The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders

Figures & data

Table I. Cognitive Behavioural Treatment (CBT).

		Methods		Results
References	Characteristics of the patients	Treatment conditions	Outcome measures	Treatment efficacy
Becker et al. (1988)USAOpen studyNo comparison group	N=24 MalesOutpatientsSex offenders: 22/24 (one case > 2 offences)Victims: majority <13 y (36/47)Type of paraphilia?Mean age: 15.6 y (range: 13–18)Previous history of sexual abuse?Comorbidities:23/24 cases with no previous psychiatric hospitalization	Structured CBT programme (Abel et al. 1984):Multicomponent treatment programme with verbal satiation, cognitive restructuring, covert sensitisation, social skills, anger training control, sex education and relapse prevention sessionsDuration of follow-up?	Timepoints:Before treatment1 week after treatment completionOutcome measures:No scalesSexual activity and interestsPlethysmography: (2 min audiotapes description of paedophilic behaviour and 2 min audiotapes description of conventional sexual behaviour between adults) Levels of aggression for the victim rated	Plethysmography: Mean erection response to verbal coercion cue, physical coercion cue, sadism cue and pure assault cue:11 cases of deviant sexual behaviour with male victims: Significant decrease in arousal post treatment: Pre-low aggression level, n=4 cases (mean levels of decrease: – 39). Pre-high aggression level, n=7 cases (mean levels of decrease: –17)13 cases of deviant sexual behaviour with female victims: No significant decrease in arousal post treatment: Pre-low aggression level, n=1 case (mean levels of increase: +24). Pre-high aggression level n=12 cases (mean levels of decrease: –13.5)
Hunter and Santos (1990)USAOpen studyNo comparison group	N=27 MalesType of paraphilia: 27 paedophilesVictims: Mean age of victims: 6 y. Use of force: 60%12 male paedophilic sex offenders: mean number of offences: 20. Mean number of male victims: 4. Mean age: 15.75 y (range: 13–17)15 female paedophilic sex offenders: mean number of offences: 31. Mean number of female victims: 4. Mean age: 15.87 y (13–17)Previous history of sexual abuse: 80%Comorbidities: drug or alcohol abuse: 53–58%	CBT (Becker et al 1988):Multicomponent treatment programme including:satiation therapy (extinction model) 4 sessions per week (1 h);laboratory satiation (1 h/week) (slides and plethysmography);covert sensitisation;social skills training; anger control and sex educationPlusInpatient residential programmeInsight-oriented individual psychotherapy (2 sessions per week)Insight-oriented group psychotherapy (1 session per week)Family therapy (1–2 sessions per month)Therapeutic milieuSubstance abuse counsellingDuration of follow-up?	Timepoints:Twice before treatmentMonthlyOutcome measure:Plethysmography:Audiotape stimuli (conventional and deviant sexual behaviour)	Plethysmography:Significant differences in terms of arousal (plethysmography):Female paedophiles (15):Non deviant/deviant arousal: 12% at baseline and 44% after 2-month treatmentArousal for non aggressive and aggressive sexual activity with a child decreased by respectively 32 and 35%Male paedophiles (12):Non deviant/deviant arousal: 37% at baseline and 62% after 2-month treatmentArousal for non aggressive and aggressive sexual activity with a child decreased by respectively 37 and 41%
Hunter and Goodwin (1992)USAOpen studyNo comparison group	N=39 MalesSex offenders: 39Victims: 18% males 38% femalesType of paraphilia?Previous history of sexual abuse: 59%Mean age: 15.4 yComorbidities:Learning disabilities +/ADHD 59%Mean total IQ: 94	Satiation therapy adapted to adolescents:Sexual thoughts and visual stimuli in conjunction with repetitive and prolonged exposure to deviant and non deviant stimuli (conditioning paradigm of extinction)4 sessions (1 h)/weekPlusIndividual group and family therapies insight-oriented and problem solving natureDuration of treatment: 6 monthsDuration of follow-up: 6 monthsAt 3 months: +15 min covert sensitisationIn 12 cases: 3 additional months of verbal plus laboratory satiation (slides and plethysmography)In 27 cases: verbal satiation for 3 additional months	Timepoints:Prior to treatmentEvery monthOutcome measures:Plethysmography:Auditory stimuli (conventional and deviant sexual behaviour)	Plethysmography:At month 6: no differenceAt month 9:Deviant score significantly decreased as compared to baseline with verbal satiation only in 27/39 casesAge at time of admission was correlated with the deviance score at month 9 (deviant score lower in older sex offenders)
Kaplan et al. (1993)USAOpen studyNo comparison group	N=15 MalesSex offendersType of paraphilia:14 paedophiles heterosexual, 1 bisexualNo non sexual crimesPrevious history of sexual abuse?Mean age: 15.4 y (13–18)Denial 95%Comorbidities:No drug or alcohol abuse	Verbal satiation8 individual verbal satiation sessions (30 min sessions for 8–13 weeks or 90 days maximum)If arousal to deviant sexual stimuli >20% (only 5 cases): CBT was used for 40 weeksDuration of follow-up?	Timepoints:Prior to treatmentAfter verbal satiation (within 4 to 30 days)Outcome measure:Plethysmography	Decrease in arousal for deviant stimuli in 14/15 cases but in 5 cases erection > 20% for deviant sexual stimuliBaseline: arousal 70% (range: 29–100)After 8 sessions: 34% (except for 1 case: increase from 60 to 96% instead of decrease)In 2 young subjects: pre-treatment arousal 100% and post treatment arousal: respectively 69 and 78%
Weinrott et al. (1997)USARandomly allocated in 2 groups	N=69 MalesSex offendersType of paraphilia:Paedophiles (among 108 with plethysmography: 24 withdrew, 15 had low deviant behaviour)Previous history of sexual abuse?Mean age?Comorbidities?No statistical differences between the 2 groups before treatment	Peer group programmes,individual and family therapyVicarious sensitisation (IT) (N=35): 25 sessions, twice a week (crime scenario and aversive vignettes audiotaped)Comparison group (N=34):3 month-waiting listDuration of treatment: 6 monthsDuration of follow-up: 6 months	Timepoints:BaselineAt 3 monthsAt 6 monthsOutcome measures:Plethysmography:using audiotapes description of consensual and deviant sexual behaviourand visual slides of child with bathing suitsScales:–Adolescent sexual interest card sort: 64 items subjective arousal to sexual scenarios–Self–perception profile: 45 item self-report scaleYouths and parents’ reports	PlethysmographyVideo:IT: decreased arousal in % of full erectionMale victims: 18 to 12Female victims: 38 to 23Waiting list: no decreaseAudio:Male victims: IT statistically significant decrease from 63 to 44Female victims: IT statistically significant decrease from 90 to 63Waiting list: no decreaseSlides:Female victims: IT statistically significant decrease from 47 to 23Waiting list: decrease from 55 to 45Parents’ reports:50% of parents thought that IT greatly improved their sonsSelf-reports:78% of youths found IT > than their core treatmentPotential biases:Treatment not fully portableUpper limit of the number of trials (each vignette can be seen 3 or 4 times before decreasing its aversive power)Restricted to child molestersLong-term effect?: longest study 3 months
Worling and Curwen (2000)and Worling et al. (2010)USAOpen study	N=148 (9 females)Sex offenders:Moderate risk of reoffendingType of paraphilia:3 exhibitionists, paedophiles?Previous history of sexual abuse?Mean age: 15.5 +/1.5 (range 12–19)Treatment group:N=53 males and 5 femalesComparison group:N=86 males and 4 femalesNo group differencesComorbidities:IQ in the normal range	Treatment group SAFE-T:Treatment group: 58 includingdrop out >12 months (18/58)Sexual abuse Family and Education SAFE-T programme: a community-based programme for sexual abuse treatment (individual (100%), group and family treatment (71%))CBT intervention with family focusTreatment goals are reviewed every 4–6 months and individualised to meet each adolescent’s needsMean duration of treatment: 24.4 months (range: 16–24)Comparison group: 90 subjectsIncluding treatment refusals: 17; treatment drop outs: 27 before 1 y; and 16 no treatment67% of cases in this comparison group received treatment but the nature or duration of treatment is unknownDuration of follow-up: 6 years (range: 2–10 years)Study published in 2010:Duration of follow-up: 16.2 y (range: 12–20)	Timepoints:Baseline and end of follow-upOutcome measures:Scales:–Assessment environment scale AES III (punitive early family environment)–Tennessee Self-Concept Scale TSCS (self-esteem and self-criticism)–Youth Self-Report (social competencies and problem behaviour)–Beck Depression Inventory BDI–Buss Durkee Hostility Inventory BDHI (hostility)–Socialization Scale (from the California Psychological Inventory) (impulsive and antisocial traits)–Child Molest and Rape Total Scales from the Multiphasic Sex Inventory Juvenile Male Research Edition (MSI-J-R) (self-report) (child molest and rape)Criminal charges (sexual and non sexual, national database)	Follow-up: 10 yearsRecidivism in the treatment group: 3 casesSignificant differences between comparison and treatment groups for any criminal offence (54 vs. 35% p<0.01); for violent non sexual recidivism (32 vs. 19% p<0.05); for non violent non sexual offences (50 vs. 21% p<0.01) and for sexual recidivism (18 vs. 5% p<0.05)Recidivism was associated with child interest but not with previous non sexual delinquencyPrevious history of sexual abuse was not related to sexual recidivismFollow-up: 20 yearsOverall rate (for all 148 participants) for any, non-violent, non sexual, violent non sexual and sexual recidivism was 49.3% (73 of 148), 42.6% (63 of 148), 32.4% (48 of 148), and 16.2% (24 of 148), respectively.Treatment group: significantly less likely to be charged for a sexual reoffense: Chi square 4.41; a non sexual violent reoffense Chi square 4.35; a non-violent reoffense; Chi square 10.57; or any criminal reoffense: Chi square 6.37.Recidivism rates at 20-year follow-up:Any offence: Treatment vs. Comparison 38% (22/58) vs. 57% (51/90)Sexual offence: Treatment vs. Comparison 9% (5/58) vs. 21% (19/90)Relative risk of relapse: 0.41 (CI: 0.16–1.03)Drop outs:27 early drop outs (<12 months) transferred to the control group18 after 12 months
Eastman (2004)USAThree different groups pre- and post-treatmentOpen studyNo comparison groupEastman 2005 USA (38 additional cases)No comparison group	N=100/138 MalesCourt-ordered sex offenders:Prior sexual charges: 30%Prior criminal charges: 47%Type of paraphilia:Mean age: 17.2 y (range: 13–22)Previous history of sexual abuse: 50-60%Comorbidities: Mean total IQ 91In 32% of cases: past history of psychiatric care	Residential sex offenders programme for incarcerated adolescents: no other information. Treatment not describedCBT?Duration of follow-up?Three different groups were compared:Pre-treatment: 40-56 casesPost-treatment pre-release: 40-63 casesPost treatment post release: 20 casesNo significant differences between the 3 groups except for IQ19 had not successfully completed treatment	Timepoints:Pre- and post-treatmentOutcome measures:Scales:– Cognitive distortions:Molest and Rape scales 38 items related to cognitive distortions about sexual assault of children and 36 items related to cognitive distortions about sexual violence against women (rated from 1 strongly disagree to 4 strongly agree)–Sexual knowledge questionnaire–Attitude and value inventory related to sexual behaviour, 70 questions, Lickert-5 options responses–Empathy: Interpersonal reactivity index, 28 items, Lickert-5 option responses–Index of self-esteem, 25 items, Lickert-5 option responses	Significant differences between the pre-treatment group and the two other groups except for the Empathy scale
Waite et al. (2005) USANo random assignment to treatment groups	N=256 MalesSex offenders:Criminal conviction for a felony before treatment: 67%Type of paraphilia:SCI programme as compared to outpatient programme (higher total IQ, more history of sexual abuse, fewer prior offences, more child molestations)Previous history of sexual abuse?Mean age?Comorbidities?	SCI-CBT: 144 casesSelf-contained intensive programme (housed in dedicated units for sex offenders), sex offender CBT including relapse preventionOutpatient sex offender specific CBT: individual or group sessions: 112 cases (Wieckowski et al. 2004)Duration of follow-up: 10 years	Timepoints:Outcome measures:Scales:J-SOAP scaleRe-arrest rates	Self-contained treatment vs. outpatient programme:–Rates for re-arrest 4.9 and 4.5. respectively–At risk for a sex offence for 5 years 56.2 vs. 69.3 for 6 years–All offences 27.8 and 39.3 (statistically significant from baseline) and longer mean time to re-arrest (64 vs. 47.8)
Thoder and Cautilli (2011)USANo comparison group	N=39 MalesSex offendersType of paraphilia?Mean age: 14–17 yPrevious history of sexual abuse?Comorbidities?	CBT:Mode deactivation therapy(theory of a network of cognitive, motivational, affective and behavioural components that create a personality)Weekly individual or group sessions involving imaging and relaxationDuration of follow-up: 1 year	Timepoints:Baseline and post-treatmentOutcome measures:Scales:–Devreux Scale of mental Disorders: DSMD–Child Behaviour Check List: CBCL–Beliefs about victims–Beliefs about aggression–JSOP-A (if >28: high risk of sexual offending)	Significant decrease in antisocial behaviourPre- and post-treatment scores:JSOP-A: 28.5 to 22.2BSP (composite score including all scales): 10.25 to 4.9After 1 year: recidivism 7% (no sexual offence) (4/7 related to drugs)
Edwards et al. (2012)UKOpen studyNo comparison group	N=34 MalesSex offenders: 47%Victims: Adult or peer only 21%Type of paraphilia:Paedophiles: 35%Mean age: 14 y 3 months (range: 11.6–16.3)Previous history of sexual abuse: 47%,Comorbidities:35% learning disabilities6% ADHD + 9% suspected6% autism + 6% suspected53% conduct disorders	SWAAY a multicomponent treatment facility for sex offenders: residential care in groups, education and therapeutic interventionsWeekly CBT based programme (3–5 weeks modules concerning sex relationships, decision making, rights and responsibilities and victim focus, relapse prevention)PlusIndividual interventions based on CBT25 cases completed the main programmeDuration of follow-up: 3 years	Timepoints:Pre- and post-treatment Outcome measures:Scales:–Adolescent Sexual Abuser project (1997) extension of the STEP programme to adolescents: evaluate psychological functioning and sexual behaviour of adolescent sex offenders and offence-related attitudes and beliefs and impulsivity–ERASOR 2.0 (psychosocial functioning, sexual interests and behaviour)	Positive significant improvement of all measures except for impulsivityAll offence-related scales improved significantly post treatment and the proportion of “I don’t know” was 0 post treatmentERASOR 2.0 scores: significant improvement post treatmentBiases:Non anonymous questionnairesContribution of the therapeutic milieu?No reconviction follow-up study
McConaghy et al. (1989, 1990)USASubjects randomly allocated to one treatmentTwo studies (respectively 20 and 30 subjects)No specific focus on adolescents	N=45 (6 adolescents) MalesSex offenders: 3 were charged for sex offencesNone adolescent ask for voluntary treatmentType of paraphilia:2 homosexual paedophiles, 1 heterosexual paedophile, 1 exhibitionist, 2 fetishists including 1 attempted rapeMean age: range: 14–19 yPrevious history of sexual abuse?Comorbidities:1 had mental retardation	STUDY 1:Covert sensitisation CS:10 casesImaginal desensitisation ID:10 cases(sexual stimuli excitation controlled by relaxation)1 week course of 14 sessions (15–20 min)STUDY 2Imaginal desensitisation ID:10 casesMedroxyprogesterone MPA:10 cases (150 mg i.m./15 days for 4 injections, then 4 injections per month – 6 months in total –Imaginal desensitisation ID + Medroxyprogesterone MPA:10 casesDuration of follow-up: at least 1 year	Timepoints:After 1 month and after 1 yearTreatment adjusted if necessaryOutcome measures:Self-report scalesRecidivism ratesNo plethysmography	Lower efficacy as compared to adults at 1-year (not significant) but the decrease became significant during the following years1 adolescent with low IQ was resistantRecidivism rates in adolescents:4/6 adolescents required additional treatment as compared to 7/39 adults (statistically significant) during 2 to 5 years after the end of the study3/6 adolescents reoffended vs. 3/39 adultsHistory of reoffenses in adolescents:–14 y low IQ homosexual paedophile: sexually offended at months 7 and 10 after CS then use of 1 week aversive therapy and no recidivism after 5 years–15 y fetishist: recidivism after ID then use of 1 week aversive therapy and recidivism then 6 month-MPA treatment and recidivism after 1 year and then 1 week aversive therapy with good control of fetishism–18 y exhibitionist and sexual molester: MPA treatment, after 3 injections reduction of deviant behaviour but still present then 1 week ID, then MPA 150 mg/15d for 7 months then monthly, and after 4 months, sexual reoffense, then 150 mg/15d plus 1 week aversive therapy, deviant sexual behaviour still present but under control and then gradually decreased after 25 months with minimal urges under control–19 y homosexual paedophile: 6 months MPA treatment, 2.5 years later he sexually offended, then another 6 months MPA treatment with no deviant urges for the next 2 years–1 heterosexual paedophile: no deviant behaviour for 4 years after cessation of ID–1 fetishist: ID + MPA: no deviant behaviour for 4 years after cessation of treatmentBiases: Insufficient duration of treatment? Heterogeneity of the sample Not designed for adolescents

Table II. Multisystemic treatment (MST).

		Methods		Results
References	Characteristics of the patients	Treatment conditions	Outcome measures	Treatment efficacy
Borduin et al. (1990)USARandomised study	N=16 MalesSex offenders arrested:6 rapes, 5 sexual assaults, 4 sodomy, 1 exhibitionismType of paraphilia?Mean age: 14 yearsPrevious history of sexual abuse?Comorbidities:Majority of conduct disorders	Multisystemic therapy (MST) N=8Adolescent and family systemic approachMean 37 hoursvs.Individual therapy N=8Combination of psychodynamic, behavioural and psychotherapyMean 45 hoursMean duration of treatment: 4 monthsDuration of follow-up: 21–49 months (mean 37)	Timepoints:Pre- and post-treatmentOutcome measures:No scalesRecidivism rate for sexual offences	Drop out: 3 cases in each groupRe-arrest rates:In 4/6 cases: re-arrest for sexual offenceMST group recidivism rate for sexual offences: 12.5%IT group recidivism rate for sexual offences: 75%p=0.04
Borduin et al. (2009)USARandomised controlled study	N=48 MalesSex offenders arrested as well as non sexual offencesPrevious offences mean 4.3 (sexual 1.6 and non sexual 2.7)Moderate baseline risk of reoffendingMean age: 14 ± 2 yNo differences between the 2 groups except for more behavioural problems in the MST groupType of paraphilia?Previous history of sexual abuseComorbidities:No psychosis, no mental retardation	Multisystemic therapy (MST) at home N=24 (Borduin et al. 2003)Duration: 31 wks ± 12vs.Usual community services (UCS) using CBT N=24(CBT group, 90 min twice a week + individual treatment 60–90 min once a week)2 withdrawn in the UCSDuration: 30 weeks ±18Duration of follow-up: mean 9 years	Timepoints:Pre- and post-treatmentOutcome measures:Scales:–Global Severity Index of theBrief Symptom Inventory(self-report scale 53-item(from 0 to 4)–Youth behaviour problems:89 item form, 0 to 2–Revise Behaviour Problem Checklist(report by parents)– Family Adaptability and CohesionEvaluation Scales II (parents and youth reports) 30-item (1–5)–Missouri Peer RelationsInventory (parents, youths and teachers reports) 13-item (1–5)–Self-report delinquency scale: 40-itemNumber of offencesNumber of days of incarcerationRe-arrest: sexual assault or attempted sexual assault	Post-treatment:MST participants had 83% fewer arrests for sexual crimes than UCSand 70% fewer arrests for other crimesthan the UCS groupAfter 9 years:MST participants spent 80% fewer days in detention facilities than UCSReoffenders: 2/24 MST vs. 11/24 in the control groupRelative risk of reoffending: 0.18 (0.04–0.73)Re-arrest rates for sexual and non-sexual crimes: 45.8% of UCS for sexual crimes and 58.3% for a non sexual crime compared with 8.3 and 29.2% respectively of MST casesCox proportional hazards tests showed small to medium effect sizes for MST versus UCS (sexual offences, beta = 0 .124, p = 0.007; non sexual offences, beta=.433, p = 0.050).All other items were significantly improved in MST and deteriorated in UCS Drop outs: MST: 0vs. 2 in UCS
Henggeler et al. (2009)USARandomised studyAndLetourneau et al. (2009, 2013)	N=127124 Males 3 FemalesSex offenders35% of youths had no sexual offencesTreatment completion was mandatory (probation or diversion)Type of paraphilia?Mean age: 14.6 y (range 11–17)Previous history of sexual abuse?Comorbidities:No psychosis, no mental retardation	Multisystemic therapy (MST) at home delivered by community-based practitioners N=67Mean duration of treatment: 7 monthsvs.Standard treatment (TAU) N=60Primarily group-based CBT including: weekly group-based treatment with decreasing deviant arousal, increasing victim empathy, addressing cognitive distortions, relapse prevention, and family counselling.Mean duration of treatment: 14.6 months, and 8.2 months for diverted youthsDuration of follow-up: 2 years	Timepoints:From baseline through 2-year follow-upEvaluation at 6 and 12 monthsEvaluation at 24 monthsOutcome measures:Scales:–Externalising T scores of the Youth Self-Report (YSR) and of the Child Behaviour Checklist (youth externalising behaviours.)–The Child Behaviour Checklist (CBCL) (youth mental health functioning)–40-item Self Report Delinquency Scale (SRD)–General Delinquency subscale during the previous 3 months–Two items from the Personal Experience Inventory (PEI) (frequency of self-reported alcohol and marijuana use for the previous 3 months–Adolescent Sexual Behaviour Inventory, a 45-item instrument (inappropriate sexual behaviours reported by youth and parents (2 subscales were used)Sexual offence re-arrests	Drop out: 6 in each groupAt 1 year:Caregiver reports of youth sexual risk/misuse declined by about 77% for youths in the MST vs. minimal decline for youth in the TAUSelf-reported delinquent behaviour and substance use decreased by respectively 60 and 50% in the MST vs. 18% and an increase of 65% in the TAUThe probability that an MST youth was in an out-of-home placement (i.e., detention, residential treatment, foster care) during the past 30 days remained approximately 7% vs. an increase from 8 to 17% in the TAU groupAt 2 years:MST treatment effects were maintained for 3 of 4 measures of youth problems: sexual behaviour, self-reported delinquency, out-of-home placements.The base rate for sexual offence was too low for statistical analyses and no between-groups difference were observed for other criminal arrests

Table III. Pharmacological treatments.

		Methods		Results
References	Characteristics of the patients	Treatment conditions	Outcome measures	Treatment efficacy
Galli et al. (1998)Case report	N=1 MaleAge: 17 yType of paraphilia:Paedophilia, zoophilia, necrophilia, sexual sadism, exhibitionism, frotteurism, voyeurismComorbidities:Bipolar disorder type 2, OCD	Fluoxetine: 40 mg/d	Outcome measures:Self-report	Disappearance of deviant sexual thoughts from 4 weeks post-treatment to 1 year
Ryback (2004)Open prospective studyNo comparison group	N=21 MalesSex offendersMean age: 15 y (range: 13–17)Type of paraphilia: 19 heterosexual paedophiles, 1 homosexual paedophile, 1 bisexual Victims: children 2–12 y, number: 1–37 victimsPrevious history of sexual abuse: 6 casesComorbidities:11 ADHD, 5 substance abuse8 depression, 4 IED, 3 PTSD	CBT treatment:9 patients discharged before the end (mean 26 weeks)Naltrexone: 100–200 mg/day Mean dose: 160 mg/dayMean duration of treatment: 12.1 y (range: 4.5 to 21)Leuprolide: 3.75 or 7.5 i.m. per monthConcomitant medications:(antidepressants 8 with no efficacy of SSRIs, antipsychotics 6, mood stabilisers 5, stimulant medications 11)Duration of follow-up?	Naltrexone used if excessivemasturbation, erection out of control, sexual fantasies >30% of awake timeLeuprolide used if no efficacy of naltrexone after 3 monthsOutcome measures:Self-reports of daily sexual fantasies and masturbation numberIf decrease >30% for at least 4 months: considered as positive effect	In 20/21: 100 mg/day naltrexone but no duration of efficacyIn 19/20, dosage increased:–in 9 cases: to 150 mg/day–in 11 cases: to 200 mg/day (10/11 initial benefit) but:In 6/11 cases: decreased efficacy after 3 monthsIn 5/11 cases: ongoing benefitsIn total, in 15/21 cases: masturbation: 3/week and sexual fantasies: 1/dayIn 5/6 cases: good efficacy of leuprolide at 3.75 to 7.5 mg/month (used in more severe patients at baseline)

y, years; MPA, medroxyprogesterone acetate; SSRIs, selective inhibitors of serotonin reuptake; ADHD, attention deficit and hyperactive disorder; PTSD, post-traumatic disorder; IED, intermittent explosive disorder; CBT, cognitive behaviour therapy.

Table IV. Algorithm of pharmacological treatment of adolescent sexual offenders with paraphilic disorders.

Treatment	Pharmacological treatments	Psychological treatments
Level 1Sexual offenders with paraphilic disorders without violenceAge 12 or more	None	Indicated in all cases as a first-line treatmentTypes of psychological treatments:Motivational interviewing to prevent treatment drop outs (Level D)–Multisystemic treatment (MST) (Level C)–Cognitive behaviour therapy (CBT) (Level C)–Psycho-social-educational interventions (at least if both previous therapies are not available) (Level D)Treatment preferably delivered in peer group settingsCommunity treatment, or residential if indicated
Level 2Adolescent “hands off” or “hands on” sexual offender with low or moderate levels of violence (e.g., indecent exposure, touching the body or genital parts of another person)	SSRIs: increase the dosage at the same level as prescribed in OCD (e.g., fluoxetine (up to 40 mg/day) or sertraline (100–150 mg/day)) (depending on age) (Level D)
Level 3Adolescent sexual offender with high risk of violent sexual offending behaviour (e.g., associated with coercive sexual sadism in fantasies and/or behaviour)Tanner stage V required	Add antiandrogens at the lowest effective dosage and check every 6 months the need for antiandrogen treatment (Level D)Depending on the risk of sexual violence:first step:SSRI’s plus a low dose of antiandrogen (e.g., cyproterone acetate 50 mg/day)second step (if no success with step 1 or very high risk):Cyproterone acetate: 100–200 mg/dayorMedroxyprogesterone acetate: 50–300 mg/day if CPA is not availableorLong acting GnRH agonists, e.g., triptoreline or leuprolide acetate: 3 mg/month or 11.25 mg i.m. every 3 months(cyproterone acetate may be associated with GnRH agonist treatment one week before and during the first month of GNRHa to prevent a flare-up effect and to control the relapse risk of deviant sexual behaviour which may be associated to the flare-up effect)
Level 4Same as level 3, but age 17 or olderTanner stage V required	Same as level 3, but no time limit for antiandrogen treatment (Level C for adults)

SSRIs, selective serotonin reuptake inhibitors; GnRHa, gonadotrophin-releasing-hormone agonists.

Level of evidence (C, D) (see definitions in the previous chapter: Methods of our analysis).

Definition of Tanner stage: see Annexe 1.

Description of the psychological approaches, refer to previous chapter on psychological treatments.

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