Correspondence

“Chemical Castration” for Sex Offenders

N Engl J Med 1997; 336:1030-1031April 3, 1997

Article

To the Editor:

California recently enacted legislation requiring either surgical castration or “chemical castration” — a misnomer — for persons convicted of repeated sexual crimes against children.1 Other states may follow suit. The California law requires that parolees either receive periodic injections of medroxyprogesterone acetate or undergo surgical castration. The legislation applies to parolees with a second conviction and to some first-time offenders whose victims are 12 years old or younger. The drug treatment begins one week before release from prison and continues for as long as the state Department of Corrections deems necessary. No physician is required to participate.

The bill passed without support from the scientific and medical communities. There is no requirement for an individual assessment of the parolee to determine the medical necessity for the treatment, which is administered involuntarily, without informed consent.

The California legislation is problematic for two main reasons. It imposes a medical intervention in the absence of evidence that forced (as opposed to voluntary) treatment is likely in and of itself to be effective. Medications that lower the sex drive, such as medroxyprogesterone acetate, may be helpful only for that group of persons whose crimes are driven by abnormal erotic cravings,2 such as persons with pedophilia.3 The legislation makes no provision for an individualized assessment to determine whether a given person belongs to this group.

Some persons with pedophilia may be helped if medroxyprogesterone acetate is prescribed, but current evidence shows this to be the case only when the drug is administered voluntarily. People discover that they are afflicted with pedophilia; they do not choose it. Just as dieting can be difficult because the urge to eat is driven by a powerful biologic force, resisting unacceptable sexual cravings can be a problem for some.4 Currently, there are no medications that can change sexual orientation; pharmacologic treatments can only lower the intensity of unacceptable sexual urges.5 Pedophilia cannot be punished or legislated away. It is as much a public health problem as it is a matter of criminal justice.

To enhance community safety, the state of California should require that sex-drive–lowering treatments be available to all offenders who want and need them and who are found to be appropriate candidates after a proper psychiatric and medical assessment. The state should also provide collateral psychological therapies and support and should systematically track clinical outcomes and criminal recidivism among patients undergoing voluntary treatment.6 In the absence of evidence that treatment is likely to be efficacious when administered involuntarily, the state should not mandate it.

Fred S. Berlin, M.D., Ph.D.
Johns Hopkins Hospital, Baltimore, MD 21287

6 References

1. 1

   California Penal Code, section 645.
   

2. 2

   Berlin FS, Meinecke CF. Treatment of sex offenders with antiandrogenic medication: conceptualization, review of treatment modalities, and preliminary findings. Am J Psychiatry 1981;138:601-607
   Web of Science | Medline

3. 3

   Berlin FS, Krout E. Pedophilia: diagnostic concepts, treatment, and ethical considerations. Am J Forensic Psychiatry 1986;7:13-30
   

4. 4

   Berlin FS. Pedophilia: driven by an invisible force. In: Haglin R, Krauss Whitbourne S, eds. Partners in change: growth through the therapeutic process. London: Oxford University Press (in press).
   

5. 5

   Berlin FS. The paraphilias and depo-provera: some medical, ethical and legal considerations. Bull Am Acad Psychiatry Law 1989;17:233-239
   Medline

6. 6

   Berlin FS, Hunt WP, Malin HM, Dyer A, Lehne GK, Dean S. A five-year plus follow-up survey of criminal recidivism within a treated cohort of 406 pedophiles, 111 exhibitionists and 109 sexual aggressives: issues and outcome. Am J Forensic Psychiatry 1991;12:5-28
   

Citing Articles (7)

Citing Articles

1. 1

   J. Paul Fedoroff. 2008. Treatment of Paraphilic Sexual Disorders. , 563-586.
   CrossRef

2. 2

   Helen D. Pratt, Donald E. Greydanus, Dilip R. Patel. (2007) The Adolescent Sexual Offender. Primary Care: Clinics in Office Practice 34:2, 305-316
   CrossRef

3. 3

   Charles F. Thurber. (2005) Reconfiguring Child and Parental Rights: A Case for Coerced Contraception. Child and Adolescent Social Work Journal 22:5-6, 459-475
   CrossRef

4. 4

   Gregory Lehne, Kate Thomas, Fred Berlin. (2000) Treatment of sexual paraphilias: a review of the 1999-2000 literature. Current Opinion in Psychiatry 13:6, 569-573
   CrossRef

5. 5

   Ariel Rsler, Eliezer Witztum. (2000) Pharmacotherapy of paraphilias in the next millennium. Behavioral Sciences & the Law 18:1, 43-56
   CrossRef

6. 6

   Maria A. Galus. (1998) RE. The Journal of Urology1314
   CrossRef

7. 7

   Maria A. Galus. (1998) RE: OSTEOPOROSIS AFTER ORCHIECTOMY FOR PROSTATE CANCER. The Journal of Urology 159:4, 1314
   CrossRef