

3.75 mg IM every month or in a long-acting Monitoring Clinical Point form as 11.25 mg IM every 3 months. Laboratory investigations are recommend- When starting a When starting these medications, an ini- ed to monitor for side effects of antiandro- 19,27,31 GNRH agonist, an tial surge of LH and testosterone can last gen medications (Table 3). Medical up to 3 weeks.26 Theoretically, this could contraindications to rule out before initiat- initial surge of LH worsen paraphiliac interests. Many practi- ing antiandrogen medications include: and testosterone tioners will use a testosterone blocker such • thromboembolic diseases could worsen as fl utamide, 250 mg tid, for the initial • paraphiliac interests weeks of treatment. • bone demineralization disorders Side effects of the GNRH agonists are • hypersensitivity to the drug. similar. Most patients initially experience Measure prolactin to rule out pituitary hot fl ashes. A systemic literature review27 adenomas. Monitor serum testosterone reported: because some patients will not experience • weight gain testosterone suppression from GNRH ago- • perspiration nists or other antiandrogens. Noncompli- • gynecomastia ant patients could potentially reverse the • urinary incontinence effects of MPA and GNRH agonists by tak- • hot fl ashes ing exogenous testosterone. • decreased growth of facial and body hair • asthenia Medication selection • erectile failure The goals of pharmacologic treatment of • muscle tenderness sex offenders are to: • frequent bone demineralization. • reduce sexual offending and victim- Rare cases of pituitary apoplexy (a clini- ization cal syndrome secondary to infarction of • suppress sexual drive to a controllable the pituitary gland) have been reported, level possibly related to an underlying pituitary • possibly preferentially eliminate devi- adenoma.28 ant arousal/thoughts In a literature review that totalled 118 • allow normal sexual relationships. patients,27 GNRH agonists signifi cantly decreased erections, ejaculations, paraphil- Gauging risk. In determining which phar- iac fantasies, and paraphiliac behavior. Pa- macologic treatment to offer a patient, fi rst tients also reported feeling more relaxed, evaluate the individual’s risk for recidi- and recidivism rates were low. Some pa- vism. Actuarial scales32,33 suggest that re- tients who failed to respond to CPA and cidivism risk can be categorized, based on MPA responded to GNRH agonists. Subse- clinical factors (Table 4).4,25,34 Current Psychiatry 70 October 2009 quent studies found similar results.29,30 In addition to statistical risk factors,

70_CPSY1009 70 9/16/09 2:43:56 PM Table 4 Will my patient commit another sexual off ense? Evaluating risk

Low-risk High-risk offenders offenders

Self-referred Developmental delay Offenses while receiving Open about offense Ongoing substance use treatment Situational offenders Male victims Minimization of offense (ie, nonpredatory on Predatory offender known victim) Violent offense No hands-on offenses Younger age (ie, only child , Social instability , ) Paraphilic preference No previous offenses (ie, preferential Older age arousal to children Social stability or nonconsensual sex) Clinical Point Nonparaphiliac preference Recurrent offenses Long-term (ie, preferential arousal to consensual sex with adults) Severe sexual sadism antiandrogen Invested in treatment Victim was a stranger treatment should Source: References 4,25,34 include monitoring for osteopenia and osteoporosis several other factors affect medication se- oral MPA or CPA would be tried next. For lection. Self-referred individuals may be higher-risk individuals or treatment fail- more reliable in taking oral medications ures, IM MPA or CPA would be offered than those referred by the courts. A devel- next, followed by a GNRH agonist. For in- opmentally delayed individual may be a dividuals at highest risk for re-offending, poor candidate for oral medication, unless combinations of agents may be indicated. he resides in a group home setting where This simple strategy is appealing, but compliance can be assured. Effi cacy also in reality, treatment should be individu- guides medication choice. Finally, some alized. Choose medications based on the patients will be legally required to provide patient’s risk, wishes, and the previously proof of compliance, which only IM medi- mentioned clinical factors. cations provide. References 1. First MB, Halon RL. Use of DSM paraphilia diagnoses in Treatment. Based on clinical experience sexually violent predator commitment cases. J Am Acad Psychiatry Law. 2008;36(4):443-454. and available literature, Bradford5 created 2. Meston CM, Frohlich PF. The neurobiology of sexual function. an algorithm to help clinicians select ap- Arch Gen Psychiatry. 2000;57:1012-1030. 3. Bezchlibnyk-Butler KZ, Jeffries JJ, eds. Clinical handbook of propriate pharmacologic interventions. psychotropic drugs. 16th ed. Seattle, WA: Hogrefe & Huber Although it has not been validated, this Publishers; 2006:222-225. 4. Maletzky B. The use of medroxyprogesterone acetate to assist algorithm provides a reasonable starting in the treatment of sexual offenders. Annals of Sex Research. place. 1991;4:117-129. 5. Bradford JM. The neurobiology, neuropharmacology, and In general, start treatment with an SSRI pharmacological treatment of the paraphilias and compulsive for low-risk individuals (Table 1, page 61).3-5 sexual behaviour. Can J Psychiatry. 2001;46(1):26-34. 6. Baldwin DS. Sexual dysfunction associated with antidepressant If this strategy is insuffi cient, consider aug- drugs. Expert Opin Drug Saf. 2004;3(5):457-470. mentation with methylphenidate, naltrex- 7. Greenberg DM, Bradford JMW. Treatment of the paraphilic disorders: a review of the role of the selective serotonin one, or fi nasteride. reuptake inhibitors. Sex Abuse. 1997;9(4):349-360. The next step would be to add oral MPA 8. Hill A, Briken P, Kraus C, et al. Differential pharmacological treatment of paraphilias and sex offenders. Int J Offender Ther or CPA, 50 mg/d, which would partially Comp Criminol. 2003;47(4):407-421. inhibit testosterone and may allow some 9. Bradford JMW. The paraphilias, obsessive compulsive spectrum disorder, and the treatment of sexually deviant Current Psychiatry normal sexual functioning.4,23 Higher-dose behaviour. Psychiatr Q. 1999;70(3):209-219. Vol. 8, No. 10 71 continued

71_CPSY1009 71 9/16/09 2:44:00 PM 10. Krueger RB, Kaplan MS. Behavioral and psycho- pharmacological treatment of the paraphilic and hypersexual disorders. J Psychiatr Prac. 2002;8(1):21-32. Related Resources 11. Adi Y, Ashcroft D, Browne K, et al. Clinical effectiveness and • Krueger RB, Kaplan MS. The paraphilic and hypersexual cost-consequences of selective serotonin reuptake inhibitors disorders: an overview. J Psychiatr Pract. 2001;7:391-403. in the treatment of sex offenders. Health Technol Assess. 2002;6(28):1-66. • Krueger RB, Kaplan MS. Behavioral and 12. Raymond NC, Grant JE, Kim SW, et al. Treatment of psychopharmacological treatment of the paraphilic and compulsive sexual behaviour with naltrexone and serotonin hypersexual disorders. J Psychiatr Pract. 2002;8:21-32. reuptake inhibitors: two case studies. Int Clin Psychopharm. 2002;17(4):201-205. • Association for the Treatment of Sexual Abusers. www.atsa.com. Sex off enders 13. Grant JE, Kim SW. A case of and compulsive sexual behavior treated with naltrexone. Ann Clin Psychiatry. Drug Brand Names 2001;13(4):229-231. 14. Sandyk R. Naltrexone suppresses abnormal sexual behavior Cyproterone acetate • Medroxyprogesterone in Tourette’s syndrome. Int J Neurosci. 1988;43(1-2):107-110. Androcur acetate • Depo-Provera, 15. Ryback RS. Naltrexone in the treatment of adolescent sexual Finasteride • Propecia, Proscar Provera offenders. J Clin Psychiatry. 2004;65(7):982-986. Fluoxetine • Prozac Methylphenidate • Ritalin 16. Kafka M, Hennen J. Psychostimulant augmentation during • Eulexin Naltrexone • ReVia treatment with selective serotonin reuptake inhibitors in Fluvoxamine • Luvox Paroxetine • Paxil men with paraphilias and paraphilia-related disorders: a case Goserelin • Zoladex Sertraline • Zoloft series. J Clin Psychiatry. 2000;61(9):664-670. Leuprolide • Eligard, Lupron Triptorelin • Trelstar Depot 17. Langstrom N, Sjostedt G, Grann M. Psychiatric disorders and recidivism in sexual offenders. Sex Abuse. 2004;16(2):139-150. 18. Smith MR. Osteoporosis during androgen deprivation therapy Disclosure Clinical Point for . Urology. 2002;60(3 suppl 1):79-85. Dr. Booth reports no fi nancial relationship with any company 19. Grasswick LJ, Bradford JM. Osteoporosis associated with whose products are mentioned in the article or with Base medication the treatment of paraphilias: a clinical review of seven case reports. J Forensic Sci. 2003;48:849-855. manufacturers of competing products. selection on your 20. Rösler A, Witztum E. Pharmacotherapy of paraphilias in the next millennium. Behav Sci Law. 2000;18:43-56. patient’s risk for 21. Finn DA, Beadles-Bohling AS, Beckley EH, et al. A new look at the 5-alpha-reductase inhibitor fi nasteride. CNS Drug Rev. 28. Blaut K, Winiewski P, Syrenicz A, et al. Apoplexy of clinically recidivism, his 2006;12(1):53-76. silent pituitary adenoma during prostate cancer treatment with 22. Mantzoros CS, Georgiadis EI, Trichopoulos D. Contribution LHRH analog. Neuro Endocrinol Lett. 2006;27(5):569-572. wishes, and other of to male sexual behaviour. BMJ. 29. Schober JM, Kuhn PJ, Kovacs P, et al. Leuprolide acetate 1995;310(6990):1289-1291. suppresses pedophilic urges and arousability. Arch Sex Behav. clinical factors 23. Bradford JMW, Pawlak A. Double-blind placebo crossover 2005;34(6):691-705. study of cyproterone acetate in the treatment of the paraphilias. 30. Ösler A, Witztum E. Treatment of men with paraphilia with a Arch Sex Behav. 1993;22(5):383-402. long-acting analogue of gonadotropin-releasing hormone. N 24. Meyer WJ, Cole CM. Physical and chemical castration of sex Engl J Med. 1998;338:416-422. offenders: a review. J Offender Rehab. 1997;25(3/4):1-18. 31. Reilly DR, Delva NJ, Hudson RW. Protocols for the use of 25. Maletzky BM, Tolan A, McFarland B. The depo- cyproterone, medroxyprogesterone, and leuprolide in the Provera program: a fi ve-year follow-up. Sex Abuse. treatment of paraphilia. Can J Psychiatry. 2000;45:559-563. 2006;18:303-316. 32. Quinsey VL, Harris GT, Rice ME, et al. Violent offenders: 26. van Poppel H, Nilsson S. Testosterone surge: rationale appraising and managing risk. Washington, DC: American for gonadotropin-releasing hormone blockers? Urology. Psychological Association; 1998. 2008;71:1001-1006. 33. Epperson DL, Kaul JD, Huot SJ, et al. Minnesota Sex Offender 27. Briken P, Hill A, Berner W. Pharmacotherapy of paraphilias Screening Tool–revised (MnSOST-R). St. Paul, MN: Minnesota with long-acting agonists of luteinizing hormone–releasing Department of Corrections; 1998. hormone: a systematic review. J Clin Psychiatry. 2003;64:890- 34. Bradford JMW. The treatment of sexual deviation using a 897. pharmacological approach. J Sex Res. 2000;37(3):248-257.

Bottom Line Pharmacologic treatment of male sex off enders can decrease deviant sexual behavior. Tailor treatment to the patient’s risk for recidivism and other clinical factors. Start with an SSRI for lower-risk patients. Consider oral or IM medroxyprogesterone or gonadotropin-releasing hormone agonists for those with higher risk.

Current Psychiatry 72 October 2009

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