ABSTRACT
Sexual offenders are acknowledged to be a heterogeneous group of mostly males, with varying types and degrees of personality disorders as well as having a paraphilia or more commonly multiple paraphilias (Bradford, Boulet, and Pawlak 1992). Female sexual offenders do occur, but constitute a small percentage of the overall numbers of sexual offenders. They will not be discussed specifically in this chapter, although the same psychopharmacological agents can be used to treat paraphilias in females. In females, if hormonal psychopharmacological agents are to be used, then careful consideration must be given to the hormonal differences in females (Bradford 1985). This is evident in the classification of sexual deviations in DSM I and DSM II where they were classified as personality disorders (American Psychiatric Association 1952; American Psychiatric Association 1965; Travin 1994). For the first time in DSM III the concept of erotic or sexual preference was recognized, and the sexual deviations were classified as Paraphilias as opposed to Personality Disorders (American Psychiatric Association 1980; American Psychiatric Association 1987). This accepted the empirical evidence that individuals who were sexually deviant had an abnormal sexual or erotic preference. A person with a paraphilia was seen as sexually attracted to non-human objects; pain, suffering and humiliation; children or sexual acts involving non-consenting partners. For example, pedophilia was recognized as a paraphilia where the deviant sexual preference was to children. The paraphilias are defined in DSM IV as:
Sexual offenders are individuals who commit sexual offenses and largely suffer from a sexual deviation or paraphilia. There are a number of sexual offenders who do not have a paraphilia but fail to control their sexual impulses for other reasons. Their sexual offending behavior may be opportunistic or impulsive, and most commonly is the result of serious personality disorders rather than a paraphilia. Sexually deviant behavior can also occur secondary to various Axis 1 psychiatric conditions. The deviant sexual behavior in this instance would occur as a result of disinhibited behavior caused by the primary psychiatric condition (e.g., bipolar disorder). In these cases, the treatment of the sexual deviant behavior is through the treatment of the primary psychiatric disorder. Where the primary psychiatric problem is a serious personality disorder, the prognosis would be poor because of the inherent problems in the treatment of serious personality disorders. At the same time, there is a possibility that the symptoms of serious personality disorders such as impulsivity may respond to psychopharmacological treatment (Lee and Coccaro 2001). As there are these diagnostic issues to be resolved prior to a diagnosis of a paraphilia being made, it is clear that a careful psychiatric evaluation needs to be completed. The psychopharmacological treatment of sexual offenders is focused on the paraphilia or multiple paraphilias that are present. It would be very unusual for only one paraphilia to be present as it
is well established that there is considerable comorbidity amongst the various paraphilias (Bradford, Boulet, and Pawlak 1992). There is also considerable comorbidity with substance abuse and dependence, and particularly alcohol dependence (Allnutt et al. 1996). The association with alcohol dependence is not surprising and is related to the degree of violence seen in conjunction with the paraphilia.
