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Medical and Surgical Treatment of Sex Offenders

Medical and Surgical Treatment of Sex Offenders. Alina Gonzalez-Mayo, M.D. St. Petersburg, Florida. Purpose of Treatment. Reduce the deviant sexual urges and behaviors of paraphiliacs Reduce testosterone levels. Role of Human Testosterone. Development of sexual characteristics

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Medical and Surgical Treatment of Sex Offenders

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  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

  6. 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.

  7. 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.

  8. Function of Hypothalamus and GnRH

  9. Types of Treatment • Surgical • Medical

  10. Surgical treatments

  11. 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

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

  13. Medical treatments

  14. 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

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

  16. 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

  17. Side effects of Cyproterone Acetate • Gynecomastia • Thromboembolic phenomenon • Depression • Liver damage • Bone mineral loss

  18. 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

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

  20. 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

  21. Function of Hypothalamus and GnRH

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

  23. 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

  24. 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

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

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