Pharmacological Management of Problematic Sexual Behaviours

• Author: Robert Dickey
• Pages: 887-902

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CHAPTER 41

Pharmacological Management of

Problematic Sexual Behaviours

Robert Dickey

I. INTRODUCTION

Problematic or unwanted sexual behaviour can present in domestic, institutional, social, or criminal jus-

tice contexts. Experience has demonstrated that if this problem is of a signicant degree and is persistent

for a particular individual, psychosocial treatments alone may be limited in their ecacy and thorough

management will likely require adjunctive or alternate pharmacological management. Optimal manage-

ment is also important because of the potentially enormous risk unchecked sexual deviancy raises for

the public. e available literature suggests that there are many cases that would not respond to psycho-

therapeutic or behavioural treatment alone (Furby et al., 1989; Barbaree & Marshall, 1998).

Reviews concerning the ecacy of antiandrogen medications (and other pharmacological prepara-

tions) for sexually deviant behaviour have been mixed. A recent Cochrane Systematic Review (White et

al., 2000) concluded that “a strong evidence base” for the ecacy of antilibidinal or sex-drive reducing

drugs for sex oenders was lacking, and that randomized long-term trials are needed (and see Rösler &

Witztum, 2000). ibault et al. (2010) oer a more optimistic view.

Treating patients who have paraphilic diagnoses with antiandrogen or sex-drive reducing drugs

raises several ethical considerations. First, there are no long-term outcome studies that have claried

long-term risks and adverse eects. e second and corollary ethical concern relates to the implications

of randomized trials. Double-blind placebo controlled studies — the gold standard to determine drug

ecacy — creates the possibility that oenders who receive (just) placebo will victimize members of the

public (Krueger & Kaplan, 2001).

Finally, one needs to consider that recipients of antiandrogen medications are oen reluctant patients.

Although no court in Canada can require a sex oender to take sex-drive reducing medications, the of-

fender’s failure to take these drugs can have serious implications for his sentencing, and subsequently,

for how he is seen by both prison and probation and parole ocials. Given the stakes, antiandrogen

medication may be perceived by the oender as an oer he nds hard to refuse. at being said, Fedoro

(2010) asserts that once in treatment, however, compliance problems are rarely an issue when proposed

pharmacological interventions are tabled in the context of a positive therapeutic relationship.

II. TYPES OF UNWANTED SEXUAL BEHAVIOUR

Unwanted sexual behaviour refers to the imposed sexually motivated behaviours of a perpetrator against

an unwilling or disinterested victim, and/or one who by age and/or debility cannot consent. It also in-

cludes a victim who knows nothing about the perpetrator’s actions (e.g., the subject of voyeuristic activ-

ity), but has not acceded to being a source of sexual gratication for him.

e types of unwanted sexual behaviour can vary considerably but are oen a function of the pres-

ence of a paraphilia. Paraphilic disorders can be relatively overt, as is the case with pedophilia or sado-

Robert Dickey

masochism. Alternatively, the behaviours may be more subtle and consequently, dicult to diagnose,

such as those involving non-consenting, but non-violent, sexual situations, for example voyeurism, ex-

hibitionism, or telephone scatalogia (obscene phone calls). Other non-violent behaviours involving, for

example, exaggerated need for partner novelty, including attending massage parlours and prostitutes,

and use of telephone sex hotlines, are less well dened. A number of such behaviours (i.e., voyeurism,

exhibitionism, telephone scatalogia) oen occur in combination and are subsumed under the concept of

courtship disorder as described by Freund (1976).

While many patients with one or more of the paraphilic sexual disorders present aer an encounter

with the criminal justice system, others are either self-referred or are referred by family doctors. In the

case of self-referral or referral by a family physician, the patient or the patient’s family reports the behav-

iours or urges as being distressing or problematic to themselves or to others. Not surprisingly, it appears

that this group of patients (i.e., those that come for help either at their own or family’s instance) is less

likely to have co-existent antisocial personality and substance use problems. is would be consistent

with actuarial literature, which predicts considerably greater criminal reoence rates based on the pres-

ence of such characteristics (Quinsey et al., 1995). (See Chapter 36 for a detailed discussion of recidivism

in sexual oenders.)

Other individuals are referred from institutions, specically, psychiatric institutions. e presence of

major mental illness and its active symptoms can and oen does confound the diagnosis of paraphilia

in these patients. is is because the hallucinations and delusions oen associated with psychosis can

sometimes produce a picture of predominantly sexually inappropriate behaviour and preoccupation.

Treating the psychosis generally reduces or eliminates the inappropriate sexual behaviour, and more

than not, when a psychiatric disorder is diagnosed, there is oen no evidence of an underlying paraphilia.

It may similarly be dicult to arrive at a diagnosis prior to or early in the workup of a patient with

a potential organic brain disorder associated with disinhibited and impulsive sexually inappropriate

behaviour. Management of unwanted behaviours such as touching of sta, co-patients, compulsive mas-

turbation, or approaching children may be the reason for the referral for members of this group.

Treating patients who both exhibit anomalous sexual behaviour and have developmental disabilities

through pharmacological means has been, in this author’s experience, particularly challenging. In mem-

bers of this group, a diagnosis of paraphilia can at times be dicult to distinguish from generalized

problematic, unwanted, or intrusive sexual behaviour based on the underlying organic brain disorder;

however, some particularly complicated and clearly expressed deviant sexual preferences can sometimes

be diagnosed even in patients who have signicant developmental delay.

III. PRE-TREATMENT EVALUATION

Treatment goals and outcomes are frequently looked at in reference to pre-treatment baseline indices.

is is so in the case of paraphilic patients with respect to both psychosocial and pharmacological inter-

vention. As regards pharmacological modalities, however, the risk of potentially serious adverse eects

mandates a thorough pre-treatment workup.

Fedoro (2011) suggests that treatment be preceded by a full psychiatric and sexual behaviours as-

sessment, noting in particular past history of response — or lack thereof — to pharmacologic treatment.

Following a battery of biological tests and sexological questionnaires, results are reviewed in detail with

patients for various reasons, including to allay concerns, set treatment objectives, and to maximally for-

tify the working alliance and spirit of collaboration in the patient’s interests. Table 41.1 below reviews

information to be gathered for a typical pre-antiandrogen workup.