Treatment providers shall recognize that the usage of
pharmacological interventions may be beneficial to the offender and support
effective risk management and risk reduction.
a) For adult sex offenders, when used in
combination with other treatment approaches, biological interventions like
testosterone-lowering hormonal treatments may be linked to greater reductions
in sexual arousal. Nonhormonal psychotropic medications can also be effective
supplements to standard therapeutic interventions for sex offenders.
Pharmacological interventions are not typically used for all sexual offenders,
but are often applied to those with paraphilias or offense-specific patterns of
sexual arousal that could be altered through the use of these interventions.
Further, the interventions should be integrated into a comprehensive treatment
program that addresses other static and dynamic risk factors that contribute to
sexual offending.
b) Hormonal
Agents for Managing Sexually Abusive and Paraphilic Behaviors
A number of hormonal agents have been introduced as
pharmacological treatments for reducing testosterone and sexual drive in
individuals with paraphilias and/or who have engaged in sexually abusive
behaviors. Primary examples include medroxyprogesterone acetate (MPA - Depo
Provera), Leuprolide acetate, cyproterone acetate, and gonadotropin-releasing
hormone analog. These chemical agents, referred to as antiandrogens, act by
breaking down and eliminating testosterone and inhibiting the production of
leutinizing hormone through the pituitary gland, which in turn inhibits or
prevents the production of testosterone. Because testosterone is associated
with sexual arousal, the use of these agents generally results in a reduction
of sexual arousal. This reduction in sexual arousal is assumed to also reduce
the motivation for sexual offending in individuals predisposed to those
behaviors.
c) Nonhormonal
Agents for Managing Sexually Abusive and Paraphilic Behaviors
1) Despite there being no double-blind
placebo-controlled treatments of the efficacy of selective serotonin reuptake
inhibitors (SSRI) for the treatment of sexual offenders, SSRI have been
reported to be the most commonly prescribed agents for sexual offenders, at
least in the United States and Canada (i.e., 50.3 % of community and 55.3 % of
residential programs in the United States, and 47.4 % of community and 75% of
residential programs in Canada, treating adult male sex offenders prescribe
SSRI for clients).
2) As is the
case with hormonal agents, the prescriptive use of nonhormonal pharmacological
agents to treat sexual offenders will not address all etiologies and risk
factors and should therefore be combined with psychotherapy specific to sexual
offenders.
d)
Pharmacological Treatment of Comorbid Psychiatric Conditions
1) Studies of sexual offenders, men with
paraphilias, and those with nonparaphilic expressions of "hypersexuality"
suggest that mood disorders (dysthymic disorder, major depression and bipolar
spectrum disorders), certain anxiety disorders (especially social anxiety
disorder and childhood-onset posttraumatic stress disorder), psychoactive
substance abuse disorders (especially alcohol abuse),
Attention-Deficit/Hyperactivity Disorder (ADHD), and neuropsychological
conditions (e.g., schizophrenia, Asperger's syndrome, head injury) may occur
more frequently than expected in sexually impulsive men, including sexual
offenders.
2) Empirically
established effective pharmacological treatments for mood disorders, ADHD and
impulsivity are well documented. These conditions affect prefrontal/orbital
frontal executive functioning and are associated with impulsivity; therefore,
amelioration of those conditions could certainly affect, if not markedly
ameliorate, the propensity to be sexually impulsive.
e) Practice Guidelines
1) Nonphysician treatment providers do not
make specific recommendations about what medications should be prescribed. It
is appropriate for treatment providers to refer clients to physicians who have
experience working with individuals who sexually offend as possible candidates
for pharmacological therapy. They can provide information about the role of
pharmacological therapy in sexual deviancy treatment to the consulting doctor.
Nonphysician treatment providers could consider referring clients to a
physician for possible pharmacological therapy if these clients have relatively
high levels of deviant sexual arousal, are considered to be at moderate to high
risk for reoffending, or have not been able to achieve control over their
deviant sexual arousal using sexual arousal conditioning procedures. Clients
who repeatedly engage in impulsive or compulsive behavior, or who report a
persistent inability to control deviant sexual fantasies, arousal or behavior
may also be reasonable candidates for pharmacological therapy. Motivated and
informed clients are often the best candidates for pharmacological
therapy.
2) A physician prescribes
medications only after a comprehensive sexual abuser evaluation has been
completed. It is important to individualize medical treatment for the patient
based on the patient's particular need, response, medical history and personal
agreement with the treatment offered. Pharmacological therapy is linked to
appropriate treatment and supervision and is medically monitored. As with any
treatment, appropriate informed consent is obtained when pharmacological
therapy is implemented. Informed consent includes a discussion of medication
options, targeted symptoms, potential side effects, and the expected course of
pharmacological therapy.
3) The use
of medication may help clients manage their risk for sexually abusive behavior,
but medications do not "cure" deviant sexual interests or fully eliminate the
risk of reoffending.
f)
Ethical Considerations
Research support for the effectiveness of pharmacological
treatments such as testosterone-reducing agents is mixed. Without clear data
regarding the efficacy of pharmacological treatments, providers should be sure
to balance the risks of the interventions with potential benefits of
treatment.