Treating Sexual Impulsivity
Sexual Impulse Disorders: Paraphilias
Harvard Medical School Associate Professor of Clinical Psychiatry, Martin P. Kafka, M.D., defines paraphilias as it appears in the DSM-IV, being “sexual impulse disorders, mainly seen in males, are characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors (of at least six months’ duration) that are considered deviant with respect to cultural norms and that produce clinically significant distress or impairment in social, occupational, or other important areas of psychosocial functioning.” Common paraphilias include exhibitionism, pedophilia, voyeurism, fetishism, sexual sadism, sexual masochism, and frotteurism.1 In Kafka’s article, “Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders,” he focuses on the pharmacotherapy available for paraphilias and paraphilia-related disorders. Currently, there are two classes of psychopharmacological agents that are available for treatment of sexual impulse disorders: antiandrogens and serotonergic antidepressants.1
Treating Paraphilias: Which Medicine to Choose?
The two most commonly prescribed antiandrogens for individuals with sexual impulse disorders are cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA).1 Neither are FDA-approved specifically for the treatment of such disorders; however, both are commonly used in Canada and Europe.1 Currently, only medroxyprogesterone is available in the United States.1 Common side-effects of antiandrogens are weight gain, fatigue, hypertension, headache, hyperglycemia, and leg cramps.1 Medroxyprogesterone lowers a male’s serum testosterone, and, according to Kafka, is usually prescribed in the parental depot form, injected every one to two weeks in doses of 100 to 800 mg.1 Men who are prescribed antiandrogens report feeling calmer regarding sexual aggression and general irritability. Normally, effects can be seen in two to four weeks after beginning the drug.1
It is not uncommon for individuals with sexual impulse disorders to feel anxiety and depression; however, these symptoms may increase the frequency and intensity of paraphiliac behavior.1 According to Kafka, serotonergic antidepressants, specifically serotonin reuptake inhibitors (SRIs), may be prescribed, even in the absence of anxiety and depression.1 Research states that mammalian sexual behavior is promoted by decreased serotonin and increased dopamine in the brain; therefore, increasing serotonin and decreasing dopamine may inhibit sexual behavior.1 Kafka states that fluoxetine is one of the most commonly used medicines, although lithium, clomipramine, buspirone, fluvoxamine, and sertraline are also used, all in the usual antidepressant dosages.1 Effects are usually seen after four weeks of use, with sexual behaviors, anxiety, and depression all decreasing.1 Currently, according to Kafka, SRIs are the primary treatment for individuals with paraphilias.1
The Best Medicines for Different Paraphilias
Kafka believes that antiandrogens should be the treatment of choice for sexually dangerous paraphiliacs, however, as SRIs require a motivated patient to be successful.1 On the other hand, for those who are more motivated and not deemed dangerous, the SRI fluoxetine should be the drug of choice, as it has a long half-life and a missed dose here and there will not affect the treatment.1 Kafka states that he believes medroxyprogesterone acetate may be combined safely with an SRI, allowing for even more advantages and control over socially deviant sexual impulse disorders.1
 Kafka, M.P. (2006, August 25). Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/masochism/content/article/10168/58676. Paraphilias.