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dcyphr | Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review

Abstract

Different pharmacological treatments are used to treat paraphilic disorders in sexual offenders (i.e., pedophiles). Luteinizing hormone-releasing hormone (LHRH) agonists are the most recently used treatments combined with psychotherapy. The authors aimed to update what is known about LHRH in treating sexual offenders. They used 24 eligible studies reporting on 256 patients. LHRH agonists seem to be more effective than steroidal antiandrogens (testosterone blockers) in reducing paraphilic thoughts and behaviors. LHRH agonists come with many side effects so it should be reserved for those with paraphilic disorders at the highest risk of offending. 

Introduction

Paraphilias are not synonymous with paraphilic disorders. Paraphilias are conditions in which one’s sexual thoughts and interests deviate “significantly” from the socially acceptable (i.e., genital penetration with a consenting partner). Paraphilic disorders maintain this but must also cause distress or harm to oneself or others. Also, not all sexual offenders necessarily have paraphilic disorders. 

Testosterone and its accompanying brain structures/mechanisms (i.e., hypothalamic-pituitary-gonadal axis) are thought to be involved in paraphilic disorders since they play a large role in male sexuality. Brain imaging studies have confirmed structural and functional brain differences between healthy controls and paraphiliacs. It is not clear how changes in testosterone levels/concentrations are associated with these brain differences and paraphilic disorders. The current guidelines for treating paraphilic disorders under the World Federation of Societies and Biological Psychiatry include the use of SSRIs, steroidal antiandrogens, and luteinizing hormone-releasing hormone agonists. 

Steroidal antiandrogen and LHRH agonists function to restrain serum testosterone concentrations to below castration levels. The evidence for steroidal antiandrogen agonists is dated. But, both steroidal antiandrogen and LHRH agonists reduce the frequency of paraphilic thoughts, urges, and behaviors. There is very little research using objective methods (i.e., penile plethysmography (PP)) to measure the effectiveness of PPG. The authors conducted a systematic review of all types of studies to assess the efficacy and side effects of LHRH agonist treatment on sexual offenders with a paraphilic disorder. 

Methods

PubMed and Google Scholar were used to search for all relevant studies published from January 2003 to October 2017.

Results 

24 studies reporting on 256 patients being treated with leuprorelin, triptorelin, goserelin for different paraphilic disorders (mostly pedophilia) were used. LHRH agonist treatment proved to be effective in treating urges, sexual thoughts, and behaviors of paraphilic disorders, with recidivism (re-committing a crime) or paraphilic behaviors resurging immediately after stopping treatment. LHRH agonist treatment has a lot of side effects. Fatigue, headache, sleep disorders, hot flashes, depression, weight gain, decreased testicular size, loss of erectile function and loss of bone mineral density were observed. Treatment had to be stopped after some side effects (i.e., lowered bone mineral density). Changes in brain functions were also observed in some studies of LHRH agonist treatment. 

Discussion

LHRH agonists bring serum testosterone levels below castration level (<20-50ng/dL). This entails a dramatic decrease in paraphilic and non-paraphilic “normal” sexual desires and behaviors, so LHRH treatment should only be used in severe cases with a paraphilic disorder. The use of LHRH treatment on moderate cases (i.e., no history of sexual offense) would be unethical and legally questionable. 

Brain imaging studies suggest that LHRH might influence most neural components related to sexual behavior and change how paraphilic stimuli are appraised. These studies have displayed lowered activation in brain areas involved in:

  • Visual processing of sexual stimuli
  • Emotional appraisal of sexual stimuli
  • Processes of motivation


LHRH treatment may also affect top-down and bottom-up processing of preferred paraphilic stimuli. 

More research using measurements aside from self-reports are needed to increase the validity of LHRH treatment. Studies examining LHRH treatment side effects and the associations between treatment and changes in brain areas are also warranted. 

Conclusions

LHRH treatment may the most effective treatment for reducing sexual paraphilic thoughts, urges, and behaviors. It is applicable to adults and adolescents. It should always be used alongside psychotherapy, which is the first line of treatment. LHRH treatment is not meant to be lifelong.