CLINICAL ROTATION IN METRO PSYCH FACILITY

OUR LADY OF FATIMA UNIVERSITY-QC

NCM 104-GROUP 148
Azores, Mae Ann A.

PROCESS RECORDING: Nurse-Client Interaction

CLINICAL DISCUSSION: Sexually Connotative Disorder
ADDENDUM: Latest trends and therapy for Sexually
Connotative Disorders
EVALUATION: Clinical Experience
Area
Clinical Instructor

August 24, 2010

 SEXUALLY CONNOTAIVE DISORDERS
OUR LADY OF FATIMA UNIVERSITY-QC
NCM 104-GROUP 2

Ofelia C. Ibarrientos,RN,PhD.
Clinical Instructor

August 24, 2010

SEXUAL DYSFUNCTIONS AND PARAPHILIAS

 DSM-IV CLASSIFICATIONS
SEXUAL DESIRE DISORDERS
302.71 Hypoactive sexual desire disorder
302.79 Sexual aversion disorder
SEXUAL AROUSAL DISORDERS
302.72 Female sexual arousal disorder
302.72 Male erectile disorder
ORGASMIC DISORDERS
302.73 Female orgasmic disorder
302.74 Male orgasmic disorder
302.75 Premature ejaculation
SEXUAL PAIN DISORDERS
302.76 Dyspareunia (not due to a general medical condition)
306.51 Vaginismus (not due to a general medical condition)
(Refer to DSM-IV manual for sexual dysfunctions due to a general medical condition)
PARAPHILIAS
302.4 Exhibitionism
302.81 Fetishism
302.89 Frotteurism
302.2 Pedophilia
302.83 Sexual masochism
302.84 Sexual sadism
302.82 Voyeurism
302.3 Transvestic fetishism

Sexual dysfunction is defined as persistent impairment/disturbance of a normal or desired pattern in any phase of the
sexual response cycle.

Paraphilias are more specific disorders in which unusual or bizarre imagery or acts are necessary for realization of
sexual excitement. Because many paraphiliac behaviors are illegal in most states, individuals usually come for
psychiatric treatment because of pressure from others, partners, or the authorities/judicial system.

OTHER TYPES OF PARAPHILIAS:

DSM
Formal name Source of arousal
code

Abasiophilia People with impaired mobility

Acrotomophilia People with amputations

Agalmatophilia Statues, mannequins and immobility

Pain, particularly involving an erogenous zone; differs from masochism as there is a

Algolagnia
biologically different interpretation of the sensation rather than a subjective interpretation

Andromimetophilia Female-to-male transsexuals; also known as gynemimetophilia

Apotemnophilia Having an amputation

Asphyxiophilia Asphixiation or strangulation

Autagonistophilia Being on stage or on camera

Autassassinophilia Being in life-threatening situations

Autoandrophilia Arousal by a biological female imagining herself as a male

Autoerotic
Self-induced asphyxiation, sometimes to the point of near unconsciousness
asphixiation

Autogynephilia Arousal by a biological male imagining himself as a female]

Autopedophilia Being prepubescent

Biastophilia Arousal based on the rape of an unconsenting person

Chremastistophilia Being robbed or held up

Chronophilia Partners of a widely differing chronological age

Coprophilia Feces; also known as scat, scatophilia or fecophilia

Dacryphilia Tears or crying

Dendrophilia Trees

Emetophilia Vomit

Erotic asphyxiation Asphyxia of oneself or others

Erotophonophilia Murder]
Exhibitionism Exposing oneself sexually to others, with or without their consent 303.4

Formicophilia Being crawled on by insects

Frotteurism Rubbing against a non-consenting person 302.89

Gerontophilia Elderly people

Gynandromorphophilia Women with penises, men cross-dressed as women, or male-to-female transsexuals

Hebephilia Pubescent children

Homeovestism Wearing clothing emblematic of one's own sex

Hybristophilia Criminals, particularly for cruel or outrageous crimes

Infantophilia Children five years old or younger

Kleptophilia Stealing; also known as kleptolagnia

Klismaphilia Enemas

Lactaphilia Breast milk

Liquidophilia Attraction, or desire to immerse genitals in liquids

Macrophilia Giants, primarily domination by giant women or men

Mammaphilia Breasts; also known as mammagynophilia and mastofact

Masochism The desire to suffer, be beaten, bound or otherwise humiliated 302.83

Menophilia Menstruation
Morphophilia Particular body shapes or sizes

Mucophilia Mucus

Mysophilia Dirtiness, soiled or decaying things

Narratophilia Obscene words, colloquially known as "talking dirty"

Nasophilia Noses

Necrophilia Cadavers

Olfactophilia Smells

Paraphilic infantilism Being a baby; also referred to as autonepiophilia

Partialism Specific, non-genital body parts

Pedophilia Prepubescent children, also spelled paedophilia 302.2

Peodeiktophilia Exposing one's penis

Pedovestism Dressing like a child

Pictophilia Pornography or erotic art, particularly pictures

Pyrophilia Fire

Raptophilia Committing rape

Sadism Inflicting pain on others 302.84

Salirophilia Soiling or dirtying others

 Observing others' sexual activities; also known as scopophilia and more commonly as
Scoptophilia
voyeurism

Sexual fetishism Nonliving objects 302.81

Somnophilia Sleeping or unconscious people

Sthenolagnia Muscles and displays of strength

Stigmatophilia Body piercings and tattoos

Symphorophilia Witnessing or staging disasters such as car accidents

Telephone scatologia Obscene phone calls, particularly to strangers; also known as telephonicophilia

Transvestic fetishism Wearing clothes associated with the opposite sex; also known as transvestism 302.3

Transvestophilia A transvestite sexual partner

Trichophilia Hair

Cuckoldism, watching one's partner have sex with someone else, possibly without the
Troilism
third party's knowledge; also known as triolism

Urolagnia Urination, particularly in public, on others, and/or being urinated on

Ursusagalmatophilia Teddy bears

Vampirism Drawing or drinking blood; also known as murphyism

Vorarephilia Eating or being eaten by others; usually swallowed whole, in one piece

Voyeurism Watching others while naked or having sex, generally without their knowledge 302.82

Zoophilia Animals (actual, not anthropomorphic)

Zoosadism Inflicting pain on or seeing animals in pain

ETIOLOGICAL FACTORS

Psychodynamics
Individual causes of sexual desire disorders may include religious beliefs, obsessive-compulsive personality,
conflicts with gender identity or sexual preference, sexual phobias, fear of losing control over sexual urges, secret sexual
deviations, fear of pregnancy, inadequate grieving following the death of a spouse, depression, and aging-related
concerns. Psychological factors may also be involved in arousal disorders.

Psychoanalytical theories
Immature forms of libido during childhood are not released
↓
Fixations in Freud’s oral, anal and phallic stages
↓
Compromised emotional development
↓
Fear develops/castration
↓
Impulses dominates over reality
↓
Immature forms of libido dominate adult sexual life
↓
Sexual deviations

Biological
Sometimes the cause is clearly biological (e.g., temporal lobe epilepsy that may cause changes in sexual behavior
between seizures). It has also been suggested that the problem arises out of interference with brain pathways governing
rage and sexual arousal. Sex hormones have been studied. Rat studies have demonstrated that small, properly timed
doses of androgens (male hormones) or estrogens (female hormones) in the fetus or newborn can influence sexual
behavior. Various organic reasons, medication and other drug use, physical illnesses (most notably diabetes mellitus),
surgery (such as prostatectomy), and degenerative neural disorders (e.g., multiple sclerosis) may be involved in sexual
desire, arousal, and pain disorders.
It is generally accepted that abnormal hormonal activity and biological (genetic) predisposition interacting with
social and family factors influence the development of these fantasies/sexual acts. Although these behaviors may occur
in normal sexual activity, when they become the primary source of sexual satisfaction they may result in problems for the
individual/others.

Family Dynamics
 There appears to be some evidence that paraphilias run in families and may be the result of dysfunctional family
interactions and social learning.
Sexual dysfunctions are believed to be influenced by what the individual has learned/not learned as a child within
the family system and by values and beliefs that may be based on myths and misconceptions.

CLIENT ASSESSMENT DATA BASE

SEXUAL DYSFUNCTIONS
Neurosensory
Mental Status: Findings may indicate intense distress about situation/condition or coexisting psychiatric disorders
Mood and affect may reveal evidence of increased anxiety and depression

Sexuality
Problems may be lifelong or acquired after a period of normal sexual functioning
May report inhibition or interference with some part of the human response cycle (e.g., low sexual desire, aversion to
genital sexual contact, arousal/erectile/orgasmic disturbances, premature ejaculation, genital pain during or after sexual
intercourse, and involuntary spasm of the outer third of the vagina interfering with coitus)
May display negative attitude(s) toward sexuality

Social Interactions
Impairment may be noted in marital/conjugal relations but rarely affects job performance

Teaching/Learning
Most commonly occur in early adulthood, although male erectile disorder may surface later in life

PARAPHILIAS
Ego Integrity
May express shame or guilt about behavior
May or may not act on fantasies

Neurosensory
Personality disturbances frequently accompany sexual disorder(s)

Safety
Physical injury may be seen following episodes of sadomasochistic activity
Sexuality
Recurrent, intense sexual urges and fantasies involving the exposure of one’s genitals to a stranger that have been acted
on, cause severe distress, and may be accompanied by masturbation (exhibitionism)
Use of nonliving object(s) to stimulate recurrent intense sexual urges and sexually arousing fantasies (e.g., female
undergarments [fetishism])
Rubbing and touching against a nonconsenting person to invoke recurrent, intense sexual urges and fantasies, with the
touching, not the coercive nature of the act, causing sexual excitement (frotteurism)
Sexual activity with a prepubescent child or children (pedophilia)
Participation in the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer (sexual
masochism)
Participation in acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the
victim is sexually exciting to the person (sexual sadism)
Cross-dressing activities (transvestic fetishism)
Observing unsuspecting person(s), usually a stranger, who is naked, in the process of disrobing or engaging in sexual
activity (voyeurism)

Social Interactions
May not view self as ill; however, behavior may cause distress for the individual or may bring suffering to others
May be in conflict with partner or society because of behavior
Possible interference with interpersonal/occupational functioning

Teaching/Learning
Occurs mostly in males
Some evidence of occurrence in families of paraphiliacs and of depressed individual; high correlation between
pedophiles and family history of pedophilic activity

DIAGNOSTIC STUDIES
As indicated, to rule out physical causes of sexual dysfunction.
Screening for sexually transmitted diseases (STDs) including HIV/AIDS.

NURSING PRIORITIES
1.Assist client to understand the nature of the behavior (disorder/dysfunction).
2.Encourage use of acceptable methods for reduction of anxiety.
3.Help to recognize the legal/interpersonal consequences of paraphilic behaviors.
4.Explore options for change.
5.Encourage involvement of client/family (significant other) in treatment regimen.

DISCHARGE GOALS
1.The nature of the problem and consequences for the individual/family understood.
2.Anxiety reduced/managed in acceptable ways.
3.Options explored and appropriate one(s) chosen.
4.Confidence in own capabilities/sense of self-worth expressed.
5.Participating in treatment program and using community/treatment resources effectively.
6.Plan in place to meet needs after discharge.

NURSING DIAGNOSES:

1. Sexual dysfunction/ sexuality patterns, altered

2. Anxiety, moderate to severe
3. Self-esteem chronic/situational, low
4. Family Process, altered

MANAGEMENT:
1. Surgical Castration: advocated as a therapy for men with pedophilia, but has been abandoned for the time
being because most governments consider it a cruel punishment where the express
willingness and consent of the patient is not objectively indicated.
2. Psychotherapy:
3. Self-help groups:
4. Cognitive behavioral therapy:
5. Pharmacotherapy:
a. Hormonal/Chemical Castration:
 Cyproterone Acetate (Androcur)- indicated to reduce drive in sexual deviations for men;
Dose: PO Initially 18 tab b.i.d. may increase to 2 tabs
2-3x a day.
Precaution in prosthatic Ca, DM, liver tumors.
Adverse rxn: Gynecomastia, inhibition of spermatoge
nesis (recovery for 3-5mos),changes
in body weight, tiredness, depression
 Medroxyprogesterone Acetate
(Provera) indicated to reduce drive in sexual deviations for
women
Dose: 150mg deep IM (gluteal) q3mos
Precaution: Fluid retention, breakhrough bleeding,
Climacteric onset. Patients with astma
Migraine, weight changes.
Adverse rxn: anorgasmia, leg cramps, depression,
Insomnia, elvated BP, hirsutism, vagi
nitis, beast pain, bloating, edema.
b. Antidepressants:
 Sertraline (Zoloft) indicated for depression, OC disorders
Dose: 50mg/day once daily PO. May be increased
to 200 mg/day over a period of 2 wks by
50 mg increments.
Precaution: pregnancy, electroconvulsive therapy
unstable epilepsy
Adverse rxn: Nausea, loose stools, dyspepsia, tremor
dizziness, ejaculatory delay, ↑sweating
 Flouxetine (Prozac) Indication: depression, OC, bulimia nervosa
Dose: Adults: 20-80mg/day PO.
Precaution: Pregnancy, DM, hx of seizures, renal/ hepa
tic impairment
Adverse rxn: hot flashes, wt loss, palpitations, angina,
abnormal dreams, delusions, seizures
hypogly, hyponat, N/V, pneumonia
asthma, visual disturbances
c. Psychostimulants:
 Methylphenidate (Ritalin) indicated for ADHD and used as adjunct to SSRI
to reduce sexual impulses
Dose: individualized. take c food swallow whole with
liquid once a day in morning
Precaution: hx of tics, hx of drug dependence, alcoho
lism, seizures, problems compromised
with ↑BP or HR. GI irritation
Adverse rxn: headache, stomachache, loss of appetite,
insomnia, tics, wt loss, lability, hostility
 Psychotherapeutic Treatments for Paraphilias and Paraphilia-Related Disorders

• Paraphilias and Paraphilia-Related Disorders • Mar 29, 2006

Individual Psychotherapy

1. Psychodynamic psychotherapy, however, may help to uncover developmental antecedents of PAs and
PRDs, reduce anxiety and depression, improve social adjustment, and develop an empathic perspective
toward the victim’s experience.

 The informed individual psychotherapist, regardless of theoretical persuasion, may function

as the practitioner who selects and integrates different therapeutic interventions, akin to the
model of “primary-care therapist” advocated by Khantzian (1986) for the recovering
substance abuser.
 facilitate the learning of relapse prevention principles and the exploration of behavioral
sequences that precede and contribute to the “deviant cycle.”
 complement group therapies using the same theoretical model especially in the treatment of
sexually aggressive paraphilic individuals, multimodal treatment approaches, including
individual, cognitive-behavioral, group, psychoeducational, and pharmacological treatments,
are commonly prescribed and are tailored to the specific needs of the offender (Maletzky
1998).

Combination Therapies

 the most commonly prescribed combination of therapies associated with successful outcome is
that of 12-Step group therapy and individual psychotherapy with a clinician familiar with PRDs
This outcome literature, however, is based on skewed samples collected by surveys of self-
selected 12-Step attendees.

Sample Case:

Mr. H is a 42-year-old married man who had repetitively molested his stepdaughter. When
referred for treatment, he was diagnosed with current major depression; dysthymic disorder,
 early-onset subtype; social phobia, generalized subtype; and alcohol abuse. His social phobia and
substance abuse were in remission. In addition to pedophilia, Mr. H had a history of compulsive
masturbation and pornography dependence. He had been molested by a neighbor during his own
childhood and described his mother as intrusive, anxious, and overprotective.
After pharmacotherapy with an SSRI antidepressant and ongoing relapse prevention group
therapy, Mr. H greatly benefited from individual psychotherapy, which helped him to understand
and then change his hostile-dependent relationship with his spouse. It was hypothesized that
internalized anger at women and a passive/submissive approach to the expression of appropriate
aggressive feelings had substantially contributed to the sexualizing of his stepdaughter.

Group Psychotherapies, Including Relapse Prevention Treatment

1. Professionally facilitated cognitive-behavioral-oriented group therapies

 are the most common treatment modalities for confronting denial in sex offenders and
exploring the developmental antecedents that may have contributed to symptom formation.
 Such groups may include modules (or feature separate therapy groups) for learning the
principles and practice of relapse prevention, victim empathy, anger management, or social
skills (Laws 1989).
2. Relapse prevention
 is an integrated cognitive-behavioral and group therapy treatment approach that originally
evolved from a theoretical understanding of, and treatment for, addictive disorders such as
alcohol abuse, nicotine dependence, and overeating (Marlatt and Gordon 1980).
 The techniques developed were based on the clinical observation that although habitual
behaviors (i.e., addictions) may respond positively to a variety of short-term interventions,
maintenance of remission was problematic, and relapse was a common outcome in follow-up
studies of addiction treatments.
 aims:

1) identify specific recurrent cognitive distortions and inappropriate beliefs and

then implement “cognitive restructuring,”

2) sensitize the paraphilic individual to recognize and then anticipate high-risk

situations,

3) identify specific behavioral/affective/cognitive precursors to relapse.

 Following identification of recurrent affective and behavioral chains preceding paraphilic

behavior, behavioral rehearsal of new, comprehensive problem-solving techniques and social
and sexual skills training are implemented (Laws 1989).
 Individual and group therapies can be enhanced by providing homework and specialized
workbooks (Bays and Freeman-Longo 1989; Bays et al. 1990; Freeman-Longo and Bays
1988).

3. Self-help groups
 Since the formation of Alcoholics Anonymous and the articulation of the 12-Step recovery
program, self-help groups based on 12-Step methodology have been established for many
forms of impulsive/addictive behaviors, including substance abuse disorders, eating
disorders, “sex addictions,” gambling, and kleptomania. These programs can have a profound
effect on the process of recovery, especially if the program is zealously adhered to. For
example, 12-Step recovery programs commonly require daily attendance at a 12-Step
meeting for the first 3 months of recovery from alcoholism (Galanter et al. 1990), and
 positive outcomes in bulimia nervosa have been associated with attendance of five or more
12-Step meetings per week for at least 3 years (Malenbaum et al. 1988).

 Several different 12-Step programs for recovering “sex addicts” now exist, some of which
are distinguished by geographic location or differing philosophies as to what constitutes
recovery, abstinence, and “bottom line” in the context of normalizing sexual behaviors
(Salmon 1995).
 Sample Case: Mr. J was a 36-year-old married man who was referred for treatment of
persistent low self-esteem, anxiety, and continued paraphilia-related sexual behaviors. He
met DSM-IV diagnostic criteria for dysthymic disorder (early-onset subtype) and cocaine
abuse (in remission), and he had subclinical obsessive-compulsive disorder. Mr. J’s sexual
diagnoses included compulsive masturbation, protracted promiscuity (homosexual subtype),
and pornography dependence. There was no developmental history of physical, sexual, or
emotional abuse. Several months of intensive treatment with individual psychotherapy and
near-daily attendance in 12-Step sexual addiction groups resulted in substantial amelioration
of Mr. J’s PRDs.

Behavior Therapies

Behavior therapy techniques are used frequently in treatment centers specializing in the assessment and
treatment of sexually aggressive paraphilic individuals, and these techniques can be applied to
nonviolent PAs and PRDs as well (Maletzky 1991b). Although these techniques have a different
theoretical approach than relapse prevention, they are sometimes integrated with cognitive-behavioral
therapy treatments (Maletzky 1993).

1. Aversive techniques,
 The use of imagined but highly detailed aversive consequences interrupting the arousal
inherent in specific imagined sexually arousing scenarios represents a palatable form of
aversion therapy when the technique is applied repetitively
 Olfactory aversion is designed to reduce unconventional sexual arousal with aversive smells,
utilizing foul odors such as ammonia (Colson 1972) or rotting animal or human tissue
(Maletzky 1991a).
 The advantage of olfactory aversion derives from the immediacy of a powerful aversive odor
paired repetitively with conditioned sexually arousing fantasies. For example, ammonia
aversion involves encapsulated ammonia ampoules that are portable and can be broken and
inhaled in conjunction with both behavioral homework and in vivo practice, as well as in
situations that trigger sexual impulses.
 Theoretical support exists for the use of smells that produce nausea (e.g., rotting animal
tissue) rather than pain (ammonia) for the aversive treatment of consummatory behaviors
(Maletzky and George 1973); however, such smells are not easily packaged for in vivo use.
 Sample Case: Mr. K was a 35-year-old divorced male who was referred to following his
third arrest for exhibitionism. As a preadolescent, Mr. K was repetitively molested by an
uncle. In addition, Mr. K’s father was alcoholic during his formative years. Mr. K was
diagnosed with DSM-IV dysthymic disorder, early-onset subtype; major depression (in
remission); ADHD, inattentive subtype; social phobia; and both alcohol and cocaine abuse
(in remission). Mr. K’s sexual diagnoses included exhibitionism, voyeurism, pornography
dependence, compulsive masturbation, and protracted promiscuity, heterosexual subtype.
Prior to his arrest, Mr. K masturbated at least 12 times per week in addition to engaging in
partnered sex.
 Mr. K had been in a highly structured cognitive-behavioral therapy program involving
closely monitored probation. Although this had been helpful, he still was hypersexual and
continued to experience strong urges to expose himself, accompanied by “cruising” parks
where he might do so. Mr. K was eventually treated with fluoxetine 40 mg/day, to which
methylphenidate-SR 40 mg/day was subsequently added. This combination of medications
markedly reduced his sexual arousal, improved his chronic low self-esteem and depressive
symptoms, and helped him to be moderately more socially interactive.
After pharmacotherapy, Mr. K additionally benefited from ammonia aversion therapy, which
he reported helped him specifically to cope with residual urges to expose himself. He was
motivated to practice the aversion therapy, carried the ammonia ampoules with him at all
times, and practiced using them to extinguish self-generated “homework” sexual fantasies
that were arousing.
2. Nonaversive or “positive” conditioning techniques

 are not as widely established as primary treatments for sexually aggressive paraphilic
individuals.
 Reconditioning behavioral techniques employ the shifting of the content, timing, or sequence of
events present during unconventional sexual fantasies, urges, and activities.
 The shift is aimed at “fading” the intensity of the conditioned unconventional stimulus and
strengthening the presence, proximity, and arousal produced by “conventional” sexual fantasies
during masturbation (Marques 1970).
 A variant of this technique has also been developed that is called masturbatory satiation
During masturbatory satiation, the subject is instructed first to masturbate to orgasm using
socially acceptable sexual fantasies, and then, for 30-60 minutes during the postejaculatory
latency period, to continue to masturbate to deviant fantasy. The theory supporting this technique
is that prolonged masturbation following ejaculation is aversive.

3. imaginal desensitization

 was effective in reducing compulsive sexual behaviors (promiscuity) in a group of 20 men with PAs
and PRDs at both 1-month and 1-year follow-ups. Since men with PAs report social and
interpersonal anxiety, a hierarchical systematic desensitization could be of assistance in reducing
interpersonal anxiety and, perhaps, could be combined with other learning-based techniques to
improve interpersonal relationships and assertiveness.

.
 Other Therapies for Paraphilias and Sexual Offenders

In contrast to the slowly increasing 'current' psychiatric literature reporting treatment efficacy of testosterone-
lowering 'hormonal' agents, novel clinical reports providing an empirically based rationale for and reporting prescriptive
use of nonhormonal medications appear to have diminished during the past few years. Theory-based and empirically
supported rationales for nonhormonal medical therapies have been proposed that are founded specifically on the ability of
these treatments to ameliorate axis I comorbid diagnoses in sexual offenders or enhance serotonergic
neurotransmission.Such a theory is based upon the presence of a common putative biological substrate for both a specific
axis I disorder and sexual impulsivity (e.g. unipolar and bipolar mood disorders and attention deficit hyperactivity
disorder (ADHD), impulsivity associated with Asperger's syndrome). Other nonhormonal medication interventions have
been proposed as general treatments for 'impulsivity', for which sexual impulsivity might be one manifestation (e.g. opiate
antagonists such as naltrexone).

As is the case for hormonal agents, the prescriptive use of nonhormonal pharmacological agents to treat sexual
offenders should almost always be combined with psychotherapy specific to sexual offenders. Despite there being no
double-blind placebo-controlled treatments of the efficacy of SRIs for the treatment of sexual offenders, such medications
have been reported to be the most commonly prescribed agents for sexual offenders in nonresidential settings (53.6% of
programmes treating adult males), at least in the USA.

In fact, current clinical practice in the USA favours the prescription of nonhormonally based treatments, even
though the cumulative treatment outcome data are more supportive of hormonal treatments. How, then, can such
pharmacological practices be clinically and ethically justified? We answer this important question in two ways. First, as
mentioned above, despite their demonstrated better efficacy in terms of outcome and the sound biological rationale that
markedly lowering testosterone diminishes sexually motivated behaviours, many sexual offenders refuse hormonally
based medical interventions. 'Chemical castration', as the prescriptive use of depo-MPA and cyproterone acetate came to
be known, has a socially punitive rather than a therapeutic or ameliorative connotation. Second, the more medically
intensive (and therefore much more expensive) hormonally based interventions, the need for intramuscular or
subcutaneous injection, and their long-term side effect burden (e.g. liver toxicity, hypertension, weight gain, calcium loss
and osteopenia) require the involvement of a dedicated psychiatric clinician, medical/endocrinological back up, and a well
informed and highly motivated client. In essence, many psychiatrists and other physicians become 'gun shy' about the
medical responsibility associated with the prescription of powerful testosterone-ablating drugs that have not been
specifically approved by the US Food and Drug Administration for the treatment of paraphilias or sexual offenders.

Despite the absence of double-blind clinical trials, it is important to review the rationale for the prescriptive use of
nonhormonal medications so that both the risks and the benefits can be considered. In addition, given the scarcity of
recent literature on treatment with nonhormonal medications, these interventions must still be considered promising
treatments but ones whose value in sexual offenders is not yet definitively proven.

Axis I neuropsychiatric disorders are generally associated with prefrontal cortical dysfunction, inasmuch as
empathy, impulse control, social judgement and insight are commonly affected in these disorders. If certain specific axis I
neuropsychiatric disorders were consistently identified in male sexual offenders and if the treatment of such conditions
enhanced frontal and prefrontal cortical function (or mollified limbic over-activation), then such treatments might affect
'moral' judgements and ameliorate antisocial sexual impulsivity.

Recent studies of sexual offenders, men with paraphilias and 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 post-traumatic stress disorder), psychoactive substance abuse
disorders (especially alcohol abuse), ADHD and neuropsychological conditions (e.g. schizophrenia, Asperger's syndrome
and head injury) may occur more frequently than expected in sexually impulsive men, including sexual offenders.
Empirically established effective pharmacological treatments for unipolar and bipolar mood disorders, ADHD and
impulsivity are well documented. These conditions affect prefrontal/orbital frontal executive functioning and are
associated with impulsivity; therefore, amelioration of such conditions could certainly affect, if not markedly ameliorate,
the propensity to be sexually impulsive.

The most comprehensive and contemporary review of the role for SRI antidepressants for sexual offenders
highlighted significant methodological flaws in the treatment data available, and it indicated that further investigation of
treatment of sexual offenders with active SRI antidepressants is warranted. Since that review was published, Kraus et al.
reported a retrospective case series on 16 men with different paraphilias (50% paedophilia and 25% sexual sadism) who
were treated with different ective SRI agents and psychotherapy. Although retrospective, this study is of interest because
the length of follow up was longer than most prior reports (22 months, standard deviation 15.6 months). Masturbation
with paraphilic fantasies, impulsivity and paraphilic acting-out as well as depressive symptomatology decreased
significantly. Only one patient had a new criminal allegation because of a possible sexual offence. Although 75% of the
patients reported that they suffered from any sexual dysfunction during treatment, 63% were satisfied with the medical
intervention.

Remarkably, except for some older studies that suggested efficacy of lithium salts in sexual offenders, literature
supporting the prescriptive use of the 'newer' mood stabilizers such as limbic anticonvulsants and atypical neuroleptics for
sexual offenders is lacking. Given the virtual absence of such data, I (MPK) am of the view that such medications do
indeed significantly ameliorate sexual offending behaviours that are found to be comorbidly associated specifically with
bipolar spectrum disorders and Asperger's syndrome, but clinical outcome treatment data are currently unpublished.

The effective use of psychostimulants to both treat ADHD and enhance SRI responsiveness in men with sexual
impulsivity has also been reported, but there are no specific studies on the prescriptive use of psychostimulants alone as a
primary pharmacological treatment without other concomitant medications to sexual offenders.

Finally, there have been sporadic case reports of the prescriptive use of naltrexone for adults with 'compulsive
sexual behaviour' and adolescent persons with Tourette's syndrome, and a case series with adolescent sexual offenders. In
the 21 adolescent offenders studied by Ryback, 150-200 mg/day naltrexone was required to sustain a response in 15
offenders. Concomitant prescription of a broad range of psychotropic drugs targeting axis I comorbidity in this sample
had not adequately ameliorated sexual impulsivity symptoms, but they were continued during the naltrexone trial. The
presumed mechanisms of action - endogenous opiate receptor blockade, a subsequent increased accumulation of
endogenous opioids, or inhibition of dopamine release in the nucleas accumbens - may account for their therapeutic
benefit in a broad range of impulse control disorders. As is the case for the other nonhormonal pharmacological treatments
for sexual offenders, more rigorous trials, comparison control groups and longer follow-up periods are needed.