Medical and Surgical Medical and Surgical Treatment of Sex OffendersTreatment of Sex Offenders

Alina Gonzalez-Mayo, M.D.Alina Gonzalez-Mayo, M.D.

St. Petersburg, FloridaSt. Petersburg, Florida

Purpose of TreatmentPurpose of Treatment

Reduce the deviant sexual urges and behaviors Reduce the deviant sexual urges and behaviors of paraphiliacs of paraphiliacs

Reduce testosterone levelsReduce testosterone levels

Role of Human TestosteroneRole of Human Testosterone

Development of sexual characteristicsDevelopment of sexual characteristics Control of sexualityControl of sexuality AggressionAggression CognitionCognition EmotionEmotion PersonalityPersonality Major determinant of sexual desire, fantasies Major determinant of sexual desire, fantasies

and behaviorand behavior

Physiology of TestosteronePhysiology of Testosterone

Main androgen produced by the testesMain androgen produced by the testes Produces typical sexual characteristics and Produces typical sexual characteristics and

maintenance of sexual behaviormaintenance of sexual behavior Produced in Leydig cells of the testes by Produced in Leydig cells of the testes by

stimulation of LH and FSH, however, mostly stimulation of LH and FSH, however, mostly LHLH

Hypothalamus and Pituitary GlandHypothalamus and Pituitary Gland

Role of the HypothalamusRole of the Hypothalamus

Links the nervous system to the endocrine systemLinks the nervous system to the endocrine system Synthesizes neurohormones which stimulate the Synthesizes neurohormones which stimulate the

secretion of gonadotropin-releasing hormonesecretion of gonadotropin-releasing hormone Involved in the control of emotions and sexual Involved in the control of emotions and sexual

activity activity Mediates or exerts significant or controlling Mediates or exerts significant or controlling

influences on eating, drinking, sleeping and the influences on eating, drinking, sleeping and the experience of pleasure, rage, and aversion. experience of pleasure, rage, and aversion.

Subject to feedback regulation by the same structures Subject to feedback regulation by the same structures that it controls. that it controls.

Gonadotropin releasing hormone Gonadotropin releasing hormone (GnRH)(GnRH)

The principle regulator of LH and FSH The principle regulator of LH and FSH Ten amino acid peptide that is synthesized and Ten amino acid peptide that is synthesized and

secreted from hypothalamic neurons secreted from hypothalamic neurons BBinds to receptors on gonadotrophs. inds to receptors on gonadotrophs.

Function of Hypothalamus and Function of Hypothalamus and GnRHGnRH

Types of TreatmentTypes of Treatment

SurgicalSurgical

MedicalMedical

Surgical treatmentsSurgical treatments

CastrationCastration

Removal of the testes, the source of Removal of the testes, the source of testosteronetestosterone

Considered cruel and unusual punishmentConsidered cruel and unusual punishment Highly effective in European literature given Highly effective in European literature given

the lower rates of recidivismthe lower rates of recidivism However, not 100% effectiveHowever, not 100% effective

Stereotaxic neurosurgeryStereotaxic neurosurgery

Removes part of the hypothalamusRemoves part of the hypothalamus Disrupts production of testosteroneDisrupts production of testosterone Reduces sexual arousalReduces sexual arousal Reduces impulsive behaviorReduces impulsive behavior Significantly high failure rates Significantly high failure rates

Medical treatmentsMedical treatments

Role of medicationsRole of medications

Goal of treatment is to reduce the level of Goal of treatment is to reduce the level of testosterone, thus, reducing the sexual drivetestosterone, thus, reducing the sexual drive

Deviant sexual fantasies, urges and behaviors Deviant sexual fantasies, urges and behaviors of men with paraphilias are triggered by of men with paraphilias are triggered by testosteronetestosterone

Can be achieved with numerous medicationsCan be achieved with numerous medications

Ways of reducing testosteroneWays of reducing testosterone

Antiandrogen medicationAntiandrogen medication Progestin derivedProgestin derived Gonadotropin releasing hormone agonistsGonadotropin releasing hormone agonists

Antiandrogen medicationAntiandrogen medication

Cyproterone acetate (CPACyproterone acetate (CPA): works by ): works by blocking testosterone receptors and blocking testosterone receptors and suppressing the effects of testosterone on the suppressing the effects of testosterone on the tissuestissues

Lowers testosterone Lowers testosterone Blocks LH and FSH secretionBlocks LH and FSH secretion Effective in reducing recidivism ratesEffective in reducing recidivism rates

Side effects of Cyproterone AcetateSide effects of Cyproterone Acetate

GynecomastiaGynecomastia Thromboembolic phenomenonThromboembolic phenomenon DepressionDepression Liver damageLiver damage Bone mineral lossBone mineral loss

Progestin derivedProgestin derived

Medroxyprogesterone acetate(MPAMedroxyprogesterone acetate(MPA): acts ): acts on the brain to inhibit hormones that stimulate on the brain to inhibit hormones that stimulate the testes and the release of testosteronethe testes and the release of testosterone

Effective in reducing recidivism ratesEffective in reducing recidivism rates Known as Depo-ProveraKnown as Depo-Provera

Side effects of MedroxyprogesteroneSide effects of Medroxyprogesterone

Weight gainWeight gain LethargyLethargy NightmaresNightmares HyperglycemiaHyperglycemia Leg crampsLeg cramps Bone mineral lossBone mineral loss

Gonadotropin releasing hormone Gonadotropin releasing hormone agonistsagonists

Leuprolide and TriptorelinLeuprolide and Triptorelin : causes release : causes release of FSH and LH which later paradoxically of FSH and LH which later paradoxically inhibits their releaseinhibits their release

Release of testosterone from the testes Release of testosterone from the testes decreasesdecreases

Useful alone or in combination with Useful alone or in combination with antiandrogensantiandrogens

Effective in reducing recidivism ratesEffective in reducing recidivism rates

Function of Hypothalamus and Function of Hypothalamus and GnRHGnRH

Advantages of TriptorelinAdvantages of Triptorelin

PotentPotent Effective in men resistant to other treatmentsEffective in men resistant to other treatments May cause bone lossMay cause bone loss Given 1x monthGiven 1x month Reduces abnormal sexual behaviorReduces abnormal sexual behavior

Side effects of TriptorelinSide effects of Triptorelin

Reduction in mean volume of bone mineralReduction in mean volume of bone mineral Transient pain at injection siteTransient pain at injection site Hot flashesHot flashes Decreased growth of facial and body hairDecreased growth of facial and body hair AsteniaAstenia Progressive erectile failure proportional to age Progressive erectile failure proportional to age

(found in all men over the age of 35)(found in all men over the age of 35) HypogonadismHypogonadism

Alternate Medical TreatmentsAlternate Medical Treatments

Oral estrogensOral estrogens: too many side effects to : too many side effects to recommend their userecommend their use

Typical AntipsychoticsTypical Antipsychotics: of limited use due : of limited use due to side effect profiles, however, may be of to side effect profiles, however, may be of benefit in sex offenders with co-morbid benefit in sex offenders with co-morbid psychiatric disorderspsychiatric disorders

Atypical AntipsychoticsAtypical Antipsychotics: may be of more : may be of more use given the side effect profileuse given the side effect profile

Serotonin Selective Reuptake Serotonin Selective Reuptake InhibitorsInhibitors

May reduce the obsessional components of the May reduce the obsessional components of the paraphiliasparaphilias

Reduce sexual urges Reduce sexual urges Inhibit orgasmInhibit orgasm May also include Buspirone, an anxiolytic May also include Buspirone, an anxiolytic

medicationmedication