Given these clinical caveats, antiandrogens should still remain as the treatment of choice for sexually dangerous paraphiliacs. Pharmacotherapy with serotonergic antidepressants requires a highly motivated patient inasmuch as no antidepressant is currently available as a parenteral preparation. In that regard, fluoxetine in comparison to the other SSRIs has the advantage of a long metabolic half-life, so that an occasional missed dose should not affect clinical status.

Last, from this clinician's experience, the antiandrogen medroxyprogesterone acetate (and likely cyproterone acetate), either as an oral or parenteral preparation, can be combined safely and administered concomitantly with an SRI. In these circumstances, this combination has several potential advantages, including the use of a relatively lower dose of antiandrogen to have a beneficial clinical effect, a potential additive effect to rapidly control socially deviant sexual arousal and the ability to maintain control over sexual impulsivity symptoms when switching from one SRI to another agent.

Paraphilias and paraphilia-related disorders are more clinically prevalent than most clinicians suspect. Since these disorders are cloaked in shame and guilt, it is common that the diagnosis of these conditions may not be adequately revealed until a therapeutic alliance is firmly established. Even then, it is more helpful to inquire directly about sexual impulsivity disorders than to hope or expect that a patient will be spontaneously forthcoming. Once a diagnosis is established, appropriate psychoeducation regarding sexual diagnoses, associated Axis I comorbidity and appropriate use of psychopharmacological agents can greatly improve the prognosis for these conditions.
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