Deep Brain Stimulation to Reduce Sexual Drive

To date there are few treatment options to reduce high sexual drive or sexual urges in paraphilic patients with a risk for sexual offending. Pharmacological therapy aims to reduce sexual drive by lowering testosterone at the cost of severe side effects. We hypothesize that high sexual drive could also be reduced with deep brain stimulation (DBS) of circuits that generate sexual drive. This approach would help to avoid systemic side effects of antiandrogenic drug therapies. So far the best investigated target to reduce sexual drive is the ventromedial hypothalamus, which was lesioned unilaterally and bilaterally by stereotaxic interventions in paraphilic patients in the 1970s. Here, we discuss DBS as a treatment strategy in patients with severe paraphilic disorders with a serious risk of sexual offending. There are profound ethical and practical issues associated with DBS treatment of paraphilic patients that must be solved before considering such a treatment approach.

Currently, reduction of sexual drive in patients with psychiatric disorders can be achieved with antihormonal pharmacotherapy (medroxyprogesterone acetate, antiandrogen cyproterone acetate, GnRH agonists), selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy.¹ Although solid evidence is lacking for antihormonal treatment,² some countries decide by verdict to treat sex offenders with antihormonal therapy in order to reduce the risk for reoffending.³ Large meta-analyses have suggested that antihormonal therapy reduces recidivism rates in sexual offenders.^4,5 Therefore the World Federation of Societies of Biological Psychiatry has suggested guidelines for the biological treatment of paraphilias, including antihormonal and SSRI treatment.⁶

In addition to sexual offenders, paraphilic and hypersexual patients who have never shown delinquent behaviour and experience severe distress from recurrent sexual urges demand antihormonal therapy.⁷ The sexual urges of these patients are linked to qualitative (e.g., pedophilic sexual interest) and/or quantitative (hypersexual, compulsive or addictive) abnormalities, and they seek medical assistance in hopes of overcoming or at least controlling sexual urges that could bring them into conflict with society and the law or that impair their social and occupational functioning. Treatment of these patients and of sex offenders, however, raises thorny ethical problems because potential harm to a third person (e.g., in sexual sadism or pedophilic disorder) has to be considered. The meager evidence for these treatments further complicates ethical concerns; a first double-blind controlled clinical trial for antihormonal treatment is only in the planning stages.⁸ Moreover, patients have to accept severe side effects like osteoporosis, mood disturbances and increased risk for thromboembolic complication as well as cerebrovascular and cardiovascular diseases that can be associated with antihormonal treatment.⁹ Thibaut and colleagues⁶ therefore suggested ethical standards for the indication of antihormonal therapy.

A targeted therapy that reduces sexual drive specifically without the systemic hormonal disturbances of antiandrogens would be desirable. While it seems unlikely that biological therapy would target the appearance of distinct paraphilic thoughts in the brain, neural circuits that generate sexual drive could be identified and inhibition of these circuits might lead to a reduction of sexual urge and hence relieve patients and open new venues for psychotherapy…

  

Full article at: http://goo.gl/jYaNf4

By: Johannes Fuss, MD, Matthias K. Auer, MD, Sarah V. Biedermann, MD, Peer Briken, MD, and Werner Hacke, MD, PhD

From the Institute for Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Germany (Fuss, Briken); the RG Neuroendocrinology, Max Planck Institute of Psychiatry, Munich, Germany (Auer); the Department of Psychiatry and Psychotherapy, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Germany (Biedermann); and the Department of Neurology, University of Heidelberg, Germany (Hacke).

Correspondence to: J Fuss., Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany; Email: ed.eku@ssuf.oj

  

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