Abstract
The use of cyproterone acetate to reduce paraphilias has been well documented; however, its side effects can be intolerable [1]. Such treatment can raise ethical and professional dilemmas. We describe here a case study of a young man treated with a high dose of cyproterone for paedophilia.
The patient is a single man 25 years old who sexually assaulted a five year old boy when he was fifteen, by oral stimulation of his penis. He was also engaged in sexualized behaviour towards his younger brother. Subsequently he was placed under the auspices of Juvenile Justice and ordered to attend a programme for sexual offenders.
He is the eldest of two brothers, both with developmental delay. His parents separated when he was nine. There is a history of poor adjustment at school, difficulties forming relationships with peers and teachers and being suspended from school.
Previously he was diagnosed with oppositional defiant disorder, pervasive developmental delay, congenital frontal lobe dysfunction, Asperger's disorder, obsessive–compulsive and bipolar affective disorders. He had no history of substance misuse.
Although his highly sexualized behaviour was indicative of him being a victim of sexual abuse at an early age, he denied this. He never experienced any sexual dysfunction and identified himself as homosexual since the age of 13 with fantasies about young boys.
When 18, he started taking cyproterone 400 mg daily. Subsequently he noticed significant breast development, weak bones, weight gain, lack of libido and an inability to have an erection or ejaculation. After reduction in the dose three years ago, he re-experienced sexual urges and dreams towards young boys.
He was admitted to the Mental Health Rehabilitation Unit with depressed mood and social withdrawal with an aim to review cyproterone treatment. He presented as an overweight young man with feminine features. He had insight into the paraphilia and its treatment. There was no evidence of a mood disorder or obsessive symptoms, also there was no evidence to suggest past diagnostic hypotheses.
His testosterone level was low, bone mineral density confirmed osteopenia; parathyroid hormone, sex hormone-binding globulin, follicle stimulating hormone, luteinizing hormone and blood sugar levels were normal. His assessment of verbal and performance tasks showed a low average intelligence.
During his admission cyproterone was gradually ceased with close monitoring of sexual fantasies and urges towards young boys. There was no indication to continue treatment with sodium valproate. Sertraline was increased to 200 mg for an antilibidinous effect. He was supplemented with Caltrate and cholecalciferol for osteopenia. Following his discharge from the hospital, he remains free of sexual fantasies. He is overweight and feminized but able to get an erection.
Our patient was treated with cyproterone for paedophilia throughout the critical phase of his psychosexual development. Due to debilitating side effects, we ceased cyproterone without recurrence of his sexual urges. This case demonstrates the need to balance the risks and benefits of cyproterone in the long-term treatment of paraphilias.