Anti-libidinal Medication in Managing Sexual Offenders

1. Anti-libidinal Medication in Managing Sexual Offenders Dr. Karen Harrison Law School, University of Hull.

2. Overview What is anti-libidinal medication? Why might we need it in managing sex offenders? How does it work? Availability in England and Wales. Some legal and ethical issues.

3. What is Anti-libidinal medication? • Also known as: Pharmacotherapy, Biomedical treatment, Chemical castration and Anti-androgen treatment. • Primary effect is to either stop androgens from being produced or to prevent them from working altogether. • Testosterone is thought to influence sexual arousal and responsiveness. • Therefore a reduction in testosterone = a reduction in a man’s libido and desire to engage in sexual activity.

4. Why might we need to use medication in managing sex offenders? Recent events have led to the demonization of all sex offenders but especially paedophiles. Public fear has led to a culture of ‘populist punitiveness’ (Bottoms). Shift from penal welfarism to risk penology. Emphasis on accredited programmes and risk management.

5. Current sentencing options in managing risk. Indeterminate prison sentences. Extended supervision periods. The Violent and Sex Offender Register. The Multi-Agency Public Protection Approach (MAPPA). The community order with requirements e.g. electronic monitoring or exclusion. The Child Exploitation and Online Protection Centre website’s ‘most wanted’ page. Polygraphs.

6. Risk penology. • All based on risk penology. • Emphasis on managing the risk of the offender through containment and surveillance. • Emphasis not on reducing risk of reoffending. • If the offender reoffends this is only used as evidence for further containment and heightened surveillance.

7. Current sentencing options to reduce risk. Sex offender treatment programmes both in prison and within the community. Outreach work. Public education campaigns. Accommodation projects. Circles of Support and Accountability. Informal support and encouragement from MAPPA personnel.

8. But is this enough? Acceptance that we need a strategy based around containment and surveillance, but do we need more than this? Some options centre on penal welfarism but they may not be working effectively enough for those offenders who are high in risk and highly deviant. The only programme which seemed to have positive results for high risk sexual predators is no longer operating. Can we or even should we be including something else in the strategy?

9. The goal of pharmacotherapy “This has changed from the complete suppression of sexual drive, creating an asexual individual, to the selective suppression of deviant sexual urges and fantasies and the relative reduction of normophilic sexual interests”. (Bradford 2012).

10. Types of medication involved • Anti-libidinal medications: • Medroxyprogesterone Acetate (MPA). • Cyproterone Acetate (CPA). • Luteinizing Hormone–Releasing Hormone (LHRH) inhibitors and Long-acting Gonadotropin-releasing Hormones (GnRH) agonists. • Psychotropic medication: • Selective Serotonin Reuptake Inhibitors (SSRIs)

11. Medroxyprogesterone Acetate (MPA) • Main hormonal agent used in the USA (depo-Provera). • Has a tranquilizing effect. • Usually administered through IM injection. • No evidence that a tolerance will develop.

12. Effect of MPA. Effects of MPA include reductions in sex drive, testicular size, spermatozoa, loss of libido and difficulties producing seminal fluid through masturbation. Particularly good for unconventional sexual cravings. Effects usually noted after three-four weeks on the drugs. With complete reversal occurring four-six weeks from cessation of drugs.

13. Side effects of MPA Gagne (1981).

14. Cyproterone Acetate (CPA). • A synthetic steroid analogue. • Usually given in oral form. • Libido decreased within two weeks of treatment. • Effects reversed within four weeks of treatment withdrawal.

15. Effect of CPA. Reductions in sexual drive, erections and the ability to orgasm. Also has negative side effects – although not feminisation. Should not be used with those who had a history of cardiovascular disease, malignancy, deep vein thrombosis and embolism, chronic liver disease, organic brain disease, chronic alcoholism, diabetes mellitus, active psychosis, severe chronic depression and sickle cell anaemia.

16. Luteinizing-Hormone Releasing Hormone (LHRH) inhibitors and Gonadotropin-releasing Hormones (GnRH) agonists • Works by inhibiting testosterone production. • ‘Flare-up’ effect noticed for first two weeks. • Causes less serious side effects than MPA/CPA. • Arguably more effective than MPA/CPA.

17. Effect of LHRH inhibitors. Reductions in the frequency of masturbation and other inappropriate behaviour, a lessening in deviant sexual thoughts and imagery and reductions in penile erections and ejaculations. But there are still negative side effects.

18. Side effects of LHRH inhibitors

19. Side effects depending on duration of therapy (Voss, T. 2012)

20. Research on side effects in Denmark (Colstrup et al. 2012) • 46 offenders given GnRH agonists + CPA • Side effects: • Median increase in 2 points for body mass index (BMI) • 14 complaints of breast enlargement • 5 treated for hot flushes • 39 received treatment due to bone mineral density issues • 11 treated for osteoporosis

21. Comparing the Anti-libidinals. MPA and CPA is thought to work equally well although side effects in MPA are believed to be worse. LHRH agonists thought to be better than MPA and CPA. CPA better at reducing sexual activity; LHRH inhibitors more effective at reducing deviant fantasies.

22. Psychotropic medication • Two hormones closely linked to sexual performance = dopamine and serotonin. • Dopamine is associated with the pleasure system of the brain and increases sexual functioning. • Serotonin conversely inhibits it, with low levels contributing to depression, OCD and other anxiety disorders. • Increasing serotonin in the brain = reduction in sexual functioning.

23. Selective serotonin reuptake inhibitors (SSRIs) • SSRIs inhibit the reuptake of serotonin, increasing amounts in the brain. • Common drugs = Fluoxetine (Prozac), Paroxetine (Seroxat), Citalopram (Cipramil), Sertraline (Lustral) and Fluvoxamine (Faverin). • Duration is unclear so use is “highly uncertain” (Adi et al. 2002: 10). • Effects occur from four weeks onwards.

24. Effects of SSRIs Reductions in the frequency and intensity of sexual fantasies, sexual urges, resulting deviant behaviour, anxiety, depression and irritability and a diminishing of low self-esteem. Some negative side effects. Should not be used if the patient is hypersensitive to the drug or enters into a manic phase; is receiving electroconvulsive therapy or has a history of epilepsy, cardiac disease, diabetes, renal and hepatic impairment, or bleeding disorders.

25. Level If strong deviant fantasies/impulses or risk of sex offence Mild SSRI If insufficient improvement and moderate-high risk of hands on sex offence Moderate CPA or MPA If insufficient improvement or liver dysfunction with CPA/MPA + SSRI If insufficient improvement Severe LHRH IM/SC If risk of use of anabolic steroids IM = Intramuscular SC = Subcutaneous LHRH IM/SC + CPA IM The hierarchy of medication Briken et al. (2003: 896)

26. Efficacy . . . • On the whole studies have been positive. • Maletzky et al. (2006): ‘valuable addition to a treatment program for selected offenders’ (312). • Cooper (1981): ‘significant action for Cyproterone acetate . . . in reducing sexual interest and concomitant physiological arousal’ (461), • Berlin (1994): only 8% of 629 men had reoffended after five years. • Hansen and Lykke-Olesen (1997): reduction in reoffending plus change in personality.

27. Availability in England and Wales. • Action 6: Review of the Protection of Children from Sex Offenders (June 2007) • Given on a purely voluntary basis and in conjunction with specialist psychological counselling. • Referral from prison or probation staff so a need to be within the CJS. • Available since 1st Dec. 2007 (PC 35/2007) – referral based on ‘specific mental health issues’ or ‘evidence of hyper-arousal, intrusive sexual fantasies or urges, sexual urges which are difficult to control and/or sexual sadism’.

28. HMP Whatton(Hocken and Winder 2012) • Largest sex offender prison in Europe (830/841) • Has used SSRIs and CPA – since November 2009 • Effectiveness study = 62 sex offenders • Initial results show reductions in: • Number of days masturbated per week • Strength of sexual urges • Time spent thinking about sex • Ability to distract from sexual thoughts • Strength of sexual excitability

29. HMP Whatton(Lievesley et al. 2012) • SSRI Study: 13 sex offenders • Decreased frequency and intensity of sexual thoughts, fantasies and urges. • Reduction in masturbatory frequency. • Increased control of sexual thoughts and ability to distract • Increased ability to communicate with and to socialize. • Increased ability to recognise inappropriate sexual thoughts. • Altered nature of fantasies. • Improved management of emotions. • Side effects = tiredness, drowsiness, nausea, constipation and headaches .

30. I can still use other techniques while on the medication…I’m more able to think about techniques now” “ I think it’s one of the best steps I made …” Offender views from HMP Whatton “if I’m honest I’ve found that it helps quite a lot” “the tablets alone are not enough for anyone really…support on top of the tablets is probably what’s needed most” (Lievesley et al. 2012)

31. Some legal and ethical issues

32. Voluntary or mandatory? • Mandatory in many USA States. • Even if voluntary – issues with validity of consent. • Is consent valid when side effects unknown? • No difference in treatment rates between self-referred and court-referred patients (Maletzky 1980) • No difference in recidivism rates between those who volunteered and those who did not (Grady 2012) • Maybe motivation is the key factor – voluntary more likely to work?

33. Treatment or punishment? Does voluntary participation = treatment and mandatory = punishment? Does the treatment exceed the cure? Can the side effects ever be seen as treatment? Does society want the offender to suffer? Can it be treatment when it doesn’t cure or change sexual orientation? A risk management tool?

34. Availability? • Available for convicted offenders only or also for those worried about thoughts and/or behaviour? • If medication can work and an individual wants to participate shouldn’t he be allowed? • No right to treatment as such, but several cases in USA held that MPA should be given; where offender suitable. • If treatment is withheld is this as bad as or worse than mandatory participation?

35. Guidelines for using pharmacotherapy The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the biological treatment of paraphilias (2010) Intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilias. Hierarchy of medication. No real mention of legal and ethical concerns – more guidance and continuing research needed.

36. Concluding thoughts Pharmacotherapy can work to reduce sexual fantasies and behaviour in high-risk sex offenders. It is being used in England and Wales with initial positive results. More research and guidelines are needed however, especially regarding legal and ethical concerns.

37. Contact informationDr. Karen HarrisonLaw School, University of Hullkaren.harrison@hull.ac.uk