McConaghy and co-workers (McConaghy 1990; McConaghy et al. 1985) described a treatment component for decreasing pedophiliac arousal without aversion therapy. Pedophiliac individuals frequently report having irresistible urges to become sexually involved with children. These urges are accompanied by sensations of elation, anxiety, nervousness, and/or hypervigilance. After learning progressive muscle relaxation, pedophiliac patients are instructed to imagine and describe the highly charged, anxiety-provoking scenes that normally precede initiating acts against a child. Once their typical feelings or emotions are aroused, they immediately implement the relaxation technique, waiting and experiencing the loss of the deviant urge while simultaneously experiencing relaxation. This process is repeated with a number of highly charged scenes until patients acquire the skill to tolerate the emotional discomfort that previously drove them to act on these urges to escape their discomfort. The advantage of this treatment is that patients can practice tolerating the emotions and anxiety that previously led them to believe that they must act on the pedophiliac urges. The therapist’s role is to train the pedophiliac patient in the use of this methodology and to monitor the patient’s application of it in vivo.
Surgical castration and stereotactic neurosurgery are highly invasive procedures that are not condoned, for a variety of ethical reasons. However, reviews of such treatment (Bradford 1985, 1988; Heim and Hursch 1979) have indicated that surgical interventions are very effective. Indeed, a number of long-term outcome studies have suggested recidivism below 5% following these procedures (Bradford 1985).
Drug intervention serves a critical role in treating individuals with pedophilia. The majority of such individuals are nonviolent and have reasonably good control over their pedophiliac urges. In every group of patients treated, however, there are individuals with very poor impulse control who compulsively molest children. Less commonly, there are persons who have been sexually violent with children and, in very rare cases, who have carried out sadistic acts against children. In these cases, prompt intervention is essential, especially if the pedophiliac individual remains in the community. The reduction of sex drive with selective serotonin reuptake inhibitors (SSRIs), hormonal agents, or both is much more rapidly effective than cognitive-behavioral interventions. In approximately 5% of cases, pedophiliac behavior is concomitant with a psychotic illness or major depression, and drug intervention, hospitalization, or both may be urgent. In fact, Raymond et al. (1999) concluded that Axis I and Axis II comorbidity rates are high for pedophiliac individuals. Thus, psychiatrists serve a critical role in the care of those more acutely ill or more dangerous individuals, for whom their therapeutic skills are sorely needed.
Three hormonal agents have been used to treat pedophiles. Cyproterone acetate (CPA) has antiandrogen, antigonadotropic, and progestogenic effects, leading to a blocking of the intercellular uptake of testosterone, the metabolism of intercellular androgens, and the receptor binding of testosterone. Like other hormonal agents, CPA is used to provide these patients with greater control over their pedophiliac urges by reducing their general sex drive and thereby their pedophiliac sex drive, resulting in fewer urges to molest children. Recidivism studies have indicated that pretreatment relapse rates, which ran as high as 50%-100%, fell to 5% or lower following treatment with CPA. Although not available in the United States, this drug is frequently used in other countries and has a relatively low side-effect rate. For further details regarding CPA, the reader is referred to Bradford (1988), Bradford et al. (1987), Laschet and Laschet (1975), Mainwaring (1977), and Tennent et al. (1977).
Medroxyprogesterone acetate (MPA) is a progesterone that increases testosterone metabolism, reduces the secretion of luteinizing hormone (LH), and increases antigen receptor binding while also reducing the precursors of testosterone (Bradford 1985). MPA, like CPA, is available in both an intramuscular form (given in dosages of 150-500 mg/day) and an oral form (given in dosages of 100-300 mg/day). Because the intramuscular form of MPA can have a 60-day half-life, some therapists recommend the oral route. Should side effects develop, the oral dosage can be easily tapered, whereas the sustained release, intramuscular form may cause side effects for weeks.
Potential side effects from MPA include elevation of systolic blood pressure, weight gain, decreased sperm count, decreased sperm motility, alteration of sperm morphology, cholecystitis with cholelithiasis, an elevated risk for diabetes, depression, insomnia, and the potential for thrombophlebitis with Pulmonary embolism. Although these side effects can occur, they are infrequent. The major factor contributing to discontinuation of the drug is significant erectile dysfunction. McConaghy et al. (1988) suggested that increased compliance can be obtained by using reduced dosages of MPA so that erectile dysfunction is less frequent while patients are assisted in controlling their pedophiliac urges. For further details on the use of MPA, the reader is referred to Berlin and Meinecke (1981), Bradford (1985), Gagne (1981), Langevin et al. (1979), and Meyer et al. (1985).
Leuprolid acetate (LPA) is a newer synthetic LH-releasing-hormone agonist that has recently become available in depot form. It has the advantage over CPA and MPA of being very specific in its therapeutic effects. It blocks the production of LH, and subsequent testosterone production, with fewer side effects than either CPA or MPA because it does not affect other steroid hormones. One disadvantage of LPA is its cost. The other is its delay in reducing testosterone levels, as initially patients may experience an acceleration of their sex drive until their testosterone production is exhausted. Therefore, close supervision of the pedophiliac patient for the first 4 weeks of treatment with LPA and the concomitant use of flutamide (an acetanilid, nonsteroidal antiandrogen) to control this 4-week temporary elevation of testosterone is indicated. Although no controlled outcome studies exist regarding LPA’s effectiveness in comparison with other hormonal agents, LPA does have a lower side-effect profile once the initial testosterone elevation phase is completed (Dickey 1992). An initial uncontrolled observational study involving triptorelin, a drug not available in the United States that is similar to LPA in its action, and psychotherapy yielded very promising results in decreasing deviant fantasies, desires, and incidents (Rosler and Witztum 1998).
Selective Serotonin Reuptake Inhibitors
Several uncontrolled studies report the use of a variety of pharmacological agents (e.g., antipsychotics, mood stabilizers, antianxiety and antidepressant medications) in the treatment of pedophiliac individuals. Results from a number of studies (Emmanuel et al. 1991; Kafka 1991a, 1991b; Kafka and Prentky 1991; Lorefice 1991; Perilstein et al. 1991) have suggested that fluoxetine and sertraline are effective in individuals with and without pedophiliac sexual compulsions. These agents show considerable promise in assisting pedophiliac patients in gaining control over their pedophiliac fantasies and urges. It is unclear whether these drugs are effective because of their side effect of reducing sex drive or because the anxiety, depressive, and obsessive symptoms that are concomitantly present in pedophiliac individuals represent some type of obsessive-compulsive spectrum disorder that is responsive to SSRIs.
Dosages of the SSRIs generally need to be increased beyond the customary dosages used for treating depressive or compulsive symptoms until the pedophiliac patient reports a reduction in sex drive. The advantage of these relatively new medications is that they have fewer potential side effects than tricyclic antidepressants and lack the potential serious side effects that can arise from hormonal intervention with CPA, MPA, or LPA. For further details on the SSRIs, the reader is referred to Coleman et al. (1992), Emmanuel et al. (1991), Kafka (1991a, 1991b), Kafka and Prentky (1991), Lorefice (1991), and Perilstein et al. (1991).
Revision date: July 3, 2011
Last revised: by David A. Scott, M.D.