Should We Be Castrating Sex Offenders?

• The Ministry of Justice has been rolling out a program to chemically castrate rapists, paedophiles and other sex offenders.

• At the moment, this is a voluntary program for people who wish to be relieved of a sexual drive that they feel is ruining their lives.

• Professor Don Grubin of the University of Newcastle discusses the benefits and potential pitfalls of this technique, with which he has been heavily involved.

• Does medicating rapists suggest that they are suffering from a disease, making them less morally responsible for their actions?

‘Steve’ knew he was different from a young age. Almost as soon as he had learned to drive, he would cruise around the Canadian neighbourhood in which he lived, planning to one day commit the ‘perfect crime’. It was only a matter of time until he acted out the violent sexual assault and murder that he fantasized so much about.

For whatever reason, ‘Steve’ gave himself over to a psychiatrist and ended up under the care of Dr. Paul Federoof. So concerned was he that he was a risk to women, ‘Steve’ agreed to undergo a voluntary chemical castration at the hands of Dr. Federoof. This involves the prescription of an anti-libidinal drug that removes both sexual drive and the physical ability to perform. For the pseudononymous 'Steve', the change was remarkable; he was able to live a normal life, free of his horrific sexual fantasies that, he is convinced, would only have ended in murder.

The most famous case of chemical castration is that of Alan Turing, the great British Mathematician. Aside from founding the field of computer science, Turing was heavily responsible for British wartime efforts to crack the German ‘Enigma’ code, without which the outcome of the war may have been very different.

A homosexual in an era when it was still heavily illegal, Turing was given the supposedly merciful sentence of a course of chemical castration. The drugs used caused him to develop breast tissue and sent him spiralling into a depression from which he never recovered. He was found dead, having taken a bite from a cyanide-laced apple.

Currently, chemical castration is used in some forms in the United States, Portugal, Poland, Maldova, Macedonia, Estonia, Israel, Australia, India, Russia and a host of other countries with sometimes-questionable stances on Human Rights. For some of these countries, chemical castration is a therapeutic intervention done at the request of someone who cannot control their libido, whereas in others it is a punitive measure to permanently impair the sexual function of those convicted of sexual crimes. Of particular note is the Czech Republic, who have a program to surgically castrate sex offenders, physically removing portions of their genitalia in a permanent attempt to prevent further wrongdoing. Whether this is always a consensual process has been the subject of much debate.

Many people are concerned that medicating sex offenders implies that they are suffering from a disease, relieving them of responsibility for their actions and treating them as victims of their biology.

Professor Don Grubin of the University of Newcastle is the chief architect of the Ministry of Justice’s on-going program to roll out a voluntary chemical castration program in the United Kingdom. He was able to cast some light onto the nature of sex offences and how we might go about trying to treat them.

Where do you think that sexual offenders draw their motivation from?

Where do you think that sexual offenders draw their motivation from?

There’s a number of things that drive behaviour in anybody and that includes sex offenders, so they are our thoughts, our beliefs, our whole thinking structure, emotional management and the way that we respond to emotions, our general self-management an with sex offenders there’s an additional component of sexual drive and arousal. It’s the interaction of those four boxes that determine whether someone is going to sexually offend. So, an example might be somebody who has strong arousal to children, for example, but whose thinking processes, thoughts and beliefs are that sexual behaviour with children is harmful, illegal and something that doesn’t sit well with his value system, someone who’s well able to manage their emotional states so when he gets stressed or depressed they don’t sexualise that and look to make themselves better through sex, and their general self-management is good, they’re probably not going to offend against children. But if you have that arousal together with someone who believes it is ok or ok in some circumstances or doesn’t cause harm, then you increase the likelihood that the offender will offend.

To what extent do you think that someone’s mentality regarding sex offences is derived from their instinctive attractions?

Just believing that an attraction is OK doesn’t turn someone into a sex offender, you’d also have to have the arousal to children.

If you have the arousal, to what extent do you make that okay within your value system?

People do rationalise and give themselves excuses to do all sorts of problematic behaviours so somebody with a very strong arousal to kids may look to justify it in certain circumstances and it’s similar with men who sexually offend against women so somebody might recognise that rape is wrong and harmful but excuses themselves by saying that, in this instance, the woman was a prostitute or she ‘asked for it’ in some way.

“Or she was wearing provocative clothing?”

That’s right, that sort of thing, so it makes it alright. The jargon is ‘cognitive distortion’, so you adjust your thinking pattern to justify behaviours that you want to engage in.

And where are you currently at with the Ministry of Justice? You’ve been hired as a consultant for them?”

Well, the trust that I work for has an agreement with the National Offender Management Service (NOMS) to provide a service that facilitates, more than that, gives them psychiatric advice regarding sex offenders. A big component of that is to facilitate prescribing a medication in offenders where that might be helpful, but I also provide advice on a range of psychiatric issues associated with sex offenders.

Chemical castration, do you mind if I call it that or is there a more accurate clinical term?

People tend to understand ‘chemical castration’, but it’s not a term we like to use because clearly it’s not something that would be attractive someone thinking about taking medication to help them manage their sexual drives. The other problem with the term is that there are different medications we use for sex offenders and not all of them have the effect of reducing testosterone in a way that mimics castration.

What are the main groups of drugs that people are using?

Well, there are two groups; one are anti-androgens, the ones people often think about when they are talking about chemical castration, so those are drugs that lower testosterone levels and then there’s another group that are the selective serotonin reuptake inhibitors, drugs like Prozac, which don’t have a direct on testosterone but do have an impact not only on sexual drive but on the strength of sexual thoughts, thinking and urges.

And at the moment, with the Ministry of Justice, what is your recommendation regarding the use of anti-androgens and SSRIs?

Well, there’s a small group of offenders who need assistance in managing their sex drives, and all the psychological work in the world doesn’t lower their risk because they just find it difficult to manage their drives, sometimes to the extent that they can’t even engage in treatment because they become too distracted. In that group, medication can be very helpful.

And is that a voluntary group, something that people should buy into? Is it something that they often want?

Yes, some sex offenders request it, that’s not uncommon, but in my view and certainly the policy within NOMS is that it has to be voluntary. We don’t force offenders to take medication; if they take it, they can stop it whenever they want. I’m very concerned that doctors working in this area continue to function as doctors and don’t become agents of social control.

[Doctors as agents of social control] was the subtitle of one of your letters in the British Medical Journal.

I think that’s right, if we treat it as a medical issue, helping someone manage a biological drive, then risk reduction will be a byproduct of that, but that shouldn’t be the focus of what the doctor is doing.

If it’s a voluntary buy-in process and it requires the compliance of the offender to take a tablet every morning, or twice a day for example, can it form a part of a release scheme do you think? Should taking a medication that reduces your sex drive be one of the conditions of release?

Well, if it becomes a condition then it is becoming mandatory, so you have a difficulty there, but even putting that aside, it’s no different from psychological treatments. Somebody can take part in psychological therapy and do well in it but they still have to choose whether they are going to apply that when they’re out in the world. So it’s similar to medication, the offender can choose whether or not to be taking it. I think when you’re making release decisions, you need to look at the whole picture regarding the offender, so if he’s wanting to take the medication and the medication seems to be effective and you think he’s taking it genuinely, not simply to impress the parole board, get out then stop it immediately, but is committed to reducing his risk, that becomes part of the decision making process; that he took part in sex offender treatment and seemed to respond to it and is putting to use what he learnt there. So it’s all part of a bigger picture, rather than sitting out there on it’s own as, ‘well, he’s going to take medication, therefore, he is safe’ or ‘we don’t trust him to take medication, therefore he’s not safe’.

There have been a number of observations of offenders who discontinued their medication and had a two month period of extremely elevated levels of sexual desire and functioning. To what extent could putting someone on a medication, releasing them into the general public, allowing them to discontinue it when they want to, put members of the public at a greater risk?

Well, I don’t think there’s any evidence that stopping medication makes people more likely to offend. What sometimes happens is that people make the decision that they want to offend and then they stop the medication to allow that to happen. Changes in testosterone take a long time, weeks or months to have an effect on things like sexual arousal and sex drive. There is some Korean work that shows that there is a rebound in testosterone and people report a return of sexual urges and sexual thoughts. I don’t know that there was any evidence to show that was greater than it was at baseline.

To what extent does a sex offender forgo their right to a private sexual life? Are these people that simply can’t be trusted to have libido, to have sexual thoughts and action them?

Well, again, when we talk about medication we’re talking about a small group of offenders, it’s not simply that if somebody is a sex offender, they’re appropriate for medication. There needs to be medical indication to put somebody on it and that medical indication is that they are finding it difficult to manage their arousal. They’re asking for help with that, so in doing that, it doesn’t mean that their sexual world is no longer private, but it’s no different than going to a doctor with another medical complaint, say a cough and wanting help with that but keeping things secret, like you’re a smoker. So if the individual is wanting help then he needs to be honest about that and about the impact that the medication is having if the doctor is being able to do that, but I don’t think that takes away his right to have a sexual life. As I said, we’re ot simply prescribing medication because someone is a sex offender.

You visited the Czech Republic didn’t you? Could you tell me a little about that?

Well, it was quite interesting, it arose because the Committee for the Prevention of Torture was concerned that they were carrying out physical castrations and there was a working party that went there and were appalled at the idea of physical castration. I went with a television company to the hospital where this was happening. It’s difficult because I don’t speak Czech, you’re reliant on what the interpreters are saying and what they’re willing to show you, but certainly the offenders that we met seemed to genuinely be asking for physical castration. They’d all been on medication for a number of years and decided that they would prefer castration. I don’t know that was really what was going on, but that was certainly what we were being told. It made me rethink a little bit because I occasionally get letters from offenders saying ‘I want to be physically castrated, I don’t want to offend again’ and so on. In the past, I would have simply dismissed that. Now, I’m a bit less sure and I think hat for some individuals it might be an appropriate intervention but with really tight constraints around it. One would be that they’ve experienced anti-libidinal drugs for a number of years so that they know what it’s like to be physically castrated. I think if somebody has capacity to ask for it and they’re taking the medication, why should we say that they can’t do it and go through the procedure?

Is there evidence to show that a surgical castration has merit in people who don’t respond to chemical processes?

No, but if somebody didn’t respond to medication, I wouldn’t be recommending castration. It’s for someone who is responding to chemical castration, is responding to it and thinks life is so much better without having a sex drive that they want to make it permanent. If they have the capacity to make that decision I don’t see why they shouldn’t, but I wouldn’t do it as an alternative if medication isn’t working as the next step. I certainly wouldn’t recommend it in that situation.

To what extent can it become a bit of a placebo? That it’s much easier to think about all your crimes and you sexual paraphilias and offences as a biological process that you can’t control. To what extent is it a way of saying it’s not really me, it’s this illness that I have?

Well, I think there are a number of ways to respond to people who say this is a way of evading responsibility. Firstly, we don’t ted to prescribe medication without also providing psychological treatment because the likelihood is that people are going to come off medication at some point and what you hope is to have a window in which that psychological treatment can work. Secondly, it’s not saying that these people have an illness, it’s still very much their fault that they have this sexual arousal that they are not managing. This is just giving them another way to help manage it. Sometimes I think, and I have written this before, there’s a view that if you could give a pill that could guarantee that someone wouldn’t reoffend, it would be cheating because they haven’t gone through the hard work. They haven’t confessed and said it’s my fault and gone through weeks or months of psychological treatment. But the reality is, if you can give a pill that would stop someone from offending that would be great, if only such a thing existed. I think that medication is a way to help these individuals manage their behaviour It’s not saying that it’s not their fault and that they’re not responsible for it. I get concerned when people talk about ‘medicalising sex offending’ and somehow medication does that, turning it into a disease. That’s certainly not the way we prescribe or look at the behaviour.

Do you think we should offer a surgical castration program in this country?

No. Medication is as effective, it’s reversible, it doesn’t have all the other psychological baggage that goes along with physical castration. In some instances where people have capacity and they are sure they want it, they’ve tried the medication, then they could be considered, but I certainly wouldn’t advocate a physical castration program.These would be one offs, they would be rare. Typically someone on medication, you’re hoping, is going to be able to come off it in a few years. If they’re physically castrated, that’s not an option.

What changes to allow these people to come off the medication?

You hope that during that period where they’re not overwhelmed, a lot of these men are overwhelmed by their sexual drives, during that period you can get some access psychologically that helps them better manage their sex drive when it comes back.