Transcript Medical treatment of sex offenders

Medical and Surgical
Treatment of Sex Offenders
Alina Gonzalez-Mayo, M.D.
St. Petersburg, Florida
Purpose of Treatment
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Reduce the deviant sexual urges and behaviors
of paraphiliacs
Reduce testosterone levels
Role of Human Testosterone
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Development of sexual characteristics
Control of sexuality
Aggression
Cognition
Emotion
Personality
Major determinant of sexual desire, fantasies
and behavior
Physiology of Testosterone
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Main androgen produced by the testes
Produces typical sexual characteristics and
maintenance of sexual behavior
Produced in Leydig cells of the testes by
stimulation of LH and FSH, however, mostly
LH
Hypothalamus and Pituitary Gland
Role of the Hypothalamus
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Links the nervous system to the endocrine system
Synthesizes neurohormones which stimulate the
secretion of gonadotropin-releasing hormone
Involved in the control of emotions and sexual
activity
Mediates or exerts significant or controlling
influences on eating, drinking, sleeping and the
experience of pleasure, rage, and aversion.
Subject to feedback regulation by the same structures
that it controls.
Gonadotropin releasing hormone
(GnRH)
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The principle regulator of LH and FSH
Ten amino acid peptide that is synthesized and
secreted from hypothalamic neurons
Binds to receptors on gonadotrophs.
Function of Hypothalamus and
GnRH
Types of Treatment
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Surgical
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Medical
Surgical treatments
Castration
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Removal of the testes, the source of
testosterone
Considered cruel and unusual punishment
Highly effective in European literature given
the lower rates of recidivism
However, not 100% effective
Stereotaxic neurosurgery
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Removes part of the hypothalamus
Disrupts production of testosterone
Reduces sexual arousal
Reduces impulsive behavior
Significantly high failure rates
Medical treatments
Role of medications
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Goal of treatment is to reduce the level of
testosterone, thus, reducing the sexual drive
Deviant sexual fantasies, urges and behaviors
of men with paraphilias are triggered by
testosterone
Can be achieved with numerous medications
Ways of reducing testosterone
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Antiandrogen medication
Progestin derived
Gonadotropin releasing hormone agonists
Antiandrogen medication
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Cyproterone acetate (CPA): works by
blocking testosterone receptors and
suppressing the effects of testosterone on the
tissues
Lowers testosterone
Blocks LH and FSH secretion
Effective in reducing recidivism rates
Side effects of Cyproterone Acetate
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Gynecomastia
Thromboembolic phenomenon
Depression
Liver damage
Bone mineral loss
Progestin derived
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Medroxyprogesterone acetate(MPA): acts
on the brain to inhibit hormones that stimulate
the testes and the release of testosterone
Effective in reducing recidivism rates
Known as Depo-Provera
Side effects of Medroxyprogesterone
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Weight gain
Lethargy
Nightmares
Hyperglycemia
Leg cramps
Bone mineral loss
Gonadotropin releasing hormone
agonists
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Leuprolide and Triptorelin : causes release
of FSH and LH which later paradoxically
inhibits their release
Release of testosterone from the testes
decreases
Useful alone or in combination with
antiandrogens
Effective in reducing recidivism rates
Function of Hypothalamus and
GnRH
Advantages of Triptorelin
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Potent
Effective in men resistant to other treatments
May cause bone loss
Given 1x month
Reduces abnormal sexual behavior
Side effects of Triptorelin
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Reduction in mean volume of bone mineral
Transient pain at injection site
Hot flashes
Decreased growth of facial and body hair
Astenia
Progressive erectile failure proportional to age
(found in all men over the age of 35)
Hypogonadism
Alternate Medical Treatments
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Oral estrogens: too many side effects to
recommend their use
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Typical Antipsychotics: of limited use due
to side effect profiles, however, may be of
benefit in sex offenders with co-morbid
psychiatric disorders
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Atypical Antipsychotics: may be of more
use given the side effect profile
Serotonin Selective Reuptake
Inhibitors
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May reduce the obsessional components of the
paraphilias
Reduce sexual urges
Inhibit orgasm
May also include Buspirone, an anxiolytic
medication