Ethical issues regarding risk assessment and treatment of sex offenders in Brazil

Danilo Baltieri - XXXVII Congresso Brasileiro de Psiquiatria

Treatment of Paraphilic Sexual Offenders in Brazil:
Issues and Controversies

Danilo Antonio Baltieri and Arthur Guerra de Andrade

Department of Psychiatry of the ABC Medical School—Santo Andre—São Paulo, Brazil; Penitentiary Counseling of the State ˜
of Sao Paulo, Brazil; Interdisciplinary Group of Studies on Alcohol and Drugs of the Psychiatric Institute of the Clinical ˜
Hospital of the University of Sao Paulo, Brazil

Psychopharmacological treatments have not only proven to be valuable but sometimes indispensable in the management of paraphilic sexual offenders. Despite not being approved
by the FDA, some medications commonly used in paraphilic outpatients, such as Medroxyprogesterone and Leuprolide Acetate, cannot be considered an experimental or investigative
medical procedure. Unfortunately, in Brazil, the use of hormonal medications for the treatment
of dangerous sexual offenders has been seen as amoral and insufficiently effective and safe.
This position creates many difficulties in the adequate management of sexual offenders in our
Keywords: pedophilia, pharmacological treatment, ethical issues

Notwithstanding the fact that many researchers around the world demonstrate that the adequate treatment of sexual offenders can be effective to control their inadequate sexual urges, in Brazil and other countries the use of hormonal medications for the treatment of paraphilic sexual aggressors has been considered amoral. To date, there is no cure for these problematic conditions, but the paraphilic disorders can be treated effectively with one or more than the available biologic and psychotherapeutic treatments (Briken & Kafka, 2007). Whenever cravings for unacceptable and unconventional sexual acts become intense and overwhelming, the people affected by paraphilias may present not only a risk to the targets of their inadequate behaviors but also to their own welfare. However, if left untreated, patients present considerably higher rates of sexual offenses than those who undergo treatment (Bradford & Harris, 2003; Hill, Briken, Kraus, Strohm & Berner, 2003). Psychopharmacological treatments have not only proven
to be valuable but sometimes indispensable in the treatment and management of paraphilic patients (Fagan, Wise, Schmidt & Berlin, 2002). Although some medications commonly used in paraphilic patients are not approved by the U.S. Food and Drug Administration (FDA), these drugs cannot be considered an experimental or investigative medical procedure. It is common for doctors to prescribe off-label drugs for the treatment of many different disorders, and this
procedure may not be considered an experimental therapeutic. Experimental treatment is hard to define but, broadly speaking, it is considered a kind of care that is new and not widely accepted due to the lack of proven efficacy (Saleh & Berlin, 2003).
The essential drugs used in the treatment of sexual offenders with paraphilias are: a) testosterone-lowering agents, and b) serotoninergic antidepressants. In any phase of the treatment of sexual offenders, the cognitive behavioral therapy must be carried out (Kravitz et al., 1995; Reilly, Delva & Hudson, 2000; Saleh & Fishman, 2004; Stompe, 2007).
In a Task Force Report of the American Psychiatric Association for the treatment of dangerous sex offenders (APA, 1999), which represents the opinions of some researchers on this subject, the sexual offender should receive cognitivebehavioral therapy in any phase of the treatment. When the urge to re-offend tends to accelerate, the psychiatrist must consider the use of antidepressants (selective serotonin reuptake inhibiting drugs) to decrease the offender’s sexual drive. The staff must consider the use of hormonal drugs, such as Medroxyprogesterone, in an oral or injectable form, if the following situations occur:

1) repetitive sexual urges continue, despite previous pharmacological and psychotherapeutic treatments;
2) the potential victim is a child;
3) the sexual demeanors involve sadistic fantasies;
4) the sexual assault behavior includes physical force against
the victim.

If this medical intervention is unsuccessful, the psychiatrist should consider the use of Leuprolide Acetate. The pharmacological treatments of paraphilic sexual offenders are based upon the premises that the behavior is sexually motivated and that the suppression of sexual drive will decrease sexually inadequate demeanors. Another aim is to preserve normal sexual interests and behaviors while deviant sexual fantasies and activities are reduced. In fact, pharmacological treatments have shown to overcome the main pathology in pedophilia, that is, the deviant erotic preference. Unfortunately, the lack of controlled clinical trials for the hormonal treament of paraphilic sexual offenders can create the false belief that drugs such as Medroxiprogesterone are experimental.

Certainly, there are some ethical, legal, and cultural issues associated with the use of hormonal drugs for the treatment of sexual offenders. According to the opponents of this type of treatment, the hormonal medications are a violation of the human rights, such as the procreative freedom and the free expression of sexuality. Antiandrogen treatment has been viewed as a “chemical castration” by some. On the other hand, the proponents evaluate the needs of the society and the
individual’s freedom, and as a general rule, the patient must agree with this form of treatment and give written consent before receiving these medications (Katz, 1999).

In fact, people convicted or accused of sexual molestation against children are not, categorically, considered pedophiles. Many acts of child molestation are single acts and are not repeated. On the contrary, pedophilia tends to be a chronic disorder, and the sexual urges and the fantasies involving children must continue for more than six months. Therefore not all of those who sexually abuse minors are pedophilic. According to Murray (2000), men with pedophilia may wish to touch or undress children; others expose themselves to children; some of these men want to fondle them, and when sexual activities happen, they often involve oral sex or touching the genitals of the child or of the perpetrator. People suffering from pedophilia manifest redominant or almost exclusive sexual arousal related to children (Hall, 2007). In research carried out by our group and published elsewhere, almost 20% of convicted child molesters can be considered as suffering from pedophilia (Baltieri & De Andrade, 2006). Therefore, based on scientific evidence,
specialized and experienced psychiatrists must diagnose and treat these patients who present with a history of activities or fantasies involving children.

For pedophilia, which is considered a psychiatric disorder by the two main diagnostic manuals, DSM-IV-TR (APA, 2000) and ICD-10 (WHO, 1992), there are some effective models of treatment and management which need to be used when necessary.
Below, we report a case of a male with pedophilia who underwent pharmacologic and psychotherapeutic treatment for his uncontrolled sexual behavior directed to female children.
He was given hormonal medication, but he stopped receiving it after the Brazilian media divulged distorted news of this type of treatment.


Mr. Z, a 40-year-old married white male, reported a 15-year history of regular exhibitionism and a five-year history of sexual activities with extrafamilial female children. His sexual fantasies involved the exposure of his penis to female children, followed by masturbation and forced oral sex. When he saw a girl alone, he exhibited his penis to her, masturbated in front of her, and ejaculated on her arms or legs. He had never been arrested, but he had been physically threatened by his neighbors twice. He was being treated for alcohol abuse in a specialized
center for addiction management when he was referred to the Ambulatory for the Treatment of Sexual Disorders of the ABC Medical School (ABSex) for the treatment of his sexual behavior. Since the beginning of the management in our service, the patient was submitted to cognitive-behavioral therapy weekly, with emphasis on relapse prevention and empathy training. He found young girls sexually arousing and frequently developed sexual feelings towards female children
he encountered in public. When interacting with young girls, he would at times feel that the girls were seducing him. Mr. Z described himself as heterosexual in orientation. He declared that he was erotically more interested in girls than in women. He denied any sexual interests in boys and he preferred girls between the ages of 4to 10 years. Although he denied any sexual inclination toward his own four-year-old daughter, he manifested fear of developing sexual attraction for her. Mr. Z had no previous history of psychiatric illness, except alcohol abuse. Sertraline up to 200 mg/day was prescribed for this patient, but his urges to offend girls continued. This time, Mr.
Z contended that when he saw some girls in the street or on buses, he did not have any control over his impulses. In this period, Mr. Z masturbated to orgasm with images of little girls.

After four months of treatment with Sertraline, we decided to add Topiramate up to 200 mg/day and depot intramuscular Haloperidol up to 300 mg once a month. Despite this, his fantasies and sexual behavior against children had not decreased after three months of follow-up. As the repetitive urges continued in spite of cognitivebehavioral treatment and administration of Sertraline, Topiramate, and Haloperidol, and due to the fact that the potentialvictim was a child, we considered adding Medroxyprogesterone Acetate (Depoprovera) to the therapeutic scheme. Mr. Z agreed with this treatment and signed an informed consent. During this phase of his treatment, he denied any offenses against minors, but his wife had found some little female
underpants inside his pocket, and one of them was dirty with feces. When the patient was receiving Medroxiprogesterona, 300 mg twice a month, he manifested a complete lack of fantasies or sexual activities focused on children. At this moment, his plasma testosterone level was 101 ng/dl. Unfortunately, in Brazil the phallometric test is not used as a complementary exam for patients who present this psychiatric disorder. Due to this, the self-reports were matched
with his plasma testosterone levels and with information on his behavior provided by his wife.

However, after the negative opinions of the media about the use of female hormones for the treatment of paraphilic sexual offenders, this patient decided to stop receiving this type of medication. He was afraid of being identified. Mr. Z was born after a normal pregnancy, labor, and delivery. His parents still live together. He denied any history of being sexually abused during childhood. With his history of a persistent sexual desire for prepubescent female children and a history of acting on these sexual urges on many occasions, Mr. Z met DSM-IV criteria for pedophilia, sexually attracted to females. Mr. Z completed the Temperament and Character Inventory (Cloninger, 1996; Fuentes, Tavares, Camargo & Gorenstein, 2000) and the Factorial Neuroticism Scale (Nunes & Hutz, 2001), revealing traces of high persistence and low harm avoidance, associated with high scores on vulnerability and poor social adjustment. Neuropsychological evaluation was carried out and did not reveal significant cognitive deficits. Laboratory exams and cranium tomography did not reveal any abnormalities at the beginning of the treatment.


Mr. Z shared some features with other paraphilic sexual offenders described in the literature: he had a strong and persistent sexual interest in female children; he regularly masturbated to fantasies involving girls; he described a specific erotic preference age range from 4 to 10 years; his sexual activities involved many different victims. He also shared similar cognitive distortions with other pedophilic men. He believed that his victims seduced him sexually and tended to minimize the harmful effects of his actions to his victims. He also had problems with alcohol consumption (Chow & Choy, 2002). With Sertraline, Topiramate, and Haloperidol, Mr. Z did not show any clinical improvement in his sexual fantasies and behaviors focused on girls. However, when he agreed to the use of Medroxyprogesterone and received this medication, his fantasies and impulsiveness directed toward female children disappeared. During the treatment of sexual offenders, the psychiatrist may act as treatment provider and public protector. This double role can bring serious ethical conflicts for the physician, such as issues of confidentiality. In cases like this, mental health professionals also have the duty to protect their patients’ potential victims. Naturally, these professionals must take whatever steps are reasonably necessary to perform their duty, and they may be obliged to warn the police or the victim about this possibility. Even so, the duty to protect is not similar to the duty to warn. Some procedures can be assumed without violating confidentiality and should usually be considered first, such as:
1) To add or change medications;
2) To change the method of the therapy;
3) To hospitalize the patient;
4) To expand the therapy to include a trusty member of the patient’s family (Appelbaum & Gutheil, 2007).

It should be noted that in Brazil, according to the Minor Crimes Law (Lei das Contravenc¸oes Penais) (Jesus, 2001), ˜ the previous crimes of a patient that comes to the mental health professional’s attention do not have to be reported. However, when evidences of a past crime raise the strong possibility of future crimes, as in the case of a repetitive sexual offender, the clinician has the duty to protect potential victims. This may not mean the necessity of a report to the police. In Brazil, as stated in the consultation n◦ 51.676/03 by the Regional Medical  Association of the State of Sáo Paulo (Conselho Regional de Medicina, 2003), the physician who has treated any patients suffering from pedophilia may decide not to denounce them to the police, except when these patients represent serious risk for children and are refractory to the therapeutic purposes. However, if we can talk about mental disorders in which the usual drugs (selective serotonin reuptake inhibiting drugs) can be ineffective, we must consider all available and reliable drugs for a more adequate treatment of these difficult cases. Certainly, this includes the hormonal medications. Such drugs have helped to reduce the urgency experienced by patients with pedophilia, offering them an opportunity to reconsider their choices and respond to psychotherapy more adequately. Ethically and medically, these medications may be acceptable for these cases. In fact, clinicians must remember that an individual who acts on pedophilic urges with a child committs a crime and that he also has a psychiatric disorder. This duality renders the management complex and the collaboration between the criminal justice sector and the scientific medical communities is essential for the appropriate treatment of pepophiles.

The pharmacological treatment of the paraphilias with hormonal drugs has shown to be successful in decreasing recidivism rates through the reduction of sexual fantasies, sexual drive, sexual arousal, and sexual behavior.

Although the etiology and pathophisiology of the paraphilias are still under investigation, many studies have shown abnormalities at a biological level. Also, identifiable biological deviations, such as inherited genetic disorders, hormonal abnormalities, and neuropsychiatric disorders have been associated with paraphilic or non-paraphilic behaviors (Schiltz et al., 2007). Maes et al. (2001) described high plasma epinephrine and norepinephrine levels in a sample of men with pedophilia. They also observed increased cortisol responses to the administration of metachlorophenylpiperazine in this sample when it was compared to normal men.
Gaffney and Berlin (1984) observed a significant increase in the secretion of luteinizing hormone after an intravenous administration of luteinizing hormone-releasing hormone in
a group of patients with pedophilia when compared to patients suffering from other types of paraphilias and to a control group. There are some case reports which correlate pedophilic
symptoms with brain damage. Burns and Swerdlow (2003) registered a case of a 40-year-old manwho manifested pedophilic symptoms due to a frontal orbitofrontal tumor, and Mendez, Chow, Ringman, Twitchell and Hinkin (2000) described two sexagenarian patients, one with frontotemporal dementia and another with bilateral hippocampal sclerosis, who manifested symptoms of pedophilia. According to Cantor et al. (2004), pedophilic men show lower IQs, poorer verbal memory and visuospacial scores when compared to normal men.These neuropsychological findings seem to be related to some specific brain abnormalities (Blanchard et al., 2007). Few imaging studies have also been carried out among pedophiles to verify presumptive alterations in the brain functioning. Schiffer et al. (2007) have noted that men
with pedophilia have less grey matter volume in frontostriatal circuits than noncriminal men and Cantor et al. (2008) have registered lower white matter volumes in the temporal and parietal lobes among men with pedophilia when compared to nonsexual offenders. The more scientific evidence demonstrates organic disturbances among men with pedophilia, the better our society will accept the pharmacological treatments for this condition.

Besides, many different comorbid psychiatric disorders have been found among men with paraphilias. Kafka and Hennen (2002) and Raymond, Coleman, Ohlerking, Christenson,
and Miner (1999) registered high prevalence rates of mood disorders, anxiety disorders, and substance abuse among men with paraphilia; Allnutt, Bradford, Greenberg, and Curry (1996) found high rates of alcoholism among paraphilics; and Baltieri and De Andrade (2008) have reported high rates of alcoholism among child molesters in general.

Alcohol misuse constitutes an important risk factor for sexual offense (Abbey, Clinton-Sherrod, McAuslan, Zawacki & Buck, 2003; Testa, 2002; Ullman & Brecklin, 2000). Furthermore, this patient showed a high number of previous victims, offenses against extra-familial girls, and history of more than one paraphilic behavior, which constitute relevantrisk factors for sex aggression (Hanson, Morton & Harris, 2003; Quinsey, Harris, Rice & Cormier, 2003).
Unfortunately, some lawyers in Brazil affirm that the use of hormones for the treatment of sexual aggressors is cruel. This opinion has been offered in newspapers and other communication means in our country, which negatively affects the adequate treatment of paraphilic sexual offenders in Brazil. They frequently confound the medical treatment with the misused term “chemical castration” (O Estado de S˜ao Paulo, 2007). In fact, this term should be avoided due
to the pejorative meaning that it implies. The word “castration” sums up images of pain and suffering and can denote an irreversible method. Therefore the law professionals, the
public, and the government could be more open to the hormonal treatment for paraphilic sexual offenders if another more adequate term was used (Harrison, 2007).Recently, in our country, the first author of this paper revealed that the use of hormonal medications must be available
for the treatment of patients suffering from pedophilia, when there are correct medical indications for this procedure. This author emphasized that there are some steps in the treatment
of sexual offenders with pedophilia before the use of hormones. This provoked a stirring repercussion in the media and sensational magazines. Both the Regional Medical
Association of the State of S˜ao Paulo (Conselho Regional de Medicina) and the Brazilian Bar Association (Ordem dos Advogados do Brasil) manifested issues about this procedure
and some people condemned this medical approach. Unfortunately, the treatment of the patient in the previous case was harmed due to the misunderstandings of some segments of our society. Currently, this patient gave up receiving the hormonal medication and is at risk of re-offending.
The adequate treatment for dangerous paraphilic sexual offenders needs to be more adequately divulged to our society, showing its benefits and safety when it is carried out by specialized professionals. In our opinion, although these types of negative reactions are expected, especially in a country where this subject is not usually debated, the devastating responses of the important organizations have caused many difficulties in the adequate management of sexual offenders
who suffer from paraphilias, such as pedophilia and sexual sadism. Essentially, prejudice and misunderstandings contribute to the failure of science.


Pedophilia is a chronic psychiatric disorder that is treatable in terms of developing strategies for relapse prevention, based on the association between psychotherapeutic and pharmacologic
therapies. The treatment must focus on stopping the pedophilic behavior and improving the quality of life of the patient. The adequate treatment for paraphilic and nonparaphilic
sexual offenders needs to be better divulged to our society and others where the use of hormonal medications can be seen with prejudice, so that the offender can be given the best possible chance to reduce his risk of reoffending. Naturally, all treatment should be provided on a purely voluntary basis. Unfortunately, the name “chemical castration” is still used in the specialized literature on sexual offenders. It is important to avoid this term and call this medical procedure “hormonal therapy” instead, because in fact, that is what it is: a therapy, not a punishment as it might be understood by the use of the word “castration.” This could render the government,
the public, and legal professionals more amenable to the option of hormonal drugs in cases of dangerous paraphilic sexual offenders. The mere change of words could make all the difference
in the minds of people and perhaps then the victims, the offenders, and the society as a whole could profit from this medical procedure. We should not forget that, to some extent, we are all guilty if certain problems still afflict our society, but we are also responsible for the change, respecting everyone’s rights. The victims must have the right to receive proper medical care and legal attention as should the offenders have the right to receive proper treatment.