Paraphilia

Much of what we know about the manifestation, etiology, and prognosis for sexual offenders stems from research with adults. Despite the fairly high prevalence and harsh punishments for juvenile sexual offenders, the field still knows little about the course and roots of these behaviors in youth. Developmental differences in psychopathology and amenability to treatment highlight the need for separate etiological and treatment models when dealing with juveniles. This chapter reviews our current understanding of adult sex offending and contrasts this literature with our gaps in knowledge pertaining to juvenile sex offenders. We conclude with suggestions for future research and treatment strategies.

Sex offending behavior perpetrated by youth is not a rare phenomenon. Indeed, about half of all adult sex offenders are thought to have initiated their criminal careers during adolescence. According to the Federal Bureau of Investigation (FBI), juveniles were arrested for approximately 12.4% of all forcible rapes committed in 2001 (FBI, 2002). Older statistics suggest that juveniles were responsible for approximately one-half of all child molestation cases committed in the United States in the late 1990s (Sickmund, Snyder, and Poe-Yamagata, 1997). Increases in violent crime among juveniles such as this led to nationwide legal reforms in the 1990s that lowered the age at which youths could be tried in adult criminal court (Snyder and Sickmund, 1999) and increased the severity of penalties available to juvenile courts (Torbet et al., 1996). Now, registration as a sex offender is among the penalties available for juvenile offenders in many states.

Despite the need for increased attention to juvenile offenders that these prevalence rates and harsh punishments instigate, our knowledge of the causes and course of sexual offending and paraphilic disorders has been largely limited to adults. Consequently, juvenile treatment modalities are often simply downward extensions of adult treatment designs despite the even wider heterogeneity found in juvenile sex offender populations (Hunter, Hazelwood, and Slesinger, 2000). Here we review what is known about the course and treatment of juvenile sexual offending by first providing a brief review of findings with adult offenders, then discussing the similarities and differences among juveniles, and concluding with suggestions for research and treatment.

ADULT SEX OFFENDERS

Course of Sex-Offending Behaviors

Most of what we know about adult sex offenders derives from research with incarcerated or hospitalized males. Despite concerns that sex offenses have among the highest recidivism rates relative to other violent crimes, a small group of adult offenders are responsible for a disproportionate amount of the crime and the course of offending varies based on the nature of the offense (Quinsey et al, 1995). In a recent review, Quinsey et al. (1995) concluded that the average recidivism rate across sex offender studies was fairly equivalent for rapists (22.8%) and child molesters (20.4%). However, differences by victim are apparent, with homosexual child molesters being the most likely to be reconvicted of a sex offense (35.2%) and heterosexual incest offenders being the least likely (8.5%), on average. Within one study, however, Quinsey, Rice, Lalumiere, and Harris (1995) found rapists to be at higher risk of reoffending than child molesters. Overall, high-risk sex offenders were those with prior violence or sex convictions and psychopathic traits or traits of other personality disorders. These are characteristics more prevalent among rapists. Findings such as these initiated the common dichotomy between convicted rapists and child molesters for deriving etiological theories and treatment strategies with adult offenders.

Psychopathology

Human sexual behavior presents on a continuum ranging from normalcy to deviancy. Differentiating between putative pathological conditions and normal psychosexual variants becomes paramount when evaluating an alleged sex offender. Because people may engage in similar behaviors (i.e., sexual offending behavior) for many unrelated reasons, all facets of a behavior-including the person's motivation-should be taken into account when formulating an opinion regarding the significance and root of the behavior. A difficulty for treating clinicians is that sex offending, in itself, is not a mental disorder. Indeed, some persons may engage in illegal sexual activities in response to psychiatric symptoms, such as hallucinations or delusions. For some perpetrators whose behavior can be classified as reactive, sex crimes may be a product of situational factors interacting with disinhibition accompanying drug or alcohol use. Yet others may have certain personality or cognitive proclivities that render them more vulnerable to sexually offending behavior. Nevertheless, some sex offending does result directly from a mental disorder.

Paraphilias, or the Sexual Deviation Syndromes

A subpopulation of sex offenders presents with persistent and specific difficulties in patterns of sexual arousal and behavior because of an underlying paraphilic disorder. These often-chronic syndromes are characterized by "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons, that occur over a period of at least 6 months" (American Psychiatric Association, 2000, p. 566). Nine distinct categories are listed:

1. Exhibitionism (exposing of one's genitals to a stranger)

2. Fetishism (using inert objects)

3. Frotteurism (rubbing or touching)

4. Pedophilia (involving children age 13 or younger)

5. Sexual masochism (suffering of pain)

6. Sexual sadism (inflicting of pain)

7. Transvestic fetishism (cross-dressing)

8. Voyeurism (observing of unsuspecting person)

9. Paraphilia not otherwise specified (e.g., necrophilia, telephone scatologia, zoophilia)

These conditions are characterized by persistent and focal difficulties in patterns of sexual arousal and behavior in which the sexual domain is disturbed out of proportion to other domains or other broad problems of conduct, interpersonal relationships, or both. They are clinical syndromes and are classified as psychiatric disorders. Not all paraphiliacs are sex offenders; sex offense is a legally defined term, and sex offenders comprise a heterogeneous group of individuals. It is uncertain to what extent the DSM definitions can apply to adolescent patients. They are categorical definitions of syndromes. Their reliability and validity have not been determined in this age group. Etiology is not taken into account. Finally, there is a lack of clear and distinct definitions of terms and concepts (e.g., behavior, recurrence, and so on).

Other definitions exist: Kafka (1994) coined the term paraphiliarelated disorder (PRD) to describe sexual activities that are acceptable in contemporary culture but may resemble paraphilias when they involve repetitive, impulsive or compulsive or addictive behaviors and are accompanied by intrusive sexual fantasies and urges and psychosocial distress or impairment. These include protracted promiscuity, compulsive masturbation, pornography dependence, and telephone or cyber sex. However, the question of whether these are phenomenologically related to paraphilias is unanswered. Equally unclear is how or if a juvenile could be diagnosed with a PRD.

Among the nine paraphilic categories listed in the DSM-IV-TR, pedophilia and exhibitionism are the most common conditions seen in outpatient treatment settings (Berlin, 1983; Balon, 1998). Though the true incidence and prevalence of these conditions is unknown, males seem to greatly outnumber females (Bradford, 1993; Kafka, 1996; Balon, 1998; Bradford et al., 1998). In adults, these conditions are considered to have a chronic course (Berlin, 1983; Money, 1984; Bradford, 1993; Seligman and Hardenburg, 2000).

Comorbidity

Case 1. This case is an example of the kind of complex comorbidity that is not uncommon with juvenile offenders. A 17-year-old Caucasian male presented with pedophilia and frotteurism. He had a childhood history of deviant sexual fantasies and behaviors: cross-dressing had begun at age 6, voyeuristic and frotteuristic behaviors at age 9, and pedophilic fantasies at age 9 or 10. All of these had continued through adolescence. At age 13, he engaged in forced fellatio, cunnilingus, and vaginal intercourse with prepubescent children (younger than age 8). He acknowledged fantasies that involved coercive sexual acts with children. These fantasies were ego-syntonic.

In addition, he had a history of neglect and abuse. His academic performance, not surprisingly, was poor. His legal history included adjudications for delinquency. The patient had a history of numerous psychiatric hospitalizations for affective instability, intermittent psychotic symptoms, and recurrent self-injurious behaviors. He had also been placed in residential treatment settings for juvenile sex offenders but did poorly there. On evaluation, he was found to have the following comorbidity: bipolar affective disorder, conduct disorder, mild mental retardation, and a mixed receptive-expressive language disorder.

Both paraphilic and nonparaphilic adult sex offenders have high rates of comorbid psychiatric and neurological disorders (Fedoroff et al., 1994; Kafka and Hennen, 2002). For example, in a sample of 36 male sex offenders with a 58% prevalence of paraphilic disorders, McElroy and colleagues (1999) reported high lifetime rates of substance abuse disorders (83%), impulse control disorders (39%), anxiety disorders (36%), mood disorders (22%), and eating disorders (17%). Genetic and developmental disorders have also been reported to be present among general offenders and sex offenders (Nielsen, 1970; Schröder et al., 1981). Berlin (1983) reported cases of patients with Klinefelter's syndrome, characterized by primary hypogonadism, who presented with comorbid paraphilic disorders (e.g., homosexual pedophilia, ephebophiHa, transexualism, and transvestism). Autistic spectrum disorders and precocious puberty (a syndrome caused by testosterone-secreting tumors) have also been associated with paraphilic behaviors (Bradford, 1993; Realmuto and Ruble, 1999; Milton et al., 2002).

Though these correlations may be merely coincidental rather than indicative of etiological vulnerabilities, recognition of comorbid neuropsychiatrie and major mental illnesses (similar to the situation of the first case example given here) is essential when implementing a treatment plan. If left untreated, they may adversely impact or even undermine the rehabilitative effect of sex offender treatments (Berlin et al., 1981; Seligman and Hardenburg, 2000).

The role of personality disorders. Personality disorders and styles also appear to predispose adult males to engage in inappropriate sexual behaviors, but these styles differ somewhat depending on the type of sex offense and age of the victim. Among rapists, for example, Prentky and Knight's (1991) thorough review of the rapist literature identified antisocial personality and lifetime impulsivity as among the most consistent discriminating characteristics among adults. Alternatively, personality characteristics related to social incompetence (such as poor social skills, social isolation, and low self-esteem) better discriminate sex offending adults who molest children (Prentky, Knight, and Lee, 1997). To make matters more confusing, antisocial behavior and personality styles are strong predictors of sexual reoffending, regardless of the type of sex offense (Prentky et al, 1997).

Studies on the impact of psychopathic personality disorder on sex offender lifestyles have had mixed findings (e.g., Brown and Forth, 1997; Fernandez and Marshall, 2003). Psychopathy does not consistently distinguish sex offenders from other offenders, but among sex offenders, psychopathy is most characteristic of those who have engaged in both rape and child molestation as opposed to one or the other (Porter et al., 2000). Thus, it seems that psychopathy is related to impulsive or opportunistic offending, that is, offending motivated largely by the presentation of an opportunity (e.g., seeing a female alone on a deserted street) rather than by attachment to a particular pattern of sexual deviance or pedophilia. Psychopathy is also strongly associated with sadistic violence among sex offenders (Porter et al, 2003).

JUVENILE SEX OFFENDERS

The majority of juvenile sexual misconduct emerges out of pathologies other than paraphilias, for example, global patterns of conduct problems. Some juvenile offenders have no recognizable pathological condition at all. As many scholars have noted, the dichotomy between rapists and child molesters common to adult sex offender researchers and practitioners does not define homogenous groups of juveniles (e.g., Hunter et al., 2003). As such, this categorization is of little use for predicting the course of offending, deriving etiological theories, or designing treatments. In fact, the dichotomy between adult rapists and adult child molesters is not always entirely clear either. Nonetheless, it appears that precursors to adult sex offending often appear in adolescence. Retrospective reports of adult offenders have indicated that paraphilias and sex crimes begin during adolescence in about 50% of cases. With the exception of homosexual pedophilia, patients typically report an early awareness of deviant sexual thoughts and fantasies, beginning at age 15 years for 42% and age 19 years for approximately 57% (Berlin, 1983). Based on histories obtained from adult offenders, three stages of the development of the condition can be identified, with deviant sexual fantasies first experienced around the time of puberty (Stage 1); deviant behaviors enacted after two to three years (Stage 2); and, ultimately, patterns of sexually deviant behaviors established in early adulthood (Stage 3). ,

Normal Adolescent Psychosexual Development and Sexual Behavior

Analysis and understanding of juvenile sexual offending behavior requires a working knowledge of normal psychosexual development and normative behavior in general. Normal development takes place along specific, typically discordant and intertwined developmental lines or trajectories (e.g., physical, psychological, moral, etc.). Obedient and serene children become rebellious, defiant, and at times emotionally labile. Reckless and acting out behaviors or periods of regression are prevalent. Beginning in early adolescence, the child shows increased curiosity and concern about his or her body, appearance, and selfimage. Moreover, sexual fantasies and masturbatory behaviors increase in frequency, occasionally causing feelings of shame and guilt in the youth and discomfort and anxiety in parents and caregivers. In middle adolescence, sexual energy increases. Casual relationships are common, and both coital and noncoital contacts are prevalent. Denial of the consequences of sexual behavior (e.g., pregnancy, sexually transmitted diseases) is typical. Sexual relations can be exploratory, promiscuous, or even exploitative rather than expressive and sharing. During this tumultuous phase, a youth must negotiate his or her needs with the demands of everyday life in order to thrive and grow. In late adolescence, full physical maturation is attained. Sexual behavior becomes more expressive and less exploitative, and intimate sharing relationships begin to develop. It is hoped that ultimately, by the end of adolescence, the young adult will have developed a stable psychosexual identity, his or her own moral and ethical value system, and attained sufficient emotional and social resources to continue to develop independently, allowing the gradual emancipation from parents and primary caregivers.

Within this framework, human sexual behavior occurs on a continuum ranging from normalcy to deviancy. Children and adolescents may engage in sexual behaviors that are inappropriate but not necessarily predictive of sexual deviancy. There is not a clear demarcation between the antecedents of emerging psychopathology and what is thought to be normative behavior.

Psychopathology in Youthful Offenders

Accurate differentiation and analysis of the offending behavior, as well as diagnosis of any comorbid psychiatric disorder, are important for prognosis, treatment recommendations, and ongoing management. It is difficult to discern the contribution of psychiatric disorders to criminal sexual activity in juveniles. The complication is that the stability and continuity of childhood and adolescent disorders is unclear (e.g., Mash and Dozois, 2003). And youth may engage in sexual behavior that is not necessarily predictive of psychopathology or future criminality. Other nonparaphilic adolescent sex offenders have time-limited, reactive patterns of oversexualized behaviors. For these youth, behavioral modeling (e.g., premature sexualization) may have played a role in their offending. Many youth engage in sexual offending behavior because of broad and pervasive patterns of conduct problems and not because of clearly definable psychopathology. Some have pervasive impairment in interpersonal relationships. Some of these youth who are impaired in many domains of functioning may present with time-limited and isolated opportunistic sexual behavior problems. In these cases, inappropriate sexual behavior is only one among many problem areas a youth has to manage and often is not the most challenging condition to treat. The field of risk assessment, obviously crucial in determining treatment, is still relatively undeveloped with respect to juvenile offenders.

Personality factors that appear to be strongly associated with adult sex offending have not been fully elucidated in children and adolescents. It has been argued that personality disorders may not or perhaps even cannot exist during childhood and adolescence (Rutter, Tuma, and Lann, 1988; Kernberg, Weiner, and Bardenstein, 2000). The DSM-IVTR cautiously claims that personality disorders may be applied to children and adolescents "in those relatively unusual instances in which the individual's particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage" (American Psychiatric Association, 2000, p. 631). However, cases that fall within these parameters are difficult to find. Mental disorders can arise early in life and change greatly in nature or remit altogether as a result of developmental processes (e.g., see Cicchetti and Cohen, 1995). It is possible, then, for a person who appears to have a personality disorder in childhood to develop into an adult free from any sign of antisocial behavior, for example. Indeed, at least 50% of seriously antisocial children do not go on to be antisocial adolescents (Robins, 1978), and a substantial portion of serious antisocial adolescents do not go on to be antisocial adults (e.g., Moffitt and Caspi, 2001).

With respect to juvenile offenders who actually do have a paraphilia, research suggests that, similar to adult offenders, high comorbidity with other psychiatric disorders is common. In one study of a sample of male adolescents meeting criteria for pedophilia (with the exception of the diagnostic age requirement in some cases), Galli and colleagues (1998) reported high rates of psychiatric disorders. Ninety-five percent of participants had two or more paraphilias, 82% met criteria for a mood disorder, and 55% met criteria for an anxiety disorder. Not surprisingly, a substantial portion of this sample presented with behavior disorders, including 55% with an impulse-control disorder, 71% with attention-deficit/hyperactivity disorder, 94% with conduct disorder, and 50% with a substance use disorder.

Butler and Seto (2002) reported that conduct problems and antisociality were more characteristic of juveniles with global offending histories that included sex crimes than juveniles who committed only sex offenses. This may explain why juvenile sex offending has been inconsistently associated with conduct disorder and hostile personality styles (e.g., Worling, 2001; Hunter et al., 2003). Schizoid and socially isolative personality styles are more consistently associated with juvenile sex offending than are antisocial personality traits; however, further study is needed (Losada-Paisey, 1998; Myers, 2003).

EXPLANATORY THEORIES

Many theories have been advanced to explain sexual offending behavior by means of psychosocial concepts such as childhood sexual abuse, dysfunctional home environments, and so on. Though psychological factors and vulnerabilities probably play a role, firm conclusions are untenable at this time due to inconsistent findings and the use of less than optimal research methods. Thus, psychosocial explanations alone are insufficient to explain pervasive patterns of sexual offending or deviant behavior.

Though many questions remain unanswered with respect to the biological basis of normative and deviant sexual behavior, some consensus has emerged among researchers that sexual phenomena are influenced by intricate and complex neurobiological systems. see figure 11.1 for a graphic illustration of this process.

This is particularly true for persons who present with de-novo paraphilic features (Miller et al., 1986; Mielke, Donauer, and Luthe, 1996; Riley, 2002; Burns and Swerdlow, 2003). Because an in-depth discussion of the neurobiology and physiology of sexual behavior is beyond the scope of this chapter the reader is advised to review the listed references for a more detailed discussion (Bradford, 2001).

With respect to adolescents, the view that neurological abnormalities predispose individuals to sex offending behaviors implies that the underpinnings of discriminatory variables exist prior to adulthood. However, findings have been inconsistent. For example, Brooks and colleagues (1996) compared morning serum testosterone concentrations among adolescent offenders (N = 194, ages ranged from 15 to 17). Based on the index offense the cohort was divided into three groups, violent offenders (n = 75) had committed any violent offense against a person, non violent offenders (n - 102) had committed only nonviolent offenses, and sexually violent offenders (n = 17) were those who committed at least one sex offense that was violent. Notably, sexually violent, and nonviolent offenders had comparable testosterone levels, whereas violent offenders had increased levels.

DIAGNOSTIC ASSESSMENT

An accurate diagnostic assessment is important from the point of view of risk assessment, prognosis, treatment planning, and ongoing management. As is the case for seriously violent delinquents, it is quite common for individuals committing sex offenses in their youth to desist on their own, whereas a small proportion will offend throughout their lifetimes (Aalsma and Lapsley, 2001). This complicates matters with respect to the treatment of juvenile sex offenders, because potentially harmful pharmacological treatments would be unwarranted. The consequences of mislabeling a juvenile as paraphilic or as a pathological sex offender cannot be understated, especially when many will desist without treatment because the crime was opportunistic or prompted by a need for stimulation (Caldwell, 2002). Such youth may not respond to traditional treatments. One of the main tasks of the assessment is to differentiate and analyze the sexually offending behavior in accordance with the typology outlined above for juvenile offenders. That is, an attempt should be made to determine if the behavior is truly paraphilic, is part of some other disorder, or is likely to be a transient phenomenon.

The diagnostic workup should include a comprehensive psychiatric and medical evaluation. Psychiatric history should include particular attention to psychosexual functioning; developmental history; and social, cognitive, and academic functioning. As untreated comorbid psychiatric disorders may negatively affect the course and prognosis (Berlin and Meinecke, 1981; Raymond et al, 1999; Seligman and Hardenburg, 2000), recognition of these conditions so that they can be addressed in the treatment plan is critical.

Medical evaluation is an integral part of a comprehensive evaluation. This should include physical examination, with particular attention to sexual maturation and coexisting medical conditions. Depending on the findings of the initial evaluation, subsequent studies may also include chromosomal karyotyping, electroencephalogram (EEG), and/or neuroimaging. Phalloplethysmography (volumetric or circumferential) is used in some specialized treatment centers. Relevant laboratory studies include an endocrinological profile as well as routine blood chemistry, complete blood count, and liver function tests.

TRENDS IN TREATMENT RESEARCH AND PRACTICE

Though a multitude of medications and therapies is at the disposal of a treating clinician, data derived from psychosocial or pharmacological trials specifically designed for juvenile sex offenders or paraphiliacs remain rare. Psychosocial treatments have included individual, family, and group therapy in inpatient or outpatient settings. Court-based specialized programs have been designed. However, few follow-up studies have been done to determine the efficacy of these modalities (for an in-depth discussion, see Berlin and Meinecke, 1981; Balon, 1998). Multisystemic therapy (MST) has been used, and there is one controlled study showing efficacy compared with individual therapy in a small group of offenders followed for 37 months (Borduin et al, 1990); recidivism rates for the treatment group were only 12.5% compared with 75.0% for the controls. This finding has not been replicated, however. Cognitive-behavioral group therapies are commonly used for adult offenders; the goals of these therapies are confronting denial in sex offenders and exploring the developmental antecedents that may have contributed to symptom formation. Other therapeutic goals include victim empathy, anger management, and social skills. Behavioral therapies (i.e., aversion therapy, masturbatory satiation) have also been employed for adult offenders. On the assumption that sex offending involves a type of addictive behavior, some groups have been modeled on 12-step programs used for alcohol and substance abuse, and include a focus on relapse prevention. Psychosocial therapies for adolescents generally have been adaptations of these approaches, with the important addition of a family therapy component.

Psychosocial treatments, in theory at least, can be tailored to address specific needs or skill deficits in youngsters for whom these are problems. Although there is no universal developmental pathway to sexually deviant behavior, an understanding of developmental antecedents is important for treatment planning. In specific cases, it may be necessary to address issues of past sexual abuse or other trauma. Given the high rate of comorbidity, it is crucial to address such concomitant conditions as depression, anxiety, substance abuse, conduct disorder, and attentiondeficit/hyperactivity disorder as well as providing specialized treatment for the problematic sexual behavior.

Pharmacologie Treatments

Case 2. Saleh, Niel, and Fishman (2002) have described the case of an 18-year-old male with mild mental retardation who met DSM-IV criteria for bipolar affective disorder, Type I. This adolescent presented with multiple paraphilias (frotteurism, pedophilia), which had continued despite many years of pharmacological interventions with anticonvulsants, antipsychotics, and sex-offender-specific treatment programs. A comprehensive psychiatric and medical evaluation revealed that he had Klinefelter's syndrome (XXY). Magnetic resonance imagery disclosed a pineal cyst. He was treated with intramuscular leuprolide acetate 7.5 mg per month, with reduction of deviant sexual thoughts and urges.

There is a role for pharmacotherapy with adolescents whose paraphilias who do not respond to other forms of treatment. Even in this group, however, pharmacotherapy should not be the sole intervention but should be combined with other interventions as indicated: family therapy, individual psychotherapy, group psychotherapy, social skills training, and/or academic or vocational education. Pharmacological therapies are an accepted part of the therapeutic armamentarium for adults with paraphilias, both because of the limited success of psychosocial treatment alone in those who have well-established paraphilias and because of the increased availability of drug and hormonal agents in recent years. As a result, a sizable body of knowledge has developed about the use of these modalities in the treatment of adult paraphilic sex offenders. Indications for pharmacotherapy in adults include high sexual drive and intrusive deviant sexual arousal states, preoccupation and distraction by deviant sexual thoughts, and frequent erections and other manifestations of arousal in inappropriate situations. Obviously, these are not necessarily deviant behaviors in adolescents. Other indications in adults that may be considered reasons for pharmacotherapy in adolescents are severity; frequent sexual behaviors despite consequences, and unusually high frequencies of masturbation; or a fixed or increasingly emerging pattern of Stereotypie and deviant arousal (e.g., deviance in the objects of sexual arousal or in the mode of sexual expression). The primary indication, however, is a failure to respond to psychosocial treatment together with the likelihood of continued pattern of sexual behavior that poses a danger to the patient, to others, or to both.

Many caveats are necessary in considering pharmacotherapy, especially testosterone-lowering agents, for adolescents. Young people differ from adults in both pharmacodynamics and pharmacokinetics. Neurotransmitter systems are not fully operational and anatomically developed until adulthood (Green, 1991). Sometimes, higher unit doses per body weight are necessary to obtain the same plasma levels. Evidence for the efficacy of pharmacotherapy in adolescents is based mostly on case series. Finally, when used to treat paraphilias, all medications are used in an off-label manner.

The goals of pharmacotherapy for paraphilia include a reduction in the intensity of deviant sexual urges and cravings, in the frequency of associated thoughts and fantasies, and in deviant sexual behaviors. Ultimately, control over deviant sexual symptoms should be achieved and consequently, interruption and prevention of a cycle of victimization. Pharmacologic agents used to treat adults fall into three broad categories: testosterone-lowering agents, serotonergic agents, and other (e.g., dopaminergic). The reader should be cautioned, however, that most of the efficacy and safety data are extrapolated from the adult literature.

Testosterone-Lowering Agents

These agents act by reducing testosterone levels. Antiandrogens and the hormonal agents have an impact within a relatively short period of time on both frequency and intensity of paraphilic symptoms. Recidivism rates are similar to those seen in patients who undergo orchiectomy (Berlin and Meinecke, 1981; Berlin et al., 1991). The shortcoming of treatment with these agents is that it is an invasive and intrusive form of treatment with potentially serious side effects. Obviously, with adolescents, extreme caution is warranted.

Medroxyprogesterone acetate (MPA), a potent synthetic progestational agent, has proved effective in the treatment of adult paraphilic patients (Gagne, 1981; Berlin, 1989; Kierch, 1990; Meyer, Cole, and Emory, 1992; Kravitz et al, 1995). MPA is not an antiandrogen, because it does not bind to intracellular androgen receptors (Southren et al., 1977). It is a potent synthetic progestational agent that has manifold combined pharmacological effects. Through its combined pharmacological effects on the hypothalamic-pituitary-gonadal (HPG) axis and the liver, MPA reduces testosterone levels and thus the frequency and intensity of sexual arousal and sexual desire. Berlin and Meinecke (1981) studied 20 male paraphilic patients who were treated with intramuscular MPA. It is of interest that high recidivism rates were observed in only those patients who were noncompliant with treatment.

Cyproterone acetate (CPA), a progestogen with true antiandrogenic properties (Bradford, 2001, p. 31), is not available in the United States but is commonly used in Canada and Europe. CPA exerts its sexual suppressant effects via competitive antagonism of intracellular androgen receptors (Goldenberg and Bruchovsky, 1991). CPA has also been used in the juvenile population. Bradford (1993), for example, reported the case of a mildly retarded 16-year-old male with pedophilic and fetishistic proclivities who was successfully treated with CPA. Both of these agents (MPA and CPA) have many side effects: weight gain and gynecomastia are two that may pose particular difficulties for adolescents.

Leuprolide acetate (leuprolide), a luteinizing hormone-releasinghormone agonist (LHRH-A), has been available since the 1990s and is increasingly used to treat paraphilic patients. It is administered intramuscularly once every four weeks. Because of its relatively benign side effect profile, leuprolide is considered a possible alternative to the more established (but more adverse-prone) antiandrogens (Briken, Nika, and Berner, 2001; Krueger and Kaplan, 2001; Saleh et al, 2002). Moreover, leuprolide was shown to be effective in patients who do not respond to MPA or CPA (Rousseau et al., 1990). In an open-label trial, Dickey (1992) treated with leuprolide a treatment-resistant patient with multiple paraphilias who had failed trials with MPA and CPA. After about one month, deviant sexual behaviors declined, particularly masturbation to deviant sexual thoughts. In an uncontrolled observational study, Saleh et al. (2002) treated six paraphiliacs ranging in age from 18 to 20 with leuprolide, at a dose of 7.5 mg per month. All six patients reported a reduction in deviant sexual arousal, interests, or both. There is one case report of an adolescent with autistic disorder who responded favorably to leuprolide after having failed behavioral and educational programs (Realmuto and Ruble, 1999). This patient was able to be maintained in a community placement and tapered to a low dose over a period of almost three years; he showed no adverse physical effects.

Leuprolide is administered intramuscularly. Following intramuscular administration, the parent compound exerts its pharmacodynamic actions at the level of the target tissues. It is excreted to some extent via the kidneys. Leuprolide's active-phase dose (intramuscular) is 7.5 mg per month or 22.5 mg every three months. A potential side effect of leuprolide is bone demineralization (i.e., osteopenia), which can occur secondary to the induction of a hypoestrogenic state (this can be treated with biophosphonate: alendronate). For all of the testosterone-lowering agents, there is a very thin line between desired therapeutic effects and subjectively intolerable side effects; this is especially true for adolescent patients. None of these drugs have been used on a long-term basis in adolescents, and only MPA and CPA have long-term experience with adults.

Medications Without Testosterone-Lowering Properties

Over the last decade, agents with less serious adverse effect profiles have been introduced into the armamentarium of medications used to treat paraphilias. In particular, serotonergic medications such as the serotonin-specific reuptake inhibitors (SSRIs) have been gaining increasing popularity with prescribing providers. The fact that these drugs have been used safely for many years to treat depression, anxiety, and obsessive-compulsive disorder in children and adolescents is reassuring, although their use for paraphilias is still not well established. In an open-label trial, Galli and colleagues (1998) treated a 17-year-old male paraphiliac with fluoxetine at a mean dose of 30 mg per day. Besides multiple paraphilias (including elements of sexual sadism, zoophilia, pedophilia, and necrophilia), the patient was diagnosed with obsessivecompulsive disorder (OCD) and bipolar disorder. Following treatment with fluoxetine, both paraphilic and OCD symptoms abated. Bradford et al. (1995) conducted an open-label trial using sertraline at a mean daily dose of 131 mg per day in 18 patients with pedophilia. Sertraline was not only effective in reducing the paraphilic symptoms, but it was also well tolerated. However, in a retrospective chart review (N = 13), Stein and colleagues (1992) reported that patients with paraphilias were less responsive to the SSRIs when compared with patients who had sexual obsessions. Though serotonergic agents seem to be a valuable adjunct in the treatment of a subset of patients, in particular those who present with comorbid obsessive spectrum disorders, more data are needed before these medications become an integral part of the pharmacopeia for paraphilias.

Other medications with different pharmacodynamic characteristics have been tried; however, evidence for efficacy is limited to a few anecdotal case reports and open clinical trials. Drugs in this category include buspirone hydrochloride, nefazodone, lithium, phenothiazine, and risperidone (Bartholomew, 1968; Fedoroff, 1993; Bourgeois et al., 1996; Coleman et al., 2000).

TREATMENT AND CLINICAL IMPLICATIONS FOR YOUTH

The ultimate goal of treatment is to assist the patient in gaining greater control over inappropriate or deviant sexual symptoms and impulses (symptom reduction), while also preventing the suffering of the patient's potential victims. This practice calls for integration of risk management strategies. As explained by Douglas et al. (2001), risk management involves four components. Monitoring or repeated assessments are essential to evaluate changes in risk that may lead to modifications in the management plan. Second, treatment should be aimed at improving psychosocial adjustment and reducing acute Stressors. Third, plans for supervision or restriction of freedoms must be in place and must be commensurate with an individual's risk level. Finally, victim safety planning to minimize the impact of further attempts for sex offending is essential and often overlooked.

Given the inherent risks associated with pharmacological interventions, pharmacotherapy should only be considered if, for example, cravings for deviant sexual acts become intense or overpowering, or if specific symptoms are not amenable to psychological interventions. Given that untreated or inadequately treated comorbid psychiatric disorders are likely to have an adverse impact on course and prognosis of an underlying paraphilia, where present, recognition and treatment of comorbid conditions is, in our judgment, imperative. The selection of the medication should primarily be based on the severity and frequency of the presenting symptoms and the presence of concomitant psychiatric or medical conditions. Figure 11.2 illustrates the indications for pharmacological treatment.

Because of the dearth of pharmacological data involving juvenile sex offenders, we recommend a conservative approach when treating this population. After a careful screening process, patients should have a thorough medical and psychiatric workup before pharmacotherapy is commenced, in particular, treatment with one of the testosterone-lowering agents. Pretreatment workup should consist of a complete physical and laboratory assessment, for example, complete blood count, electrolyte panel, liver function tests, thyroid function test, folliclestimulating hormone (FSH), and serum luteinizing hormone (LH). Although data on testosterone levels and sexual behavior are mixed, baseline serum and free testosterone levels should also be obtained before initiating antiandrogen treatment. Furthermore, neuroimaging and/or chromosomal karyotyping should also be considered when clinically indicated. Because leuprolide acetate can decrease bone density, dual energy X-ray absorptiometry of bony structures (e.g., lumbar spine, long bones) is recommended at baseline and at follow-ups.

The Importance of Informed Consent

Informed consent is crucial. Patients and parents should be told about the nature of the condition, including its prognosis, the nature and purpose of the recommended treatment, and the risks associated with the proposed treatment and alternative treatments (including the risks of no treatment). Particular considerations are relevant in the treatment of sexual offenders that impinge on informed consent. Whether consent is voluntary is inevitably affected by issues related to perceived or real coercion. Incarcerated youth or those whose treatment is enforced by the court may be motivated to consent in the hope of obtaining earlier release. Cognitive impairment and poor social judgment may interfere with competency to give consent or assent. Whether or not parental consent is necessary will be determined by the age of the patient as well as existing statutes; however, efforts should be made to obtain parental consent whenever possible.

In summary, pharmacotherapy has proven valuable in the treatment of the paraphilias in adults, and to a limited extent in adolescents. Antiandrogens or the hormonal agents are generally not considered first-line treatments for juveniles with paraphilias, but rather should be reserved for those who do not respond to other treatments, and should be given in conjunction with appropriate psychosocial treatments. Finally, the optimal duration of treatment is not known, and there are no long-term safety data. The rationale is that continuing treatment simultaneously with other treatment modalities such as cognitivebehavioral therapy and social skills training will give these psychosocial treatments a chance to work.

FUTURE RESEARCH DIRECTIONS

Research into the nature, etiology, and treatment of juvenile offending is substantially limited, and, as such, we provide several recommendations here. First, the research on psychopathological influences is in dire need of better instruments for psychological testing. Studies have been largely limited to multidimensional scales such as the Minnesota Multiphasic Personality Inventory-Adolescent and the California Personality Inventory, which have limited support for use in forensic settings. Methods of exploring the link between psychopathology and sex offending could be improved by categorizing juvenile sex offenders on the basis of symptoms and behaviors rather than the legal definition of the crime. Herkov et al. (1996), for example, found that their scheme for categorizing adolescents into rapists, sodomists, and sexual abusers led to more consistent personality discriminators. Another pressing issue is that most juvenile sex offender studies have used small sample sizes that leave much to be desired in terms of the validity of statistical conclusions. Finally, the biological substrates of paraphilic disorders should be investigated further, using more innovative techniques such as neuroimaging.

CONCLUSION

In summary, the state of our knowledge about juveniles who commit sex crimes is deficient in many respects. Like other areas of child and adolescent psychiatry, much knowledge about this group has been extrapolated from data on adults. Compared with adults, juvenile offenders are much more heterogenous, have higher rates of comorbidity, and include many youngsters for whom sexual deviancy is a temporary aberration. However, among youthful offenders are those who are on a dangerous trajectory to adult criminal behavior. Therefore, accurate assessment is challenging, but it is essential if we are to deal with juvenile sex offenders in an appropriate manner. The challenge to adolescent psychiatry is to diagnose accurately and comprehensively, provide appropriate and comprehensive treatment, and expand the knowledge base with respect to this challenging population.

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