Impact case study
Changing Policy and Practice to Widen the use of Anti-Libidinal Medication to Reduce Problematic Sexual Arousal for People Convicted of a Sexual Offence
Unit(s) of assessment: Psychology, Psychiatry and Neuroscience
Research theme: Safety and Security of Citizens and Society
School: School of Social Sciences
Sexual offending is at its highest recorded level since 2002. The Office for National Statistics estimates that 700,000 sexual offences are committed against adults and children annually and the Ministry of Justice reports that 13,400 people are serving prison sentences for a sexual offence (19% of the prison population and rising). This makes sexual offending a significant health, social and financial concern.
Since 2000, problematic sexual arousal (PSA; also termed sexual preoccupation, hypersexuality and sexual compulsivity) has been highlighted as an important dynamic risk factor for sexual (re)offending. Despite this, PSA is the sole known risk factor that is not directly addressed by UK sexual offending treatment programmes (SOTPs). Individuals suffering from PSA are more likely to reoffend, both in prison and the community, and PSA also appears to be a barrier to meaningful engagement in SOTPs, meaning it must be addressed prior to psychological interventions.
In this five-year period, research by NTU’s Sexual Offences, Crime and Misconduct Research Unit (SOCAMRU) has:
- Demonstrated the effectiveness of Fluoxetine (Selective Serotonin Reuptake Inhibitors; SSRI) as a prescription option for problematic sexual arousal (PSA)
- Initiated a new UK treatment pathway across eight prisons and the community
- Directed UK government debate about the prescription of anti-libidinal medication
- Ensured that medical professionals and the UK Parole Board understand the research regarding the use of anti-libidinal medication
- Provided training for prison and probation staff about anti-libidinal medication
- Expanded international knowledge about best practice use of anti-libidinal medication among prison and medical professionals
This research provides the first empirical evidence for the clinical effectiveness of SSRI, Fluoxetine (currently prescribed off-label) in reducing difficulties associated with PSA and the crucial basis for further and on-going research. The results have been a critical contribution to national and international changes in best practice for reducing PSA and risk of sexual reoffending.
The utility of pharmacological treatment for the treatment of PSA was raised in the 1990s by researchers. However, before research by NTU's Sexual Offences, Crime and Misconduct Research Unit, anti-libidinal medication as a potentially valuable addition to the treatment of people convicted of sexual offences (PCSOs) had not been empirically evaluated in the UK prison context, and there was no such treatment pathway available.
In 2007, Her Majesty’s Prison and Probation Service (HMPPS) facilitated a pilot trial in HMP Whatton, one of the largest prisons for PCSOs in Europe, and the trial commenced in 2009. The SOCAMRU team were approached by the Governor of HMP Whatton to lead the evaluation of this trial, due to their record of peer-reviewed studies in prisons, which began in 2011 led by Professor Belinda Winder. This research has been funded by Nottingham Trent University, HMP Whatton, Nottinghamshire Offender Healthcare, and the Offender Personality Disorder pathway, with the aim of addressing the health, social and financial impact of sexual offending.
Since 2014, the SOCAMRU team has published the first longitudinal studies demonstrating the impact of pharmacological treatment on PSA for PCSOs, assessed through multiple clinical tools and psychometrics. This research has demonstrated that both Selective Serotonin Reuptake Inhibitors (SSRIs; mainly Fluoxetine) and Anti-androgens (AAs) are effective at reducing difficulties associated with PSA by 50% and to levels similar to the general public. In their 2021 study, both medications reduced the number of participants exhibiting problematic/clinical levels of sexual compulsivity, while these effects were not found for a control group. This triggered the decision by the National Offender Management Service (NOMS) in April 2016, to make anti-libidinal medication available across the majority of the UK prison estate.
Furthermore, between 2014 and 2018, the team conducted the first qualitative research into pharmacological treatment of PSA, conducting interviews with: (i) prison officers and psychological therapists (ii) PCSOs taking anti-libidinal medication for PSA and (iii) probation staff who managed PCSOs in the community. This research has corroborated the finding that pharmacological treatment is effective in managing PSA and allows PCSOs more ‘head space’ to engage in psychological interventions, which are essential to effective treatment. Furthermore, it demonstrated the need for training to help prison staff understand who should be referred for the medication and how individuals taking the medication could be better supported, as well as for probation staff on what taking the medication may mean about the individual’s risk in the community.
Demonstrated the effectiveness of Fluoxetine (Selective Serotonin Reuptake Inhibitors; SSRI) as a prescription option for problematic sexual arousal (PSA)
Initiated a new UK treatment pathway across eight prisons and the community
Directed UK government debate about the prescription of anti-libidinal medication
Ensured that medical professionals and the UK Parole Board understand the research regarding the use of anti-libidinal medication
SOCAMRU research demonstrated that Parole Boards were sometimes ‘seeing’ prisoners on anti-libidinal medication as being more risky than other prisoners, since they needed ‘drugs’ to control themselves. Based on the work of the SOCAMRU team, changes were made to Parole Board Guidance to ensure that, parole boards understand the evidence regarding the use of anti-libidinal medication for PSA and have the confidence to make effective decisions in cases where the individual is taking this medication. An article was published in the Independent Monitoring Board magazine, a magazine sent to all members of the Association of Member of Independent Monitoring Board (AMIMB), where experts address a range of topics and identify best practice.
Provided training for prison and probation staff about anti-libidinal medication
Expanding international knowledge about best practice use of anti-libidinal medication among prison and medical professionals
The research team has worked with a wide-ranging group of international experts to create consistency and encourage international good practice. For example, in June 2019, the Justice Health Research Program in Sydney, Australia, requested ongoing support and guidance in setting up their own programme and evaluation of the medication. This research was helpful in guiding treatment approaches for PCSOs under supervision in the community, on parole, and those returning to the community across the country, thereby addressing Australian Government research priority Safeguarding Australia, which seeks to “protect Australia from terrorism and crime”. The Head of the Justice Health Research Program described the ‘valuable collaborative’ relationship with Winder and noted that Winder had successfully ‘advised on the study and also offered guidance for therapeutic intervention within our program’.
- Lievesley, R., Elliott, H.J., Winder, B., & Norman, C. (2014). Understanding service users’ and therapists’ experiences of pharmacological treatment for sexual preoccupation and/or hypersexuality in incarcerated sex offenders. The Journal of Forensic Psychiatry and Psychology, 25: 3, 262-287. Doi:10.1080/14789949.2014.909867.
- Elliott, H., Winder, B., Manby, E., Edwards, H., & Lievesley, R. (2018). “I kind of find that out by accident”: probation staff experiences of pharmacological treatment for sexual preoccupation and hypersexuality. Journal of Forensic Practice, 20(1), 20-31.
- Winder, B., Lievesley, R., Kaul, A., Elliott, H. J., Thorne, K., & Hocken, K. (2014). Preliminary evaluation of the use of pharmacological treatment with convicted sexual offenders experiencing high levels of sexual preoccupation, hypersexuality and/or sexual compulsivity. The Journal of Forensic Psychiatry & Psychology, 25(2), 176–194.DOI:10.1080/14789949.2014.903504.
- Winder, B., Lievesley, R., Elliottt, H., Hocken, K., Faulkner, J., Norman, C. & Kaul, A. (2018). Evaluation of the use of pharmacological treatment with prisoners experiencing high levels of hypersexual disorder. Journal of Forensic Psychiatry and Psychology, 29:1, 53-71, DOI: 10.1080/14789949.2017.1337801.
- Winder, B., Fedoroff, J. P., Grubin, D., Klapilová, K., Kamenskov, M., Tucker, D., & Vvedensky, G. E. (2019). The pharmacologic treatment of problematic sexual interests, paraphilic disorders, and sexual preoccupation in adult men who have committed a sexual offence. International Review of Psychiatry, 1-10.
- Winder, B., & Blagden, N. (2020). In C. Stott, B. Bradford, M. Radburn, & L. Savigar-Shaw (Eds.), Making an Impact on Policing and Crime: Psychological Research, Policy and Practice. Routledge.