The World Journal of Biological Psychiatry ISSN: 1562-2975 (Print) 1814-1412 (Online) Journal homepage: https://www.tandfonline.com/loi/iwbp20 The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders Florence Thibaut, Paul Cosyns, John Paul Fedoroff, Peer Briken, Kris Goethals, John M. W. Bradford & The WFSBP Task Force on Paraphilias To cite this article: Florence Thibaut, Paul Cosyns, John Paul Fedoroff, Peer Briken, Kris Goethals, John M. W. Bradford & The WFSBP Task Force on Paraphilias (2020): The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders, The World Journal of Biological Psychiatry To link to this article: https://doi.org/10.1080/15622975.2020.1744723 Published online: 26 May 2020. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iwbp20 THE WORLD JOURNAL OF BIOLOGICAL PSYCHIATRY https://doi.org/10.1080/15622975.2020.1744723 REVIEW ARTICLE The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders Florence Thibauta , Paul Cosynsb, John Paul Fedoroffc , Peer Brikend, Kris Goethalse, and f à John M. W. Bradford ; The WFSBP Task Force on Paraphilias aDepartment of Psychiatry and Addictive Disorders, University Hospital Cochin, University of Paris, INSERM U1266, Institute of Psychiatry and Neurosciences, Paris, France; bCollaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium; cDivision of Forensic Psychiatry, The Royal Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada; dInstitute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; eCollaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp and University Forensic Centre, Antwerp University Hospital, Antwerp, Belgium; fThe Royal Institute of Mental Health Research, University of Ottawa, McMaster University, Ottawa & Hamilton, ON, Canada ABSTRACT ARTICLE HISTORY Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological Received 9 December 2019 agents in the treatment and management of patients with paraphilic disorders, with a focus on Revised 6 March 2020 the treatment of adult males. Because such treatments are not delivered in isolation, the role of Accepted 12 March 2020 specific psychotherapeutic interventions is also briefly covered. These guidelines are intended KEYWORDS for use in clinical practice by clinicians who diagnose and treat patients, including sexual Paraphilic disorder; sex offenders, with paraphilic disorders. The aim of these guidelines is to bring together different offender; antiandrogen views on the appropriate treatment of paraphilic disorders from experts representing different treatment; SSRI; GnRH countries in order to aid physicians in clinical decisions and to improve the quality of care. agonist Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990À2018 for SSRIs) (1969À2018 for hormonal treatments), sup- plemented by other sources, including published reviews. Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders. Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels. 1. A historical perspective deviance and the secular with greater liberalism (Group for the Advancement of Psychiatry 2000). While it is almost certainly the case that all human A range of factors influencing social perceptions societies have historically imposed boundaries or limits on the types of sexual behaviour regarded as accept- concerns whether specific sexual behaviours are ‘ ’ able, there has been variation across cultures. In add- regarded as sexually deviant. These include degrees ition, within cultural traditions, changes in sexual of consent, geographical location of the sexual behav- mores have also occurred. It is, therefore, evident that iours, the ages of those involved, the nature of the societies maintain concepts of sexual deviancy, but sexual acts, whether any distress or harm may occur, they are subject to evolving changes of social perspec- the prevalence of the sexual practice in society and tive. Reference to biblical Israel as well as ancient the degree of aversion felt by others about the spe- Greece indicates historical influences of both a reli- cific sexual behaviour (Hensley and Tewksbury 2003). gious and secular nature, of which the religious are It was not until the end of the nineteenth century more associated with moral condemnation of sexual that sexual deviance came to be regarded as a CONTACT Florence Thibaut [email protected] Department of Psychiatry and Addictive Disorders, Hopital^ Tarnier, 89 rue d’assas, Paris 75006, France à Fred Berlin: Sexual Behavior Consultation Unit, Psychiatry and Behavioral Sciences, John Hopkins Hospital, USA; Marc Graf: Department of Forensic Psychiatry, University of Basel, Switzerland; Andrey A. Tkachenko: Serbsky National Medical Research Centre for Psychiatry and Narcology, Sechenov First Moscow State Medical University, Moscow, Russia. ß 2020 Informa UK Limited, trading as Taylor & Francis Group 2 F. THIBAUT ET AL. medical phenomenon, with the publication of ‘Etude criminal disposition. The case for paraphilias as real medico-legale sur les attentats aux moeurs 7th edition’ medical entities is based on their inclusion in the by the French psychiatrist Ambroise Tardieu (1878) international classifications, that they can be diag- and then ‘Psychopathia Sexualis’ by the German nosed according to various defined symptoms and psychiatrist, Krafft-Ebing (1886), describing a range of behaviours, that they might be regarded as a form of sex crimes, including sexual murders. Krafft-Ebing’s impulse control disorder (Pearson 1990) or on the emphasis on the connection between sexual fantasy obsessional compulsive spectrum (Stein et al. 1992), or and the compulsion to kill reflects views about para- as an intrinsic abnormality of sexual development as philic disorders beginning a century earlier (Krafft- earlier noted, that they have a high level of co-mor- Ebing 1886; reviewed in Schlesinger 2004). The inter- bidity with a range of other mental disorders (Gordon est by some German psychiatrists in sexual deviance and Grubin 2004), they may be associated with ele- at the turn of the twentieth century is further illus- vated risk of harm to self and others and that there is trated by the case history of a man with paedophilic increasingly effective treatment available. Further tendencies described by Emil Kraepelin debate and better data are required to resolve some (Johnstone 1913). of the problems in diagnosis of paraphilias, including Despite the initial medicalisation of sexual deviance whether ‘deviant’ sexual fantasies are sufficient to by clinical psychiatrists, during the twentieth century, make the diagnosis or if they must also be acted the main focus of study and treatment was psycho- upon. Other diagnostic considerations include whether ’ analytic. Freud s early theory of sexuality remains the sexual fantasies and or ‘deviant’ behaviours are suffi- basis of psychoanalytic explanations of sexual devi- cient, the necessary duration and persistence of the ance (Rosen 1997; Freud 1905/1953). Subsequently, a fantasies or behaviours, how significant the degree of century of psychoanalytic thought has contributed to opportunity to act on the paraphilic interest is, the one perspective on the assessment and treatment of intensity of the fantasies or urges and the degree of sexual deviance (see especially Fenichel 1954; Stoller occupational or social deterioration resulting (Laws 1975; Kernberg 1991; Rosen 1997). and O’Donohue 1997; Marshall 2006; for a more Running alongside the psychoanalytic perspective detailed review of varied perspectives of the para- of sexual deviance, one resulting from a psychological, philias beginning last century, see Gordon 2008 and developmental abnormality of sexual maturation, was Fedoroff 2009). a trend towards viewing the pathology as being The beginning of treatment of the paraphilias can organically determined. Freud himself saw the roots of be traced back to the late nineteenth century, though perversion as a combination of biological and devel- not directly connected to the new concept of sexual opmental factors (Rosen 1997). The British psycholo- deviance as a medical condition. This initial treatment gist, Havelock Ellis (Ellis 1933) and the German approach was that of surgical castration, used first for physician, Magnus Hirschfield (1948), attempted to reform public attitudes towards a range of sexual therapeutic purposes in 1892 in Switzerland to treat a ‘ ’ behaviours primarily homosexual behaviours, by advo- patient with imbecility