16 The defendant is currently prescribed Sertraline by Dr Korbel. Sertraline is a selective serotonin reuptake inhibitor (SRRI). He has also been prescribed Cialis, a medication for erectile dysfunction, by his private general practitioner. The use of Sertraline (conventionally prescribed as an anti-depressant), or the use of SSRIs generally to address paraphiliac disorders, is relatively new. While preliminary clinical trial data indicates that SSRIs reduce deviant sexual fantasy arousal and associated behaviours there are no current studies establishing any link between the prescription of SSRIs and reduced rates of recidivism. Dr Roberts was of the view however that since there is evidence to support use of the medication in the treatment of paraphilia and the suppression of other deviant sexual desires the absence of a link of that kind was not a prohibiting factor. That said, since the effect of Sertraline is idiosyncratic, in the sense that there can be no accurate prediction as to whether it will cause either a desired effect or side effects, continued supervision of the defendant and his response to the proposed pharmaceutical regime is essential. Dr Roberts did emphasise that the use of SSRIs for the reduction of sexual function would be considered "an off label use" such that the pharmaceutical companies that produce the drug would not sanction it for that use. As a consequence, it is not supported under the Pharmaceutical Benefits Scheme.
17 The doctors emphasised that given the chronicity of the defendant's disorder Sertraline was not the preferred treatment. Dr Ellis emphasised the advantage of treatment by anti-libidinal hormonal medication, where it is not contraindicated, in that observational studies conducted over an extended period bear out a relationship between the use of the drug and a reduction in the rates of recidivism in serious sex offenders. In addition, the use of hormonal medication is more reliably monitored as compared with SSRIs since compliance (and the effectiveness of the hormonal medication in reducing deviant sexual arousal) can be measured by the extent to which testosterone levels are reduced on serum testing. By contrast, monitoring compliance with a regime of treatment by SSRIs is neither practical or affordable and the measurement of the drug's efficacy in suppressing sexual desire depends largely on self report.
18 The doctors were asked to consider whether an SSRI has any work to do in circumstances where the subject denies deviant sexual fantasy - the position strenuously advocated by the defendant. Dr Ellis was of the view that treatment by SSRIs may prevent the occurrence of deviant sexual fantasies even in a person who falsely denies experiencing them. On the other hand, where the subject's sexual fantasies are unconscious, or not necessarily accessible to a rational conscious awareness, the drug may have a role to play in suppressing the emergence of sexual fantasies at a conscious and rational level and be effective in this way.
19 The doctors were of the shared view that the defendant should remain under continued psychiatric observation and treatment and that his current pharmaceutical regime be the subject of ongoing monitoring and adjustment, particularly if there is an admitted or observed emergence of deviant sexual fantasies, urges or behaviour and generally be maintained to minimise the risk of him committing a serious sex offence, a risk which remains high. It was also the recommendation of the psychiatrists that any medication for erectile dysfunction be discontinued at this time in order that the cause of his dysfunction, whether it be psychological or physiological, be investigated. While there was no reason to suppose that the use of Cialis would decrease the effectiveness of the Sertraline it was the shared view of the experts that further investigation was called for.
20 It was also the view of the doctors that the defendant not engage with multiple treatment providers, such as private psychiatrists, psychologists or relationship counsellors as there is serious risk, in the short term at least, that fragmentation of his therapy will worsen his underlying disordered personality structure. There is no need for me to refer to the evidence bearing upon that issue in detail since the defendant ultimately consented to a condition that he not seek other psychological or psychiatric treatment and advice otherwise than by persons approved by the treating psychiatrist appointed by Justice Health.
21 The defendant sought to persuade me that he should not be the subject of extended supervision for a period in excess of 2 years. It was submitted on his behalf that a further term of supervision of 4 years and 9 months, subject to the same conditions to which he has been subject over the last 3 months, involved an not only an unwarranted curtailment of his liberty but had the potential to hinder his adaptation to community life and his integration into the community. It was also submitted that if at some stage in the course of 2 years of supervision the plaintiff came to the view that the defendant's rehabilitation was not progressing satisfactorily, or that the risk of his reoffending remained high despite treatment of the kind envisaged by the conditions he has expressly consented to, a fresh application for an extended supervision order could be made. This approach, so it was argued, ensured a proper balance between the safety and protection of the community and the rehabilitation of the defendant as a serious sex offender as the dual statutory objects provide for in s 3 of the Act.