The effect of assertiveness training, Provera and sex of therapist in the treatment of genital exhibitionism

Langevin 1979 was assessed as high risk of bias because the intervention common to both arms (assertiveness training) could not be blinded.

“We assessed Langevin 1979 as being at high risk of bias for the same reason (the intervention common to both arms of the trial was assertiveness training).”

Only two included studies formally measured recidivism by reports of being charged for sexual offences (Langevin 1979; McConaghy 1988).

“Only two studies formally measured recividism by reports of being charged for sexual offences (Langevin 1979; McConaghy 1988).”

Langevin 1979 compared assertiveness training with MPA (orally) versus assertiveness training alone.

“Langevin 1979 compared assertiveness training with MPA (orally) versus assertiveness training alone.”

Two studies (Langevin 1979; Hucker 1988) were assessed as at 'high' risk of bias for incomplete outcome data, given that Langevin 1979 featured a dropout rate of 67% in the combined treatment arm and 29% in the psychological treatment alone arm.

“We have assessed two studies as at 'high' risk of bias for this criterion (Langevin 1979; Hucker 1988), given that the former featured a dropout rate of 67% in the combined treatment arm and 29% in that involving a psychological treatment alone.”

Two studies (Langevin 1979; Bradford 1993) were assessed as having unclear risk of bias due to lack of information (Langevin 1979) or changes to study protocol based on participants being allowed to change treatment phase (Bradford 1993).

“We assessed two studies as having an unclear risk due to lack of information (Langevin 1979), or changes to study protocol based on participants being allowed to change treatment phase (Bradford 1993).”

Testosterone data are missing from Langevin 1979, but this may have been an artefact of measurement issues (data were described as 'erratic').

“Testosterone data are missing from one study (Langevin 1979), but this may have been an artefact of measurement issues (data were described as”

Langevin 1979 and McConaghy 1988 feature MPA plus psychological treatment versus psychological treatment alone.

“Whilst some trials are superficially similar (Langevin 1979 and McConaghy 1988 feature MPA plus psychological treatment versus psychological treatment alone), the former trial reports few real data for analysis due to catastrophic dropout”

Langevin 1979 reports few real data for analysis due to catastrophic dropout (100% of the MPA arm, 29% of the psychological treatment arm, and 67% of the combined treatment arm left the study).

“the former trial reports few real data for analysis due to catastrophic dropout (100% of the MPA arm of the trial, 29% of the psychological treatment arm, and 67% of the combined treatment arm left the study).”

Of those few remaining in a combined drug and psychological treatment condition, 20% recidivated (Langevin 1979).

“of those few remaining in a combined drug and psychological treatment condition, 20% recidivated.”

All participants in the arm of the trial assessing drug treatment alone dropped out immediately (Langevin 1979).

“all participants in the arm of the trial assessing drug treatment alone dropped out immediately”

Participants who dropped out did so even though treatment had been mandated by the court (Langevin 1979).

“Participants who dropped out did so even though treatment had been mandated by the court (Langevin 1979).”

The largest study in this review randomised 37 men charged with exposure to either MPA (100 to 150 mg daily) with assertiveness training, assertiveness training alone, or both MPA and assertiveness training.

“The largest study in this review randomised 37 men charged with exposure to either medroxyprogesterone acetate (MPA, aka Provera®) almost certainly delivered orally (100 to 150 mg daily) with assertiveness training involving 15 x one-hour sessions of communication-based training and with a third treatment group involving both MPA and assertiveness training (Langevin 1979).”

In Langevin 1979, few participants experienced a decrease in urges to expose themselves.

“indicated that few participants experienced a decrease in urges to expose themselves”

Results for one trial of oral MPA in combination with psychological treatment were discouraging (Langevin 1979).

“In contrast, results for one trial of oral MPA in combination with psychological treatment were discouraging”

It is unclear how the decrease in urges to expose themselves was measured in Langevin 1979.

“but it is unclear how this was measured.”

Six studies provided information on adverse events (Bancroft 1974; Tennent 1974; Langevin 1979; Hucker 1988; McConaghy 1988; Bradford 1993).

“Six studies provided information on adverse events (Bancroft 1974; Tennent 1974; Langevin 1979; Hucker 1988; McConaghy 1988; Bradford 1993).”

All participants in the MPA-only group dropped out immediately (Langevin 1979).

“All participants in the first group dropped out immediately”

Five left the assertiveness training condition (Langevin 1979).

“five left the assertiveness training condition”

Ten left the combined treatment condition (Langevin 1979).

“and 10 left the combined treatment condition (Langevin 1979).”

The most severe dropout took place in the three-armed study conducted by Langevin et al (n = 37) in which MPA, assertiveness training, and MPA combined with assertiveness training, were compared.

“The most severe dropout took place in the threearmed study conducted by Langevin et al (n = 37) in which MPA, assertiveness training, and MPA combined with assertiveness training, were compared.”

The largest study included in the review included only sexual exhibitionists (Langevin 1979).

“the largest study included within this review included only sexual exhibitionists (Langevin 1979).”

Only two of the seven trials described in this report were considered in the Lösel and Schmucker meta-analysis (Langevin 1979; McConaghy 1988), because their inclusion criteria specified recidivism as a prospective outcome.

“Moreover, only two of the seven trials described in this report were considered in their meta-analysis (Langevin 1979; McConaghy 1988), because their inclusion criteria specified recividism as a prospective outcome.”

The difficulty in recruiting participants may be due to factors involving typical characteristics of sex offenders, including denial, cognitive distortion, and antisocial attitudes, as well as the intrinsic consequences of antilibidinal medication such as stigma and perceived demasculinisation.

“This may be due to a number of factors involving typical characteristics of sex offenders, including denial, cognitive distortion, and antisocial attitudes (Hanson 2005), as well as the intrinsic consequences of the use of antilibidinal medication, such as stigma, and psychological effects such as perceived demasculinisation (Langevin 1979).”

In Langevin 1979, randomisation was based primarily on gender of therapist rather than intervention.

“Parallel RCT design, although randomisation was based primarily on gender of therapist rather than intervention.”

In Langevin 1979, allocation concealment (selection bias) was judged at unclear risk.

“Allocation concealment (selection bias) | Unclear risk”

In Langevin 1979, other bias was judged at low risk.

“Other bias | Low risk”

In Langevin 1979, random sequence generation (selection bias) was judged at unclear risk.

“Random sequence genera- tion (selection bias) | Unclear risk”

In Langevin 1979, blinding of participants and personnel (performance bias) was judged at high risk.

“Blinding of participants and personnel (perfor- mance bias) | High risk”

In Langevin 1979, blinding of outcome assessment (detection bias) for all outcomes was judged at low risk.

“Blinding of outcome as- sessment (detection bias) All outcomes | Low risk”

In Langevin 1979, incomplete outcome data (attrition bias) for all outcomes was judged at high risk.

“Incomplete outcome data (attrition bias) All outcomes | High risk”