VIOLATORS HAVE MORE RIGHTS THAN THE SICK, THE SAME DRUGS FOR ENDOMETRIOSIS AND VIOLATORS
It is scandalous that there is an ethical debate on the use of these drugs for rapists, because of their side effects and that those who suffer from endometriosis are applied without ethics or debate.
RAPISTS HAVE MORE RIGHTS AND INFORMATION THAN WE DO.
“Side effects also include increased appetite, weight gain of fifteen to twenty pounds, fatigue, mental depression, hyperglycemia, impotence, abnormal semen, decreased ejaculatory volume, insomnia, nightmares, dyspnea (difficulty breathing), hot and cold flashes, loss of body hair, nausea, leg cramps, irregular gallbladder function, diverticulitis, a worsening of migraine, hypogonadism, elevation of blood pressure, hypertension, phlebitis, diabetic sequelae, thrombosis (leading to heart attack), and contraction of the prostate and seminal vessels” 10 10 Therefore the drug treatment to be used instead of imprisonment will have to foresee significant risks to the health of the defendant. The drug should not be experimental and should be routinely prescribed by the medical community for this use. Furthermore, it should be used in conjunction with appropriate psychotherapy.
Pharmacological interventions with adult male sex offenders
Approved by the ATSA Executive Board of Directors on August 30, 2012
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The treatment of sexual offending behaviors is complex and involves multiple etiologies, individualized risk reduction and risk management needs, and heterogeneous biopsychosocial, interpersonal, and legal factors. Clinicians and researchers have attempted to identify approaches that promise the greatest success in treating these behaviors. The results of a meta-analysis examining the effectiveness of various treatment interventions for adult sex offenders indicated that, when used in combination with other treatment methods, biological interventions such as hormonal testosterone treatments to lower testosterone may be associated with a greater reduction in recidivism for some offenders than the use of psychosocial treatments alone (Losel & Schmucker, 2005). Other data, described below, suggest that non-hormonal psychotropic medications may also be effective complements to standard therapeutic interventions for sex offenders as well.
This paper is designed to provide an overview of the key issues related to the use of hormonal and non-hormonal agents to reduce or inhibit sexual arousal and recidivism in some sex offenders. [I] Mechanism of action, expected outcomes of drug administration, side effects, ethical considerations, and empirical evidence regarding the efficacy of drug interventions will be highlighted. It should be noted that pharmacological interventions are not typically used for all sex offenders, but are often applied to those with paraphilias or specific patterns-typification of sexual arousal, which could be altered by the use of this type of intervention. In addition, these types of interventions should be integrated into a comprehensive treatment program that addresses other static and dynamic risk factors that contribute to sexual offending.
Hormonal agents for the management of sexually abusive and paraphilic behaviour
A number of hormonal agents have been introduced as drug treatments to reduce testosterone and sexual desire in people with paraphilias and/or who have engaged in sexually abusive behavior.
Major examples include:
GINECRIN DEPOT 3.75 mg (ABBOTT SCIENTIFIC)
PROCRIN VIAL: 2.8 mL (ABBOTT)
PROCRIN DEPOT: 7.5 mg/vial (ABBOTT)
PROCRIN 22.5 mg/vial (ABBOTT)
– Cyproterone acetate
CIPROTERONE/ETHINYLESTRADIOL ACETATE GINESERVICE Comp. 2/0.035 mg
SANDOZ EFG CIPROTHERONE/ETHINYLESTRADIOL ACETATE Film-coated comp. 0.035 mg/2.0 mg
ANDROCUR Comp. 50 mg
CLIMEN Coated Comp. 2/1 mg
DIALIDER Film-coated comp. 0.035/2 mg DIANE 35 Film-coated comp.
DIANE 35 Coated comp. 0.035/2 mg
DIANE 35 DAILY Coated comp. 0.035/2 mg
GYNEPLEN Comp. 2 mg/0.035 mg
-Gonadotropin-releasing hormone analog.
Some research suggests that offenders treated with anti-androgens, compared with those who have not received such treatment, have lower rates of detected sexual recidivism, as well as decreased sexual arousal in response to the specific offence, stimulated by self-reporting and physiological testing (e.g. Maletzky, Tolan, and McFarland, 2006; see also Briken and Kafka, 2007). However, there is also evidence that offenders treated with hormonal agents alone show similar rates of sexual recidivism after a standard course of drug therapy and follow-up as their non-hormonally treated counterparts (for example, Maletzky, 1991; McConaghy, Blaszczynski, and Kidson, 1988). Overall, well-designed control studies are lacking, and more rigorous empirical research is needed in this area.
The use of antiandrogens carries negative and punitive connotations (i.e., linked to the idea of “castration”), and testosterone lowering agents have important medical side effects (e.g., breast enlargement or swelling, weight gain, blood clots, depression, gallstones, diabetes mellitus, osteoporosis, hot flashes). As a result, individuals may be prone to refuse such treatments, or to later demonstrate non-compliance after they initially agree to a treatment regimen.
The limited outcome data on all testosterone lowering agents make definitive therapeutic recommendations premature. Due to significant side effects, prescription of these drugs should be limited to paraphiliac patients and sex offenders with at least moderate or high risk of practice in sex crimes. In addition, because other causes and risk factors are present, the use of hormonal agents should be combined with empirically supported psychotherapy practices (Briken, Hill, & Berner, 2003).
Non-hormonal agents for the management of sexually abusive and paraphilic behaviors
Studies of sex offenders, men with paraphilias, and those with non-paraphilic expressions of ‘hypersexuality’ suggest that mood disorders (dysthymic disorder, major depression and bipolar spectrum disorders), certain anxiety disorders (mostly social anxiety disorder and post-traumatic onset childhood stress disorder), Substance abuse disorders (especially alcohol abuse), attention deficit/hyperactivity disorder (ADHD), and neuropsychological conditions (e.g., schizophrenia, Asperger’s syndrome, and head injury) may occur more frequently than expected in sexually impulsive men, including sexual offenders (e.g., Kafka, 1994, 1998, and 2002).
Empirically established effective drug treatments for mood disorders, ADHD, and impulsivity are well documented. These conditions affect prefrontal/orbital frontal executive function and are associated with impulsivity; therefore, improvement of such conditions could certainly affect, if not significantly improve, the propensity to be sexually impulsive.
Although there is much evidence demonstrating the efficacy of these treatments for other Axis I disorders, few empirical studies have examined the role of these interventions in reducing sexual arousal or sexual assault. One retrospective study reported a significant reduction in paraphilic activity among participants (Kraus, Strom, Hill, et al., 2007), all of whom had received selective serotonin reuptake inhibitor (SSRI) medications and psychotherapy.
Literature supporting the prescriptive use of mood stabilizers such as limbic anti-convulsants and atypical neuroleptics for sex offenders is insufficient. There have also been reports of sporadic cases of prescriptive use of naltrexone for adults with “compulsive sexual behavior” (Raymond, Grant, Kim, & Coleman, 2002).
Although there are no placebo-controlled, double-blind treatments of the efficacy of SSRIs for the treatment of sex offenders, such medications have been reported as the most commonly prescribed agents for sex offenders (i.e., 50.3% of the community and 55 3% of housing programs in the United States, and 47.4% of community and 75% of residential programs in Canada, treat adult male sex offenders by prescribing such medications), at least in the United States and Canada (McGrath, Cummings, Burchard, Zeoli, and Ellerby, 2010).
As is the case with hormonal agents, the prescriptive use of non-hormonal pharmacological agents for the treatment of sex offenders does not address all etiologies and risk factors and therefore must be combined with sex offender-specific psychotherapy.
Support for research into the effectiveness of drug treatments, such as testosterone-reducing agents is mixed. Without clear data on the efficacy of these treatments, providers must ensure that they balance the risks of such interventions with the potential benefits of the treatment.
Medications available for anti-androgen therapy often cause significant negative side effects for men who take them, including metabolic changes, fatigue, gastrointestinal problems, cardiovascular problems, bone loss, and headaches (Giltay & Gooren, 2009).
In addition to these systemic effects that can compromise an offender’s health, these medications may also contribute to increased depression and mood instability, which have been identified as possible dynamic risk factors for actually increasing the risk of sexual recidivism (e.g. Hanson and Harris, 2000) . Similarly, reducing the sex drive may contribute to difficulties in forming healthy intimate relationships, and these support systems may be necessary to improve quality of life and reduce the risk of continued sexual violence. While the use of other non-hormonal agents may produce less aversive side effects than those associated with hormonal agents, side effects are still a concern and may affect the decision to use such interventions.
Access to these specific forms of treatment may be limited for some offenders, either because of cost or the availability of qualified medical professionals experienced in the use of this type of medication, especially in individuals with paraphilias or problematic sexual behaviour. Whenever possible, physicians should be included as part of the treatment team.
As noted above, because of unpleasant side effects and other complaints, there are often compliance problems among those selected to take anti-androgen medications. Not only should providers consider medication refusal, but also the possible use of illegally obtained anabolic steroids or other hormonal agents to counteract androgen reduction or the use of sildenafil citrate (Viagra), tadalafil (Cialis), or other similar medications to increase sexual response. In addition, providers may be pressured to administer such medications unintentionally, adding legal and ethical conflicts to the prescribing of physicians and their clients.
The potential benefits and risks of many anti-androgen medications such as medroxyprogesterone acetate have not been evaluated by the U.S. Federal Drug Administration as a treatment for adult men or as a treatment for controlling sexual behavior. Therefore, the immediate and long-term impact of these medications on adult male sex offenders has not been thoroughly tested and remains unknown. And in some jurisdictions or agencies, off-label use of pharmacological interventions is strongly discouraged. Insurance companies may be less likely to reimburse you for the use of off-label medications, thus increasing the cost of treatment compliance.
The use of anti-androgen drugs to reduce sexual desire and therefore sexual behaviour could be classified as a form of chemical restraint, a practice generally used to describe efforts to sedate or restrict the freedoms of psychiatric patients. However, this definition could be expanded to include the use of specific hormonal agents to restrict sexual freedoms and behaviors. The use of such chemical interventions – particularly unintentional – as forms of coercion carries a negative ethical connotation and may be illegal in some jurisdictions. In addition, in some agencies involving persons with intellectual and developmental disabilities, policies exist that prohibit the limitation of individuals’ sexual behaviors and freedoms (which result as a reaction to prior efforts to sterilize or control the otherwise reproductive behaviors of such individuals), and the use of such medications may in fact violate these policies.
A variety of pharmacological interventions, both hormonal and non-hormonal, are used with adult sex offenders, although only limited empirical research has been conducted on the use and effectiveness of these medications as preventive strategies for continued sexual assault in paraphiliac offenders. Preliminary evidence suggests that they may be effective interventions for reducing paraphilic sexual arousal and associated sexual offending.
When pharmacological intervention is used, physicians should be included as part of the treatment team.
Pharmacological treatments should not be used as ‘stand-alone’ interventions, and are very well combined with other therapeutic treatment modalities, most commonly cognitive behavioural based treatments, in addition to community-based and supervised probation or parole interventions. These treatments hold promise as an important aspect of sex offender management.
Briken, P., Hill, A., and Berner, W. (2003). Pharmacotherapy of paraphilias with long-acting luteinizing hormone-releasing hormone agonists: a systematic review. Journal of Clinical Psychiatry. 64. 890-897.
Briken, P., and Kafka, M. P. (2007). Drug treatments for paraphiliac patients and sex offenders. Current views in Psychiatry. 20. 609-613.
Giltay, E. J., and Gooren, L.J.G. (2009). The possible side effects of androgen deprivation treatment in sex offenders. Journal of the American Academy of Psychiatry and the Law, 37 (1), 53- 58.
Hanson, R.K. and Harris, A.J.R. (2000). Where should we intervene? Dynamic Predictors of Sexual Crime Recidivism. Criminal Justice and Behavior, 27, 6-35.
Kafka, M.P., and Hennen, J. (2002). A study of Axis I DSM IV comorbidity of men (n¼120) with paraphilias and paraphily-related disorders. Sexual Abuse: A Journal of Research and Treatment. 14. 349 a 366.
Kafka, M. P., and Prentky, R. A. (1994). Preliminary observations of DSM III-R for Axis I comorbidity in men with paraphilias and paraphily-related disorders. Journal of Clinical Psychiatry. 55. 481 a 487.
Kafka, M. P., and Prentky, R. A. (1998). Attention-deficit hyperactivity disorder in males with paraphilias and paraphilia-related disorders: a study of comorbidity. Journal of Clinical Psychiatry. 1998; 59: 388-396.
Kraus, C., Strohm, K., Hill, A., et al. (2007). Selective serotonin reuptake inhibitors (SSRIs) in the treatment of paraphilia: a retrospective study [in German]. Fortschr Neurol Psychiat. 75. 350-136.
Losel, M, Y Schmucker, M. (2005). The effectiveness of treatment for sex offenders: a comprehensive meta-analysis. Journal of Experimental Criminology. 1. 117-146.
Maletzky, B.M. (1991). The use of medroxyprogesterone acetate to assist in the treatment of sex offenders. Annals of Sexual Research. 4. 117-129.
Maletzky, BM, Tolan, A., and McFarland, B. (2006). The Oregon Depo-Provera program: a five-year follow-up child. Sexual abuse: a journal of research and treatment. 18. 303 a 316.
McConaghy, N., Blaszczynski, A., and Kidson, W. (1988). Treatment of sex offenders with desensitization and/or imaginal medroxyprogesterone. Scandinavian Psychiatric Act. 77. 199-206.
McGrath, RJ, Cummings, GF, Burchard, BL, Zeoli, S., and Ellerby, L. (2010). Current Practices and New Trends in Managing Sexual Abusers: The 2009 North American Safer Society Survey. Brandon, VT: Safer Society Foundation Inc.
Raymond, N., Grant, JE, Kim, SW, and Coleman, E. (2002). Treating compulsive sexual behavior with naltrexone and selective serotonin reuptake inhibitors: two case studies.
International Journal of Psychopharmacology. 17. 201 a 205.
Ryback, R.S. (2004). Naltrexone in the treatment of adolescent sex offenders. Journal of Clinical Psychiatry. 65. 982-986.
Sandyk, R. (1988). Naltrexone suppresses abnormal sexual behaviour in Tourette’s syndrome. International Journal of Neuroscience. 43. 107-110.
i] This fact sheet only addresses issues related to the use of pharmacological interventions with adult sex offenders. Effective interventions and best practices for adolescents will be addressed in forthcoming ATSA publications (see, for example, the policy paper entitled, Adolescents who have committed sexually abusive behavior: Effective policies and practices, and Practice Guidelines for Adolescents). Treatment providers should use caution when considering the use of hormonal or even non-hormonal treatments with adolescents who have committed sexual offenses. These individuals may be more susceptible to the side effects of these medications, and due to developing physiology may respond to these interventions in a more unpredictable and idiosyncratic manner.
In general terms, so-called “chemical castration” consists of treating the sex offender with a series of drugs that aim to reduce the levels of testosterone in the man. One of the most commonly used drugs for this purpose is Depo-Provera,
What is chemical castration? – Very Interesting
What is chemical castration and how does it work?
Support for Chemical Castration for Rapists and Pedophiles
Chemical castration methods
Chemical castration – an ethical alternative?