Effects of Chemical Castration on Sex Offenders in Relation to the Kinetics of Serum Testosterone Recovery: Implications for Dosing Schedule

The impact of testosterone-lowering medication on recidivism in individuals convicted of sexual offenses

INTRODUCTION

Treatment of individuals who have committed sexual offences with Testosterone-Lowering Medication (TLM) is a comparatively intrusive kind of intervention, which regularly takes place in coercive contexts. Thus, the question of efficacy, but also the question of who should be treated, when and for how long, are of great importance.

METHODS

Recidivism rates of TLM-treated high-risk individuals (+TLM; n = 54) were compared with high-risk individuals treated with psychotherapy only in the same forensic outpatient clinic (-TLM; n = 79).

RESULTS

Group differences suggested a higher initial risk of + TLM (e.g. higher ris-assessment, previous convictions). Despite the increased risk, after an average time at risk of six years, +TLM recidivated significantly less often and significantly later than - TLM (27.8% vs. 51.9%). Such an effect was also found for violent (1.9% vs. 15.2%), but not for sexual (5.6% vs. 10.1%) and serious recidivism (5.6% vs. 10.1%), which could be explained partly by the small number of cases. In the course of treatment, TLM proved to be a significant variable for a positive process, whereas a high risk-assessment score indicated a rather negative course. In total, n = 19 individuals had stopped their TLM treatment, of these 31.6% recidivated.

CONCLUSION

The results support the efficacy of TLM, particularly in the group of high-risk offenders.

Androgens, brain and androgen deprivation therapy in paraphilic disorders: A narrative review

Sexual delinquency is a global problem where those with paraphilic disorders, such as paedophiles, are more likely to commit and reoffend. Androgen deprivation therapy (ADT) has been suggested as a solution. The objective of this narrative review is to present current information on its risks, benefits and limitations as a treatment for paraphilias. The importance of testosterone in sexual function, the effect of its deficiency by age or by pharmacological treatment (anti-androgens, GnRH agonists and GnRH antagonists) and the effect of testosterone replacement therapy will be reviewed. The relationship between androgens, brain, sexual behaviour and pathophysiology of paraphilic disorders will also be explored. ADT reduces sexual urges, but has adverse effects and, because its reversible nature, it does not ensure less recidivism. Likewise, the research quality of ADT drugs is limited and not enough to support their use. Child sex offenders, and not paraphilic subjects who have not committed assaults, show signs of elevated prenatal exposure to androgens and a higher methylation state of the androgen receptor gene. Sexual behaviour is regulated by subcortical (hypothalamus, brainstem and spinal cord) and cortical structures of the brain, in addition to brain circuits (dopaminergic, serotonergic). Those with paraphilic disorders show abnormalities at these levels that could relate to the risk of sexual offences. In conclusion, androgens represent a significant part of the pathophysiology of paraphilias and therefore, ADT seems promising. Nonetheless, more studies are needed to make definite conclusions about the efficacy of long-term ADT in paraphilic patients.

The impact of androgen deprivation therapy on bone mineral density in men treated for paraphilic disorder: A retrospective cohort study

BACKGROUND

Guidelines suggest treating men with paraphilic disorder with androgen-deprivation therapy (ADT). However, little evidence is available about the long-term impact on bone loss and how to manage this adverse event.

OBJECTIVES

The aim of this study is to assess the impact of ADT on bone mineral density (BMD) in men treated for paraphilic disorder with the androgen receptor blocker cyproterone acetate (CPA) and/or GnRH agonist triptoreline (GnRHa) and to evaluate the effect of treatment with bisphosphonates.

METHODS

Baseline and follow-up dual-energy X-ray absorptiometry scan (DXA-scan) data (lumbar and femoral T-scores) were retrospectively extracted from electronic medical files of paraphilic men who received CPA and/or GnRHa.

RESULTS

A total of 53 patients with a mean age of 39.1 years (range 17.5-74.6) were included. Lumbar (-0.39 ± 0.17, Mean ± SEM, p = 0.046), femoral neck (-0.34 ± 0.09, p = 0.002) and total femur (-0.33 ± 0.12, p = 0.014) T-scores decreased significantly in the CPA-only group (n = 13) during a mean follow-up of 6.0 ± 5.3 years. In the GnRHa group (n = 29), T-scores at all sites decreased significantly over 6.6 ± 4.4 years (lumbar: -0.55 ± 0.12, p < 0.001, femoral neck: -0.53 ± 0.09, total femur: -0.44 ± 0.09, p < 0.001). In the group, who received bisphosphonates (n = 11), no significant T-score change was observed (lumbar: -0.25 ± 0.14, p = 0.106, femoral neck -0.15 ± 0.17, p = 0.402, total femur -0.25 ± 0.14, p = 0.106) during 5.0 ± 2.8 years of follow-up.

DISCUSSION AND CONCLUSION

Following a mean duration of 6 years of ADT, we observed a significant decline in BMD of approximately half a standard deviation in T-score at lumbar and femoral site. Although the number of patients who received bisphosphonates was limited, this treatment seems to have a positive stabilizing effect on bone density.

Testosterone-Lowering Medication and Its Association With Recidivism Risk in Individuals Convicted of Sexual Offenses

For a particular subgroup of individuals with severe paraphilic disorders and a high risk of sexual recidivism, the combination of sex drive-reducing medications and psychotherapy is a promising treatment approach. The present quasi-experimental study aims at comparing differences in clinical characteristics and dynamic risk factors between persons receiving (+TLM, n = 38) versus not receiving (-TLM, n = 22) testosterone-lowering medications (TLMs). Individuals receiving TLM were more frequently diagnosed with paraphilic disorders. Neither the criminal history nor average risk scores differed between the two groups. In the +TLM, Stable-2007 scores showed a stronger decrease after TLM treatment was started. This accounted especially for the general and sexual self-regulation subscales. Individual variations in risk, however, were not predicted by TLM but were significantly related to treatment duration and Psychopathy Checklist-Revised (PCL-R) Factor I. Paraphilic patients with problems in self-regulatory abilities seem to profit most from pharmacological sex drive-reducing treatment. Furthermore, therapists seem to underestimate deviant sexual fantasies in medicated patients.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

A narrative review of research on clinical responses to the problem of sexual offenses in the last decade

Research on the treatment and programs for people who have committed sexual offenses has greatly increased in the past decade. The aim of this review is to discuss research that has been published over that period (2010-2019) that is relevant for treatment providers. The articles included in this review were found through PsycINFO and PubMed (Medline) using the keywords "treatment or therapy" and "sex offen*". The inclusion criteria were publications that discuss treatment of persons who have committed sexual offenses (written in the English language only). Any articles that examined only special populations were excluded, such as those that examined persons who committed sexual offenses who were female, had intellectual disabilities, deafness, juveniles, etc., because these groups will likely have needs and responsivity factors that differ from the "average" natal-born male sex offender. Results showed that several meta-analyses indicate that treatment is effective in reducing sexual recidivism. The most frequently used treatment for sex offenders is cognitive behavioral therapy, which is often provided in conjunction with pharmacological treatment to reduce sexual impulsivity and/or sex drive. This review is limited to the specific key search terms. The findings of this review support the use of treatment and a community reintegration approach when treating persons who have committed sexual crimes to prevent sexual recidivism.

A Case of Paraphilia with Osteoporosis and Administered with Depot Leuprorelin

Paraphilia is a complex psychological and psychiatric disorder that has been difficult to treat. Leuprorelin has been used as one of the therapeutic methods for paraphilia. Leuprorelin administration could change insulin resistance and accelerate bone loss. The case study in this work was a 59-year-old man who visited a hospital with the chief complaints of frotteuristic behaviors in public places, a continuous increase in sexual desire, and sexual molestation behavior that started in 2007. We injected leuprorelin (3.6 mg) intramuscularly every month for this patient with paraphilia and comorbidities of osteoporosis and hyperthyroidism. The clinical global impression (CGI), Sex Addiction Screening Test (SAST), Wilson Sex Fantasy Questionnaire (WSFQ), physical examination, and laboratory tests were performed. After 12 months of leuprorelin injection for paraphilia, we found a significant improvement in abnormal sexual behavior/desire without aggravation of osteoporosis/hyperthyroidism. Gonadotrophin-Releasing Hormone (GnRH) analogs could be used as alternative or supplementary treatment methods for paraphilia with osteoporosis/hyperthyroidism.

Monitoring urinary testosterone and epitestosterone levels, and their ratio, in Korean chemical castration subjects using liquid chromatography–tandem mass spectrometry

In Europe, chemical castration has been adopted as a treatment for paraphilia since the 1930s. Among the various chemical castration agents, luteinizing hormone-releasing hormone (LHRH) agonists are now used widely because of their effectiveness and safety. In South Korea, a legislation of chemical castration to control the sexual impulses of sexual offenders was enforced in July 2011. Most of these subjects are treated with leuprorelin acetate, an LHRH agonist, for chemical castration. Despite this, there are few studies that address the long-term influence of LHRH agonists on testosterone (T) and epitestosterone (E) levels in chemical castration subjects. In order to analyze the urinary levels of T in chemical castration subjects, whose T levels are extremely low, we developed and validated an analytical method for the detection of both T and E in human urine using a liquid chromatography-tandem mass spectrometry (LC–MS/MS) system. The urine samples were hydrolyzed, extracted, and analyzed by LC–MS/MS with electrospray ionization in the positive-ion mode. The limits of detection were 0.02 ng/mL and the limits of quantitation were 0.05 ng/mL, which provided great sensitivity. The established method was applied to urine samples from chemical castration subjects and healthy male volunteers. The chemical castration subjects showed significantly lower urinary T levels than the control subjects. In addition, the urinary E levels were also lower in the chemical castration subjects; however, the T/E ratios were constant and did not show a notable decrease because of the simultaneous decrease in both urinary T and E. The urinary T levels and T/E ratio did not exceed the doping control criteria for exogenous T ingestion for any subject. This study shows the trend of urinary T and E levels in long-term treated chemical castration subjects by establishing a highly sensitive LC–MS/MS method, that provides useful information for monitoring chemical castration.

Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts

Guidelines for pharmacological treatment of patients with paraphilic disorders have been developed by a working group of the World Federation of Societies of Biological Psychiatry (Thibaut et al., 2010 ). With an increasing duration of experience and number of treated patients as well as aging patients, change of or withdrawal from testosterone-lowering medications (TLM) has become an important issue. The current study aimed to assess the quality of a structured professional judgment procedure that helps switching or discontinuing TLM in patients with paraphilic disorders. We used the Delphi method to estimate the quality of 10 factors originally proposed by the authors. A total of 30 experts participated in the first stage; 18 experts participated in the second stage. The experts' assessment resulted in an instrument of 15 factors that can be used to structure the process of changing or discontinuing TLM. These factors can be grouped into five broader categories: age and duration of treatment; therapeutic alliance; psychopathology and risk factors; motivation; and compliance and level of control. The developed COSTLow-R Scale provides an instrument that can be used to structure the process of changing or discontinuing TLM in patients with severe paraphilic disorders.

Gonadotrophin-releasing hormone agonist treatment for sexual offenders: A systematic review

BACKGROUND

Sexual offending is a significant international issue causing long-term consequences for victims, perpetrators and society.

AIMS

The purpose of this study was to review the existing research data assessing the efficacy of gonadotrophin-releasing hormone agonists for treating adult, male, sexual offenders.

METHOD

The method of this review involved the examination of studies involving participants prescribed at least one month of a gonadotrophin-releasing hormone agonist for the purposes of reducing sexual drive related to offending. The primary outcome measures were recidivism rates and sexual functioning. Secondary outcome measures included assessment of side effects and effects on interpersonal/psychiatric functioning. Studies in the English language that were dated 1969-2015 were included.

RESULTS

Twelve eligible studies (323 participants) were identified. A reduction in a variety of measures of sexual functioning and/or risk was found in all studies. Robust recidivism data was limited. Medication was rarely described as ineffectual. All studies reported side effects. Reduction in bone density and potential long-term reduction in fertility in some subjects were issues of concern.

CONCLUSION

Whilst identified studies showed promising results with respect to sexual functioning, challenges in performing randomised control trials in this subject group meant that included studies were methodologically limited. This review recommends that future research must be performed before the effectiveness and tolerability of gonadotrophin-releasing hormone agonists in this population can be confirmed.

The efficacy, safety and ethics of the use of testosterone-suppressing agents in the management of sex offending

PURPOSE OF REVIEW

The use of endocrine medications to reduce sexual offending recidivism is established and may involve clinicians from diverse specialities. The present review aims to outline relevant background information and note a Medical Ethics framework upon which to facilitate decision-making.

RECENT FINDINGS

There have been several systematic reviews in recent years. A number of problems with research in the area of the medical treatment of sex offenders have been highlighted. There remains scope for improvement in the research to answer a number of relevant clinical issues. Nonetheless, some very useful indicators of relevance to clinical practice have emerged.

SUMMARY

The use of medication to manage the risk of sex offending in males is appropriate under the right circumstances. These include, for example, hypersexuality with sexual deviance and psychological-treatment interfering sexual preoccupation.

Effects of crude kerosene on testosterone levels, aggression and toxicity in rat

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Kerosene supplementation increases serum testosterone levels in rat.

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Increased testosterone levels were associated with increased aggression.

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Kerosene supplementation had varied effects on blood parameters, notably, increased WBC counts.

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Supplementation resulted in active/chronic gastritis in the stomach of our rat model.

The use of crude kerosene as a dietary supplement in boarding schools has been a common practice in east Africa and other countries for many years, with the belief of it reducing the sex drive (libido) at the pubertal stage. There is however no scientific basis for this belief. The present study aimed at using a rat animal model to investigate the effects of crude kerosene on serum testosterone levels, aggression and its possible toxic effects. Fifteen male albino rats of approximately similar age and average weights were put into three groups of five animals each; the control group (placebo), low kerosene dose (10 μl/day) group and high kerosene dose (300 μl/day) group. ELISA was used to determine the serum testosterone levels. During treatment, changes in aggression were observed and noted. Liver toxicity was determined using enzyme assays, total protein and albumin while renal toxicity was monitored using serum creatinine levels. A full hemogram was conducted to determine hematological effects. Various tissue biopsies were obtained and examined using histopathological techniques for evidence of toxicity. Contrary to the common belief, our findings showed an overall increase of serum testosterone levels of up to 66% in the low dose and 75% in the high dose groups, with an increasing trend by the end of the study. The high dose group showed significantly increased levels of white blood cells (WBC) (p = 0.036), red blood cells (RBC) (p = 0.025), hematocrit (HCT) (p = 0.03), red cell distribution width (p = 0.028) and platelets (p = 0.017). The histological results of the stomach indicated chronic gastritis.

Unrecognized kinetics of serum testosterone: impact on short-term androgen deprivation therapy for prostate cancer

PURPOSE

To evaluate the kinetics of serum testosterone (T) recovery following short-term androgen deprivation therapy (ADT), as the understanding thereof is essential for the proper management of prostate cancer (PCa), especially intermittent ADT.

MATERIALS AND METHODS

This prospective analysis included male sex offenders who voluntarily received leuprolide acetate in order to alleviate sexual aberrance. Thirty-three and 25 patients who received 3 and 6 months of ADT were assigned to Group A and Group B, respectively. Serum T levels were obtained every week during the on-cycle period, then monthly during the off-cycle period for at least 12 months.

RESULTS

The kinetics of serum T during the on-cycle period were similar in both groups. After flare reaction at week 2, a nadir of 0.45±0.29 ng/mL was achieved. In Group A, an abrupt rebound-upsurge was observed during the first 2 month off-cycle period, which surpassed the baseline level and reached a plateau level of 8.74±2.11 ng/mL during the flare (p<0.001). This upsurge was followed by a gradual decline back to baseline over the following 10 months. In Group B, a gradual increase was observed, and a baseline level of 7.26±1.73 ng/mL was reached at 5 months. Thereafter, an ongoing upsurge that surpassed baseline levels was observed until 12 months (8.81±1.92 ng/mL; p=0.002).

CONCLUSION

The kinetics of serum T recovery during the off-cycle period varied according to the duration of ADT. Serum T should be monitored beyond normalization, as an excessive rebound may improve quality-of-life, but hamper the treatment efficacy of PCa.