IN REVIEW

The Neurobiology, Neuropharmacology, and Pharmacological Treatment of the Paraphilias and Compulsive Sexual Behaviour

John MW Bradford, MB, ChB, DPM, FF Psych, FRC Psych, DABPN, DABFP, FRCPC1

There has been increasing interest in the treatment of sexual disorders in recent years. Sexual disorders are classified in DSM-IV as sexual dysfunctions, paraphilias, and gender identity disorders. The sexual dysfunctions are nondeviant or nonparaphillic. The sexual dysfunction  disorders should include “hyperactive sexual desire disorder”  under sexual desire disorders . Further, there should be a specifier for paraphilias of “with hypersexuality” or “without  hypersexuality.”  There is still incomplete understanding of the neurobiology of sexual disorders although functional neuroanatomy and neoropharmcological research has exposed the neurotransmitters, receptors, and hormones that are involved in sexual desire. Various pharmacological agents including serotonin reuptake inhibitors, antiandrogens, LHRH agonists, and others have been documented as reducing sexual desire. An algorithm for the use of these drugs in the treatment of the paraphilias as well nonparaphilic hypersexuality is outlined. The modes of action, dosages, aims of treatment, and usual methods of prescribing these agents is reviewed in this article. Some future directions of research in pharmacological treatment is also discussed.

(Can J Psychiatry 2001;46:26-34)

Key Words: sexual desire disorders, paraphilias, hypersexuality, compulsive sexual behaviour, antiandrogens, specific serotonin reuptake inhibitors, LHRH agonists

Although it would be premature to say that the neurobiology  and neuropharmacology of sexual behaviour is understood, there clearly have been major advances in recent years. There has been significant research on the serotonin receptors and their function in the brain. Serotonin (5-HT) is involved in the neurobiology of many psychiatric disorders, particularly mood disorder, and specifically depression, anxiety, schizophrenia, eating disorders, and obsessive–compulsive disorder (OCD). It also plays a role in migraines. Although the etiology of these disorders is not understood, pharmacological treatments that modulate levels of 5-HT have shown to be effective in all of them. Further, sexual disorders, both paraphilic (sexual deviation) and nonparaphilic (compulsive sexual disorder or nonparaphilic hypersexuality), have also responded to pharmacological treatments modulating serotonin levels (1). This has led to the speculation that a group of disorders could be classified together as obsessive–compulsive spectrum disorders (1,2). This is based not only on the diagnostic characteristics of these disorders as outlined in DSM-IV but also on the fact that they respond to pharmacological treatment affecting the central nervous system level of 5-HT (1,2).

Manuscript received and accepted December, 2000.
1 Professor and Head, Division of Forensic Psychiatry, University of Ottawa; Royal Ottawa Hospital, Ottawa, Ontario.
Address for correspondence: Dr JMW Bradford, Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, Ontario K1Z 7K4
e-mail: jbradfor@rohcg.on.ca

In general, the assessment and treatment of all types of sexual disorders have been neglected by psychiatry. In recent years, however, advances in psychiatric research have focused general psychiatry on these important clinical entities. OCD spectrum disorders include OCD, eating disorders, somatoform disorders, impulse control disorders, and neuropsychiatric disorders such as Tourette syndrome (TS); they may also include the sexual disorders (1,2).  There are clinical similarities between OCD and sexual disorders that can be summarized as follows (1):

  • Obsessions are similar to sexual fantasies, both paraphilic and nonparaphilic.
  • Compulsions are similar to compulsive sexual behaviour (CSB), which can be paraphilic or nonparaphilic.
  • There is a crossover of comorbidity between OCD and the sexual disorders, with depression and anxiety disorders being common in both groups.
  • At a neurobiological and neuropharmacological level, there is a significant overlap between these disorders.

    • There is no consensus at this time as to whether the paraphilias and compulsive sexual behaviour (nonparaphilic hypersexuality) should be included in the OCD spectrum disorders.

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