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Pharmacological Treatment of Paraphilias Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012) Pharmacological Treatment of Paraphilias Florence Thibaut , MD, PhD Psychiatric Department, University Hospital Ch. Nicolle, INSERM U 614, Rouen, France unclear despite years of research. Numerous psycho- logical, developmental, environmental, genetic, and ABSTRACT organic factors have been discussed, but none of the Background: The psychiatrist’s main role is to provide theories fully explains paraphilic behaviors. The causes care to the paraphilic patient and to reduce personal are probably multifactorial, rendering treatment dif- distress. However, in cases of paraphilia associated with ficult. Recidivism of sex offences is a major concern sexual offences, reducing paraphilic behavior is critical in in the treatment of paraphilias such as pedophilia. an approach to preventing sexual violence and reducing Most people recognize that incarceration alone will victimization. This review will focus on this specific not solve sexual violence. Indeed, treating the sexual population. offenders with a diagnosis of paraphilia is critical in an approach to preventing sexual violence and reducing Method: We discuss the recently published recom- victimization. This paper was intended to present and mendations for the treatment of paraphilias of the World summarize pharmacological treatment of paraphilias Federation of Societies of Biological Psychiatry which and will focus on paraphilias associated with a risk of were based on a review of the available literature about sexual offending such as pedophilia or exhibitionism. pharmacological treatment of paraphilias (1970-2010). Results and Conclusion: Antiandrogens, and mostly GnRH analogues, significantly reduce the intensity and DEFINITION OF PARAPHILIAS frequency of deviant sexual arousal and behavior, although According to the Diagnostic and Statistical Manual informed consent is necessary in all cases. GnRH analogue Disorder, Fourth Edition, Text Revision (DSM IV-TR) treatment constitutes the most promising treatment or to the International Classification of Mental Diseases for sex offenders at high risk of sexual violence, such as (ICD 10th), paraphilias are defined as sexual disorders pedophiles or serial rapists. SSRIs remain an interesting which are characterized by “recurrent, intense, sexually option in adolescents, in patients with depressive or OCD arousing fantasies, sexual urges or behaviors, generally disorders, or in mild paraphilias such as exhibitionism. involving (1) non-human objects, (2) the suffering or Pharmacological interventions should be part of a more humiliation of oneself or one’s partner, or (3) chil- comprehensive treatment plan including psychotherapy dren or other nonconsenting individuals, that occur and, in most cases, behavior therapy. over a period of 6 months” (criterion A), which “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (criterion B). DSM IV-TR describes eight specific disor- ders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeur- Treatment of paraphilias began during the late nine- ism and transvestic fetishism) along with a residual teenth century at a similar time, though not directly category called “paraphilia not otherwise specified.” connected, to the new concept of sexual deviance as Rape is not included in this classification, because it a medical condition. Etiology of paraphilias remains represents an heterogeneous behavior and an expression Address for Correspondence: Prof. F. Thibaut, Psychiatric Dept., University Hospital Ch. Nicolle, 1 rue de Germont, 76031 Rouen, France [email protected] Potential conflict of interest: consultant for Debiopharm, Swiss 297 PharmacoLogicaL TREatmENT OF PARAPHILias of aggression rather than a specific paraphilia. However, hormone (GnRH) agonists. These compounds reduce a small number of rapists may meet the criteria for testosterone to very low levels and result in very low having a paraphilia (e.g., exhibitionism or pedophilia, levels of recidivism.There is also emerging evidence sexual sadism). Simply having paraphilia is not illegal, for the use of selective serotonin reuptake inhibitors but acting in response to certain paraphilic urges may (SSRIs)A pharmacological approach is essential in the be illegal and, in some cases, subjects the person with treatment of patients with severe paraphilias, but a paraphilia to severe sanctions. Conversely, not all sex psychotherapeutic context to the treatment is equally offenders meet the criteria for a paraphilic disorder. necessary (especially cognitive behavioral therapy). Some paraphilic subjects show evidence of comorbid major axis I mental illness which may require specific treatment, in most cases: affective disorders (3-95%), ETHICAL CONSIDERATIONS substance use disorders (8-85%), anxiety disorders Treatment for paraphilia should reduce or eliminate (3-64%) and less often: schizophrenia or other psychotic paraphilic fantasies and behaviors and decrease the level disorders (1-16%) (1-4), dementia or other cognitive of distress of paraphilic subjects, permitting them to disorders (for review, 2). Attention deficit and hyper- live a normal sexual life, it should not have significant activity disorders (ADHD) may also represent 36% of side-effects and, most importantly, it should prevent the cases and eating disorders 10% of cases. Paraphilia may risk of acting out and victimization in case of pedophilia also be secondary to major axis I mental disorders (e.g., or exhibitionism, for example. The optimal treatment schizophrenia or manic episodes), in these cases, anti- for paraphilias is currently unavailable and treatments psychotic treatment and/or mood stabilizers are used already used decrease, in an unspecific manner, sexual as first line treatment. In cases of comorbid depressive arousal level and behavior. In the case of hormonal or anxiety disorders, antidepressant treatment may treatment, deviant but also non-deviant (if any) sexual be used as first line treatment or in combination with behavior and fantasies are largely decreased in most antiandrogen treatment if necessary. subjects. An explanation of the sexual side effects associ- Paraphilias may also occur within the context of ated with hormonal treatment and obtaining informed axis II disorders, the prevalence of personality disor- consent of the patient are considered by many authors ders may vary from 33 to 52% (among them antisocial a necessary prerequisite (2). personality disorder is the most frequently observed) Paraphilic sex offenders referred for hormonal treat- (3-5). Heterogeneity of both the samples and the diag- ment are often the object of some external coercion, be nosis criteria may have contributed to the discrepancies it from a court decision or under the pressure of their observed in terms of prevalence between the studies. family, employers or other involved persons. From an These personality disorders may be addressed with ethical point of view, the patient may be subjected to psychological therapies such as behavioral or cognitive hormonal treatment only if all of the following condi- treatments. tions are met: • The person has a paraphilic disorder diagnosed by a HISTORY OF TREATMENTS psychiatrist after a careful psychiatric examination. Surgical castration was first used in 1892 in Switzerland. • The person’s condition represents a significant risk By the 1940s, some attempts had been made to treat of serious harm to his health or to the physical or paraphilias using oestrogens, but due to feminiz- moral integrity of other persons. ing side-effects, this was supplanted in the 1960s by • No less intrusive treatment means of providing care medications reducing testosterone levels (cyproterone are available. acetate [CPA] is available in most countries, while in • The psychiatrist in charge of the patient agrees to the U.S., medroxyprogesterone acetate [MPA] is the inform the patient and receive his or her consent, drug of choice). Unlike surgical castration, the effects to take the responsibility for the indication of the of antilibido medication are reversible on discontinua- treatment and for the follow up including somatic tion. A more recent and promising development in the aspects with the help of a consultant endocrinolo- treatment of paraphilias at high risk of sexual offend- gist, if necessary. ing is the use of gonadotrophin hormone releasing In some cases, coerced treatment may be used in sex 298 FLORENCE Thibaut offenders with paraphilia. The decision to subject a violence in incarcerated sex offenders. The comparison sex offender to coerced treatment should be taken by between studies is often difficult due to methodologi- a court or another competent body. The court or other cal differences between studies such as: heterogeneity competent body should: of paraphilias included; different durations of follow up; different definitions of recidivism (sexual or non • Act in accordance with procedures provided by law sexual offences); the presence or absence of previous based on the principle that the person concerned offences and/or previous convictions which (if any) should be seen and consulted; may increase the recidivism risk; the retrospective or • Not specify the content of the treatment (hormonal prospective design of the study; outpatients or prisoners or not) but force the person to comply with the treat- may be included which may interfere with treatment
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