Pharmacotherapy of Sexual Offenders Paraphilias Paraphilias –Includes exhibitionism, fetishism, frotteurism, pedophilias, sexual masochism or sadism, travestic fetishism and voyeurism Characteristics of paraphilias Characteristics of paraphilias – Intense recurrent sexual urges selectively focused on non-human objects, children, non- consenting adults or oneself Rape — sexual expression of aggression Rape — sexual expression of aggression

Cyproterone Acetate Treatment of Sexual Offenders Cyproterone acetate Cyproterone acetate Antiandrogenic and antigonadotropic Antiandrogenic and antigonadotropic Inhibits cellular uptake of testosterone Inhibits cellular uptake of testosterone Blocks receptor binding Blocks receptor binding Decreases sexual drive and interest and sexual deviant fantasies. Does not alter erectile response to erotica Decreases sexual drive and interest and sexual deviant fantasies. Does not alter erectile response to erotica Doses of mg/day Doses of mg/day Administer for few months for antilibidinal effects Administer for few months for antilibidinal effects Effects reverse in three to six weeks after treatment Effects reverse in three to six weeks after treatment

Medroxyprogesterone acetate Treatment of Sexual Offenders As effective as CPA As effective as CPA Duration of treatment similar to CPA Duration of treatment similar to CPA Libido and sexual arousal depressed Libido and sexual arousal depressed Adverse effects include weight gain, mild lethargy, cold sweats, nightmares, dyspnea, hyperglycemia and leg cramps Adverse effects include weight gain, mild lethargy, cold sweats, nightmares, dyspnea, hyperglycemia and leg cramps

LHRH Antagonist Treatment of Sexual Offenders Nafarelin continued administration suppresses response to LHRH Nafarelin continued administration suppresses response to LHRH Decreases testosterone to castration levels Decreases testosterone to castration levels Eliminated exhibitionist behavior Eliminated exhibitionist behavior Patient could maintain erectile capacity Patient could maintain erectile capacity Exhibitionistic behavior returned 9 weeks after cessation of therapy Exhibitionistic behavior returned 9 weeks after cessation of therapy

Methods of Contraception Used Worldwide Female sterilization — 17 % Female sterilization — 17 % IUD— 12% IUD— 12% –IUD (U.S.)— 2% The Pill (E + P)— 8 % The Pill (E + P)— 8 % Other methods Other methods –Depo-Provera –Norplant

New Contraceptives Oral combinations with 20 µg ethynylestradiol plus new progestins Oral combinations with 20 µg ethynylestradiol plus new progestins IUD that delivers levonorgestrel directly into uterus IUD that delivers levonorgestrel directly into uterus Vaginal rings that deliver progestins (easily removed) Vaginal rings that deliver progestins (easily removed) Norplant II (only two rods) Norplant II (only two rods)

New Generation of Progestins Desogestrel, norgestimate and gestodene Desogestrel, norgestimate and gestodene Active orally Active orally Minimal androgenic and anti-estrogenic activity Minimal androgenic and anti-estrogenic activity Cause fewer adverse effects such as acne and hirsutism Cause fewer adverse effects such as acne and hirsutism Should not switch to newer progestins unless problems with current OC Should not switch to newer progestins unless problems with current OC

Long-Term Tamoxifen Treatment Estimated that 1 million women taking tamoxifen long-term to prevent recurrence of breast cancer Estimated that 1 million women taking tamoxifen long-term to prevent recurrence of breast cancer Estimated that 20% have taken tamoxifen more than 5 years Estimated that 20% have taken tamoxifen more than 5 years Recent study concluded that tamoxifen no longer effective after 5 years, may increase likelihood of recurrence after 5 years Recent study concluded that tamoxifen no longer effective after 5 years, may increase likelihood of recurrence after 5 years

Status of Contraceptive Research and Development “People think that just because there are roughly 100 million people a day having intercourse, this is a hugh market. It is not. Why should a pharmaceutical company take these risks?” —Djerassi* *Developer of norethindrone, the first progestational oral contraceptive in 1951.

Future Contraceptives Non-latex condoms to avoid allergic reactions Non-latex condoms to avoid allergic reactions Spermicidal/microbicidal creams, gels, films, and foams. Spermicidal/microbicidal creams, gels, films, and foams. Immunocontraception — immunize against progesterone or cytokines necessary for implantation or embryo growth Immunocontraception — immunize against progesterone or cytokines necessary for implantation or embryo growth