IN REVIEW

The Neurobiology, Neuropharmacology, and Pharmacological

Treatment of the Paraphilias and Compulsive Sexual Behaviour
John MW Brad ford, MB, ChB, DPM, FF Psych, FRC Psych, DABPN, DABFP, FRCPC1

There has been in creas ing in ter est in the treat ment of sex ual dis or ders in re cent years. Sex ual dis or ders are clas si fied in DSM-IV
as sex ual dysfunctions, paraphilias, and gen der iden tity dis or ders. The sex ual dysfunctions are nondeviant or nonparaphillic.
The sex ual dys func tion dis or ders should in clude “hy per ac tive sex ual de sire dis or der” un der sex ual de sire dis or ders . Fur ther,
there should be a speci fier for paraphilias of “with hypersexuality” or “with out hypersexuality. ” There is still in com plete un der-
stand ing of the neurobiology of sex ual dis or ders al though func tional neuroanatomy and neoropharmcological re search has ex-
posed the neurotransmitters, receptors, and hormones that are in volved in sex ual de sire. Various pharmacological agents
in clud ing se ro to nin reuptake in hib i tors, antiandrogens, LHRH agonists, and oth ers have been doc u mented as re duc ing sex ual
de sire. An al go rithm for the use of these drugs in the treat ment of the paraphilias as well nonparaphilic hypersexuality is out lined.
The modes of ac tion, dos ages, aims of treat ment, and usual meth ods of pre scrib ing these agent s is re viewed in this ar ti cle. Some
fu ture di rec tions of re search in phar ma co log i cal treat ment is also dis cussed.

(Can J Psy chi a try 2001;46:26– 34)

Key Words: sexual desire disorders, paraphilias, hypersexuality, compulsive sexual behaviour, antiandrogens, specific
serotonin reuptake inhibitors, LHRH agonists

A l though it would be pre ma ture to say that the

neurobiology and neuropharmacology of sex ual be hav-
iour is un der stood, there clearly have been ma jor ad vances in
they respond to pharmacological treatment af fecting the
cen tral ner vous sys tem level of 5-HT (1,2).
In gen eral, the as sess ment and treat ment of all types of sex ual
re cent years. There has been sig nif i cant re search on the se ro-
dis or ders have been ne glected by psy chi a try. In re cent years,
tonin receptors and their function in the brain. Serotonin
how ever, ad vances in psy chi at ric re search have fo cused gen-
(5-HT) is in volved in the neurobiology of many psy chi at ric
dis or ders, par tic u larly mood disorder, and specifically de - eral psychiatry on these important clinical entities. OCD
spec trum dis or ders in clude OCD, eat ing dis or ders,
pres sion, anx i ety, schizo phre nia, eat ing dis or ders, and ob ses-
somatoform dis or ders, im pulse con trol dis or ders, and neu ro-
sive–compulsive dis order (OCD). It also plays a role in
psychiatric dis or ders such as Tourette syn drome (TS); they
mi graines. Al though the eti ol ogy of these dis or ders is not un-
may also in clude the sex ual dis or ders (1,2). There are clin i cal
der stood, phar ma co log i cal treat ments that mod u late lev els of
5-HT have shown to be ef fec tive in all of them. Fur ther, sex- sim i lar i ties be tween OCD and sex ual dis or ders that can be
sum ma rized as fol lows (1):
ual disor ders, both paraphilic (sexual devi a tion) and
nonparaphilic (com pul sive sex ual dis or der or nonparaphilic
· Ob ses sions are sim i lar to sex ual fan ta sies, both paraphilic
hypersexuality), have also responded to pharmacological
and nonparaphilic.
treat ments mod u lat ing se ro to nin lev els (1). This has led to the
spec u la tion that a group of dis or ders could be clas si fied to- · Com pul sions are sim i lar to com pul sive sex ual be hav iour
gether as obsessive–compulsive spectrum disorders (1,2). (CSB), which can be paraphilic or nonparaphilic.
This is based not only on the diagnostic characteristics of · There is a cross over of comorbidity be tween OCD and the
these dis or ders as out lined in DSM-IV but also on the fact that sex ual dis or ders, with de pres sion and anx i ety dis or ders be-
ing com mon in both groups.
· At a neurobiological and neuropharmacological level,
there is a sig nif i cant over lap be tween these dis or ders.
Manu script re ceived and ac cepted De cem ber, 2000.
1 Pro fes sor and Head, Di vi sion of Fo ren sic Psy chia try, Uni ver sity of Ot tawa;
There is no con sensus at this time as to whether the
Royal Ot tawa Hos pi tal, Ot tawa, On tario.
Ad dress for cor re spon dence: Dr JMW Brad ford, Royal Ot tawa Hos pi tal,
paraphilias and com pul sive sex ual be hav iour (nonparaphilic
1145 Car ling Ave nue, Ot tawa, On tario K1Z 7K4 hypersexuality) should be included in the OCD spectrum
e- mail: jbrad for@rohcg.on.ca disorders.

Can J Psy chia try, Vol 46, Feb ru ary 2001 26

February 2001 Treat ment of the Paraphilias and Com pul sive Sex ual Be hav iour
There has been con sid er able re cent prog ress in map ping out
5-HT receptor sub types (3). Many phar ma co log i cal treat-
ments act ing on the cen tral 5-HT sys tem, such as se lec tive se-
ro to nin reuptake in hib i tors (SSRIs), an ti de pres sants act ing
presynaptically to serotonergic neurons, and 5-HT receptor
an tag o nists used in the pro phy laxis of mi graine, have mostly
nonselective ef fects on postsynaptic 5-HT re cep tor sub types
(3). The ini tial work on 5-HT re cep tor sub types was based on
phar ma co log i cal tools. Since that time, re cep tor bind ing pro-
files, com mon sec ond mes sen ger cou pling, and func tional ac-
tivity of ligands have iso lated fur ther re cep tor types (3).
Based on this work, 4 main sub groups of 5-HT re cep tors have
been identified, spe cifically 5-HT1, 5-HT2 , 5-HT 3, and
5-HT4. This clas si fi ca tion has been con firmed by the so phis ti-
cated tech niques of mo lec u lar bi ol ogy, but the lat ter have also
led to the iden ti fi ca tion of “novel” 5-HT re cep tors, spe cif i-
cally 5-HT1F, 5-HT 5, 5-HT6, and 5-HT 7 (3). Var i ous sub types
have also been iden ti fied. The 5-HT1 re cep tor has 5-HT 1A,
5-HT1B, 5-HT 1D, 5-HT1E, and 5-HT1F subtypes. The 5-HT 2
sys tem has been shown to have 5-HT2 A, 5-HT2B , and 5-HT2C
sub types. There do not yet ap pear to be any sub types of 5-HT3
and 5-HT 4 re cep tors, but 5-HT5 has 2 sub types, 5-HT 5A and
5-HT 5B. No sub types have been iden ti fied for the 5-HT6 and
5-HT7 re cep tors (3). All of the 5-HT re cep tors be long to a
fam ily of G pro tein-coupled re cep tors (3). Phar ma co log i cal
re search is es tab lish ing se lec tive lig ands for the var i ous re-
cep tor sub types, facil i tat ing the de vel op ment of sub -
type-specific agonists and an tag o nists. This will help
elu ci date how 5-HT re cep tor sub types af fect be hav iour, in-
clud ing sex ual dis or ders. It is also pos si ble that other 5-HT re-
cep tor sub types will be iso lated or that fur ther vari a tions in
re cep tor sub types will be found. Perhaps mu ta tions of the
5-HT re cep tor or subreceptor struc tures will be found to play
a r o l e i n a v a r i e t y of psy c h i a t r i c dis or d e r s ( 3 ) .
Neuropharmacological re search into 5-HT re cep tors is likely
to con tinue to be of sig nif i cant in ter est to gen eral psy chi a try
and to the eval u a tion and treat ment of sex ual dis or ders.
There have been several studies on the neurobiology of
hypersexuality. Broadly, the re search lit er a ture shows that le-
sions in cer tain parts of the brain can lead to disinhibition of
sex ual be hav iour that may re sult in com pul sive sex ual be hav-
iour (3). In the neu ro log i cal and neu ro psy chi at ric lit er a ture,
there are ref er ences to disinhibited sex ual be hav iour as a re-
sult of fron tal lobe le sions. The cau tion here is that this is most
likely part of a gen eral be hav ioural disinhibition rather than
be ing spe cific to sex ual be hav iour. The clin i cal pre sen ta tion
of cer tain el derly pa tients with de men tia and disinhibited be-
hav iour in clud ing paraphilic behav iour (ex hi bi tion ism) and
nonparaphilic hypersexuality (in ap pro pri ate sex ual ad vances
to women) is mostly re ported. A more de tailed clin i cal eval u-
a tion would usu ally show that this is more clin i cally ob vi ous
disinhibited be hav iour among a spec trum of other
disinhibited be hav iours (4,5). Paraphilic be hav iour has been
reported secondary to a wide variety of neuropsychiatric
27
dis or ders. These in clude tem po ral lobe ep i lepsy,
postencephalitic neu ro psy chi at ric syn dromes, septal le sions,
TS, fron tal lobe le sions, tu mours in var i ous sites, bi lat eral
temporal lobe les ions, and multiple sclerosis (5). Both
nonparaphilic hyposexuality and hypersexuality have been
reported in as so ci a tion with var i ous brain le sions. In ter est-
ingly, OCD has also been ob served sec ond ary to var i ous neu-
ro log i cal dis or ders, and the sites of the le sions caus ing OCD
over lap con sid er ably with the ones that are as so ci ated with
sex ual dis or ders (5). There has also been re search show ing
that corticostriatal cir cuits are most likely in volved in OCD
and TS (4,6,7). It has also been noted that there is
comorbidity be tween sex ual dis or ders and TS, in clud ing ex-
hi bi tion ism, other paraphilias, and nonparaphilic
hypersexuality (8). It is interesting that coprolalia and
copropraxia in TS clearly have a sex ual be hav iour com po nent
(8). Other re search shows that these symp toms are re lated to
the de gree of Tourette syn drome gene-loading that is pres ent
(7). These sexual symp toms de crease with treat ment us ing
SSRIs and dopamine blockers (4,6,7). These observations
sup port a re la tion be tween paraphilic be hav iour, com pul sive
sex ual behav iour, and a neurobiological ab normality;
paraphilia and CSB ap pear to be a be hav ioural re sponse to
that ab nor mal ity. At the same time, there is pos si bly an over-
lap of the neurobiological ab nor mal ity and OCD spec trum
dis or ders.
The ex act na ture of hypersexuality is dif fi cult to de fine. The
to tal sex ual out let (TSO), orig i nally de fined by Kinsey as the
num ber of or gasms per week, is one mea sure o f
hypersexuality. Kafka has at tempted to ad dress this prob lem
in a study of men pre sent ing for treat ment with com pul sive
sex ual be hav iour, which he de scribes as “paraphilia re lated
dis or ders” (PRD) (9). In di vid uals with PRD were found in a
small study to have 5 or more sex ual out lets (or gasms) per
week for long pe ri ods of their adult lives, while the av er age
man would have 3 (9). Al though this is sim ple and at trac tive
in clin i cal terms, it does not de fine hypersexuality in em pir i-
cal terms. What is needed is a large study of paraphilic and
nonparaphilic men and women in whom typ i cal pat terns of
sex ual drive are ex am ined. In ad di tion, in my opin ion, there
would have to be some de gree of so cial or oc cu pa tional or
other dys func tion cou pled with it, rather than sim ply a quan ti-
ta tive mea sure of to tal or gasms per week. Var i ous lev els of
sex drive could be es tab lished and de fined as hyposexuality,
normosexuality, and hypersexality, based on ranges of sex ual
out let mea sures. What is im por tant con cep tu ally, how ever, is
that there are some men who have hypersexuality, some of
whom may be paraphilic and some who are not. Testing for
the pres ence or ab sence of paraphilia would be rep li cated at
all levels of sexual drive, as men and women who have a
paraphilia may be hypersexual, normosexual, or hyposexual.
In ad di tion, some in di vid u als ex hibit com pul sive sex ual be-
hav iours (CSB) which are nonparaphilic. These in clude com-
pul sive mas tur ba tion, com pul sive use of por nog ra phy, and
28 The Ca na dian Jour nal of Psy chia try
pro mis cu ity. In di vid uals with CSB may also be hypersexual,
normosexual, or hyposexual. As com pul sive sex ual be hav-
iour be comes more de fined con cep tu ally and di ag nos ti cally,
a spe cific pharmacological approach to hypersexuality
(paraphilic or nonparaphilic), in con trast to normosexuality
or hyposexuality, would be developed. Hypersexuality
would be rec og nized as dis tinct from CSB and paraphilic be-
hav iour. What is not clear from re search to date is whether
hypersexuality is an ag gra vat ing fac tor in paraphilias. A con-
sis tent di ag nos tic for mu la tion for hypersexuality must be de -
vel oped, and it should be in cluded in DSM-V.
Animal re search and clin i cal stud ies have shown that the
monoamines 5-HT and dopamine affect sexual behaviour
(1,10). Fur ther, ma nip u la tions of 5-HT and do pa mine can ei-
ther decrease or increase sexual behaviour, depending on
which neuropharmacological intervention occurs (1,10).
Any dis cus sion of the ef fects of neurobiology on sex ual be-
hav iour has to take into ac count the neuropeptides in the brain
that are significantly involved with the regulation of hor -
mones (10). A neuropeptide, by def i ni tion, is a chain of 2 or
more amino ac ids linked by pep tide bonds and dif fers from
other pro teins only in the na ture of the pep tide links (10).
Over 100 unique, bi o log i cally ac tive pep tides, rang ing in size
from 2 to about 40 amino ac ids, have been found, in clud ing
go nad o tro pin-releasing hor mone (GRH) and prolactin (10).
GRH stim u lates the re lease of fol li cle-stimulating hor mone
(FSH) and luteinizing hormone (LH) from the pituitary,
which drive the pro duc tion of tes tos ter one in the tes tes and es-
tro gen and other hor mones in the ova ries (11). The be hav-
ioural ef fects of neuropeptides have been ob served af ter their
injection di rectly into the cen tral ner vous sys tem—the pre -
ferred method of ad min is tra tion be cause most of the pep tides
can not pen e trate the blood-brain bar rier in amounts suf fi cient
to be ac tive (10). These neuropeptides are simi lar to
monoamine neurotransmitters in having receptors on neu -
rons, which they can ex cite or in hibit (10). One dif fer ence,
how ever, is that the rate of ac tiv ity for neuropeptides is slow
com pared with that of the monoamine neurotransmitters, and
the du ra tion of their ac tiv ity can be ex tended for sub stan tially
lon ger pe ri ods of time (10).
Neuropeptides are found through out the cen tral ner vous sys-
tem as well as in pe riph eral or gans such as the gas tro in tes ti nal
tract, the pan creas, and the ad re nal glands (10). The hy po tha-
lamic re gions con tain con sid er able amounts of these
neuropeptides, in clud ing, a m o n g o t h ers, G R H ,
corticotropin-releasing hor m o n e (CRH), and thy-
roid-releasing hor mone (TRH) (10). Clearly, the role of the
neuropeptide trans mit ter GRH is crit i cal to an un der stand ing
of hu man sex ual be hav iour (11). Al though re search in rats
has shown that the ef fects of neuropeptides on sex ual be hav-
iour are me di ated solely through cer tain se ro to nin re cep tor
sub types (12), the as sump tion that ei ther 5-HT or do pa mine
independently have a dominant neurobiological role in
Vol 46, No 1
controlling sexual be hav iour in hu mans is most likely com-
pletely in ac cu rate. The sit u a tion in humans is much more
com pli cated (11). How ever, both an i mal re search and re-
search on the hu man male have shown that sex ual be hav iour
de clines fol low ing sur gi cal cas tra tion and that this oc curs at
dif fer ent rates in dif fer ent spe cies. The first el e ment that dis-
appears is ejaculation, followed by intromission, and then
mount ing be hav iour (11). These re sponses are re stored in the
re verse se quence with an dro gen re place ment (11). The sites
of ac tion of an dro gens in the male an i mal are known to a cer-
tain de gree. These are in the limbic sys tem of the brain, the
spi nal cord, and the pe nis (11). In the spi nal cord, the re flexes
con trol ling erec tion and ejac u la tion are an dro gen-dependent
and in the penis, tactile sen sitivity is androgen-dependent
(11). Studies of hor mone re place ment in hypogonadal men as
well as stud ies of the ef fects of hor mone lev els in men with
sex ual dys func tion have all con trib uted to our knowl edge of
the role of an dro gens in male sex ual be hav iour (11). Studies
of hyperprolactinemia show that it causes a de cline in sex ual
de sire, as seen in cer tain prolactin-producing tu mours (11).
The be hav ioural ef fects of the prin ci pal an dro gens in the hu-
man male, tes tos ter one (T) and dihydrotestosterone (DHT),
are me di ated through T re cep tors and DHT re cep tors in the
brain, par tic u larly in the septal re gion, the pi tu itary, and the
hy po thal a mus (11–13). Tes tos ter one can also be aromatized
to estradiol. Aromatization oc curs in the hy po thal a mus and
else where and is also re lated to sex ual drive in hu mans (11).
Thus, the neurobiology of human sexual behaviour is ex-
tremely com pli cated and in volves not only the monoamine
trans mit ters 5-HT and, to a lesser ex tent, do pa mine but is also
reg u lated by neuropeptide neurotransmitters, lo cated prin ci-
pally in the hy po thal a mus. In ad di tion, cir cu lat ing an dro gens
and intracellular DHT and T receptors, specifically in the
septal area and hy po thal a mus, also play a very im por tant role.
Clearly, com pli cated mech a nisms both fa cil i tate and in hibit
sex ual be hav iour and in volve all of these neurobiological sys-
tems—and prob a bly oth ers as well. It is ob vi ous that these
mechanisms are not fully understood at this time and it is
there fore ex tremely pre ma ture to talk about a “monoamine
hypothesis of compulsive sex ual be hav iour.” At the same
time, certain pharmacological agents, by their actions on
monoamine neurotransmitters and their ef fects on an dro gen
re cep tors and cir cu lat ing hor mone lev els, can have very sig-
nif i cant and last ing ef fects on sex ual be hav iour (1, 14–16). A
reduction in sexual behaviour, whether nonparaphilic or
paraphilic, can be achieved.
The etiology of the paraphilias or sex ual de vi a tions is un-
known (17,18). Fur ther, the ac tual in ci dence and prev a lence
of the paraphilias is un known (18,19). What is known is that
the level of vic tim iza tion of males and fe males in the gen eral
pop u la tion is fairly con sis tent. As ini tially re ported by Kinsey
in the late 1940s, 24% of fe males had been vic tims of sex ual
abuse when they were 14 years of age or youn ger (20). A na-
tional sur vey in Can ada in 1984 found that 23.5 % of fe males
February 2001 Treat ment of the Paraphilias and Com pul sive Sex ual Be hav iour
and 12.8% of males were vic tims of child hood sex ual abuse
(21), which is quite con sis tent with Kinsey’s data. This may
assist in gaug ing the prev a lence of one paraphilia, spe cif i-
cally, pedophilia. For ex am ple, it is known that among iden ti-
fied pedophiles, ap prox i mately 35% were vic tims of sex ual
abuse as children. The average number of victims per
pedophile is also known. It may there fore be pos si ble to es ti-
mate the prev a lence of pedophilia in the gen eral pop u la tion
through extrapolation. In one study of sexual fantasies,
two-thirds of males re ported het ero sex ual pedophilic fan ta-
sies and about one-third of males had rape fan ta sies (22). As
the pres ence of de vi ant sex ual fan ta sies is an in di ca tion of the
pres ence of a paraphilia at a mild level, this im plies that mild
pedophilia is prev a lent at a stag ger ingly high rate in men in
the gen eral pop u la tion. Fur ther, as sum ing that the pres ence of
rape fantasies indicates the presence of another paraphilia,
spe cif i cally sex ual sa dism, then mild sa dism would also be
highly prev a lent in the pop u la tion at large. In my opin ion,
these are gross overestimates of the prev alence of mild
pedophilia and sex ual sa dism. How ever, even if these fig ures
were over es ti mated by a fac tor of 10, and the real lev els are
6% and 3%, these dis or ders would still have a vastly higher
prevalence than most other psychiatric disorders. At this
time, the prev a lence of paraphilias in the gen eral pop u la tion
is un known, and the prev a lence of com pul sive sex ual be hav-
iour is also un known.
There are a num ber of phar ma co log i cal in ter ven tions that are
avail able for the treat ment of CSB and the paraphilias. These
agents ap pear to have a di rect im pact on sex ual drive. Sex ual
drive con sists of var i ous com po nents, in clud ing a psy cho log-
i cal com po nent of sub jec tive de sire to en gage in sex ual ac tiv-
ity (the sex ual equiv a lent of hun ger); the pres ence of sex ual
fan ta sies which may be nonparaphilic or paraphilic; a state of
sex ual arousal that pro vides mo ti va tion for seek ing out sex ual
ac tiv ity; and fi nally, the ac tual sex ual ac tiv ity it self, which ul-
ti mately re sults in an or gasm (23). Phar ma co log i cal agents
have been iden ti fied that can af fect all of the com po nents of
sex ual drive. Ideally, how ever, one would want phar ma co-
log i cal agents that could af fect de vi ant sex ual in ter ests in the
case of paraphilias but not af fect nondeviant sex ual be hav-
iour. As dis cussed later in this pa per, there is at least some ev i-
dence that this might occur with the spe cific antiandrogen
cyproterone ac e tate and the SSRI sertraline (24). In the case
of CSB, the ideal treat ment would re sult in a gen eral re duc -
tion of sex ual drive with out ex tin guish ing it—but giv ing the
in di vid ual more con trol over his or her sex ual be hav iour.
The evaluation of sexual behaviour re quires ex per tise and
training in sexology and a specialized sexual behaviours
clinic. In such a clinic, there is typ i cally a de tailed psy chi at ric
and phys i cal ex am i na tion and an as sess ment of sex ual be hav-
iour, us ing var i ous psy cho log i cal and phys i o log i cal tests. As
var i ous neu ro psy chi at ric prob lems can have a sig nif i cant ef-
fect on sexuality, neuropsychiatric expertise should be
29
avail able and should be used to com plete the eval u a tion. The
eval u a tion in cludes a sex hor mone pro file, con sist ing of free
and to tal tes tos ter one, FSH, LH, estradiol, prolactin, and pro-
gesterone. This sex hormone profile will also provide the
base line for any treat ments in volv ing antiandrogens or hor-
mones. In addition, sex drive abnormalities and cer tain
high-risk cases for sex ual vi o lence may in volve hor mone ab-
normalities. Var i ous ques tion naires are used to provide a
struc tured sex ual his tory and mea sure the na ture and de gree
of sex ual fan ta sies, the na ture and de gree of cog ni tive dis tor-
tions and how they re late to paraphilias, com po nents of sex-
ual drive and of nonparaphilic sexual behaviour, and the
pres ence and ex tent of sub stance abuse. The last com po nent
of the eval u a tion is phys i o log i cal test ing of sex ual arousal to
establish whether a de vi ant sex ual pref er ence is pres ent or
not.
This author has recently established an al gorithm for the
treatment of paraphilias (24) that is based on an enhanced
clas si fi ca tion of paraphilias de scribed in the DSM-III-R (23).
The new clas si fi ca tion scheme has 4 cat e go ries (24):
1. Mild
2. Mod er ate
3. Se vere
4. Cat a strophic
The last cat e gory, cat a strophic, has been added to the orig i nal
3 de scribed in DSM-III-R. The full ver sion of this clas si fi ca-
tion is avail able in a re cent pub li ca tion by this au thor (23).
The newly-developed algorithm encompasses 6 levels of
treat ment for the 4 cat e go ries of paraphilia.
Level 1: Re gard less of the se ver ity of the paraphilia, cog ni-
tive-behavioural treat ment and re lapse-prevention treat ment
would al ways be given.
Level 2: Phar ma co log i cal treat ment would start with SSRIs.
This would be in di cated in all cases of mild paraphilia.
Level 3: If the SSRIs were not ef fec tive in 4 to 6 weeks at ad e-
quate dos age lev els, a small dose of an antiandrogen would be
added. A typ i cal phar ma co log i cal re gime would be sertraline
200 mg daily with 50 mg of medroxyprogesterone acetate
(MPA) or 50 mg of cyproterone ac e tate (CPA). This would be
used in mild and mod er ate lev els of paraphilia.
Level 4: The full antiandrogen or hor monal treat ment would
be given orally. This would in volve 50 to 300 mg of MPA
daily or 50 to 300 mg of CPA daily. This reg i men would be
used in most mod er ate cases and in some se vere cases.
Level 5: The full antiandrogen treat ment or hor monal treat-
ment would be given intramuscularly (IM). This would
30 The Ca na dian Jour nal of Psy chia try
in volve 300 mg of MPA given IM each week with 200 mg of
CPA given IM ev ery 2 weeks. This reg i men would be used in
se vere cases and some catastophic cases.
Level 6: A com plete sup pres sion of an dro gens and sex drive
would be sought by giv ing CPA 200 to 400 mg IM weekly or
pro vid ing a luteinizing hor mone–re leas ing hor mone (LHRH)
ag o nist. This reg i men would be used for some se vere cases of
paraphilia and would be the treatment of choice in cat a-
strophic cases.
The aims of treat ment us ing this al go rithm would be the sup-
pres sion of de vi ant sex ual fan ta sies, urges, and be hav iours,
with a mi nor im pact on sex ual drive at Levels 2 and 3. Sup-
pression of de vi ant sex ual fan ta sies, urges, and behaviour,
with a mod er ate re duc tion in sex ual drive, would be seen at
Levels 3 and 4, but this would be dose-dependent. Sup pres -
sion of de vi ant sex ual fan ta sies, urges, and be hav iour, and a
se vere re duc tion of sex ual drive (de pend ing on the dose of
med i ca tion) would oc cur at Levels 4 and 5. A com plete or
near-complete sup pres sion of sex ual drive would be seen at
Level 6.
In gen eral, the aims of phar ma co log i cal treat ments would be
to sup press de vi ant sex ual fan ta sies, to sup press de vi ant sex-
ual urges and be hav iour, and to re duce the risk of re cid i vism
and further victimization. With regard to nonparaphilic
hypersexuality (NPH), a mild, mod er ate, and se vere clas si fi-
ca tion would ap ply fol low ing the out line in DSM-III.
Pharmacological Treatment
There are 3 main cat e go ries of phar ma co log i cal in ter ven tion
in the paraphilias, and to a cer tain de gree, they could also be
used for the treat ment of nonparaphilic hypersexuality. These
phar ma co log i cal treat ments are (24):
· The spe cific se ro to nin reuptake in hib i tors (SSRIs)
· The antiandrogens and hormonal treatments
· The LHRH agonists
The SSRIs
The SSRIs have long been doc u mented as caus ing a re duc tion
in sex ual de sire. They have also been an im por tant ad vance in
the treat ment of the paraphilias be cause they are well-known
to the av er age psy chi a trist (15,25). De creasing brain 5-HT in
an i mals re sulted in sex ual drive in creases as mea sured by in-
creased mounting behaviour. In contrast, increasing brain
levels of 5-HT reduced sex ual drive and sex ual behaviour.
There fore drugs that in crease 5-HT lev els in the brain have
been used to treat paraphilias (15, 25). Starting in 1990, treat-
ment suc cesses for var i ous paraphilias, such as ex hi bi tion-
ism, us ing fluoxetine hy dro chlo ride and sertraline, have been
reported (25–36). Fluoxetine and sertraline have been the
Vol 46, No 1
most com monly used phar ma co log i cal agents for the treat-
ment of the paraphilias and nonparaphilic hypersexuality.
Kafka re ported on 4 pa tients treated for NPH with fluoxetine
hydrochloride (30). Significant reductions in sexual drive
were observed. He also reported on 3 cases of paraphilia
treated with fluoxetine hydrochloride, where considerable
clin i cal im prove ment was ob served (30). Kafka and Prentky
completed an open-label outpatient study on one group of
men with paraphilia and an other group suf fer ing from NPH.
Both groups were treated over a 12-week pe riod with a mean
dose of 30 mg fluoxetine hydrochloride daily. Clinical im-
provement in all cases was noted (31). Stein and oth ers re-
ported a failure of treat ment of sex ual disor ders with
fluoxetine hydrochloride (32). Coleman and others com -
pleted a study of 13 men with paraphilia treated with
fluoxetine hy dro chlo ride and re ported im prove ment in all as-
pects of de vi ant sex ual be hav iour but, spe cif i cally, a re duc-
tion in de vi ant sex ual fan ta sies, urges, and be hav iours (33).
Kafka re ported on an open-label clin i cal trial of men suf fer-
ing from paraphilia and NPH us ing sertraline (34). The sub-
jects showed a significant reduction in deviant sex ual
fan ta sies, urges, mas tur ba tion, and de vi ant and nondeviant
sex ual be hav iour. The clin i cal re sponse rate was 50%. The
treat ment nonresponders were of fered fluoxetine hy dro chlo-
ride, and about 60% of this group showed some clin i cal im-
prove ment. The mean dos age of sertraline in Kafka’s study
was 100 mg daily, and for fluoxetine hy dro chlo ride it was
51.1 mg daily. The mean duration of treatment was 30.5
weeks (SD 16.8 weeks).
Brad ford and oth ers re ported on a 12-week open-label dose
study of pedophilia treated with sertraline (35). There were 20
sub jects in the study. Two sub jects dropped out. The mean ef-
fec tive dos age of sertraline was 131 mg daily. None of the pa-
tients dis con tin ued the sertraline due to in ad e quate treat ment
re sponse. The study looked at var i ous sex ual be hav iours, in-
clud ing sex ual arousal pat terns. All of the de vi ant sex ual be-
haviours were reduced by the sertraline and, in addition,
het ero sex ual in ter course showed a slight in crease over the
course of the study. This indicated some improvement in
normophilic behaviour. Physiological measures of sexual
arousal showed deviant arousal was reduced, while at the
s a m e t i m e , c o m p a r a t i v e lev e l s of normophilic
arousal—arousal to con sent ing sex with adults—was main-
tained or in fact in creased. Greenberg and oth ers treated a va-
riety of paraphilias using 3 different SSRIs, specifically
sertraline, fluoxetine, and fluvoxamine (36). The fi nal sam ple
(n = 58) showed that the 3 SSRIs were equal in their ef fec tive-
ness in re duc ing de vi ant sex ual fan ta sies, urges, and be hav-
iour. The principle ef fect was on de vi ant sex ual fan ta sies
(36). In a sim i lar study, Greenberg and oth ers looked at a sam-
ple (n = 95) of paraphilic men treated with SSRIs com pared
with a control group ( n = 104) who received only
February 2001 Treat ment of the Paraphilias and Com pul sive Sex ual Be hav iour
cognitive-behavioural treat ment (25). Over the initial
12-week pe riod of treat ment, the fre quency and se ver ity of
sexually de vi ant fan ta sies and urges were sig nif i cantly re-
duced in the SSRI-treated group com pared with the con trol
group. These stud ies pro vide ev i dence that SSRIs re duce de-
viant sexual fantasies, urges, and behaviour. This would
make them the drug of choice in the treat ment of paraphilias
as well as nonparaphilic hypersexuality. The num ber of stud-
ies com pleted to date is still small, how ever, and no dou ble
blind stud ies have been re ported.
Antiandrogens and Hor monal Agents
The initial hormonal treatment for the paraphilias used
estrogens. The effectiveness of these treatments, however,
was re duced be cause of their var i ous side ef fects, spe cif i cally
nau sea, vom it ing, weight gain, and feminization (37–41).
Medroxyprogesterone acetate (Provera) has been the most
com mon form of phar ma co log i cal treat ment for sex ual de vi a-
tion in the US. This is partly due to stud ies started at Johns
Hopkins, but has also been dic tated by the lack of al ter na tives
such as CPA. Sev eral clin i cal stud ies have been com pleted
(42-58).
MPA is a progestagen and has a mo tive ac tion through the in-
duc tion of tes tos ter one reductase in the liver, thereby de creas-
ing cir cu lat ing lev els of tes tos ter one. In ad di tion, its ac tion as
a progestagen blocks the se cre tion of the gon ado tro pins (FSH
and LH), al though the mech a nism of ac tion is not fully un der-
stood (15). Studies have shown that it does not com pete with
androgens at the androgen receptor level and therefore by
def i ni tion is not a true antiandrogen (15). MPA can be given
both orally or IM. A num ber of side ef fects have been de -
scribed, in clud ing weight gain, de creased sperm pro duc tion,
a hyperinsulinic re sponse to a glu cose load, and the po ten tial
to ag gra vate or pre cip i tate di a be tes mellitus, head ache, deep
vein thrombosis, hot flashes, nau sea or vomiting, and
feminization. Clin i cal stud ies show that MPA has a sig nif i-
cant im pact on de vi ant sex ual fan ta sies and de vi ant sex ual
urges and be hav iour. MPA has been used pri mar ily in open
clinical tri als and most com monly is given IM at a dos age
level of 300 to 400 mg weekly as part of an ini tial treat ment,
with the re duc tion to 100 mg weekly as part of a main te nance
pro gram. MPA can be given orally in dos ages rang ing from
50 to 300 mg daily (15, 24). Two open clin i cal stud ies of note
were com pleted in 1981. In the first, Berlin and Mienecke
treated 20 paraphilic men (42). They showed that MPA was
an ef fec tive treat ment in re duc ing de vi ant sex ual fan ta sies
and urges. At the same time, they ob served that there was a
significant relapse rate if treat ment were dis con tin ued. The
dos age of MPA was 200 to 400 mg IM given weekly. In the
sec ond study, Gagne treated 48 pa tients (45) and re ported ef-
fects similar to those of Berlin and Mienecke. He also
31
extensively documented various side effects, as outlined
above. Wincze and oth ers com pleted a dou ble-blind study on
3 pedophiles using MPA (58). They noted that sexual
arousal, as measured by penile tumescence in a laboratory
setting, showed significant reduction in response to erotic
stimuli. Self-reported arousal out side of the lab o ra tory set-
ting, however, was unreliable and inconsistent. Nocturnal
penile tu mes cence was also mea sured and was re duced in all
cases with ac tive treat ment. Meyer and oth ers com pleted a
study of 40 men treated with both MPA and group psy cho-
ther apy (49). The MPA was given at a dosage of 400 mg
weekly by IM in jec tions and the du ra tion of treat ment ranged
from 6 months to 12 years. They in cluded a con trol group of
treat ment re fus ers who re ceived only group psy cho ther apy
over the same pe riod. This study also as sessed treat ment out-
come. The MPA-treated group had an 18% re cid i vism rate
while the treat ment-refuser group had a 35% re cid i vism rate.
Gottesman and Schu bert used a low dos age of MPA (60 mg
daily) given orally for a pe riod of 15 months in an open-label
trial in volv ing 7 sub jects (46). They re ported a sig nif i cant re-
duc tion in de vi ant sex ual fan ta sies and pos i tive treat ment out-
come in all of these pa tients. The sig nif i cant fea ture of this
study is that it is the only one to ex am ine sys tem at i cally the
ef fects of orally ad min is tered MPA.
Cyproterone ac e tate is a true antiandrogen as well as hav ing
progestinic and antigonadotropic ef fects (15). CPA is by far
the most ex ten sively stud ied antiandrogen in terms of its ef-
fects as a treat ment for sex ual de vi a tion (15). It was orig i nally
used in Ger many in the mid-1960s and since then has been
used ex ten sively in var i ous parts of the world (59–71; and
Ortmann J, 1984, un pub lished ob ser va tions).
As a true antiandrogen, CPA is ac tive at an dro gen re cep tors
through out the body. It blocks the intracellular mo lec u lar re-
cep tors. The block of an dro gen re cep tors de creases all types
of sex ual be hav iour, in clud ing sex ual fan ta sies, de vi ant sex-
ual be hav iour, mas tur ba tion, and sexual intercourse, and it
also has an impact on erections. CPA also has strong
progestational ac tiv ity, re duc ing the lev els of FSH and LH. It
is the acetate radical that gives it the progestinic effect.
Cyproterone with out t h e a c e t a t e rad i cal has no
antigonadotropic ef fects. CPA is a com pet i tive in hib i tor of
testosterone and dihydrotestosterone at an dro gen re cep tors
through out the body (15,24).
The first clin i cal stud ies us ing CPA were con ducted in Ger-
many (66,67). In 1971, Laschet and Laschet re ported on more
than 100 sex u ally de vi ant men who were treated with CPA.
They were mostly ex hi bi tion ists and pedophiles, as well as
sex ual sa dists. About 50% of the sub jects were also sex ual of-
fend ers. This was an open-label clin i cal trial with a treat ment
du ra tion of 6 months to 4 years (67). In 80% of cases, CPA
32 The Ca na dian Jour nal of Psy chia try
given orally at 100 mg daily and sig nif i cantly re duced sex ual
drive, erec tions, and or gasms. CPA was also ad min is tered
IM at levels of 300 mg every second week. With this ap -
proach, 20% of ex hi bi tion ists had a com plete elim i na tion of
all de vi ant sex ual be hav iour and, in some cases, these be hav-
iours did not re turn even af ter the treat ment was dis con tin ued.
Side effects of weight gain, depression, and feminization
were noted. Laschet and Laschet re ported on a sim i lar study
on 300 men treated for up to 8 years with ex cel lent treat ment
out come (66). Sev eral other stud ies have since then been
completed, all of which show that CPA is gen er ally an ef fec -
tive treat ment for sex ual de vi a tion. This au thor com pleted 2
stud ies on CPA, one a dou ble-blind study and the other an ex-
amination of the sexual arousal patterns of pedophiles
(59,60). The dou ble-blind cross over study used 19 sub jects,
all of whom met DSM-III-R cri te ria for pedophilia. This sam-
ple also in cluded sex ual of fend ers, prin ci pally with high pre-
treatment re cidivism rates and a mean of 2.5 previ ous
con vic tions for sex ual of fences per sub ject. CPA was ad min-
is tered orally in 3-month ac tive-treatment phases al ter nat ing
with 3-month pla cebo phases. There was a re duc tion in sex ual
arousal re sponses by ac tive drug treat ment that did not quite
reach statistical sig nif i cance. Self-reported urges of sex ual
arousal were all reduced, as was psychopathology as mea -
sured by var i ous writ ing styles. Other mea sures of sex ual be-
hav iour, in clud ing sexual fan ta sies and mas tur ba tion, were
all sig nif i cantly re duced by CPA. In the study of CPA ef fects
on the sex ual arousal pat terns of pedophiles, it was noted that
de vi ant sex ual arousal was af fected differ ently from
normophilic arousal in the same sub jects. This dif fer en tial ef-
fect on sex ual arousal is a very im por tant clin i cal ob ser va tion
that re quires fur ther re search.
LHRH Ag o nists
Luteinizing hor mone–re leas ing hor mone agonists have also
been used to treat paraphilias. They have the spe cific treat-
ment ef fect of over stim u lat ing the hy po thal a mus. There is
ini tially an in crease in GRH se cre tion and then a re duc tion to
al most zero. Con se quently, there is no go nad o tro pin se cre-
tion and the cir cu lat ing lev els of T and DHT drop to cas tra -
tion lev els (15, 24). The LHRH agonists are given IM and
have a pro longed ac tion. They were first flagged as po ten tial
treat ment by this au thor in 1985 (14). There have been lim ited
clinical studies on the use of LHRH agonists (72–75). A
study by Rous seau and oth ers in 1998 doc u mented changes in
sexual behaviour in prostate cancer patients treated with
flutamide as well as an LHRH ag o nist. There was a sig nif i-
cant im pact on sex ual func tion ing com pared with a pre treat-
ment phase. Thibaut and oth ers re ported on the treat ment of 6
men who suf fered from a paraphilia, prin ci pally pedophilia.
Two of them had pre vi ously been treated with oral CPA at
dos ages rang ing from 150 to 300 mg daily, but they did not
ap pear to respond; how ever, their com pliance was in
Vol 46, No 1
ques tion. The pa tients were treated with triptorelin 3.75 mg
IM monthly concurrently with CPA 200 mg daily for 5
months. In 5 out of the 6 pa tients, a marked de crease in sex ual
be hav iour was noted (75). A very im por tant study was pub-
lished by Rosler and Witztum (73). This was an un con trolled
open study of 30 men with a mean age of 32 years who were
treated with triptorelin. They re ceived monthly in jec tions of
3.75 mg of triptorelin and sup port ive psy cho ther apy for a fol-
low-up pe riod of be tween 8 and 42 months. Treat ment out-
come was measured by questionnaires. All of these men
showed a de crease in de vi ant sex ual fan ta sies and de vi ant
sexual urges. Plasma testosterone levels fell to castration
levels.
Conclusion
There are sev eral phar ma co log i cal treat ments avail able for
the treat ment of the paraphilias and nonparaphilic
hypersexuality. These treat ments are based on es tab lished
neurobiological prin ci ples. Fu ture re search on se ro to nin re-
cep tors and polypeptidic neurotransmitters is likely to lead to
new phar ma co log i cal treat ments. Hypersexuality should be
in cluded as a sep a rate sex ual dys func tion (sex ual de sire dis-
or der) in DSM-V.
References
1. Brad ford JM. The paraphilas, ob ses sive com pul sive spec trum dis or der and the
treat ment of sex u ally de vi ant be hav iour. Psychiatr Q 1999;70:209–19.
2. Hollender E, Kwon JH, Stein DJ, Broatch J, Rowland CT, Himelein CA. Ob ses-
sive-compulsive and spec trum dis or der: over view and qual ity of life is sues. J Clin
Psy chi a try 1996;57(Suppl 8): 3–6.
3. Kennet GA. Se ro to nin re cep tors and their func tion. Bris tol (UK): Tocris; 2000.
4. Stein DJ, Hugo F, Oosthuizen P, Hawkridge SM, Van Heerden B. Neuropsychiatry
of hypersexuality. CNS Spec trums 2000;5:36–46.
5. Chow TW, Cummings JL. Neuropsychiatry: clin i cal as sess ment and ap proach to
di ag no sis. In: Sadock BJ, Sadock VA, ed i tors. Com pre hen sive Text book of Psy-
chiatry. 7th Edi tion. Phil adelphia: Lippincott Williams & Wilkins; 1999. p
221–41.
6. Stein DJ. The neurobiology of ob ses sive–com pul sive dis or der. The Neuroscientist
1996;2:300–5.
7. Com ings DE. A con trolled study of Tourette syn drome, VII, sum mary: a com mon
ge netic dis or der caus ing disinhibition of the limbic sys tem. Am J Hum Genet
1987;41:839–66.
8. Kerbeshian J, Burd L. Tourette syn drome and re cur rent paraphilic masturbatory
fan tasy. Can J Psy chi a try 1991;36:155–7.
9. Kafka M. Psychopharmacologic treat ments for nonparaphilic com pul sive sex ual
be hav iours. CNS Spec trums 2000;5:49–59.
10. Owens MJ, Nemeroff CB, Bissette G. Neuropeptides: bi ol ogy and reg u la tion. In:
Sadock BJ, Sadock VA, ed i tors. Com pre hen sive Text book of Psy chi a try. 7th ed.
Phil a del phia: Lippincott Wil liams & Wilkins; 1999. p 60–71.
11. Bancroft J. The bi o log i cal ba sis of hu man sex u al ity. In: Bancroft J, ed i tor. Hu man
Sex u al ity and its prob lems. Ed in burgh: Chur chill Living stone; 1989. p 12–145.
12. Liang T, Tymoczko JL, Chan KMB, Hung HC, Liao S. An dro gen ac tion: Re cep tors
and rapid re sponses. In: Mar tini L, Motta M, ed i tors. An dro gens and
antiandrogens. New York: Ra ven Press; 1977. p 77–89.
13. Davidson JM, Smith ER, Damassa DA(1997). Com par a tive anal y sis of the roles of
an dro gen in the feed back mech a nisms and sex ual be hav iour. In: Mar tini L, Motta
M, ed i tors. An dro gens and antiandrogens. New York: Ra ven Press; 1977. p
137–149.
14. Brad ford, JMW. Or ganic treat ments for the male sex ual of fender. Behav Sci Law
1985;3:355–75.
15. Brad ford, JMW. Phar ma co log i cal treat ment of the paraphilias. In: Oldham JM,
Riba M, ed i tors. Re view of Psy chi a try. Vol ume 14. Wash ing ton (DC): Amer i can
Psy chi at ric Press; 1995. p 755–78.
16. Brad ford JMW. The role of se ro to nin reuptake in hib i tors in fo ren sic psy chi a try.
P r o c e e d i n g s o f t h e 4 t h C o n gress o f E u r o p e a n C o l lege of
February 2001 Treat ment of the Paraphilias and Com pul sive Sex ual Be hav iour
Neuropsychopharmacology: The Role of Se ro to nin in Psy chi at ric Ill ness; 1991;
Monte Carlo, Mo naco.
17. Brad ford JMW. Treat ment of men with paraphilia. N Engl J Med 1998;338:464–5.
18. Brad ford JMW, Boulet J, Pawlak A. The paraphilias: a mul ti plic ity of de vi ant be-
h av iours. Can J Psy chi a try 1992; 37:104–8.
19. Abel GG, Rou leau JL. The na ture and ex tent of sex ual as sault. In: Mar shall WL,
Laws DR, Barbaree HL, ed i tors. Hand book of Sex ual As sault. New York: Ple num
Press; 1990. p 9–20.
20. Gebhard PH, John son AB. The Kinsey data: mar ginal tab u la tions of the 1938-1963
in ter views con ducted by the In sti tute for Sex Re search. Phil a del phia: Saunders;
1979.
21. Sex ual Of fences Against Children. Vol ume 1. Chap ter 6: Oc cur rences in the Pop u-
la tion, p 175–93. Ot tawa: Ca na dian Gov ern ment Pub lishing Cen tre; 1994.
22. Crepault C, Cou ture M. Men’s erotic fan ta sies. Arch Sex Behav 1980;9:565–81.
23. Di ag nos tic and Sta tis ti cal Man ual of Men tal Dis or ders. 3rd ed rev. Sex ual Dis or-
d ers, Paraphilias, p 281. Wash ing ton (DC): Amer i can Psy chi at ric As so ci a tion;
1987.
24. Brad ford JMW. The treat ment of sex ual de vi a tion us ing a phar ma co log i cal ap-
p roach. Jour nal of Sex Re search 2000;37:248-57.
25. Greenberg DM, Brad ford JMW. (1997). Treat ment of the paraphilic dis or ders: A
re view of the role of the se lec tive se ro to nin reuptake in hib i tors. Sex ual Abuse: A
Jour nal of Re search and Treat ment 1997; 9:349–61.
26. Em man uel NP, Lydiard RB, Ballenger JC. Fluoxetine treat ment of voy eur ism. Am
J Psy chi a try 1991;148:950.
27. Lorefice LS. Fluoxetine treat ment of a fe tish (let ter). J Clin Psy chi a try
1991;52:436–7.
28. Perilstein RD, Lipper S, Fried man LJ. Three cases of paraphilias re spon sive to
fluoxetine treat ment. J Clin Psy chi a try 1991;52:169–70.
29. Zohar J., Kaplan Z, Benjamin, J. Com pul sive ex hi bi tion ism suc cess fully treated
with fluvoxamine: a con trolled case study. J Clin Psy chi a try 1994;55:86–8.
30. Kafka MP. Suc cess ful treat ment of paraphilic co er cive dis or der (a rap ist) with
fluoxetine hy dro chlo ride. Brit ish Jour nal of Psy chi a try 1991;158:844–7.
31. Kafka MP, Prentky R. Fluoxetine treat ment of non-paraphilic sex ual ad dic tions
and paraphilias in men. J Clin Psy chi a try 1992; 53:351–8.
32. Stein DJ, Hol lander E, An thony DT, Schnei der FR, Fallon BA, Liebowitz MR.
Serotonergic med i ca tions for sex ual ob ses sions, sex ual ad dic tions and paraphilias.
J Clin Psy chi a try 1992;53:267–71.
33. Coleman E, Cesnik J, Moore AM, Dwyer, SM. An ex plor atory study of the role of
psychotropic med i ca tions in treat ment of sex ual of fend ers. Jour nal of Of fender Re-
h a bil i ta tion 1992;18:75–88.
34. Kafka, MP. Sertraline pharmacotherapy for paraphilias and paraphilia-related dis-
o r ders: an open trial. An nals of Clin i cal Psy chi a try 1994;6:189–95.
35. Brad ford JMW, Greenberg D, Gojer J, Martindale JJ, Goldberg M. Sertraline in the
treat ment of pedophilia: an open la bel study. New Re search Pro gram Ab stracts NR
441; Amer i can Psy chi at ric As so ci a tion Meet ing; 1995 May 24; Maimi, Florida.
36. Greenberg DM, Brad ford JMW, Curry S, O’Rourke A. A com par i son of treat ment
o f paraphilias with three se ro to nin reuptake in hib i tors: a ret ro spec tive study. Bull
Am Acad Psy chi a try Law 1996;24:525–32.
37. Field H. The treat ment of sex ual of fend ers. Med Sci Law 1973;13:195–6.
38. Foote RM. Diethyl stil boes trol in the man age ment of psychopathological states in
males. J Nerv Ment Dis 1994;99:928–35.
39. Golla FL, Hodge SR. Hor mone treat ment of sex ual of fend ers. Lan cet
1949;1:1006–7.
40. Symmers WSC. Car ci noma of the breast in trans sex ual in di vid u als af ter sur gi cal
and hor monal in ter fer ence with pri mary and sec ond ary sex char ac ter is tics. BMJ
1968;2:3–85.
41. Whittaker LH. Oes tro gens and psychosexual dis or ders. Medl J Aust 1959;2:547–9.
42. Berlin FS, Meinecke CF. Treat ment of sex of fend ers with antiandrogenic med i ca-
tion: con cep tu al iza tion, re view of treat ment mo dal i ties and pre lim i nary find ings.
Am J Psy chi a try 1981;138:601–7.
43. Coo per AJ, Sandhu S, Losztyn S. A dou ble-blind pla cebo con trolled trial of
medroxyprogesterone ac e tate and cyproterone ac e tate with seven pedophiles. Can
J Psy chi a try 1992;37:687–93.
44. Cor doba OA, Cha pel JL. Medroxyprogesterone ac e tate antiandrogen treat ment of
hypersexuality in a paedophiliac sex of fender. Am J Psy chi a try 1983;140:1036–9.
45. Gagne P. Treat ment of sex of fend ers with medroxyprogesterone ac e tate. Am J Psy-
chi a try 1981;138:644–6.
46. Gottesman HG, Schu bert DS. Low-dose oral medroxyprogesterone ac e tate in the
man age ment of the paraphilias. J Clin Psy chi a try 1993;54:182–8.
33
47. Kiersch TA. Treat ment of sex of fend ers with Depo-provera. Bull Am Acad Psy chi-
a try Law 1990;18:179–87.
48. Langevin R, Paitich D, Hucker S, Newman S, Ramsay G, Pope S, Geller G, An der -
son C. The ef fect of as ser tive ness train ing, provera and sex of ther a pist in the treat-
ment of gen i tal ex hi bi tion ism. J Behav Ther Exp Psy chi a try 1979;10:275–82.
49. Meyer WJ, Col lier C, Emory E. Depo provera treat ment for sex of fend ing be hav -
ior: An eval u a tion of out come. Bull Am Acad Psy chi a try Law 1992;20:249–59.
50. Meyer WJ, Walker PJ, Emory LE, Smith C. Phys i cal, met a bolic and hor monal ef -
fects on men of long-term ther apy with medroxyprogesterone ac e tate. Fertil Steril
1985;43:102–9.
51. Money J. Use of an dro gen de plet ing hor mone in the treat ment of male sex of fend -
ers. Jour nal of Sex Re search 1970;6:165–72.
52. Money J, Wiedeking C, Walker P, Migeon C, Meyer W, Borgaonkar D. 47, XYY
and 46, XY males with an ti so cial and/or sex-offending be hav ior: Antiandrogen
ther apy plus coun sel ing. Psychoneuroendocrinology 1975;1:165–78.
53. Money J. The ther a peu tic use of an dro gen-depleting hor mone. In ter na tional Psy -
chi a try Clinics 1972;8:165–74.
54. Money J. Dis cus sion of the hor monal in hi bi tion of li bido in male sex of fend ers. In:
Michael R, ed i tor. En do cri nol ogy and hu man be hav ior. Lon don: Ox ford Uni ver-
sity Press; 1968. p 169.
55. Money JM, Weiedeking C, Walker PA, Gain D. Com bined antiandrogen and coun -
sel ing pro gram for treat ment of 46, XY and 47, XYY sex of fend ers. In: Sachar E,
ed i tor. Hor mones, be hav ior and psychopathology. New York: Ra ven Press; 1976.
p 105–20.
56. Southren AL, Gordon GG, Vittek J, Altman K. Ef fect of progestagens on an dro gen
me tab o lism. In: Mar tini L, Motta M, ed i tors. An dro gens and antiandrogens. New
York: Ra ven Press; 1977. p 263–79.
57. Wiedeking C, Money J, Walker PA. Fol low up of 11 XYY males with im pul sive
and/or sex-offending be hav ior. Psychol Med 1979;9:287–92.
58. Wincze WP, Bansal S, & Malamud M. Ef fects of medroxyprogesterone ac e tate on
sub jec tive arousal, arousal to erotic stim u la tion and noc tur nal penile tu mes cence in
male sex of fend ers. Arch Sex Behav 1986;15:293–305.
59. Brad ford JMW, Pawlak A. Dou ble-blind pla cebo cross over study of cyproterone
ac e tate in the treat ment of the paraphilias. Arch Sex Behav 1993;22:383–402.
60. Brad ford JMW, Pawlak A. Ef fects of cyproterone ac e tate on sex ual arousal pat -
terns of pedophiles. Arch Sex Behav 1993;22:629–41.
61. Brad ford JMW, Pawlak A. Sa dis tic ho mo sex ual pedophilia: Treat ment with
cyproterone ac e tate. A sin gle case study. Can J Psy chi a try 1987;32:22–31.
6 2. Davies TD. Cyproterone ac e tate for male hypersexuality. J Int Med Res 1974;
2:159–63.
63. Coo per AJ. A pla cebo con trolled study of the antiandrogen cyproterone ac e tate in
de vi ant hypersexuality. Compr Psy chi a try 1981;22:458–64.
64. Coo per AJ, Ismail AA, Phanjoo AL, Love DL. Antiandrogen (cyproterone ac e tate)
ther apy in de vi ant hypersexuality. Br J Psy chi a try 1972;120:59–63.
65. Coo per AJ, Cernovovsky Z. The ef fects of cyproterone ac e tate on sleep ing and
wak ing penile erec tions in pedophiles: Pos si ble im pli ca tions for treat ment. Can J
Psy chi a try 1992;37:33–9.
66. Laschet U, Laschet L. Antiandrogens in the treat ment of sex ual de vi a tions of men.
Jour nal of Ste roid Bio chem is try 1975;6:821–6.
67. Laschet U, Laschet L. Psychopharmacotherapy of sex of fend ers with cyproterone
ac e tate. Pharmakopsychiatrie Neuropsychopharmakologic 1971;4:99–104.
68. Mothes C, Lehnert J, Samimi F, Ufer J. Schering sym po sium uber sex ual
deviationen und ihre medikamentose Behandlung. Life Sciences Monograph
1971;2:65.
69. Neumann, F. Phar ma col ogy and po ten tial use of cyproterone ac e tate. Horm Metab
Res 1997;9:1–13.
70. Ortmann J. The treat ment of sex ual of fend ers, cas tra tion and antihormone ther apy.
Int J Law Psy chi a try 1980;3:443–51.
71. Ott F, Hoffet H. The in flu ence of antiandrogens on li bido, po tency and testicular
func tion. Schweiz Med Wochschr 1968;98:1812.
72. Dickey R. The man age ment of a case of treat ment-resistant paraphilia with a
long-acting LHRH ag o nist. Can J Psy chi a try 1992;37:567–9.
73. Rosler A, Witztum E. Treat ment of men with paraphilia with a long act ing an a logue
of go nad o tro pin- re leas ing hor mone. N Engl J Med 1998;338:416–65.
74. Rous seau LR, Cou ture M, Dupont A, Labrie F & Cou ture N. Ef fect of com bined an-
dro gen block ade with an LHRH ag o nist and flutamide in one se vere case of male
ex hi bi tion ism. Can J Psy chi a try l990;35:338–41.
75. Thibaut F, Cordier B, Kuhn JM. Ef fect of a long-lasting gonadotrophin hor -
mone-releasing hor mone ag o nist in sex cases of se vere male paraphilia. Acta
Psychiatr Scand 1993;87:445–50.
34 The Ca na dian Jour nal of Psy chia try Vol 46, No 1

Résumé—La neu ro bio lo gie, la neu ro phar ma colo gie et le traite ment phar ma colo gique des
paraphil ies et du com por te ment sexuel com pul sif
Ces dernières années, on constate un intérêt accru pour le traitement des troubles sexuels. Les troubles sexuels sont classés dans
le Manuel diagnostique et statistique des troubles mentaux (DSM IV) comme étant les dysfonctions sexuelles, les paraphilies et
les troubles de l’identité sexuelle. Les dysfonctions sexuelles sont non déviantes ou non paraphiliques. Les dysfonctions sexuelles
devraient inclure « le trouble du désir sexuel hyperactif », dans la catégorie des troubles du désir sexuel. En outre, on devrait
spécifier si les paraphilies sont « avec hypersexualité » ou « sans hypersexualité ». On ne comprend pas encore complètement la
neurobiologie des troubles sexuels, bien que la neuroanatomie fonctionnelle et la recherche neuropharmacologique aient
exposé les neurotransmetteurs, les récepteurs et les hormones responsables du désir sexuel. Les études indiquent que divers
agents pharmacologiques, y compris les inhibiteurs de recaptage de la sérotonine (IRS), les antiandrogènes, les agonistes LHRH
et d’autres réduisent le désir sexuel. Un algorithme pour l’utilisation de ces médicaments dans letraitement des paraphilies et de
l’hypersexualité non paraphilique est présenté. Les modes d’action, les dosages, les cibles du traitement et les méthodes usuelles
de prescription de ces agents sont recensés dans cet article. On y présente aussi certaines orientations futures de la recherche en
traitement pharmacologique.