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 testosterone levels

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

4. Physiology of Testosterone
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

5. Hypothalamus and Pituitary Gland

7. Role of the Hypothalamus
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.

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

9. Function of Hypothalamus and GnRH

10. Types of Treatment
Surgical
Medical

11. Surgical treatments

12. Castration 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

14. Stereotaxic neurosurgery
Removes part of the hypothalamus
Disrupts production of testosterone
Reduces sexual arousal
Reduces impulsive behavior
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
Deviant sexual fantasies, urges and behaviors of men with paraphilias are triggered by testosterone
Can be achieved with numerous medications

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

18. Antiandrogen medication
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

19. Side effects of Cyproterone Acetate
Gynecomastia
Thromboembolic phenomenon
Depression
Liver damage
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
Effective in reducing recidivism rates
Known as Depo-Provera

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

22. Gonadotropin releasing hormone agonists
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

23. Function of Hypothalamus and GnRH

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

25. Side effects of Triptorelin
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

26. Alternate Medical Treatments
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
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
Reduce sexual urges
Inhibit orgasm
May also include Buspirone, an anxiolytic medication