Should Hormone Therapy be Considered for Inappropriate Sexual Behavior in Adolescents With Autism Spectrum Disorder?

Leena Nahata, MD, a pediatric endocrinologist at Nationwide Children’s Hospital, has seen this kind of case in her own practice, so she suspects that other specialists have as well:

An adolescent boy with autism spectrum disorder and cognitive impairment is exhibiting sexual behaviors in public that are disturbing to others. His parents are concerned for him and for the safety of younger children in the house. They have learned on the Internet about suppression therapy for luteinizing hormone and testosterone, which they believe can curtail his behavior.

Is it appropriate to provide that therapy? This question was the topic of a recent “Ethics Rounds” feature in Pediatrics, where developmental pediatric specialists and other pediatric endocrinologists provided an answer based on their experiences. Dr. Nahata was senior author of the publication, and Loyal Coshway, MD, former Endocrinology fellow at Nationwide Children’s, was lead author.

In short, the experts advised against using luteinizing hormone releasing hormone agonists in this situation because of:

• Possible health risks to children under 18 associated with long-term use
• The inability of the child to assent to the therapy due to cognitive impairment
• The open-ended use of a therapy actually intended for short-term use
• The lack of evidence concerning effectiveness in adolescents with ASD
• A number of other interventions that could be attempted without similar concerns

“I understand why parents would ask about hormone therapy,” says Dr. Nahata, who is also medical director of the Fertility and Reproductive Health Program at Nationwide Children’s and a principal investigator in the Center for Biobehavioral Health at The Research Institute at Nationwide Children’s. “They are desperate. They are trying to protect their own child and other children. We all felt, though, that exploring the psychiatric and behavioral health route first would be more appropriate.”

Luteinizing hormone releasing hormone agonists are most often used in pediatric practice to manage precocious puberty – that is, puberty occurring before 9 years of age in a male. But once an acceptable age is reached, the medication is stopped and puberty is allowed to continue. The long-term suppression of testosterone, as contemplated for the child with ASD, could have implications for growth and bone density.

Ultimately, hormone therapy would not address the underlying issues for the patient with ASD and inappropriate sexual behavior, says Dr. Nahata. The patient’s hormone levels are actually age-appropriate. Cognitively appropriate sexual education, behavioral interventions, and pharmacotherapy with serotonin reuptake inhibitors (SSRI) or other psychiatric medications are better first-line options for patients in this situation.

All of that, however, is easier said than done for many people.

“You are potentially talking about committing to weekly therapy sessions and waiting weeks or months to see benefits from psychiatric medications,” says Dr. Nahata. “It’s easy for us as providers to say, “come in for therapy,” while parents have to take time off from work, and in some cases have to find transportation. In some areas, pediatric behavioral health experts are hard to find. These are all real world problems that we do not have good solutions for.”

Reference:

Coshway L, Broussard J, Acharya K, Fried K, Msall ME, Lantos JD, Nahata L. Medical therapy for inappropriate sexual behaviors in a teen with autism spectrum disorder. Pediatrics.  2016 Apr;137(4).