Paraphilic disorders are characterized by atypical sexual interests, fantasies, and behaviors that are subjectively distressing to patients or pose a risk of harm to others. By their very nature, some paraphilic disorders may predispose an individual to commit sexual offenses. The biological treatment of paraphilic disorders, then, is of paramount importance for psychiatry and society at large. Three categories of pharmacologic agents commonly used to treat paraphilic disorders are selective serotonin reuptake inhibitors, synthetic steroidal analogs, and gonadotropin-releasing hormone analogs. Each medication uses a different mechanism of action and has different effects on the physiological and psychological features of paraphilic disorders. In general, these medications have limited high-quality research to support their use. Despite this, some authors have proposed treatment algorithms for individuals with paraphilic disorders of varying severity. These guidelines offer clinicians potentially useful, rational approaches to assessing treatment need in individuals with paraphilic disorders. Recent neuroimaging research suggests that functional magnetic resonance imaging may offer further promise in effectively assessing paraphilic disorders to help direct treatment options.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Krafft-Ebing RV. Psychopathia sexualis. 12th ed. New York: Pioneer Publications; 1950.
Laws DR, O’Donohue WT. Sexual deviance: theory, assessment, and treatment. 2nd ed. New York: Guilford Press; 2008.
Lösel F, Schmucker M. The effectiveness of treatment for sexual offenders: a comprehensive meta-analysis. J Exp Criminol. 2005;1(1):117–46.
Dennis JA. Psychological interventions for adults who have sexually offended or are at risk of offending. Cochrane Database Syst Rev. 2012;12:CD007507. This important Cochrane review evaluated evidence from studies on psychological interventions for adults who sexually offend. They found no difference between treated and untreated groups in terms of the risk of reoffending, as measured by a new sexual crime conviction. They concluded that more research is needed.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington: American Psychiatric Association; 2013.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington: American Psychiatric Association; 2000.
American Psychiatric Association (2013). Paraphilic Disorders Fact Sheet. Available at: http://www.dsm5.org/Documents/Paraphilic%20Disorders%20Fact%20Sheet.pdf. This resource document from the American Psychiatric Association summarizes the changes made in the paraphilic diagnoses between DSM-IV-TR and DSM-5 . It also explains the Sexual and Gender Identity Disorders Work Group’s rationale for these changes.
First MB. DSM-5 and paraphilic disorders. J Am Acad Psychiatry Law. 2014;42(2):191–201.
Thibaut F. Pharmacological treatment of paraphilias. Isr J Psychiatry Relat Sci. 2012;49(4):297–305. This article provides a brief, cogent summary of the more extensive World Federation of Societies of Biological Psychiatry guidelines for the treatment of paraphilias.
Thibaut F et al. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World J Biol Psychiatry. 2010;11(4):604–55.
Assumpcao AA et al. Pharmacologic treatment of paraphilias. Psychiatr Clin North Am. 2014;37(2):173–81.
Garcia FD et al. Pharmacologic treatment of sex offenders with paraphilic disorder. Curr Psychiatry Rep. 2013;15(5):356. The authors discuss medications used to treat paraphilic disorders with a focus on individuals who have sexually offended.
Bijlsma EY et al. Sexual side effects of serotonergic antidepressants: mediated by inhibition of serotonin on central dopamine release? Pharmacol Biochem Behav. 2014;121:88–101. The authors review the pharmacologic basis of the sexual side effects of selective serotonin reuptake inhibitors (SSRIs). They note that increasing dopamine neurotransmission overcomes the sexual side effects of SSRIs. They therefore hypothesize that the sexual side effects of SSRIs result from the inhibition of dopamine neurotransmission in sex brain circuits.
Meston CM, Frohlich PF. The neurobiology of sexual function. Arch Gen Psychiatry. 2000;57(11):1012.
Rosler A, Witztum E. Pharmacotherapy of paraphilias in the next millennium. Behav Sci Law. 2000;18(1):43–56.
Garcia FD, Thibaut F. Current concepts in the pharmacotherapy of paraphilias. Drugs. 2011;71(6):771–90.
Adi Y et al. Clinical effectiveness and cost-consequences of selective serotonin reuptake inhibitors in the treatment of sex offenders. Health Technol Assess. 2002;6(28):1–66.
Bradford JM. The treatment of sexual deviations using a pharmacological approach. J Sex Res. 2000;37(3):248–57.
Bradford J, Federoff JP. Pharmacological treatment of the juvenile sex offender. In: Barbaree HE, Marshall WL, editors. The juvenile sex offender. New York: Guilford Press; 2006. p. 358–82.
Rubinow DR, Schmidt PJ. Androgens, brain, and behavior. Am J Psychiatry. 1996;153(8):974–84.
Bradford JM, Bourget D. Sexually aggressive men. Psychiatr J Univ Ott. 1987;12(3):169–75.
Bradford JM, McLean D. Sexual offenders, violence and testosterone: a clinical study. Can J Psychiatry. 1984;29(4):335–43.
Seim HC, Dwyer M. Evaluation of serum testosterone and luteinizing hormone levels in sex offenders. Fam Pract Res J. 1988;7(3):175–80.
Craissati J. Managing high risk sex offenders in the community: a psychological approach. New York: Routledge; 2004.
Saleh FM, Berlin FS. Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders. J Child Sex Abus. 2003;12(3–4):233–53.
Brady BM et al. Demonstration of progesterone receptor-mediated gonadotrophin suppression in the human male. Clin Endocrinol (Oxf). 2003;58(4):506–12.
Berlin FS. The paraphilias and Depo-Provera: some medical, ethical and legal considerations. Bull Am Acad Psychiatry Law. 1989;17(3):233–9.
Guay DR. Drug treatment of paraphilic and nonparaphilic sexual disorders. Clin Ther. 2009;31(1):1–31.
Khan O et al. Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Syst Rev. 2015;2:CD007989. This Cochrane review summarizes current available research on the utility of pharmacologic treatments in sexual offenders. It highlights the paucity of high-quality research in this area.
Jeffcoate WJ et al. The effect of cyproterone acetate on serum testosterone, LH, FSH, and prolactin in male sexual offenders. Clin Endocrinol (Oxf). 1980;13(2):189–95.
Gijs L, Gooren L. Hormonal and psychopharmacological interventions in the treatment of paraphilias: an update. J Sex Res. 1996;33(4):237–90.
Meyer JW, Cole CM. Physical and chemical castration of sex offenders: a review. J Offender Rehabil. 1997;25(3–4):1–18.
Conn PM, Crowley Jr WF. Gonadotropin-releasing hormone and its analogues. N Engl J Med. 1991;324(2):93–103.
Belchetz PE et al. Hypophysial responses to continuous and intermittent delivery of hypopthalamic gonadotropin-releasing hormone. Science. 1978;202(4368):631–3.
Thibaut F, Cordier B, Kuhn JM. Effect of a long-lasting gonadotrophin hormone-releasing hormone agonist in six cases of severe male paraphilia. Acta Psychiatr Scand. 1993;87(6):445–50.
Briken P. Pharmacotherapy of paraphilias with luteinizing hormone-releasing hormone agonists. Arch Gen Psychiatry. 2002;59(5):469–70.
Czerny JP, Briken P, Berner W. Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics. Eur Psychiatry. 2002;17(2):104–6.
Hill A et al. Differential pharmacological treatment of paraphilias and sex offenders. Int J Offender Ther Comp Criminol. 2003;47(4):407–21.
Maletzky BM, Field G. The biological treatment of dangerous sexual offenders: a review and preliminary report of the Oregon pilot depo-Provera program. Aggress and Violent Behav. 2003;8:391–412.
Maletzky BM, Tolan A, McFarland B. The Oregon depo-Provera program: a five-year follow-up. Sex Abuse. 2006;18(3):303–16.
Ferretti A et al. Dynamics of male sexual arousal: distinct components of brain activation revealed by fMRI. Neuroimage. 2005;26(4):1086–96.
Karama S et al. Areas of brain activation in males and females during viewing of erotic film excerpts. Hum Brain Mapp. 2002;16(1):1–13.
Mouras H et al. Brain processing of visual sexual stimuli in healthy men: a functional magnetic resonance imaging study. Neuroimage. 2003;20(2):855–69.
Cheng JC et al. Neuroimaging and sexual behavior: identification of regional and functional differences. Curr Psychiatry Rep. 2015;17:55. The authors summarize neuroimaging findings in sexual behavior and their relevance in sexual disorders including pedophilic disorder and compulsive sexual behavior.
Wiebking C, Northoff G. Neuroimaging in pedophilia. Curr Psychiatry Rep. 2013;15(4):351. The authors provide a comprehensive summary of the use of neuroimaging in the assessment of pedophilic disorder. In addition, they discuss the potential use of neurofeedback to augment treatment of pedophilic disorder.
Renaud P et al. Real-time functional magnetic imaging—brain-computer interface and virtual reality promising tools for the treatment of pedophilia. Prog Brain Res. 2011;192:263–72.
Kärgel C et al. Diminished functional connectivity on the road to child sexual abuse in pedophilia. J Sex Med. 2015;12(3):783–95. The authors identified differences in the functional connectivity at rest (a measure of resting neural activity) between pedophiles who had committed child sexual abuse and those who had not. This suggests that fMRI may assist in identifying pedophilic individuals who are at a higher risk of engaging in sexual crimes.
Conflict of Interest
The authors declare that they have no competing interests.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Sexual Disorders
About this article
Cite this article
Holoyda, B.J., Kellaher, D.C. The Biological Treatment of Paraphilic Disorders: an Updated Review. Curr Psychiatry Rep 18, 19 (2016). https://doi.org/10.1007/s11920-015-0649-y