Anti-libidinal medication Anti-libidinal medication

Dr Prathima ApurvaDr Prathima Apurva

ST5 Forensic psychiatryST5 Forensic psychiatry

Nov 2013Nov 2013

OverviewOverview

ContextContext What is anti-libidinal medication?What is anti-libidinal medication? Why might we need it in managing Why might we need it in managing

sex offenders?sex offenders? How does it work?How does it work? Availability in Scotland.Availability in Scotland. Some legal and ethical issuesSome legal and ethical issues

Sex offenders with IDSex offenders with ID

Static variablesStatic variables Anti social attitude, poor relationship Anti social attitude, poor relationship

with mother, low self esteem, lack of with mother, low self esteem, lack of assertiveness, poor response to assertiveness, poor response to treatment,treatment,

Offences involving physical violence, Offences involving physical violence, staff complacency, an attitude staff complacency, an attitude tolerant of sexual crimestolerant of sexual crimes

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

Unplanned discharge Unplanned discharge

Dynamic variablesDynamic variables

Social effective functioningSocial effective functioning Distorted attitudes and beliefsDistorted attitudes and beliefs Self management and self regulationSelf management and self regulation Sexual preference and sexual driveSexual preference and sexual drive

Social effective functioningSocial effective functioning

This refers to the way in which the This refers to the way in which the individual relates to the other people individual relates to the other people and includes aspects of negative and includes aspects of negative affect.affect.

Low self esteem and loneliness.Low self esteem and loneliness.

Distorted cognitions and Distorted cognitions and beliefsbeliefs

Counterfeit devianceCounterfeit deviance Whilst assessing to be cautious about Whilst assessing to be cautious about

processes such as suppression, social processes such as suppression, social desirability and lying.desirability and lying.

Self management and self Self management and self regulationregulation

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

Sexual preference and sexual Sexual preference and sexual drivedrive

Interest rather than accessibility Interest rather than accessibility PaedophiliaPaedophilia

What is antilibidinal What is antilibidinal medicationmedication

Primary effect is to either stop Primary effect is to either stop androgens from being produced or to androgens from being produced or to prevent them from working prevent them from working altogether.altogether.

Testosterone is thought to influence Testosterone is thought to influence sexual arousal and responsiveness.sexual arousal and responsiveness.

Therefore a reduction in testosterone Therefore a reduction in testosterone = a reduction in a man’s libido and = a reduction in a man’s libido and desire to engage in sexual activity. desire to engage in sexual activity.

Why?Why?

It not to completely suppress sexual It not to completely suppress sexual drive and create an asexual drive and create an asexual individual.individual.

To selectively suppress deviant To selectively suppress deviant sexual urges and fantasies.sexual urges and fantasies.

Hormones and neuro-transmitters Hormones and neuro-transmitters involved in sexual responseinvolved in sexual response

Dehydroepiandrosterone Dehydroepiandrosterone (DHEA)(DHEA)

OxytocinOxytocin Phenylethylamine (PEA)Phenylethylamine (PEA) OestrogenOestrogen TestosteroneTestosterone ProgesteroneProgesterone ProlactinProlactin VasopressinVasopressin DopamineDopamine SerotoninSerotonin AcetylcholineAcetylcholine

1.1. DESIRE DESIRE (LIBIDO)(LIBIDO)

2.2. AROUSALAROUSAL

3.3. ORGASMORGASM

Types of medicationTypes of medication

Anti-libidinal medications:Anti-libidinal medications: Medroxyprogesterone Acetate (MPA). Medroxyprogesterone Acetate (MPA). Cyproterone Acetate (CPA).Cyproterone Acetate (CPA). Long-acting Gonadotropin-releasing Long-acting Gonadotropin-releasing

Hormones (GnRH) agonists. Hormones (GnRH) agonists. ( Leuprorelin, Triptorelin & Goserelin.( Leuprorelin, Triptorelin & Goserelin.

Psychotropic medication:Psychotropic medication: Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors

(SSRIs)(SSRIs)

Cyproterone acetateCyproterone acetate LICENSED FOR MALE LICENSED FOR MALE

HYPERSEXUALITYHYPERSEXUALITYMODE OF ACTIONMODE OF ACTIONBlocks testosterone receptorsBlocks testosterone receptorsAlso decreases GnRH and LH Also decreases GnRH and LH

secretionsecretion

DOSEDOSE50 – 200 mg orally50 – 200 mg orally300 – 600 mg fortnightly 300 – 600 mg fortnightly

intramuscular depot intramuscular depot (named patient basis)(named patient basis)

COSTCOST£300 – 400 per year£300 – 400 per year

Cyproterone acetateCyproterone acetate

ADVERSE EFFECTSADVERSE EFFECTS menopausal symptoms (hot flushes, depression, weight gain, menopausal symptoms (hot flushes, depression, weight gain,

cardiovascular)cardiovascular) gynaecomastiagynaecomastia osteoporosisosteoporosis carbohydrate metabolism, other endocrinecarbohydrate metabolism, other endocrine

CAUTIONS / CONTRA-INDICATIONSCAUTIONS / CONTRA-INDICATIONS under 18 (or incomplete growth)under 18 (or incomplete growth) liver diseaseliver disease malignancy (except prostate)malignancy (except prostate) cardiovascular diseasecardiovascular disease severe diabetessevere diabetes severe chronic depressionsevere chronic depression metabolic bone diseasemetabolic bone disease

LeuprorelinLeuprorelinNOT LICENSEDNOT LICENSED

MODE OF ACTIONMODE OF ACTIONGnRH agonist: exhausts GnRH agonist: exhausts

LH and FSHLH and FSH

DOSEDOSE 3.75 mg 4 weekly titrate 3.75 mg 4 weekly titrate

between every 2 weeks between every 2 weeks and every 8 weeksand every 8 weeks

or 22.5mg every 3 or 22.5mg every 3 monthsmonths

COSTCOST3.75mg = £125.40 = 3.75mg = £125.40 =

£1630 annually£1630 annually

TriptorelinTriptorelinSALVACYL LICENSED FOR SEVERE SEXUAL SALVACYL LICENSED FOR SEVERE SEXUAL

DEVIANCEDEVIANCE

MODE OF ACTIONMODE OF ACTIONGnRH agonist: exhausts LH and GnRH agonist: exhausts LH and

FSHFSH

DOSEDOSE3.75mg – 7.5 mg every 4 3.75mg – 7.5 mg every 4

weeksweeks11.5mg every 3 months11.5mg every 3 months

COSTCOST3.75mg = £105.05 = £1366 3.75mg = £105.05 = £1366

annuallyannually

GoserelinGoserelinNOT LICENSEDNOT LICENSED

MODE OF ACTIONMODE OF ACTIONGnRH agonist: exhausts LH GnRH agonist: exhausts LH

and FSHand FSH

DOSEDOSE 3.6mg every 4 weeks3.6mg every 4 weeks long acting 10.8mg every long acting 10.8mg every

12 weeks12 weeks

COSTCOST 3.6mg = £122.27 = £1590 3.6mg = £122.27 = £1590

annuallyannually 10.8 mg = £366.82 10.8 mg = £366.82 = =

£1559 annually£1559 annually

GnRH agonistsGnRH agonistsADVERSE EFFECTSADVERSE EFFECTS menopausal symptoms (hot flushes, depression, weight menopausal symptoms (hot flushes, depression, weight

gain, cardiovascular)gain, cardiovascular) gynaecomastiagynaecomastia osteoporosisosteoporosis carbohydrate metabolism, other endocrinecarbohydrate metabolism, other endocrine BUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATEBUT MAY BE ‘KINDER’ THAN CYPROTERONE ACETATE

initial increase in testosterone – not need flutamideinitial increase in testosterone – not need flutamide

CAUTIONS / CONTRA-INDICATIONSCAUTIONS / CONTRA-INDICATIONS under 18 (or incomplete growth)under 18 (or incomplete growth) malignancy (except prostate)malignancy (except prostate) cardiovascular diseasecardiovascular disease severe diabetessevere diabetes severe chronic depressionsevere chronic depression metabolic bone diseasemetabolic bone disease

GnRH agonistsGnRH agonists

STUDIESSTUDIES Case studies and case seriesCase studies and case series 118 patients in systematic review (Briken 118 patients in systematic review (Briken et et

al., al., 2003) 2003) Very low re-offendingVery low re-offending Better outcome for those previously on MPA Better outcome for those previously on MPA

or CAor CA Sexual urges and fantasies may disappearSexual urges and fantasies may disappear Frequency of masturbation reduced Frequency of masturbation reduced

drasticallydrastically Side-effects less problematicSide-effects less problematic

SSRIsSSRIsNOT LICENSEDNOT LICENSED

MODE OF ACTIONMODE OF ACTIONPotentiate serotonin activity by decreasing re-uptake Potentiate serotonin activity by decreasing re-uptake

from synapsefrom synapse

DOSEDOSE fluoxetine: fluoxetine:

20mg for 4 weeks, 40 mg for 4 weeks, 60 mg for 4 20mg for 4 weeks, 40 mg for 4 weeks, 60 mg for 4 weeksweeks

sertraline: sertraline: 50mg, 100mg, 150mg50mg, 100mg, 150mg

COSTCOST£50 - 500 annually£50 - 500 annually

SSRIsSSRIs

ADVERSE EFFECTSADVERSE EFFECTS nauseanausea agitation, restlessnessagitation, restlessness insomniainsomnia sexual dysfunction (decreased libido; delayed ejaculation)sexual dysfunction (decreased libido; delayed ejaculation) too much coffee feelingtoo much coffee feeling raised prolactinraised prolactin

CAUTIONS / CONTRA-INDICATIONSCAUTIONS / CONTRA-INDICATIONS maniamania epilepsy (poorly controlled)epilepsy (poorly controlled) history of bleeding disordershistory of bleeding disorders hypersensitivityhypersensitivity akathisiaakathisia

SSRIsSSRIs

STUDIESSTUDIES over 200 case reports and open studies reported in over 200 case reports and open studies reported in

the literature (Kafka, 2003; Greenberg & Bradford, the literature (Kafka, 2003; Greenberg & Bradford, 1997)1997) most report success in reducing the frequency and most report success in reducing the frequency and

intensity of sexual fantasy, urges and arousalintensity of sexual fantasy, urges and arousal often without negative effects on normal sexual behavior often without negative effects on normal sexual behavior

systematic review (Adi systematic review (Adi et al.et al., 2002), 2002) very few trials of reasonable methodological qualityvery few trials of reasonable methodological quality outcomes positiveoutcomes positive use of SSRI medication in sex offenders warranteduse of SSRI medication in sex offenders warranted

SSRIsSSRIs

HOW DO THEY WORK?HOW DO THEY WORK?May have effect through:May have effect through: ImpulsivityImpulsivity MoodMood Obsessive-compulsiveObsessive-compulsive Decreased deviant fantasizingDecreased deviant fantasizing AttachmentAttachment

Legal and Ethical issuesLegal and Ethical issues

Voluntary or MandatoryVoluntary or Mandatory

Mandatory in many USA statesMandatory in many USA states If Voluntary – issues with consentIf Voluntary – issues with consent Voluntary more like to work?Voluntary more like to work? Most psychiatrist feel treatment Most psychiatrist feel treatment

should be voluntary.should be voluntary. If capacity is an issue then AWI and If capacity is an issue then AWI and

DMP opinion.DMP opinion.

Treatment or PunishmentTreatment or Punishment

Voluntary = treatment?Voluntary = treatment? Mandatory = punishment?Mandatory = punishment? Side effectsSide effects Risk management tool?Risk management tool?

Concluding thoughtsConcluding thoughts

Pharmacotherapy can work.Pharmacotherapy can work. More guidance on legal and ethical More guidance on legal and ethical

concerns.concerns. Advice from SOLSAdvice from SOLS