SEX OFFENDERS

Society does not benefit by merely sending them to prison; they need treatment so as not to offend again . Therapy is not likely to be effective if the patient does not desire it, and many do not. However the fear or reality of prosecution is frequently an incentive to seek treatment. Treatment is urgently indicated if the offender is psychopathic, or if the perversion subjugates other individuals against their will. Although these cases must be referred to a psychiatrist, the primary care physician should understan the nature of these disorders and their treatment in order to help the individual and his family.

There is no single satisfactory method of treating or controlling variant or compulsive behaviour, and a multidisciplinary approach is indicated.

Medication decreases the force and intensity of sexual drive and might reduce fantasies and impulses that precede the aggressive behaviour, but does not influence the direction of the sex drive. It provides an opportunity to give appropriate treatment directed towards reorientation of sexual activity . Drugs are not curative and should be combined with psychotherapy and behaviour modification therapy. Unless the individual genuinely wishes to be treated, ensuring that the drugs are taken is a problem.

Cyproterone acetate (Androcur 100 - 200 mg daily is effective within 14 days) has a castrating but not ferninizing effect. In almost all cases there is a marked suppression of libido, and both erectile and ejaculatory capacity are reduced. Its action is probably by competitive antagonism on the androgen receptor sites, and a tranquilizing effect. Side effects (tiredness, depression) are minimal and reversible. Psychotherapy combined with cyproterone acetate therapy has been shown to control a considerable number of hypersexual conditions including exhibitionisn, fetishism, paeclophilia, transvestism and sadomasochism. Success has also been reported in schizophrenics who suffer from sexual delusions (Haslam, 1976).

Medroxyprogesterone acetate (Depo Provera) has been used in the treatment of hyperactive sexuality. It works by lowering testosterone levels and raising the threshold for erotic imagery, and reduces sex drive, and facilitates social readjustment. Dose: 100 400 mg i.m. per week to lower plasma testosterone levels, reduced progressively until a threshold is reached at which the testosterone level remains low (Medical News, 1975). 150 mg every 12 weeks may be used for long term treatment.

Benperidol (Anquil, a butyrophenone) 0.5 1 mg daily may remove the desire to indulge in antisocial forms of sexual behaviour while retaining the ability to function normally in a 11 normal" sexual environment. This drug has extra pyramidal and sedative effects (Haslam, 1976), and is little used.

Information should be given about sex response, and sexual behaviour that is socially acceptable for the patient should be discussed.

Electric aversion therapy has been reported to produce improvement in most patients treated for transvestism, fetishism and sadomasochism, but has to be part of careful clinical management (Marks, 1970). This is no longer a recommended form of therapy.

Behavior modification therapy is appropriate for transvestism, exhibitionism and voyeurism (Haslam, 1976). It includes masturbatory conditioning using fantasy, systematic desensitization, and positive conditioning of socially acceptable behaviour, improving selfesteem and a sense of social responsibility. Desired behaviour may be enhanced with the concurrent use of medication. Social skills may be taught through role playing. Group therapy may be effective in prison. The goal is to make previously arousing stimuli (such as children) lose their appeal.

Family therapy: it is rare for members of the family to be left unaffected. Guilt and blame should be alleviated through an understanding of the problems involved, and education and supportive counselling are necessary.

Psychotherapy involves resolving deep conflicts and helping the patient to develop insight into his symptoms, also to induce patients to give up pleasurable sexual practices and actively foster socially acceptable sexual activity, by removing phobic barriers and encouraging the behaviour in reality (Van der Merwe, 1980). Enclogenous depression, schizophrenia or other psychotic states may be present and require specific treatment.

Sex therapy; reinforcement of socially acceptable sexual function is the basis of therapy. Erectile or ejaculatory impairment may complicate a paraphilia. Progressively more time and effort become wrapped up in the paraphilic ritual as the patient shows a tolerance for his ritual, comparable to the tolerance of an addict for his drug (Meyer, 1980). It requires much courage and confidence in the medical attendant for an individual to present his own or his partner's deviant practices. It is important for the therapist to be non judgemental and sensitive to the patient's needs.

Follow up is essential to ensure that the patient has learned not only how to control his deviant behaviour, but how to initiate and maintain activities that are more rewarding, enabling him to reinforce his new behaviour pattern and form new non deviant relationships .