Section 1905.140  Pharmacological Interventions

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.