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Sexual Homicide and Paraphilias: The Correctional Service of Canada’s Experts Forum 2007

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The Biomedical Treatment of Sexual Sadism and Associated Conditions

Dr. John M. W. Bradford,
Professor and Head Division Forensic Psychiatry,
University of Ottawa,
Professor of Psychiatry Queen‘s University,
Professor School of Criminology, University of Ottawa
Associate Chief Royal Ottawa Healthcare Group

Address for correspondence:
Royal Ottawa Mental Health Centre
Integrated Forensic Program
1145 Carling avenue
Ottawa, Ontario K1Z 7K4
Telephone: (613) 345-1461 ext. 2618
Fax: (613) 345-4318
E-mail: john.bradford@rohcg.on.ca

 

Abstract

Sexual sadism is a serious psychiatric condition that can be associated with the death and mutilation of victims of a sexually motivated homicide or an attempted homicide. Sexually motivated homicide or attempted homicide is a rare event with catastrophic consequences when it does occur. The spectrum of sexual sadism can include necrophilia and lust murder. There is surprisingly little evidence based information available with regard to the assessment and treatment of individuals suffering from sexual sadism. Treatments for sexual sadism are principally biomedical. Specifically, pharmacological treatments with the aim of complete suppression of the sexual drive through pharmacological castration.

 

 

The Biomedical Treatment of Sexual Sadism and Associated Conditions

Sexual Sadism and Associated Conditions

Sexual sadism is part of a multidimensional concept of sexual violence. The multidimensional nature of sexual violence means that sexual sadism and sexual violence have various definitions depending upon which group is using the term and how the term is used. Sexual sadism is usually used to describe violent sexual behaviour primarily against women and children that involves torture (physical and psychological), as well as, physical violence and coercive sexual activity. This clearly involves nonconsenting partners who are degraded, humiliated, and violently physically and psychologically abused. This chapter will describe the biomedical treatment of paraphilias and conclude with a treatment algorithm recommendation. Sexual sadism coupled with sexual masochism involving consenting partners is widely practiced around the world but is not the subject of this chapter.

Definitions of Sexual Sadism and Associated Conditions

Sexual sadism is defined in Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) as one of the paraphilias “involving acts (real, not simulated) in which the individual derives sexual excitement from the psychological or physical suffering (including humiliation) of the victim. Some individuals with this paraphilia are bothered by their sadistic fantasies, which may be invoked during sexual activity but not otherwise acted on; …. Still others with sexual sadism act on their sadistic sexual urges with nonconsenting victims. In all of these cases, it is the suffering of the victim that is sexually arousing. Sadistic fantasies or acts may involve activities that indicate the dominance of the person over the victim (e.g., forcing the victim to crawl or keeping the victim in a cage). They may also involve restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape, cutting, stabbing, strangulation, torture, mutilation or killing” American Psychiatric Association, 1994). Sexual sadism with nonconsenting partners usually involves extreme sexual violence against adults and children and can result in sexually motivated homicides. Sexually motivated homicides can be sadistic or non-sadistic, with distinct clinical characteristics for each group (Gratzer & Bradford, 1995). Recent research has assisted in identifying the clinical characteristics of individuals committing sexually motivated homicide and attempted homicides against children (Firestone, Bradford, Greenberg, & Nunes, 2000). The study sample clearly showed a deviant sexual preference toward physical violence as one measure of differentiating homicidal child molesters from non-homicidal child molesters (Firestone et al., 2000). When physical violence against nonconsenting partners becomes an erotic sexual preference this is pathopneumonic of sexual sadism.

As sadistic sexual violence involves nonconsenting partners and includes physical violence associated with sexual acts that are against the law is not surprising that most of the perpetrators of these acts would be sexual offenders. However not all sexual offenders suffer from a paraphilia or sexual deviation as defined in DSM-IV (American Psychiatric Association, 1994; American Psychiatric Association & American Psychiatric Association, Task Force on DSM-IV, 2000). It is important to note that when a paraphilia is present there is considerable comorbidity between various paraphilias making it highly unlikely that any individual suffers discreetly from one paraphilia (Bradford, Boulet, & Pawlak, 1992). There is also significant comorbidity with other Axis I psychiatric conditions, specifically substance use disorders and alcoholism (Allnutt, Bradford, Greenberg, & Curry, 1996). The comorbidity with alcoholism correlates with the degree of sexual violence and sexual sadism. When the mean scores of the Michigan Alcohol Screening Test (MAST) were correlated with different paraphilias in a large sample of paraphilic men, the group with a diagnosis of sexual sadism had the highest mean scores on the MAST (Allnutt et al., 1996). Further, previous research on the effects of alcohol ingestion and sexual arousal has shown a specific effect related to rape (Wormith, Bradford, Pawlak, Borzecki, & Zohar, 1988). This means the treatments and risk management of sexual sadism must include the management of alcoholism and other substance use disorders.

The operational criteria for sexual sadism in DSM-IV-TR have recently been criticized due to a lack of diagnostic reliability. One study of experienced forensic psychologists found that the coefficient for reliability across diagnoses was extremely poor with a kappa coefficient of only 0.14 (Marshall, Kennedy, & Yates, 2002; Marshall, Kennedy, Yates, & Serran, 2002). This is a complicated issue in part related to the failure of the Council of the American Psychiatric Association to include a recommendation by the subcommittee on sexual disorders to have a section of “Coercive Paraphilic Disorders” in DSM-III-R (American Psychiatric Association & American Psychiatric Association, Work Group to Revise DSM-III, 1987). It is also related to a lack of research studies focusing on sexual sadism and sadistic sexually motivated homicide.

Research has also shown that sexual sadism is associated with organic brain damage specifically in the temporal lobe (Hucker & Stermac, 1992; Langevin, Bain, Wortzman, Hucker, Dickey, & Wright, 1988). A study of sexually sadistic homicide perpetrators found that over 50% of the sample had evidence of some neurological abnormality (Gratzer & Bradford, 1995) and a similar study by Briken, Habermann, Berner, & Hill (2005) found that over 30% of a sample of sexually motivated homicide perpetrators had brain abnormalities. In another study Briken, Habermann, Berner, & Hill (2006) found a considerably higher incidence of XYY syndrome (a distinct chromosome abnormality) in sexually motivated homicide perpetrators. Other studies have documented similar findings, specifically using brain imaging and brain activation techniques to examine this association (Mouras et al., 2003; Redouté et al., 2000; Stoléru et al., 1999). These studies indicate the need for a neuro-psychiatric workup in cases of sexual sadism and sexually motivated homicides. In addition, increased prevalence of brain abnormalities in sexually sadistic homicide perpetrators means the probability of brain abnormality must be taken into account in any treatment approach and most specifically, in biomedical treatments. In general brain abnormality is associated with disinhibited sexual behaviour and poor impulse control (Bradford, 2001).

The biomedical approach is based on a fundamental understanding of endocrinology; neurobiochemistry and the clearly documented effects of surgical castration in animal research and humans. These are all evidence-based approaches that have been in existence for many years. Surgical castration and stereotactic neurosurgery are mostly of historical interest at this time although they have contributed considerably to an understanding of the biomedical approach. Pharmacological treatments using specific serotonin reuptake inhibitors (SSRIs); hormonal agents and specific antiandrogens form the basis to pharmacological treatments and now constitute the accepted biomedical approach. These pharmacological approaches can be used in any type of paraphilia or sexual deviation. The mechanism of action for these pharmacological agents is clearly understood based on extensive animal and human research.

Neurobiology of Sexual Behaviour

Although a full discussion of the neurobiology of sexual behaviour is beyond the scope of this chapter, a brief review as a foundation to the biomedical approach to treatment of sexual sadism would be helpful. Although it would be premature to say that the neurobiology and neuropharmacology of sexual behaviour is fully understood, it would be accurate to say that there is a far greater understanding of the neurobiology of sexual behaviour when compared to many mainstream psychiatric conditions including major depression, bipolar disorder, and schizophrenia (Bradford, 1996, 2001). Serotonin (5 HT) is a neurotransmitter that is involved in the neurobiology of many psychiatric conditions. Pharmacological treatments that modulate central serotonin levels are effective treatments in many psychiatric conditions including major depression and schizophrenia. It has long been known that antidepressant and antihypertensive medications have significant sexual side effects impacting on sexual desire, sexual arousal and orgasm. This is particularly true for antidepressants that affect 5 HT levels in humans but also play an important role in the research into the neurobiology of sexual behaviour. In fact, pharmacological agents affecting serotonin have played an integral role in animal models of human sexual dysfunction (Cantor, Binik, & Pfaus, 1999; Matuszczyk, Larsson, & Eriksson, 1998; Pfaus, 1999). Antihypertensive drugs such as clonidine also have significant effects on sexual behaviour. Animal behavioural experiments on noncontact erections, the homologue of psychogenic stimulated erections in humans, have been studied using nitrous oxide and other pharmacological agents (Pfaus, 1999). Human and animal sexual behaviour has also been extensively studied from the standpoint of sexual hormones. The way in which various neuroendocrine conditions correlate with sexual stimulation, sexual arousal and sexual drive have all been well-established through extensive research over many years (Bradford, 2001; Pfaus, 1999; Stoléru, Ennaji, Cournot, & Spira, 1993). There has been ongoing scientific progress in understanding the relationship between plasma hormone levels (most specifically free and total testosterone) and other hormones as well and the relationship between these hormone levels and sexual arousal, simulation, and sexual desire or sexual drive (Halpern, Udry, & Suchindran, 1998). The effects vary by age and there are also hormonal effects in woman correlating with sexual behaviour (Sarrel, 1998; Sarrel, Dobay, & Wiita, 1998). There has also been research completed to examine the neuroanatomical correlates of sexual arousal which appear to be associated with bilateral activation of the inferior temporal cortex, the right insular and inferior frontal cortex and the left anterior cingulate cortex. These areas are related to the limbic system and the degree of activation correlates with plasma testosterone levels. One of the first studies to document this was completed by Stoléru et al. (1999) using positron emission tomography (PET). As already outlined, there is evidence of brain abnormalities being associated with sexual sadism. This is complicated by the fact that sexual sadism is also associated with antisocial personality disorder. Antisocial personality disorder is also associated with violence and there is increasing evidence of a complex interaction between biological factors of brain abnormality, hormone levels, genetic factors, as well as various psychosocial factors all of which contribute to psychopathy and violence in humans (Raine, 2002; Raine et al., 2003). As research techniques improve and more specifically as brain imaging techniques improve it is highly likely that the contribution of these individual factors to psychopathy, sexual violence and physical violence in humans, will be better understood.

Pharmacological Treatment

The pharmacological treatment of sexual sadism and necrophilia is based on what is known about the neurobiology of human sexual behaviour. It is mostly based on the modification of neurotransmitter levels principally involving serotonin (5HT) but also the reduction of sex hormones by pharmacological intervention. Pharmacological treatments that modulate levels of 5HT had been shown to be successful in treating a number of sexual disorders including sexual deviation, the paraphilias, and nonparaphilic hypersexuality. Pharmacological agents that increase 5HT levels in the brain reduce sexual desire, sexual arousal, and increase levels of sexual dysfunction. These 5HT receptors have been classified according to molecular biological techniques and various subtypes have been identified. These 5HT receptors have been classified as 5HT1; 5HT2; 5HT3; 5HT4; 5HT5; 5HT6; 5HT7. Pharmacological research has identified ligands for the various receptors and sub receptors. As this research progresses, understanding how receptor agonists and antagonists affect the various receptor systems will allow for further understanding of what receptors play a specific role in sexual behaviour, what receptors are involved in various psychiatric conditions, and the role of 5HT in various behaviours such as impulsivity and various types of aggression.

The pharmacological treatment of sexual deviation or the paraphilias includes the treatment of sexual sadism and associated conditions. The pharmacological treatments are classified as: (1) specific serotonin reuptake inhibitors (SSRIs); (2) antiandrogen and hormonal treatments; and (3) luteinizing hormone releasing hormone agonists (LHRH agonists).

The SSRIs

Drugs that increase 5HT levels in the central nervous system reduce sexual desire and deviant and non-deviant sexual behaviour. Starting in approximately 1990, SSRIs were used for the treatment of the paraphilias, such as exhibitionism, with considerable success. Fluoxetine hydrochloride and sertraline hydrochloride have been the pharmacological agents most commonly used (Emmanuel, Lydiard, & Ballenger, 1991; Kafka, 1991a, 1991b, 2003; Kafka & Prentky, 1992; Lorefice, 1991; Perilstein, Lipper, & Friedman, 1991; Stein et al., 1992; Zohar, Kaplan, & Benjamin, 1994). Kafka (1991b) reported on four patients treated for non-paraphilic hypersexuality with fluoxetine and reported significant reductions in sexual drive. Included were three cases of paraphilia also treated with fluoxetine where considerable clinical improvement was observed. Coleman, Cesnik, Moore, & Dwyer (1992) reported on a study of 13 paraphilic males and found significant reductions in deviant sexual urges and behaviour. Kafka (1994) also reported on an open clinical trial using sertraline to treat paraphilia and nonparaphilic hypersexuality and reported a clinical response rate of 50%. The subjects showed significant reductions in deviant sexual fantasies, urges, masturbation and deviant and non-deviant sexual behaviour. Bradford, Greenberg, Gojer, Martindale, & Goldberg (1995) completed a 12 week open label dose titrated study of sertraline in the treatment of pedophilia. The mean effective dosage was 131 mg per day which approximates the mean effective dosage seen in studies of sertraline in the treatment of obsessive-compulsive disorder. This provides some support for the paraphilias being part of obsessive compulsive spectrum disorders (Bradford, 1999). The treatment effects were significant, showing reductions in sexual drive, sexual fantasy, and other sexual behaviour. Most significantly there was a normalization of the sexual arousal patterns with suppression of deviant sexual arousal, coupled with a maintenance or relative increase in non-pedophilic arousal to consenting sex with adults. Greenberg, Bradford, Curry, & O’Rourke (1996) and Greenberg & Bradford (1997) completed two other studies with SSRIs. One compared the relative effectiveness of three SSRIs (Greenberg et al., 1996) and the other compared the treatment effects of SSRIs to a control group that received only cognitive behavioural treatment (Greenberg & Bradford, 1997). In the first study the three SSRIs (fluoxetine, sertraline, and fluvoxamine) were equally effective in reducing deviant sexual fantasies, urges, and sexual behaviour in a variety of paraphilias. In the second study, the SSRIs showed significant treatment effects, reducing the severity of deviant sexual fantasies and urges at a statistically significant level when compared to the control group.

In appropriate dosages the SSRIs have a significant treatment effect on sexual drive; sexual fantasies, including deviant sexual fantasies; and in addition, suppress deviant sexual arousal. As with all pharmacological agents the treatment effects are across all paraphilias, including sexual sadism. In the case of multiple paraphilias in any given individual, a single pharmacological treatment would have an impact on all of the paraphilias, reducing all deviant sexual fantasy, urges, arousal and behaviour.

The Antiandrogen and Hormonal Treatments

These pharmacological treatments were developed from the observation that surgical castration had a significant treatment effect on the recidivism of sexual offenders. Long-term studies of the recidivism of sexual offenders that were surgically castrated showed dramatic impact on recidivism, reducing it from over 60% to less than 5% in all studies (Bradford, 2000). Pharmacological agents that reduced plasma testosterone and therefore replicated the treatment effects of surgical castration were developed for treatment intervention in sexual offenders. Initially, estrogens were used. However the side effect profile of nausea, vomiting, weight gain and feminization prevented the widespread use of these pharmacological agents in the treatment of sexual deviation. They were effective however in reducing plasma testosterone levels and subsequently, a significant reduction of sexual desire, deviant sexual urges, and fantasies as well as behaviour (Bradford, 2000). Medroxyprogesterone acetate (MPA), a progestinic agent has been the most common form of pharmacological treatment for sexual deviation in the United States (Bradford, 2000). This in part is related to the lack of availability of cyproterone acetate (CPA) in the United States. MPA is a progestagen that decreases circulating levels of testosterone by enzyme induction in the liver as well as blocking the secretion of gonadotropins at the pituitary level. It is not a true antiandrogen in that it does not block the intracellular molecular androgen receptors. CPA which has been used extensively in Canada, Europe, and elsewhere is a true antiandrogen that blocks the intracellular testosterone receptors throughout the body (Bradford, 2000). The effect is to decrease sexual drive with an impact on all types of sexual behaviour including fantasies, urges and behaviour. It also decreases the secretion of gonadotropins in a similar treatment effect to MPA. Both of these drugs have been shown to have a significant treatment effect on deviant sexual fantasies, deviant sexual urges, and deviant sexual behaviour (Bradford, 2000). It is this treatment effect that has led to the extensive use of these pharmacological agents in the treatment of sexual deviation. They have also been used in the treatment of more serious sexual deviations.

MPA has principally been used in open clinical studies starting in the late 1970s and early 1980s. It can be given as an intramuscular injection of 400 mg weekly as part of an initial treatment, dropping to low dosages with maintenance treatment once the plasma testosterone levels have been reduced to prepubertal levels (Bradford, 2000). It can also be used orally in dosages ranging from 50 mg to 400 mg per day. Monitoring of treatment through a sex hormone profile at regular intervals is imperative to treatment success. The reduction of plasma testosterone to prepubertal levels is required for an adequate treatment response. It also provides an important measure of compliance. Any sudden discontinuation of the pharmacological treatment with MPA is not likely to result in any immediate consequences. Long-term treatment may result in the development of osteoporosis or osteopenia. This can be prevented or treated by medical intervention (Bradford, 2000; Grasswick & Bradford, 2003). A review of the clinical studies that have been completed using MPA can be found in review articles by the author (Bradford, 1988, 1999, 2000, 2001).

CPA has been more extensively studied and for a longer period of time than MPA and the studies include a larger number of subjects (Bradford, 2000). These studies have been mostly open clinical studies and recidivism rates as a treatment outcome measure has been included in a number of the studies as well as double-blind placebo-controlled studies. Further, many individuals included in the studies had high rates of recidivism initially and this was part of the sample selection for the studies. These studies included both rapists and pedophiles.

Some of the rapists would by definition have been sexually sadistic (Bradford, 2000). In trying to treat a number of paraphilias, recidivism as a treatment outcome measure was included in studies of CPA (Bradford, 2000). The impact on sexual offense recidivism was identical to the impact of surgical castration on sexual offender recidivism. The author of this review completed a double-blind study using CPA in the treatment of pedophilia (Bradford & Pawlak, 1993a). Further, a study of CPA on the sexual arousal patterns of pedophiles clearly showed a normalization of the sexual arousal patterns with a suppression of deviant sexual arousal and a relative increase in normophillic arousal (Bradford & Pawlak, 1993b).

CPA can be given orally in dosages from 100 mg a day to 400 mg per day. It is also given intramuscularly usually weekly or biweekly in dosages from 100 to 200 mg. Monitoring of the sex hormone profile, similar to that in MPA, is important although the plasma testosterone levels do not need to be brought down to prepubertal levels for treatment effectiveness. This is a complicated issue that is not fully understood, however, it may be due to the fact that CPA has an effect on the intracellular androgen receptors. These receptors most likely become desensitized with time as a result of the receptor blockade (Bradford, 2000, 2001). This allows lower dosages to be used with long-term treatment. It also allows for the maintenance of a degree of sexual behavior for consenting adult partners. An ideal treatment for sexual deviation would be the suppression of deviant sexual interests while allowing normophillic sexual interests to continue. CPA has been shown to have this type of treatment profile. The author also completed a single case study with repeated measures of CPA in the treatment of sadistic homosexual pedophilia. The subject had perpetrated sexually motivated homicides against children that showed sexual sadism. The subject also had extensive brain damage in the temporal lobe of the brain. Treatment with CPA resulted in a significant impact on the sexual arousal patterns as measured by penile tumescence. CPA had the effect of suppressing both pedophilic and sadistic arousal at the same time maintaining the degree of normophillic arousal that was present. This was the first time it was documented that CPA had the effect of normalizing the patterns of sexual arousal in individuals with sexual deviation (Bradford & Pawlak, 1987). CPA can be used to titrate plasma testosterone levels against treatment effects. When used intramuscularly, the treatment effects would be to reduce the plasma testosterone levels to castration levels leading to a pharmacological castration (Bradford, 2000).

The LHRH Agonists

The luteinizing hormone releasing hormone agonists have also been used to treat the paraphilias. They have a specific treatment effect where an over stimulation of the hypothalamus occurs resulting in complete suppression of gonadotropin secretion and a drastic reduction of plasma testosterone levels to castration levels in a period of four to six weeks. These are the pharmacological agents for castration and form the most intrusive of the pharmacological interventions. The LHRH agonists are given intramuscularly and have a prolonged action requiring injections on a monthly or tri-monthly basis. The pharmacological agents that have been used are luprolide acetate, goserelin acetate and tryptorelin acetate. The dosage is usually 7.6 mg monthly with an equivalent tri-monthly dosage. These drugs have mostly been used for the treatment of prostate cancer where the aim of treatment is to reduce the plasma testosterone levels to castration levels (Rousseau, Couture, Dupont, Labrie, & Couture, 1990). There have been clearly documented effects on sexual behaviour.

The clinical studies in the treatment of paraphilias are limited to single case studies and relatively small treatment outcome studies (Rosler & Witztum, 1998; Thibaut, Cordier, & Kuhn, 1993). Even though this is the case, the mechanism of action of the LHRH agonists and the effect of a reduction of free and total testosterone to castration levels is well established in the scientific literature. The impact on sexual behaviour is profound with an almost complete reduction of sexual desire, sexual fantasy, overt sexual behaviours such as masturbation, sexual intercourse and a drastic reduction of sexual arousal. Also well-established is a calming effect or anti-aggressive effect in general on the person’s behaviour.

The biomedical treatment approach has been promoted as an algorithm. This algorithm was based on an enhanced classification of severity of psychiatric disorders, and paraphilias specifically, following the guidelines of DSM-III-R and later in DSM-IV (American Psychiatric Association & American Psychiatric Association, Task Force on DSM-IV, 1994; American Psychiatric Association & American Psychiatric Association, Work Group to Revise DSM-III, 1987; Bradford, 2000). The enhanced classification scheme is as follows: (1) mild; (2) moderate; (3) severe; and (4) catastrophic.

Mild is defined as deviant sexual fantasies without any hands-on sexually deviant behaviour. Moderate is defined as deviant sexual fantasies and deviant sexual behaviour but at a low level. This would mean that the deviant sexual behaviour would be nonintrusive such as fondling as opposed to penetration and the number of victims would be low. Severe is defined as deviant sexual fantasy and deviant sexual behaviour that is occurring at a higher frequency and is also intrusive, involving penetration as opposed to fondling. Catastrophic is defined as clear evidence of sexual sadism both in fantasy and behaviour; predatory sexual behaviours such as stalking victims, sexually motivated homicidal urges and behaviour.

The Treatment Algorithm

The treatment algorithm is linked to the severity scale and encompasses six levels of treatment for the four levels of severity:

  1. Level 1: Regardless of the severity of the paraphilia everyone would receive a cognitive behavioural treatment program based on a relapse prevention model as well as individual cognitive behavioural treatment programs as necessary.
  2. Level 2: Pharmacological treatment would start with the SSRIs in appropriate dosages. This would be the treatment in all cases of mild paraphilias.
  3. Level 3: If the SSRIs were not effective in four to six weeks of adequate dosage levels, a small dose of an oral antiandrogen would be added to the SSRI treatment régime. A typical treatment régime at this level would be 150 mg of sertraline per day and 50 mg of CPA per day. The CPA could be substituted with 50 mg of MPA per day. This treatment level would cover mild and moderate paraphilias.
  4. Level 4: This would be full oral antiandrogen treatment. For example, this would be CPA or MPA at 50 to 300 mg per day. This treatment régime would be used in most moderate cases and some severe cases.
  5. Level 5: This consists of full intramuscular antiandrogen treatment. This typically would be 300 mg of MPA given intramuscularly every week as part of an initial régime of treatment. Once the levels of testosterone were sufficiently suppressed the dosage level would drop to a maintenance level of 400 mg every four weeks. For CPA this would be 200 mg given intramuscularly biweekly.
  6. Level 6: This consists of complete androgen suppression or pharmacological castration. This is achieved by CPA in dosage levels of 200 to 400 mg per week. Alternatively, LHRH agonists would be used. LHRH agonists are effective at creating pharmacological castration more effectively than CPA. A typical régime with the LHRH agonists would be Lupron (Luprolide acetate) 7.6 mg given monthly.

From this algorithm, linked to a scale of severity, sexual sadism is at the highest level of severity and in most cases would require pharmacological castration at level 6 or significant androgen suppression at level 5 to control the risk of catastrophic deviant sexual behaviour.

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Dr. Bradford’s Discussion

Mossman: What about the role of other pharmacological treatments in these individuals. You talk about a number of people with temporal lobe damage who may, whether they have seizures or not, derive benefit from anti-epileptic medications. A number of these people have attention-deficit hyperactivity disorder (ADHD), a number of these people have features, if not the full-blown clinical picture of bipolar disorder. Some of them have psychotic disorders. Is it ever the case that addressing those other disorders and not giving them anti-sexual treatments, is that ever appropriate?

Bradford: Most of the cases I am talking about, other than the brain damage, don’t have significant Axis I disorders. If there was an Axis I disorder, you can actually pick and choose atypical anti-psychotics and use them for somebody who has a psychotic condition who may be sexually disinhibited. Where it gets more complicated and I think this is where I struggle, if you look at the prevalence of ADHD in a forensic population, it is over 50%. If you accept for the moment that this may be an indictor of minimal brain dysfunction, you’ve got a population with something going on organically which really worries me. With that you get impulsivity and all kinds of other problems and that is a tough population to deal with if they are also sexually deviant. Under those circumstances, some of the times you are combining – because many of them have impulsive aggression as well as impulsive deviant sexuality. The common factor may be impulsivity but it may not be coming entirely from a sexual motivation. It may have to do with brain damage and disinhibition. So, in those circumstances what we have done is we have treated them for libido reduction, but then we have looked at some of the drugs such as Topiramate (i.e., Topemax) and the anti-epileptic drugs that may have effects on impulsivity. We may have combined them with SSRIs in some instances, so we have had to be more experimental in some ways to come up with a package for that individual.

Mossman: What about diagnostic or causal specificity in selecting treatment? There appears to be quite a bit of causal specificity in the treatments that you might pick, beyond those specifically directed toward suppressing sexual drive.

Bradford: I talked about paraphilias as sort of “hands on” and “hands off”. Hands off paraphilias would be voyeurism, fetishism and things like that. They would be mild in my algorithm. 15 years ago most of them would have been treated with cognitive behavioural therapy. Today, we treat most of them with SSRIs and cognitive behavioural therapy. As you get into “hands on” paraphilias, and obviously pedophilia is a concern, and as you go up toward sexual sadism, then the pharmacological intervention becomes more specific.

Mossman: It sounds like specificity of the pharmacological intervention has to do with greater intensity on the part of the clinician in wanting to suppress this individual’s sexuality as opposed to some sort of diagnostic consideration about the pattern in which the sexual fantasies take place. In other words, it’s not that you’d be addressing obsessionality with an SSRI, you are saying you use a more aggressive intervention and potentially more toxic intervention in situations where the cost of failing to successfully treat the individual is going to be higher.

Bradford: I would have some trouble justifying treating an exhibitionist with a lutenizing hormone releasing hormone agonist. However, there are some exhibitionists who convert into more serious activity. The first person that I ever treated with Cyproterone Acetate (CPA) was a chronic exhibitionist who had been to jail for two years and had just got out of jail. Upon his release we found that he had got better at choosing the victims he would expose to. So, he would choose people who were more likely not to report him. He came into the clinic and was starting a CPA study and he said “Ah, it’s a waste of time, I have had this treatment, that treatment, you know” and he was completely unmotivated for anything. So, he came back four weeks later and looked completely different. He walked in, and the first thing he said to me was “The fantasies have gone”. I have never forgotten that. His fantasies had gone and he no longer had the motivation to expose. But I wouldn’t treat an exhibitionist today with CPA. Certainly when we didn’t have SSRIs available about 20-30% of people in the clinic would have received pharmacological treatment and 70% cognitive behavioural treatment. Whereas today it’s probably about 90% and only about 10% that would only get cognitive behavioural treatment and that’s because of the SSRIs which are easy to give and seem to work well.

Mossman: You just described an individual who four weeks after a pharmacological intervention had a great change in his cognitive apparatus. Although I have never had those kinds of experiences, I can imagine from talking with my patients that it might be a great relief not to be obsessed with ideas that everyone knows society disapproves of. At what point relative to an individual’s sentence, when the sentence might end, do you think treatment should begin with pharmacological agents? In disorders like schizophrenia or bipolar disorder, pharmacological treatment is a precursor to other kinds of treatment in almost all cases because those pharmacological treatments make available people’s coping mechanisms to deal with other problems. I wonder if that is the case here as well?

Bradford: My opinion has changed over time. I have said that you shouldn’t give anti-androgens in a total institution because I was worried about the longer term side effects. I saw them as part of a pre-release package. Where I have changed my mind is in relation to SSRIs, where the long term side effects of SSRIs are much less problematic than anti-androgens and non-hormonal treatments. I think it has also become clear that even on low dosages, there is some suppression of the deviant fantasies. My colleagues are telling me that patients on SSRIs tend to work better in some of the cognitive behavioural programs because they are less driven by fantasies. Now, if that is the case, and at this point it is just anecdotal, then I think that is fine. Certainly, I have patients who have told me over and over again, that they feel better, that they’re not as compulsively driven, and I use that term very specifically. The interesting thing is that most of us assume that these people have sexual fantasies and that their deviant sexual fantasies are ego syntonic, but in fact, some of them are ego dystonic. People really need to get their head around that. If ego dystonic sexual fantasies are suppressed with something that is not a significant pharmacological intervention, I think it can be very helpful. So, I’ve changed my mind from say 10 or 15 years ago.

Schweighofer: We were speaking earlier about the role of fantasy and deviant masturbation as a method of coping with interpersonal, interpsychic malaise. Have you had any experience or examples where as a function of their sexually deviant fantasies being knocked down, that other problematic replacement behaviours arise?

Bradford: I had a homicide perpetrator on an intramuscular anti-androgen. He really didn’t like it, and he had become impotent and had no libido at all. It was quite clear that he was taking the medication only because he was compelled to do so. I had always felt it was critical he didn’t drink. I had tested him with phallometric testing, both in an alcohol and non-alcohol state, and there was an enormous difference. As he became more unhappy, he drank more which the supervising authorities missed, they were not monitoring his alcohol intake. He really had disinhibited arousal in the lab on alcohol, he had discovered that, and he was trying to generate arousal and in fact, I guess was partially successful. He was a homosexual pedophile, he had killed a young boy. But he acted out against an adult female, it was a very minor sexual assault, but it nonetheless could have been a lot worse. The ideal situation would be to have a person who is sexually active but in a normaphilic way at a low level. If you could achieve that, then you would be great.

Harris: When you are considering release, is libido reduction always indicated? When I see a guy I am anticipating to release, what are the things that would be on your “hit list” of factors that should cause me to say, “this guy is worth a psychiatric referral?”

Bradford: In our clinic, libido suppressants are provided to about 80 to 90% of our sex offenders, and we are treating fairly mild people. It works well and they tolerate it well, some of them have 50mg of Sertaline a day. If you ask me who needs a Luteinizing Hormone-Releasing Hormone agonist (LHRH), or who needs CPA, then these would be the people where there is any question of sadism, anybody that is highly predatory and anybody who is a significant recidivist. Those are the kinds of high risk people where I consider anti-androgen treatment. High sex drive, one orgasm a day or more, whether he has a “hands off” or “hands on” paraphilia, I think the degree of compulsivity is significant. I’d be worried about the ability of the individual to benefit from cognitive behavioural therapy without some kind of libido suppressant.

Harris: I realize these are only guidelines, but the high sex drive issue, the one plus orgasm a day guy, do you take age into account and to what extent, when you are making those mental calculations?

Bradford: Age is taken into account. Age and sexual offence recidivism are related. In fact, what you are doing with anti-androgens is bringing on age, in some ways. Many of the people who are pedophiliac only present in their 30s. I have certainly got people who are over the age of 60 that I’ve got on medication. Don’t forget that as you get older, you may have disinhibited sexual behaviour for other reasons. You have to look at the individual case. I don’t think there is a one-size-fits all.

Hart: Your treatment algorithm actually focuses on treatment of paraphilia. Paraphilia in the DSM is limited to the focus of arousal as opposed to the tone or level of arousal. However, we see many people who appear to be hypersexual or have a high tone of arousal without any specific focus. Their sexual behaviour can get them into trouble simply because of a lack of normal inhibitions. Would you say that your treatment algorithm would be suitable for people who might have sexual behaviour problems unrelated to paraphilia?

Bradford: If you look at non-paraphilic hypersexuality most of them are treated with SSRIs and some with a low dose of an oral anti-androgen. They do extremely well. Now, most of them do not have a paraphilia but they get themselves into difficulties because of inappropriate sexual behaviour. Where it gets more difficult is where you’ve got somebody who is not necessarily displaying paraphilic behaviour but disinhibited sexual behaviour as a result of, say, a head injury or dementia. So then you see things like non-paraphilic hypersexuality, the 900 phone numbers, masturbating in the washroom instead of working, touching woman’s bums at work and getting in trouble that way. When you get into these more complicated issues, there is not an easy recipe.

Proulx: Your program has quite impressive results with guys in the community for 11 or 12 years. How do you manage? They have to be involved intensively in a program where they develop skills to be able to have, relationships with other people. How did you deal with those subjects?

Bradford: Most of them have come through hospital having been found not criminally responsible. Most have some kind of legal stipulation that requires treatment. It doesn’t force them to have treatment but it puts conditions on where they might live, how they cascade out of hospital, and other things like that. Some of them, because of their progress, have been discharged a long time ago. There is one guy that sort of hums and haws about taking his medication at this point, but he takes it. There’s a lot of supportive psychotherapy and vocational rehabilitation with them. In terms of social skills training and things like that, they’ve had it. Many of them have actually got quite a good network of friends that they’ve built up, but not a lot of them have intimate partners. Now, that is not surprising, they have almost no sexual interest. But they do have other friends including both male and female friends. So they have developed their own support network without necessarily having an intimate partner.

Proulx: You reduce sexual arousal but on the other side, you help them to improve their social network, to deal with social isolation, and intense feelings?

Bradford: Right and certainly you need to get them into the community. Some of them are seen weekly; some of them are seen once or twice a week, at least initially by a community nurse or they have home visits and we bring them back into hospital for groups. Groups and social programs are a significant support and patients are encouraged to participate and socialize. A lot them go onto internet dating, or think about it, which worries me, because I’m never sure what’s going to happen with that. But, so far so good. The majority of them have not established intimate partnerships but they have friendships and real friends in the community.