1. Anti-libidinal medication
Dr Prathima Apurva
ST5 Forensic psychiatry
Nov 2013

2. Overview Context What is anti-libidinal medication?
Why might we need it in managing sex offenders?
How does it work?
Availability in Scotland.
Some legal and ethical issues

3. Sex offenders with ID Static variables
Anti social attitude, poor relationship with mother, low self esteem, lack of assertiveness, poor response to treatment,
Offences involving physical violence, staff complacency, an attitude tolerant of sexual crimes

4. Low treatment motivation, erratic attendance and unexplained break from routine, deterioration in family attitudes.
Unplanned discharge

5. Dynamic variables Social effective functioning
Distorted attitudes and beliefs
Self management and self regulation
Sexual preference and sexual drive

6. Social effective functioning
This refers to the way in which the individual relates to the other people and includes aspects of negative affect.
Low self esteem and loneliness.

7. Distorted cognitions and beliefs
Counterfeit deviance
Whilst assessing to be cautious about processes such as suppression, social desirability and lying.

8. Self management and self regulation
Deficits in self regulation and ability to engage in appropriate problem solving strategies and impulse control.

9. Sexual preference and sexual drive
Interest rather than accessibility
Paedophilia

10. What is antilibidinal medication
Primary effect is to either stop androgens from being produced or to prevent them from working altogether.
Testosterone is thought to influence sexual arousal and responsiveness.
Therefore a reduction in testosterone = a reduction in a man’s libido and desire to engage in sexual activity.

11. Why?
It not to completely suppress sexual drive and create an asexual individual.
To selectively suppress deviant sexual urges and fantasies.

12. Hormones and neuro-transmitters involved in sexual response
Dehydroepiandrosterone (DHEA)
Oxytocin
Phenylethylamine (PEA)
Oestrogen
Testosterone
Progesterone
Prolactin
Vasopressin
Dopamine
Serotonin
Acetylcholine
DESIRE (LIBIDO)
AROUSAL
ORGASM

13. Types of medication Anti-libidinal medications:
Medroxyprogesterone Acetate (MPA).
Cyproterone Acetate (CPA).
Long-acting Gonadotropin-releasing Hormones (GnRH) agonists. ( Leuprorelin, Triptorelin & Goserelin.
Psychotropic medication:
Selective Serotonin Reuptake Inhibitors (SSRIs)

14. Cyproterone acetate LICENSED FOR MALE HYPERSEXUALITY
MODE OF ACTION
Blocks testosterone receptors
Also decreases GnRH and LH secretion
DOSE
50 – 200 mg orally
300 – 600 mg fortnightly intramuscular depot (named patient basis)
COST
£300 – 400 per year

15. Cyproterone acetate ADVERSE EFFECTS
menopausal symptoms (hot flushes, depression, weight gain, cardiovascular)
gynaecomastia
osteoporosis
carbohydrate metabolism, other endocrine
CAUTIONS / CONTRA-INDICATIONS
under 18 (or incomplete growth)
liver disease
malignancy (except prostate)
cardiovascular disease
severe diabetes
severe chronic depression
metabolic bone disease

16. Leuprorelin NOT LICENSED
MODE OF ACTION
GnRH agonist: exhausts LH and FSH
DOSE
3.75 mg 4 weekly titrate between every 2 weeks and every 8 weeks
or 22.5mg every 3 months
COST
3.75mg = £ = £1630 annually

17. Triptorelin SALVACYL LICENSED FOR SEVERE SEXUAL DEVIANCE
MODE OF ACTION
GnRH agonist: exhausts LH and FSH
DOSE
3.75mg – 7.5 mg every 4 weeks
11.5mg every 3 months
COST
3.75mg = £ = £1366 annually

18. Goserelin NOT LICENSED
MODE OF ACTION
GnRH agonist: exhausts LH and FSH
DOSE
3.6mg every 4 weeks
long acting 10.8mg every 12 weeks
COST
3.6mg = £ = £1590 annually
10.8 mg = £ = £1559 annually

19. GnRH agonists ADVERSE EFFECTS
menopausal symptoms (hot flushes, depression, weight gain, cardiovascular)
gynaecomastia
osteoporosis
carbohydrate metabolism, other endocrine
BUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATE
initial increase in testosterone – not need flutamide
CAUTIONS / CONTRA-INDICATIONS
under 18 (or incomplete growth)
malignancy (except prostate)
cardiovascular disease
severe diabetes
severe chronic depression
metabolic bone disease

20. GnRH agonists STUDIES Case studies and case series
118 patients in systematic review (Briken et al., 2003)
Very low re-offending
Better outcome for those previously on MPA or CA
Sexual urges and fantasies may disappear
Frequency of masturbation reduced drastically
Side-effects less problematic

21. SSRIs NOT LICENSED MODE OF ACTION
Potentiate serotonin activity by decreasing re-uptake from synapse
DOSE
fluoxetine:
20mg for 4 weeks, 40 mg for 4 weeks, 60 mg for 4 weeks
sertraline:
50mg, 100mg, 150mg
COST
£ annually

22. SSRIs ADVERSE EFFECTS nausea agitation, restlessness insomnia
sexual dysfunction (decreased libido; delayed ejaculation)
too much coffee feeling
raised prolactin
CAUTIONS / CONTRA-INDICATIONS
mania
epilepsy (poorly controlled)
history of bleeding disorders
hypersensitivity
akathisia

23. SSRIs
STUDIES
over 200 case reports and open studies reported in the literature (Kafka, 2003; Greenberg & Bradford, 1997)
most report success in reducing the frequency and intensity of sexual fantasy, urges and arousal
often without negative effects on normal sexual behavior
systematic review (Adi et al., 2002)
very few trials of reasonable methodological quality
outcomes positive
use of SSRI medication in sex offenders warranted

24. SSRIs HOW DO THEY WORK? May have effect through: Impulsivity Mood
Obsessive-compulsive
Decreased deviant fantasizing
Attachment

25. Legal and Ethical issues

26. Voluntary or Mandatory
Mandatory in many USA states
If Voluntary – issues with consent
Voluntary more like to work?
Most psychiatrist feel treatment should be voluntary.
If capacity is an issue then AWI and DMP opinion.

27. Treatment or Punishment
Voluntary = treatment?
Mandatory = punishment?
Side effects
Risk management tool?

28. Concluding thoughts Pharmacotherapy can work.
More guidance on legal and ethical concerns.
Advice from SOLS