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Treatment of Sex Offenders with Depo-Provera

Theodore A. Kiersch, MD

Medroxyprogesterone acetate (MPA) is capable of reducing male blood levels with a corresponding reduction in sexual interest and activity. An attempt to evaluate its effectiveness with court committed sexual offenders was made with eight subjects each serving as his own control by alternating Depo- Provera injections for 16 weeks with saline injections for a corresponding 16 weeks. This paper reports the results of this study and the conclusions that appear to be appropriate.

California abolished its Mentally Dis- upon the central nervous system. In ordered Sexual Offender Laws January spite of the unknowns the question 1, 1982. On that date, there were over raised was could its effectiveness be re- 500 MDSOs in Atascadero State Hos- liably assessed in a maximum security pital. By 1984, there still remained over hospital with court committed sexual 270 hard-core offenders. Hard-core of- offenders. fenders were repeat offenders or patients Atascadero State Hospital was actively who had not achieved a recommenda- using a variety of treatment modalities tion for outpatient treatment after more including individual and group therapy, than two-and-a-half years in the hospi- , behavior modification, tal. psychodrama, Alcoholics Anonymous, Depo-Provera (medroxyprogesterone Social Skills Group, education, and oc- acetate [MPC]) had been used since cupational and recreational therapy. All 1968 to modify sexual behavior by a these efforts were directed at helping the variety of investigators, generally with patient to make a better adult social favorable results.'-' The source of Depo- adjustment and eliminate sexual deviant Provera's biological effect is not exactly behavior. known. It is believed that sexual arous- The hospital also had a fully equipped ability is facilitated by testosterone, and sexual behavior laboratory capable of it is known that Depo-Provera dimin- measuring male sexual responses to a ishes testosterone production. However, variety of visual-auditory stimuli and it is also known that Depo-Provera has self-generated audio cassettes of fanta- a sedating, even an anesthetic, effect sies. The laboratory was equipped with mercury filled strain gauges capable of Presented at the 1988 annual meeting of the American accurately measuring penile responses to Academy of Psychiatry and the Law in San Francisco, California. ~timuli.~ Kiersch

In order to attempt to answer the lower than 250 ng/100 ml as suggested question of the effectiveness of Depo- by Gagne.5 Provera in this setting, eight volunteers Each patient served as his own con- were chosen for a research project. Four trol, and for 16 weeks was given MPA subjects completed the proposed 64- in dosages of 100 to 400 mg per week or week study, and the remaining four injections of sterile saline in comparable completed 22 to 34 weeks of the study. liquid volume. The MPA and sterile sa- The volunteers were less than 40 years line were to be alternated in each patient of age, in good physical health, and free for four blocks of 16 weeks covering a of serious mental disorders such as psy- total of 64 weeks. chosis, mental retardation, affective dis- Each patient self-reported daily such order, or organic brain syndrome. They things as frequency of fantasies and mas- had to be capable of giving informed turbation in response to deviant and consent after all of the possible hazards nondeviant fantasies. He also reported were thoroughly explained. on possible side effects of the medica- The effectiveness of Depo-Provera tion. was evaluated by patients' self-reports Each patient was evaluated weekly in and sexual behavior laboratory measure- the sexual behavior laboratory to mea- ments. All the patients were continued sure his arousal to deviant and nondev- with their regular treatment programs, iant stimuli. The assumption existed and the Depo-Provera evaluations were that when the subject was receiving an added feature. MPA and his testosterone level fell to The patients were given injections below 250 ng/100 ml, his rate of mas- weekly of a substance identified only as turbation to both deviant and nondev- research material and told that MPA iant fantasies would decrease. It was also (Depo-Provera) was being given in vari- assumed that sex lab evaluations would able doses from zero to 400 mg per week. show a decline significantly to both de- The syringes were prepared by the hos- viant and nondeviant stimuli. Further- pital pharmacist and the material in- more, it was assumed that when the jected by a nurse in the medical/surgical patient was in the 16-week segment of clinic, which was entirely separate from saline injections his responses would be the patient's home ward. similar to his pretreatment evaluations. The treatment staff was unaware of Figure 1 represents the anticipated the dosage and quality of the research serum testosterone level responses to material, as was the sexual behavior lab- MPA or saline. oratory and the patient. Blood testoster- When serum testosterone levels were one levels were determined every two low, it was anticipated that rates of mas- weeks and the dosage of MPA or saline turbation to deviant and nondeviant adjusted dependent upon the blood tes- fantasies, if reliably reported, would also tosterone level. The goal was to maintain be low and high when the testosterone the subject's plasma testosterone level levels were high.

180 Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990 Treatment of Sex Offenders with Depo-Provera

Figure 1. Anticipated serum testosterone level responses to MPA or saline.

Finally, it was anticipated that meas- cent are not considered significant. The ured penile responses would be reported frequencies and significantly modified if the subject was sex lab results were unchanged through- on the MPA 16-week cycle. out the 64 weeks regardless of saline or MPA injections. The interpretation of Subject 1 these results is either an excellent ex- A 25-year-old rapist on the MPA-sa- ample of behavior modification based line-MPA-saline sequence self-reported on suggestion or inaccurate reporting by the seventh week no deviant fantasies and noncompliant behavior in the sex- and no masturbation to either deviant ual behavior laboratory, probably the or nondeviant fantasies. By the sixth latter. week, his sex lab results were insignifi- cant arousal to deviant and 75 to Subject 2 100 percent arousal to nondeviant (con- A 38-year-old pedophile on the saline- senting adult) stimuli (Fig. 2). Sex labo- MPA-saline-MPA sequence was appar- ratory arousal rates of less than 20 per- ently cooperative. His reported deviant

Figure 2. Subject 1.

Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990 Kiersch sexual fantasies were significantly re- report a decrease in deviant fantasies duced by saline and increased by MPA. that coincided with a decrease in mas- This paradoxical result is either the re- turbation to deviant stimuli during the sult of suggestion, inaccurate reporting, first 16-week MPA period. However, his or an attempt to overcome the effect of reported masturbatory activity re- MPA by use of previously learned effec- mained constant after the first 16 weeks. tive fantasies. The remainder of the stud- His penile response to deviant sexual ies, however, suggest inaccurate report- ing. His rate of masturbation was not stimuli was reduced during the first 16 influenced by MPA. His penile re- week period coinciding with his decrease sponses to child deviant stimuli was too in deviant fantasies. The next 48 weeks, variable to be certain as to the effect of however, were quite erratic and equivo- saline versus MPA. His penile responses cal from which conclusions could not be to nondeviant stimuli (adult) were un- reached (Fig. 4). affected by either saline or MPA and generally low. It should be noted how- Subject 4 ever, that once his testosterone level was A 30-year-old pedophile on the MPA- lowered by Depo-Provera during weeks saline-MPA-saline sequence reported a 16 to 32, it increased moderately during decrease in deviant fantasies and a de- the saline phase weeks 32-48 and did crease in deviant stimuli masturbation not rise above the recommended 250 during the first 16-week MPA sequence. ng/100 ml level (Fig. 3). His sex lab measurements revealed a Subject 3 corresponding decrease in deviant sex- A 28-year-old pedophile on the MPA- ual arousal during the same 16 weeks. saline-MPA-saline sequence indeed did Thereafter, he accepted the injections

Figure 3. Subject 2.

182 Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990 Treatment of Sex Offenders with Depo-Provera

Figure 4. Subject 3. and serum testosterone studies but re- Subject 6 fused to cooperate with penile measure- A 33-year-old pedophile was on the ments or engage in self-reporting. Of saline-MPA-saline-MPA sequence. His interest was the fact that his testosterone deviant fantasies, rate of masturbation, levels did correspond with anticipated and nondeviant penile arousal were all levels. There was a prompt decrease in significantly lowered during the saline serum testosterone levels with the MPA injections. After his fifth MPA injection, injections and a six to eight week delay he complained that his were in return to normal during the saline shrinking and withdrew from the re- injections (Fig. 5). search project. Physical examination re- Subject 5 vealed no change in the size of his testi- A 2 1 -year-old rapist and attempted cles. It only can be assumed that he murderer on the saline-MPA sequence. noted a reduction in his sexual He was returned to court on a writ to or had difficulty obtaining an erection complete his sentence in prison after 32 (Fig. 7). weeks on the study. His testosterone Subject 7 blood levels were as anticipated un- changed from the baseline during the The seventh subject was a 29-year-old saline injections and low on the MPA pedophile whose victims were both male injections. His reported deviant fantasies and female children. He was on the were significantly decreased by MPA. MPA-saline sequence for 32 weeks when His frequency of masturbation was min- he developed signs of borderline glau- imally reduced by MPA. His measured coma, and the injections were promptly penile responses were inconclusive, stopped. Of interest, while he was on probably reduced by MPA (Fig. 6). MPA, his deviant fantasies were re-

Bull Am Acad Psychiatry Law, Voi. 18, No. 2, 1990 183 Kiersch

Figure 5. Subject 4.

Figure 6. Subject 5. duced, as was his rate of masturbation Subject 8 to deviant stimuli. His nondeviant mas- The ,ighth subject was a 3 i-year-old turbation and nondeviant pedophile who molested both male and were minimally influenced. During the female children. He was on the MPA- saline phase all of his reports and meas- urements were unchanged. However, his saline sequence and complained of testosterone level once reduced by MPA h~adachesafter the 26th week of injec- remained low during the saline phase. It tions and requested the experiment be returned to normal five months after his stopped. While on MPA, he reported last MPA injection (Fig. 8). decreased deviant fantasies and de-

184 Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990 Treatment of Sex Offenders with Depo-Provera

Figure 7. Subject 6.

Figure 8. Subject 7. creased masturbation. His sexual jects generally self-reported what they arousal was little influenced by the MPA felt were desirable responses. Although injections, especially his arousal to male some did, the majority did not experi- children (Fig. 9). ence the results expected from MPA ver- Discussion sus the saline injections. Favorable re- Almost all hard core incarcerated sults were obtained with either injected MDSO patients have as their primary substance. concern release from confinement. The sexual laboratory measurements There seems little doubt that our sub- likewise were too variable and inconsist-

Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990 185 Kiersch

Figure 9. Subject 8. ent to accurately determine the MPA 4. Although MPA decreases sexual dose necessary to reduce penile re- drive, it did not change the object of the sponses to deviant and nondeviant stim- sexual drive, i.e., pedophiles remained uli. Although the majority of the patients interested in children. demonstrated decreased sexual arousal 5. Although all our subjects reported during the MPA injections, they also a decrease in deviant fantasies, this was demonstrated decreased arousal during not objectively substantiated by the sex the saline injections. lab results. We have learned, however, some 6. It is felt that the results of treat- things about our subjects and the possi- ment of hard-core MDSOs with MPA in ble use of MPA in this setting. this incarcerated setting is inconclusive 1. Serum testosterone levels varied and an unreliable means of predicting significantly in the same individual prior appropriate dosages and probable favor- to any injections. able outcome. 2. In two of our eight subjects, testos- 7. In no way is it suggested that these terone levels returned to pretreatment results are applicable to cases of para- levels in six to eight weeks after the last MPA injection in each sequence. How- philia that are truly voluntary, desirous ever, the majority required longer to re- of altering their sexual behavior, and turn to pretreatment levels. This fact cooperative. alone could explain the failure of our 8. Finally, although sexual desires results to follow the expected course. and impulses are influenced by blood 3. These subjects and other patients testosterone levels, which can be modi- outside of the research group demon- fied by MPA, there are indeed other strated that MPA does reduce compul- influences such as cognition, learned be- sive masturbation. havior, and probably many other factors

186 Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990 Treatment of Sex Offenders with Depo-Provera

2. Money J: Use of an depleting hor- involved in this behav- mone in the treatment of male sex offenders. ior. J Sex Res 6: 165-72. 1970 9. An interesting follow-up revealed 3. Money J: The therapeutic use of androgen- depleting hormone. Int Psychiatry Clinic four of the patients were returned to 8: 165-74, 1972 court for sentencing. Three are still in 4. Cooper AJ, Ismail AAA, Phanzoo AL, et a/: () therapy the hospital. One patient (No. 1) suc- in deviant . Br J Psychiatry ceeded in obtaining outpatient treat- 120:58-64, 1972 5. Gagne P: Treatment of sex offenders with ment status; however, he reoffended medroxyprogesterone acetate. Am J Psychia- after one year and is currently serving a try 138:644-6. 198 1 long prison term. 6. Berlin FS, Meinecke CF: Treatment of sex offenders with antiandrogenic medication: conceptualization, review, and treatment Acknowledgments modalities, and preliminary findings. Am J Psychiatry l38:6O 1-7, I98 1 The author thanks Richard Laws, Ph.D., Ms. Henlie 7. Walker PA, Meyer WJ. Emory LE, et a/: Sturgeon, and Ms. Doris Soares for their participation in the sexual behavior laboratory evaluation, and Ken- Antiandrogenic treatment of the , neth Lundgren, Pharm. D., for his assistance with the in Guidelines for the Use of Psychotropic medication. Drugs. Edited by Stancer HC, Garfinkel PE, Radoff VM. New York. Spectrum, 1984, p 439 References 8. Laws DD, Osborn CA: Setting up shop: how to build and operate a laboratory for the 1. Money J: Discussion on hormonal inhibition assessment and treatment of sexual deviance. of libido in male sex offenders, in Endocri- in The Sexual Aggressor: Current Perspec- nology and Human Behavior. Edited by Mi- tives in Treatment. Edited by Greer JG, chael R. London, Oxford University Press, Stuart L. New York, Van Nostrand and 1968, p 169 Reinhold, pp 293-335. 1983

Bull Am Acad Psychiatry Law, Vol. 18, No. 2, 1990