Are selective serotonin reuptake inhibitors (SSRIs) used to decrease sexual drive in adult male sex offenders?

SSRIs for Reducing Sexual Drive in Sex Offenders

SSRIs are used as a pharmacological intervention to reduce deviant sexual behavior and sexual drive in sex offenders with paraphilic disorders, particularly for mild paraphilias and juvenile offenders, though the evidence base is limited and dated. 1

Clinical Use and Evidence Base

SSRIs have been employed in the treatment of sex offenders with paraphilic disorders, typically reserved for milder forms of paraphilia and younger offenders. 1 The mechanism involves reducing sexual drive and deviant sexual fantasies through serotonergic modulation, though this represents an off-label use of these medications. 1

Efficacy Evidence

• A Cochrane systematic review found only limited evidence for SSRIs in sex offender treatment, with no randomized controlled trials of SSRIs specifically identified in their analysis of pharmacological interventions. 2
• One retrospective German study of 16 male outpatients treated with SSRIs and psychotherapy showed marked reduction in paraphilic symptoms, though this was an open, uncontrolled study. 3
• The available evidence suggests SSRIs may reduce the frequency of deviant sexual fantasies, but the quality of evidence is poor and studies are more than 20 years old. 2

Mechanism and Sexual Side Effects

The therapeutic effect in sex offenders relies on the same mechanism that causes sexual dysfunction in patients treated for depression:

• SSRIs cause delayed ejaculation, absent or delayed orgasm, and reduced libido through dose-dependent mechanisms. 4
• Sexual side effects occur in 40-90% of patients on SSRIs, with effects strongly dose-related. 5, 4
• Among SSRIs, paroxetine causes the highest rates of sexual dysfunction at 70.7%, making it theoretically the most potent for reducing sexual drive. 6, 5

Treatment Context and Limitations

Combined pharmacological and psychotherapeutic treatment is associated with better efficacy than either approach alone. 1

Critical Caveats

• The evidence base is extremely limited—no randomized controlled trials of SSRIs for sex offenders have been published in over two decades. 2
• SSRIs are typically reserved for mild paraphilias, while more severe sex offenders with paraphilic disorders often require antiandrogen treatments (testosterone-suppressing drugs) to reduce victimization risk. 1
• Acceptance and adherence to treatment remain significant challenges, with approximately 40% of patients refusing or discontinuing SSRI treatment within 12 months due to concerns about taking antidepressants, side effects, or cost. 7

Safety Monitoring Requirements

• Patients under age 24 should be closely monitored for suicidal ideation during treatment and dose changes. 5
• Gradual tapering is required when discontinuing SSRIs to prevent withdrawal syndrome (dizziness, nausea, headache, flu-like symptoms). 5
• Sexual side effects typically emerge within the first week of treatment. 5

Clinical Algorithm

For sex offenders with paraphilic disorders:

• Mild paraphilias or juvenile offenders: Consider SSRIs combined with psychotherapy as first-line pharmacological intervention. 1
• Severe paraphilias with high victimization risk: Antiandrogen treatments (progestogens, antiandrogens, or GnRH analogues) are more appropriate than SSRIs. 1, 2
• SSRI selection: If using SSRIs, paroxetine provides the strongest effect on sexual function (70.7% sexual dysfunction rate), though sertraline is also effective. 6, 5
• Monitoring: Assess for reduction in deviant sexual fantasies and behaviors, while monitoring for depression, suicidal ideation (especially in those under 24), and treatment adherence. 5, 3

The sparse and dated evidence base represents a significant concern given that pharmacological treatment is mandated in many jurisdictions, highlighting the urgent need for modern, well-designed trials. 2