The Treatment of Sexual Deviation Using a Pharmacological Approach

Journal of Sex Research, August, 2000 by John McDonald Wilson Bradford

In a recent editorial in the New England Journal of Medicine, this author decried the need for government and pharmaceutical industry support for research in the treatment of sexually deviant behavior (Bradford, 1998). There are a number of reasons for this, including the case of Kansas v. Hendricks (1997) where the U.S. Supreme Court upheld the civil commitment of sexually violent predators for treatment as constitutional. This means that the most seriously sexually deviant individuals are now to be held in psychiatric hospitals or special facilities for the treatment of their sexual deviation prior to their release. It is these individuals who need to be treated using a pharmacological approach in addition to cognitive behaviourial therapy. Further, pedophilia alone is a very severe public health problem of staggering proportions, with between 6 and 62% of girls and 10 to 30% of boys being the victims of sexual abuse in childhood according to various studies (Peters, Wyatt, & Finkelhor, 1986). Furthermore, in the United States the costs of incarcerating individuals convicted of sexually abusing children is staggering, with more than two billion dollars spent in 1990, while at the same time there is no evidence that the deterrence of incarceration has any impact on the problem (Pithers et al., 1995).

At this time, no one is certain of the cause of pedophilia and other sexual deviations. In addition, the actual incidence and prevalence of the paraphilias is unknown. The level of sexual abuse victimization of children in the general population today is fairly consistent with that reported by Kinsey (Gebhard & Johnson, 1979). In a study completed in the 1940s, 24% of 4,000 females surveyed disclosed a sexual interaction with a male at least five years older than them when they were 14 years of age or younger (Gebhard & Johnson, 1979). Sexual intercourse occurred in 93% of cases, and in 31% of cases there was mild petting or fondling without involvement of the genitals. A national survey by the Federal Government of Canada on sexual violence against children and adolescents found that 18.1% of children (23.5% of females and 12.8% of males) were victims of childhood sexual abuse. In only 20% of cases were the perpetrators strangers, with friends, acquaintances, parents, and other family members being the perpetrators in the majority of cases (Federal Government of Canada, 1984). The actual levels of the prevalence of pedophilia in the general population is unknown, but it could be at least at the same levels as obsessive compulsive disorder, or most likely even higher (Bradford, 1999). Despite this convincing evidence of a serious public health problem, the support for research into the causes and treatment of pedophilia (and other sexual deviations) is very weak, with little or no pharmaceutical industry support and poor government support. In a study of sexual fantasies by Crepault and Couture (1980) it was reported that over 60% of males reported heterosexual pedophilic fantasies and 33% of males had rape fantasies. While this may be a high estimate, even if this is partially accurate the prevalence of mild cases of pedophilia in the general population is staggering. The onset of paraphilic sexual fantasies and urges is usually well established by age 18 (Abel & Rouleau, 1990). This means the risk of sexually acting out is present in late adolescence, yet there are only a few programs dedicated to the treatment of sexual deviation in adolescence. Generally, mental health professionals working

with this segment of the population are not aware of this serious problem, and therefore not enough is being done to treat these conditions before they are well established. In addition, there is considerable comorbidity between the various paraphilias (Bradford, Boulet, & Pawlak, 1992). This means that for a treatment to be successful it has to be able to simultaneously reduce multiple paraphilic behaviours. All of these factors strongly support a pharmacological treatment option as being the most important intervention in the treatment of paraphilias.

The treatment of paraphilias using pharmacological agents is well established (Bradford, 1991, 1994, 1995). It is a treatment approach that is effective in all types of sexual deviations, including the simultaneous presence of multiple sexual deviations. In addition, it is the treatment of choice for the most serious sexual deviations, such as sexual sadism. The paraphilias or sexual deviations are deviant sexual behaviors that have common clinical features, specifically sexual fantasies, leading to sexual urges and then, ultimately, to the deviant sexual behavior. Ideally, if a treatment were to be successful the sexually deviant behavior would be completely suppressed, while at the same time nondeviant sexual behavior (normophilic behavior) would remain intact or would even be enhanced. As outlined later in this article various pharmacological treatment approaches have been shown to have that capability. In addition an ideal treatment would be one that was able to suppress the psychological component of sexual deviation (sexual fantasies) while at the same time having an impact on physiological components of sexual deviation (sexual arousal).