Brian Holoyda, MD, MPH, MBA
Forensic psychiatrist, Portland, OR.
Dr. Holoyda, expert for this educational activity, has no relevant financial relationship(s) with ineligible companies to disclose.
CHPR: Dr. Holoyda, please tell us about yourself.
Dr. Holoyda: I am a forensic and correctional psychiatrist. I completed my training in psychiatry and forensic psychiatry at the University of California, Davis. I provide psychiatric treatment to pre-trial detainees at a jail in the Bay Area of California. In addition, I conduct forensic psychiatric evaluations for attorneys on a variety of psycholegal issues, including sexually violent predator determinations, violence risk assessments, malpractice allegations, and emotional injury claims.
CHPR: Can you give us an overview of paraphilic disorders?
Dr. Holoyda: Paraphilic disorders are a diagnosis category in DSM-5. In DSM-IV-TR they were referred to as paraphilias, but DSM-5 distinguishes between a paraphilia and a paraphilic disorder. A paraphilia is an intense and persistent sexual interest in an atypical, sexually arousing object or act. A paraphilic disorder, in contrast, is a psychiatric diagnosis characterized by a paraphilia that causes distress or impairment or has led to personal harm or risk of harm to others. As you can see in DSM-5, all the paraphilic diagnoses now have the word “disorder” at the end. For example, pedophilia became pedophilic disorder, exhibitionism became exhibitionistic disorder, etc. Individuals with paraphilias do not necessarily have a disorder, as their atypical sexual interests may not cause them distress or impairment, or they may engage in atypical sexual behaviors with consenting human partners.
CHPR: Is there anything else we should know to diagnose paraphilias and paraphilic disorders?
Dr. Holoyda: There are a few other key points. First, we typically identify paraphilias and paraphilic disorders based on what DSM-5 refers to as “anomalous activity preferences” or “anomalous target preferences.” These terms mean that somebody has an atypical interest in either a certain type of activity that is abnormal or a partner or object that is abnormal. Second, the atypical sexual interest associated with a paraphilic disorder is typically preferential, meaning that the person will seek out that type of sexual activity or sexual interaction before they seek out normative sexual activity.
CHPR: In our inpatient psychiatry unit, we periodically admit patients with psychiatric disorders who are also registered sex offenders, typically against children. But not all registered sex offenders meet criteria for paraphilic disorders, right? Can you review the distinction?
Dr. Holoyda: A person with a history of an offense involving a minor does not necessarily have a pedophilic disorder. Sex offenses are criminal offenses defined by state statute, whereas the paraphilic disorders are psychiatric disorders. People with paraphilic disorders may not engage in behavior that would result in a sex offense, and people who commit sex offenses do not necessarily have a paraphilic disorder. Interestingly, possessing child pornography is a greater indicator of pedophilic interest than committing a hands-on offense against a child. People actively seek out pornography that appeals to their sexual interest, whereas somebody could engage in a hands-on offense against a child for other reasons—for example, while under the influence of substances or because consenting adult partners are not available.
CHPR: Can you review treatment approaches for paraphilic disorders?
Dr. Holoyda: The main treatment model was put forth by the World Federation of Societies of Biological Psychiatry (WFSBP). The organization recently updated its guidelines on medication management for paraphilic disorders in 2020, and I would strongly encourage readers to look at them (Thibaut F et al, World J Biol Psychiatry 2020;21(6):412–490). Basically, they recommend escalating levels and numbers of treatment based on a person’s risk. If a person is having atypical sexual fantasies or thoughts or urges that are bothersome to them, but they are deemed to be at low risk of acting on them or the fantasies do not entail hands-on offenses against others, then the recommendation is cognitive behavioral therapy (CBT). With escalating risk—for example, a patient having urges to commit a sexual behavior that would be a hands-on offense—then a psychiatrist should be more concerned and should consider offering medication treatments.
CHPR: What kinds of medication treatments?
Dr. Holoyda: For low-level paraphilias, we use SSRIs, which have long been a mainstay of treatment for paraphilic disorders. We do this for a few reasons. First, as a side effect of the activation of serotonin receptors, SSRIs can reduce libido and an individual’s ability to obtain an erection or have an orgasm. Second, the urges or fantasies of paraphilic disorders have been likened to compulsions or obsessive thoughts in OCD. So, by using high-dose SSRIs, we can dampen some of those urges and thoughts. Third, a lot of folks with paraphilic disorders have accompanying anxiety and depressive symptoms that make the thoughts and urges more distressing, so by reducing the associated symptoms, they might be less distressed and therefore less fixated on their thoughts and urges.
CHPR: Are there any randomized controlled trials of SSRIs for paraphilic disorders?
Dr. Holoyda: Not to my knowledge. Despite this, the WFSBP guidelines specifically recommend sertraline and fluoxetine for patients with mild paraphilic disorders.
CHPR: What about hormonal interventions?
Dr. Holoyda: There is a category of anti-androgen or testosterone-lowering medications, which includes steroid analogues like medroxyprogesterone acetate and the GnRH analogues like triptorelin, leuprorelin, and goserelin. The rationale for using anti-androgen medications is that reducing free testosterone reduces libido, can reduce the frequency of erections and masturbation, and can decrease typical and atypical sexual fantasies.
CHPR: How do you choose which anti-androgen medication to use?
Dr. Holoyda: The only steroid analogue available in the US is medroxyprogesterone acetate, which comes in a depot form called Depo-Provera. It increases the destruction of testosterone by the liver, suppresses the hypothalamic-pituitary-gonadal axis, and increases testosterone binding to testosterone-binding globulin, which increases the clearance of testosterone from the bloodstream. According to the WFSBP, there have been about 600 published cases of Depo-Provera for the treatment of paraphilic disorders and sex offenders. Some studies have shown a complete disappearance of paraphilic sexual behavior and fantasies within one or two months of starting treatment. In the latest guidelines, however, the WFSBP recommends against the use of Depo-Provera due to side effects, like fatigue, weight gain, hot flashes, and migraine headaches.
CHPR: This is surprising—a completely effective treatment, yet they don’t recommend it because of some side effects?
Dr. Holoyda: Indeed, the WFSBP opined that the risks of Depo-Provera outweigh the benefits based on currently available research. They noted a similar concern for significant side effects with the hormonal analogue cyproterone acetate, which is not available in the US, but did not recommend against its use.
CHPR: What other anti-androgen medications are there?
Dr. Holoyda: The second commonly used anti-androgen medication class is GnRH analogues. Typically, GnRH is released from the anterior pituitary gland in a pulsatile fashion, which stimulates the production of luteinizing hormone and follicle-stimulating hormone, which then stimulate the production and release of testosterone. GnRH analogues give a continuous rather than pulsatile dose of GnRH, which shuts down the hypothalamic-pituitary-gonadal axis.
CHPR: Have there been any randomized controlled trials of GnRH analogues for paraphilic disorders?
Dr. Holoyda: There are relatively few published data on them and no randomized controlled trials. As with Depo-Provera, however, studies have found complete disappearance of deviant sexual fantasies and a reduction in nondeviant sexual behavior in folks who are treated with GnRH analogues. The WFSBP recommends their use for severe paraphilic disorders.
CHPR: So why are GnRH analogues more highly recommended?
Dr. Holoyda: First, they tend to be better tolerated than hormonal analogues like Depo-Provera and cyproterone acetate. Second, it is easier to monitor patients’ compliance with GnRH analogues because they have a more predictable effect on plasma testosterone levels.
CHPR: I recently read an article about the opposite of a GnRH analogue for paraphilic disorders: a GnRH antagonist, degarelix (Firmagon). Can you say something about that agent?
Dr. Holoyda: Yes, this is a new approach. In 2020, a Swedish group published a randomized clinical trial on degarelix. The researchers compared degarelix versus placebo and assessed 52 men with pedophilic disorder on several domains of child sexual abuse, like degree of sexual preoccupation, impaired self-regulation, empathy, and individual self-rated risk. They found that degarelix resulted in significantly decreased risk scores at both two and 10 weeks compared to placebo, and they suggested that the medication may produce rapid onset of treatment for men with pedophilic disorder (Landgren V et al, JAMA Psychiatry 2020;77(9):897–905). Of course, more studies are needed, but this study gives us hope that we may have yet another medication in our arsenal to treat paraphilic disorders.
CHPR: Have you encountered any problems with administering these medications?
Dr. Holoyda: The side effects are significant and should not be taken lightly. These medications are feminizing; they can cause uncomfortable side effects like hot flashes, growth of breast tissue, and weight gain. GnRH agonists specifically can result in bone demineralization. Folks should get their bone density measured on a yearly basis when they take these medications. Furthermore, sexuality is a primary element of being a human, so many clinicians are not willing to give patients a medication that totally shuts down their sexual interests, even if they are atypical and problematic. On the other hand, many folks in the community do not seek treatment for atypical sexual interests because they are not aware that effective treatments are available to help them have more normal sex lives and sexual interests. They may also fear that they will be reported to police for having sexual thoughts or fantasies involving children.
CHPR: That brings up the question about reporting. I assume that if a patient is having atypical sexual thoughts, but has not acted on them, then there’s no mandated reporting requirement.
Dr. Holoyda: Right. That conversation is one that a provider would have with the patient when doing an informed consent for treatment. If the patient is presenting for evaluation and treatment of atypical sexual fantasies or urges, then they need to know that, as a mandated reporter, you will make a report if you have concern that there is child sexual abuse going on. In most states, the standard for reporting is “reasonable suspicion” that abuse has occurred. This does not mean that you must be 100% certain; it just means that you suspect there might be sexual abuse going on. As psychiatrists, we are mandated to report to local law enforcement or the county child welfare agency. It is also important to know that most states provide reporters immunity from civil or criminal liability that might result from a report. I would encourage people to look at their own state’s statutes about that issue.
CHPR: Returning to the subject of treatments, what about nonpharmacologic therapies?
Dr. Holoyda: Psychotherapy for sexual offending usually follows a CBT-type model based on the risk-need-responsivity, or RNR, principle. The first R, risk, refers to identifying the degree of risk that the individual poses and matching the level of treatment to that risk. The N, need, refers to identifying the individual’s dynamic sexual violence risk factors to be targeted with treatment. And the final R, responsivity, refers to tailoring treatment to the individual’s strengths, needs, and abilities. There are some organizations, like the Association for the Treatment of Sexual Abusers, that report a significant reduction in the recidivism rate with psychological interventions, but the data are quite mixed on the benefits of nonmedication treatments for sexual offending and paraphilic disorders. And there was a recent large-scale study conducted in the UK penal system that demonstrated increased rates of re-offense for individuals who received psychological interventions (www.tinyurl.com/54capywf).
CHPR: It sounds like the data are really inconclusive for psychological interventions.
Dr. Holoyda: Right, and for that reason, medications should absolutely be part of the mainstay treatment course for patients with paraphilic disorders.
CHPR: When working with these patients, we often encounter placement issues as many facilities will not take a sex offender. We work with patients’ probation or parole officers, but the options for placement are often very limited.
Dr. Holoyda: Sex offender registration laws in this country have made it extremely difficult to find housing for sex offenders because there are many rules about where they can and cannot live. That is one major reason why a lot of sex offenders end up being homeless and then frequently get violations for not updating their address history with probation. That is an unintended consequence of this type of legislation, so I absolutely hear you.
CHPR: Thank you for your time, Dr. Holoyda.
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