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

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

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

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

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

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.

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

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

Sexual preference and sexual drive Interest rather than accessibility Paedophilia

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.

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

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

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)

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

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

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 = £125.40 = £1630 annually

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 = £105.05 = £1366 annually

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 = £122.27 = £1590 annually 10.8 mg = £366.82 = £1559 annually

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

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

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 £50 - 500 annually

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

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

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

Legal and Ethical issues

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.

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

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