Norbert Konrad; Justus Welke; Annette Opitz-Welke


Curr Opin Psychiatry. 2015;28(6):440-444. 

In This Article

Therapeutic Approach

Although the offer of counselling and psychotherapy for patients with paedophilia is often a core part of prevention strategies, motivation among healthcare professionals to work with this group is low.[29] A survey by Robles et al.[30] of mental health professionals in eight countries revealed agreement in assessing paraphilias as stigmatizing diagnoses because the boundaries between normal behaviour and psychopathology are unclear. Therefore, there is need for ongoing discussion about the conceptualization of paraphilia which apparently has implications for the treatment of those with paraphilic disorders.[3]

Today, antiandrogen treatment is offered to sex offenders in many countries as an additional treatment strategy alongside psychotherapy. Since the 1940s, there have been efforts to use hormonal manipulation for the prevention of sexual offences, including the use of the antiandrogen cyproteronacetat and various gonadotropin-releasing hormone agonists. An evaluation of the outcomes of chemical castration of sex offenders has revealed that the associated decrease of serum testosterone levels leads to a reduction in the frequency and intensity of sexual thoughts. After cessation of chemical castration, the kinetics of serum testosterone recovery vary with treatment duration.[31] Although chemical castration is not considered the preferred treatment for paraphilia for ethical reasons, in some cases, such as mental retardation, the administration of antiandrogen medication may be used as an alternative therapeutic method.[32] Evidence concerning other biomedical treatment options for paraphilia is very scare, especially for individuals with comorbid psychiatric disorders. Firoz et al.[33] reported a case of fetishism with comorbid substance abuse that was successfully treated with naltrexone. Ingves et al.[34] reported the successful treatment of a 67-year-old man suffering from depression, obsessive–compulsive disorder, and signs of frontotemporal dementia with a course of electroconvulsive therapy. Because of the coincidence of Parkinson's disease and compulsive sexual behaviour, the potential case of an individual with Parkinson's disease and paedophilia is an example for an ethical treatment dilemma. In this case, administering an effective treatment to an individual may have an unwanted side-effect of impulse control impairment, with the consequence of potential harm to others. Muller et al.[35] discussed the ethical implications of potential treatment of a peadophilic patient with Parkinson's disease using principles of biomedical ethics, and emphasized that foresight and caution are strongly recommended in this difficult field of divergent interests.

There is evidence that sex offenders who are detained or civilly committed exhibit below-average cognitive function, a fact that must be considered when planning a therapeutic approach.[36] As Brouillette-Alarie et al.[37] point out, clinicians in many countries now routinely use risk tools to assess a sex offender's risk of recidivism. The most popular scales consist of historical items that cannot be modified by treatment or intervention. Analyzing common risk assessment tools reveals that the construct of persistent paraphilia was related to sexual criminality, especially of the paedophilic type.[37]