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Medical and Surgical Treatment of Sex Offenders Alina Gonzalez-Mayo, M.D. St. Petersburg, Florida.

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Presentation on theme: "Medical and Surgical Treatment of Sex Offenders Alina Gonzalez-Mayo, M.D. St. Petersburg, Florida."— Presentation transcript:

1 Medical and Surgical Treatment of Sex Offenders Alina Gonzalez-Mayo, M.D. St. Petersburg, Florida

2 Purpose of Treatment Reduce the deviant sexual urges and behaviors of paraphiliacs Reduce the deviant sexual urges and behaviors of paraphiliacs Reduce testosterone levels Reduce testosterone levels

3 Role of Human Testosterone Development of sexual characteristics Development of sexual characteristics Control of sexuality Control of sexuality Aggression Aggression Cognition Cognition Emotion Emotion Personality Personality Major determinant of sexual desire, fantasies and behavior Major determinant of sexual desire, fantasies and behavior

4 Physiology of Testosterone Main androgen produced by the testes Main androgen produced by the testes Produces typical sexual characteristics and maintenance of sexual behavior 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 Produced in Leydig cells of the testes by stimulation of LH and FSH, however, mostly LH

5 Hypothalamus and Pituitary Gland

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7 Role of the Hypothalamus Links the nervous system to the endocrine system Links the nervous system to the endocrine system Synthesizes neurohormones which stimulate the secretion of gonadotropin-releasing hormone Synthesizes neurohormones which stimulate the secretion of gonadotropin-releasing hormone Involved in the control of emotions and sexual activity 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. 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. Subject to feedback regulation by the same structures that it controls.

8 Gonadotropin releasing hormone (GnRH) The principle regulator of LH and FSH The principle regulator of LH and FSH Ten amino acid peptide that is synthesized and secreted from hypothalamic neurons Ten amino acid peptide that is synthesized and secreted from hypothalamic neurons Binds to receptors on gonadotrophs. Binds to receptors on gonadotrophs.

9 Function of Hypothalamus and GnRH

10 Types of Treatment Surgical Surgical Medical Medical

11 Surgical treatments

12 Castration Removal of the testes, the source of testosterone Removal of the testes, the source of testosterone Considered cruel and unusual punishment Considered cruel and unusual punishment Highly effective in European literature given the lower rates of recidivism Highly effective in European literature given the lower rates of recidivism However, not 100% effective However, not 100% effective

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14 Stereotaxic neurosurgery Removes part of the hypothalamus Removes part of the hypothalamus Disrupts production of testosterone Disrupts production of testosterone Reduces sexual arousal Reduces sexual arousal Reduces impulsive behavior Reduces impulsive behavior Significantly high failure rates Significantly high failure rates

15 Medical treatments

16 Role of medications Goal of treatment is to reduce the level of testosterone, thus, reducing the sexual drive 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 Deviant sexual fantasies, urges and behaviors of men with paraphilias are triggered by testosterone Can be achieved with numerous medications Can be achieved with numerous medications

17 Ways of reducing testosterone Antiandrogen medication Antiandrogen medication Progestin derived Progestin derived Gonadotropin releasing hormone agonists Gonadotropin releasing hormone agonists

18 Antiandrogen medication Cyproterone acetate (CPA ): works by blocking testosterone receptors and suppressing the effects of testosterone on the tissues Cyproterone acetate (CPA ): works by blocking testosterone receptors and suppressing the effects of testosterone on the tissues Lowers testosterone Lowers testosterone Blocks LH and FSH secretion Blocks LH and FSH secretion Effective in reducing recidivism rates Effective in reducing recidivism rates

19 Side effects of Cyproterone Acetate Gynecomastia Gynecomastia Thromboembolic phenomenon Thromboembolic phenomenon Depression Depression Liver damage Liver damage Bone mineral loss Bone mineral loss

20 Progestin derived Medroxyprogesterone acetate(MPA ): acts on the brain to inhibit hormones that stimulate the testes and the release of testosterone Medroxyprogesterone acetate(MPA ): acts on the brain to inhibit hormones that stimulate the testes and the release of testosterone Effective in reducing recidivism rates Effective in reducing recidivism rates Known as Depo-Provera Known as Depo-Provera

21 Side effects of Medroxyprogesterone Weight gain Weight gain Lethargy Lethargy Nightmares Nightmares Hyperglycemia Hyperglycemia Leg cramps Leg cramps Bone mineral loss Bone mineral loss

22 Gonadotropin releasing hormone agonists Leuprolide and Triptorelin : causes release of FSH and LH which later paradoxically inhibits their release Leuprolide and Triptorelin : causes release of FSH and LH which later paradoxically inhibits their release Release of testosterone from the testes decreases Release of testosterone from the testes decreases Useful alone or in combination with antiandrogens Useful alone or in combination with antiandrogens Effective in reducing recidivism rates Effective in reducing recidivism rates

23 Function of Hypothalamus and GnRH

24 Advantages of Triptorelin Potent Potent Effective in men resistant to other treatments Effective in men resistant to other treatments May cause bone loss May cause bone loss Given 1x month Given 1x month Reduces abnormal sexual behavior Reduces abnormal sexual behavior

25 Side effects of Triptorelin Reduction in mean volume of bone mineral Reduction in mean volume of bone mineral Transient pain at injection site Transient pain at injection site Hot flashes Hot flashes Decreased growth of facial and body hair Decreased growth of facial and body hair Astenia Astenia Progressive erectile failure proportional to age (found in all men over the age of 35) Progressive erectile failure proportional to age (found in all men over the age of 35) Hypogonadism Hypogonadism

26 Alternate Medical Treatments Oral estrogens : too many side effects to recommend their use Oral estrogens : too many side effects to recommend their use Typical Antipsychotics : of limited use due to side effect profiles, however, may be of benefit in sex offenders with co-morbid psychiatric disorders Typical Antipsychotics : of limited use due to side effect profiles, however, may be of benefit in sex offenders with co-morbid psychiatric disorders Atypical Antipsychotics : may be of more use given the side effect profile Atypical Antipsychotics : may be of more use given the side effect profile

27 Serotonin Selective Reuptake Inhibitors May reduce the obsessional components of the paraphilias May reduce the obsessional components of the paraphilias Reduce sexual urges Reduce sexual urges Inhibit orgasm Inhibit orgasm May also include Buspirone, an anxiolytic medication May also include Buspirone, an anxiolytic medication


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