Treatment of Sex Offenders with Depo-Provera Theodore A. Kiersch, MD Medroxyprogesterone acetate (MPA) is capable of reducing male testosterone 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- sex education, 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 erection responses would be reported masturbation 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 rape 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 testicles 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 desires He was returned to court on a writ to or had difficulty obtaining an erection complete his sentence in prison after 32 (Fig.