Treatment

• Behavioural and cognitive therapy: older techniques, such as aversion therapy, were designed to discourage unwanted desires and behaviours, but are now little used because of ethical objections. (A mild type of aversion therapy that might be acceptable would be a mild aversive stimulus administered by the patient, such as snapping an elastic band round the wrist when the unwanted thoughts occur.) Modern approaches place greater emphasis on positive conditioning by encouraging preferable alternatives. For example, paraphilias may be treated with 'orgasmic reconditioning', in which, during masturbation, the subject is encouraged to concentrate on acceptable fantasies. For deviations which appear to be a substitute for adult heterosexual relationships, social skills training may help.

• Group therapy is often used for offenders, who are thereby encouraged to confront the effects of their behaviour on victims. This may be within correctional facilities and run partly by warders and partly by a prison psychologist.

• Drugs: antilibidinal drugs for male sexual offenders include the anti-androgen cyproterone acetate, the major tranquillizer benperidol, oestrogens, and the gona-dorelin analogue goserilin. These drugs may cause impotence, infertility, and breast enlargement. Thus, they should be used only for dangerous sex offenders. Occasionally, they may be used under the Mental Health Act. If so, this requires the support of two approved consultant psychiatrists as well as the subject's own informed consent.

• Psychodynamic psychotherapy explores possible origins of the sexual deviation in disturbed relationships or repressed events in childhood. This option is less used nowadays, because of the move toward evidence-based treatments.

GENDER-IDENTITY DISORDERS

Few of the above treatments have been rigorously demonstrated to be effective, and it is particularly important to remember this in forensic cases. Therapeutic optimism has led to some recidivist sexual offenders being removed from the criminal justice system into the health-care system, and subsequent reoffending wrongly attributed by the media to failures of psychiatric care rather than the elective behaviour of the offender. Some sex offenders express a wish for psychiatric help because they hope to avoid a prison sentence.

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