The Impact of Surgical Castration On Sexual Recidi

22.02.
2018 The Impact of Surg cal Castrat on on Sexual Rec d v sm R sk Among Sexually V olent Predatory Offenders | Journal of the Amer can Acad…
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Other SPECIAL ARTICLE
The Impact of Surgical Castration on Sexual Recidivism

Risk Among Sexually Violent Predatory Offenders
L nda E. We nberger, Shoba Sreen vasan, Thomas Garr ck and Hadley Osran
Journal of the Amer can Academy of Psych atry and the Law Onl ne March 2005, 33 (1) 16-36;
Art cle F gures & Data Info & Metr cs  PDF
Abstract
The relat onsh p of surg cal castrat on to sexual rec d v sm n a sexually v olent predator/sexually dangerous
person (SVP/SDP) populat on s rev ewed. A rev ew of the l terature on castrated sex offenders reveals a very
low nc dence of sexual rec d v sm. The low sexual rec d v sm rates reported are cr t qued n l ght of the
methodolog c l m tat ons of the stud es. Better des gned test cular/prostate cancer stud es have demonstrated
that, wh le sexual des re s reduced by orch ectomy, the capac ty to develop an erect on n response to sexually
st mulat ng mater al s not el m nated. The relevance of th s l terature to SVP/SDP comm tment dec s ons and
eth cs s d scussed. Two v gnettes of castrated, h gh‐r sk sex offenders llustrate how to address r sk reduct on.
Two tables are presented: the f rst outl nes nd v dual case data from a d ff cult‐to‐obta n report, and the second
summar zes the most frequently c ted castrat on stud es on sexual rec d v sm. Orch ectomy may have a role n
r sk assessments; however, other var ables should be cons dered, part cularly as the effects can be reversed by
replacement testosterone.
Several states have recently enacted laws des gned to dent fy a small group of extremely dangerous
ncarcerated sexual offenders who represent a threat to publ c safety f released from custody. These laws are
known as the Sexually V olent Predator/Sexually Dangerous Person (SVP/SDP) Acts. The focus on a small
group of extremely dangerous sex offenders compr s ng the SVP/SDP group s llustrated by recent Cal forn a
stat st cs.1 Over a seven‐and‐one‐half‐year per od s nce the ncept on of the Cal forn a SVP Act n January of
1996, approx mately 65,000 sex offenders have been released from state pr son. Approx mately four percent of
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22.02.2018 The Impact of Surg cal Castrat on on Sexual Rec d v sm R sk Among Sexually V olent Predatory Offenders | Journal of the Amer can Acad…
these nd v duals were referred for comm tment, w th two percent be ng found by cl n cal evaluators to meet the
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cr ter a. As of July 2003, only 422 (0.6%) were comm tted by a judge or jury as SVPs.
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Generally, the cr ter a necessary for categor z ng an nd v dual as an SVP/SDP nclude f nd ngs that: (1) the
person has been conv cted of offenses determ ned by the state to const tute a sexually v olent cr me; (2) the
person suffers from a d agnosed mental d sorder; and (3) as a result of that d sorder, the person s l kely to
engage n sexually v olent offenses. Not all states use the term “mental d sorder”; some use “mental
abnormal ty”; “mental abnormal ty or personal ty d sorder”; “behav oral abnormal ty”; “sexual psychopath
personal ty”; “sexual d sorder, personal ty d sorder, or other mental d sorder or dysfunct on”; or “mental llness or
ser ous emot onal d sturbance.”2 Clearly, these are not formal DSM‐IV‐TR3 d agnoses. The SVP/SDP statutes do
not spec fy wh ch DSM‐IV TR d agnos s would or would not qual fy as a mental d sorder or mental abnormal ty.
However, the most common def n t on of the requ red mental cond t on among the states s s m lar to that found n
Cal forn a's § 6600(c) Welfare and Inst tut ons Code4—that s, one that affects emot onal or vol t onal capac ty
and pred sposes the nd v dual to the comm ss on of cr m nal sexual acts that pose a menace to the health and
safety of others.
Ind v duals dent f ed as SVPs/SDPs are c v lly comm tted for treatment n des gnated mental health fac l t es after
serv ng the r pr son terms. The use of c v l comm tment as a method of ach ev ng publ c safety for these
nd v duals has generated much controversy regard ng how efforts to protect soc ety have affected nd v duals'
c v l l bert es.5 Recent U.S. Supreme Court cases,6,7 however, have upheld the const tut onal ty of the SVP/SDP
laws. The Court reasoned that because these persons suffer from a mental cond t on that places them at r sk for
sexual reoffense, c v l comm tment for treatment purposes s not v ewed as pun shment.
Surg cal castrat on s not cons dered the standard treatment for the reduct on of sexual rec d v sm. Yet, there has
been ncreas ng nterest and n t at on of surg cal castrat on among men fac ng or already placed under an
SVP/SDP comm tment. There are no emp r cal data as to why persons des gnated SVP/SDP would cons der a
rad cal procedure such as orch ectomy over non nvas ve or less‐ nvas ve ntervent ons, such as cogn t ve‐
behav oral and ant androgen treatments. However, anecdotal data based on the authors' exper ence w th a
Cal forn a SVP populat on suggest the follow ng explanat ons. Persons comm tted under these laws or n the pre‐
comm tment process may v ew surg cal castrat on as the r only real st c opt on for release nto the commun ty.
Such nd v duals may have rejected trad t onal treatments such as cogn t ve‐behav oral therapy for several
reasons: ant pathy toward the SVP/SDP process because they v ew t as unfa r; a bel ef that they w ll never
successfully complete the program and be recommended for outpat ent release; and concern that part c pat on n
treatment, part cularly d scuss on of pr or offenses, w ll lead to new charges or sanct ons. Ant androgen treatment
may be rejected, as t s coupled w th a requ rement for part c pat on n psychotherapy. Another reason that
ant androgen med cat on may be rejected s because t requ res dosage‐reg men compl ance and has s de
effects (although orch ectomy can produce s m lar s de effects). An add t onal factor an nd v dual may have for
favor ng orch ectomy s the bel ef that mental health profess onals, courts, and jur es w ll be pos t vely persuaded
to release even h gh‐r sk sex offenders nto the commun ty f they are castrated. F nally, sex offenders may
undergo orch ectomy out of a bel ef that t w ll enable them to ma nta n better self‐control over dev ant sexual
mpulses. Psych atr sts and psycholog sts evaluat ng a surg cally castrated sex offender for an SVP/SDP
comm tment must face the quest on of how much r sk reduct on s assoc 0 views
ated w th orch ectomy.
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Two d fferent populat ons of men who have undergone surg cal castrat on can demonstrate the mpact of b lateral
orch ectomy on sex dr ve, capac ty to susta n erect on, and sexual nterest: sex offenders and pat ents w th
test cular/metastat c prostate cancer. More recent oncology stud es have the benef t of better des gns and
sample controls than the older surg cal castrat on tr als among sex offenders and can offer some emp r cal
markers as to sexual funct on.
The purpose of th s art cle s: (1) to prov de a cr t cal rev ew of the ex st ng stud es nvolv ng surg cal castrat on of
sex offenders; (2) to exam ne the test cular/prostate cancer l terature on orch ectom es w th reference to
reduct on of sexual funct on; (3) to d scuss the eth cal ram f cat ons of surg cal castrat on n an nvoluntar ly
comm tted group of sex offenders; and (4) to explore through case v gnettes the appl cat on of orch ectomy data
on r sk reduct on n an SVP/SDP populat on.
The art cle focuses on the eff cacy of us ng castrat on to lower cr m nal sexual rec d v sm of men who may qual fy
or have already been dent f ed as SVPs/SDPs. These men are not comparable w th paraph l acs or other sex
offenders who are not fac ng the prospect of an ndef n te per od of nvoluntary c v l comm tment. SVPs/SDPs
represent a small but extremely dangerous group of sex offenders whose mental cond t ons render them l kely to
engage n sexually v olent behav or. The leg slat ve f nd ngs of some of the SVP/SDP laws have art culated that,
because of the r personal ty d sorders and/or mental abnormal t es, nd v duals so comm tted are v ewed as
unamenable to treatment modal t es used n trad t onal short‐term c v l comm tment. Thus, spec al comm tment
statutes were enacted to prov de long‐term control, care, and treatment for these nd v duals.8–11 Therefore, t s
poss ble that SVP/SDP pat ents may have ent rely d fferent mot vat ons for elect ng surg cal castrat on than other
sex offenders not fac ng th s type of comm tment (v z, to obta n a cond t onal release or d scharge from
comm tment).
Surg cal Castrat on and Sex Offenders
Currently, the predom nant form of psycholog cal treatment for SVP/SDP pat ents s the cogn t ve‐behav oral
method. Recent stud es suggest that cogn t ve‐behav oral ntervent ons are assoc ated w th a moderate reduct on
n r sk.12–17 Thus, th s form of treatment does not reduce the r sk of sexual rec d v sm ent rely. Further, n one
meta‐analys s,13 treatment effects were found to be stronger among outpat ents than among nst tut onal zed
nd v duals; the latter compr se the SVP/SDP populat on. Therefore, whether cogn t ve‐behav oral treatments are
effect ve for h gh‐r sk offenders, such as those who are typ cally dent f ed as SVP/SDP, rema ns uncerta n.
Before cogn t ve‐behav oral therapy, ant androgen c hormones were used to treat paraph l acs and sex offenders.
The f rst t me these agents were used was n 1966 at Johns Hopk ns (medroxyprogesterone acetate) and the
Inst tute for Sex Research n West Germany (cyproterone acetate).18 Money19 found that medroxyprogesterone
acetate “suppresses or lessens the frequency of erect on and ejaculat on and also lessens the feel ng of sexual
dr ve and the mental magery of sexual arousal” (Ref. 19, p 219). Current med cal ntervent ons n sex offender
treatments nclude hormones that reduce testosterone levels, such as njectable Lupron (leuprol de acetate
depot), Lupron mplant, Goserel n, Depo‐Provera (medroxyprogesterone0 views
acetate), and cyproterone acetate.
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Testosterone and d hydrotestosterone are the hormones respons ble for ma ntenance of sexual behav or. The
product on of testosterone n males occurs pr mar ly through the secret ons of the Leyd g cells of the testes.20
The Leyd g cells are st mulated by the release of lute n z ng hormones from the anter or p tu tary gland and
related to the release of gonadotrop n‐releas ng hormones from the hypothalamus. Androgen receptors are
found n several reg ons nclud ng the m dbra n l mb c structures (as well as the hypothalamus), the sp nal cord,
and the pen s.21 B lateral orch ectomy ( .e., the surg cal resect on of the testes) results n a dramat c reduct on of
the product on of testosterone. An mal stud es demonstrate that castrat on results n a loss of sex dr ve and an
abol shment of mat ng behav or and that such dr ve could be restored by testosterone replacement.22 Wh le
hormonal therapy s more w dely accepted as a method to reduce testosterone among sex offenders, surg cal
castrat on ( .e., b lateral orch ectomy) s also presently used, albe t to a very l m ted extent.
The pract ce of surg cal castrat on on humans s not a recent phenomenon.23 As far back as the M ddle Ages,
castrat on was performed as a form of retr but on on those who comm tted rape or adultery. In Europe, the use of
castrat on of sex offenders as a form of treatment has been n ex stence s nce the early 20th century. The Dan sh
p oneered the f rst laws n 1929, legal z ng th s type of med cal ntervent on for sex offenders; soon thereafter,
Germany (1933), Norway (1934), F nland (1935), Eston a (1937), Iceland (1938), Latv a (1938), and Sweden
(1944) enacted s m lar laws.23 The theoret cal underp nn ng of the European castrat on laws was the el m nat on
of sexual urges bel eved to be the dom nant et olog cal factor n sexual cr m nal behav or.
The emp r cal stud es exam n ng the mpact of surg cal castrat on on sex offender rec d v sm were conducted n
Europe (predom nantly n Germany and Denmark) and date from the pre‐ and post‐World War II per ods. The
or g nal l terature s d ff cult to assess because research methodology n these older stud es was not well‐
spec f ed or performed to current standards. Freund24 prov ded a rev ew of pharmacolog cal sex dr ve reduct on,
nclud ng use of surg cal castrat on. The present rev ew reflects a comp lat on of data from stud es publ shed n
Engl sh and rev ewed by Freund and others, as well as a summary of other European art cles that were
translated and subsequently rev ewed by He m and Hursch.23 In add t on, data are rev ewed from one U.S. study
of castrated sex offenders conducted n Cal forn a.25
Europe
The largest number of castrat ons occurred n Germany and Denmark. In Germany, the pract ce of castrat on
dur ng the per od 1934 to 1945 arose from the Naz German Act of November 24, 1933, wh ch resulted n the
nvoluntary castrat on of sex offenders.23 Germany also enacted laws govern ng voluntary castrat on of sex
offenders that rema ned effect ve after 1945. Between 1934 and 1944, at least 2,800 sex offenders were
compulsor ly castrated n Germany, and, between 1955 and 1977, 800 sex offenders were castrated n West
Germany.
Denmark
Dan sh laws govern ng castrat on were f rst enacted n 1929 and stemmed from the government's ntent to
protect soc ety from rec d v st c rap sts.26 However, the law allowed for0 persons
views to be castrated f they bel eved
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that the r sexual drH
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placed them n danger of comm tt ng a cr me. The law was amended to nclude castrat on
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of persons whose sexual dr ve produced cons derable psycholog cal suffer ng or soc al devaluat on. He m and
Hursch23 est mated that from 1929 to 1973, there were approx mately 1,100 cases of orch ectomy n Denmark.
At the Treatment Inst tut on at Herstedvester, Denmark, a penal nst tut on, 285 surg cal castrat ons were
performed on the nmates between 1935 and 1970.27 Of these 285 nd v duals, less than 10 percent were ser ous
sex offenders.
Stürup26 reported f nd ngs from the early Dan sh stud es n a 1968 monograph. Results were publ shed of 900
pat ents who were castrated throughout Denmark between 1929 and 1959 and followed for at least s x years,
w th 39 percent followed for more than 10 years.26,28 Stürup prov ded a rev ew of the or g nal study conducted by
Sand et al.29 Of the subjects, 40 percent had comm tted one sex cr me, 18 percent had been sentenced on a
second occas on, and 24 percent had been sentenced on more than two occas ons. Further, 18 percent of the
subjects had comm tted no sex cr mes, even at the t me of castrat on. Dur ng the follow‐up per od, t was noted
that only 10 nd v duals, or 1.1 percent of the sample, had rec d vated n an obv ously sexual manner. In add t on,
there were another 10 “borderl ne cases” n wh ch there were cr m nal acts w th “sexually colored behav or.” The
sexual rec d v sm rate was extremely low among the surg cally castrated persons, and, by Stürup's report, 82
percent of the subjects were descr bed as sex offenders, w th 42 percent repeat offenders pr or to castrat on.
Although there was reference to ser ous sex offenders form ng a port on of the sample, the nature of the sex
cr mes was not spec f ed for the 900 subjects. Stürup,26 however, d d dent fy d agnost c subgroups. Forty‐four
percent were dent f ed as “mentally defect ve”, 25 percent as “psychopaths”; 13 percent as “sexually abnormal”,
10 percent as “borderl ne cases” of sexual dev ancy, 4 percent as “psychot cs”, and 4 percent as e ther
“m scellaneous” or “unclass f ed.” The large proport on of mentally defect ve subjects (44%) n relat on to clearly
dent f ed sexually abnormal nd v duals (13%) potent ally l m ts the f nd ngs of th s study. The counterargument to
th s conclus on s that the 25 percent psychopath c and 13 percent sexually abnormal cases const tute a large
enough group to apply the low rate of sexual rec d v sm after castrat on to modern‐day sex offenders.
In 1997, a rev ew by Hansen and Lykke‐Olesen27 of the treatment of sex offenders n Denmark summar zed the
h story of the Treatment Inst tut on at Herstedvester. Hansen30 observed 43 nmates who were sentenced to
Herstedvester for extended detent on because of comm tt ng v olent rape or other v olent cr mes (murder,
attempted murder, or severe bod ly njury n connect on w th a sexual offense). Or g nally, 24 nmates refused
surg cal ntervent on and rema ned ncarcerated for an extended per od, and 19 underwent castrat on. However,
of those who n t ally refused, two later underwent castrat on after they were released and then sexually
reoffended. Thus, n the follow‐up study per od, there were 21 nmates who opted for surg cal castrat on and
early release on probat on ( .e., 6–18 months after the operat on). Two of the 21 castrates comm tted other
sexual cr mes more than 15 years after orch ectomy. These new sex cr mes occurred after the r phys c ans gave
both nd v duals testosterone subst tut on therapy. Of the 22 who were not castrated, 8 sexually reoffended. The r
new cr mes occurred desp te a lengthy ncarcerat on for the r or g nal sexual cr mes (noncastrated persons spent
an average of e ght years n detent on versus two years for the castrated nd v duals). Therefore, the comparat ve
rates for sexual rec d v sm were 10 percent (more than 15 years after surgery and after be ng prov ded
replacement testosterone) n the castrated group, and 36 percent n the noncastrated group (unknown follow‐up
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Norway
In 1959, Bremer31 publ shed data on 216 male Norweg an castrated persons. He m and Hursch23 prov ded
deta led nformat on on the Bremer study. Of the sample group n wh ch 215 were observed, only 7 percent (n =
16) were descr bed as “sexual dev ates.” The major ty (51%, n = 109) were dent f ed as ol gophren cs, followed
by sch zophren cs (25%, n = 53), psychopaths (11%, n = 24), ep lept cs (5%, n = 10), and other (1%, n = 3).
Th rty‐two percent (n = 68/215) asked for castrat on and 68 percent (n = 147/215) were castrated at the request
of another person. Of the 215 persons followed, rec d v sm was noted n only 102 nd v duals. Of these, 58
percent (n = 59) reoffended pr or to the castrat on, w th 34 percent hav ng more than one prev ous reoffense.
W th n th s group of 102 subjects, the follow‐up per od ranged from 1 to 10 years, and the rate of sexual
reoffenses was 2.9 percent (n = 3). However, the observat on per od was long for only a subsample of 41 cases
that were followed up for 5 to 10 years. W th th s longer follow‐up group, the rec d v sm rate was calculated at a
max mum of 7 percent. Of the group of 102 castrated persons for whom nformat on regard ng the r att tudes
toward castrat on was ava lable (n = 89), 41 percent (n = 37) were sat sf ed w th the operat on, 26 percent (n =
23) were d ssat sf ed or b tter, and 33 percent (n = 29) were nd fferent.
He m and Hursch23 prov ded add t onal f nd ngs w th respect to changes n sexual funct on, somat c state, and
psycholog cal funct on ng for subgroups of the subjects of Bremer.31 As to changes n sexual funct on, data were
ava lable for a subgroup of 157 subjects. S xty‐s x percent (n = 103/157) nd cated that they had lost all sexual
nterest. Of those report ng loss of sexual nterest, 72 percent (n = 74) nd cated that the asexual zat on occurred
mmed ately or shortly after orch ectomy. The rema n ng 28 percent (n = 29/103) nd cated that the sexual urge
d sappeared gradually over the course of a few months to a year. Changes n somat c state were reported for a
subgroup of 201 subjects, of wh ch 69 percent (n = 139) stated they had no compla nts other than the standard
postcastrat on changes n secondary sex character st cs. However, 18 percent (n = 37/201) noted problems
nclud ng we ght ga n, aged appearance, weakness, and deter orat on n general health. Data as to psycholog cal
funct on ng after surg cal castrat on were ava lable for 175 subjects. Twenty‐f ve percent (n = 44/175) descr bed
symptoms of dysphor a.
An argument for the use of these data support ng therapeut c castrat on s that 66 percent (n = 103/157) of the
subjects reported complete loss of sexual nterest. Thus, surg cal castrat on could be h ghly effect ve n reduc ng
sexual rec d v sm among those sex offenders whose behav or s dr ven by sexual psychopathology. The
counterpo nt to th s argument s that the Bremer sample compr sed pr mar ly those who were mentally
hand capped or psychot c (75%, n = 162/215) w th only 7 percent (n = 16/215) descr bed as sexual dev ates. The
general zab l ty of these data to those whose sex cr mes are dr ven predom nantly by sexual psychopathology s
l m ted, and use of these data n a paraph l c populat on to argue for dramat c r sk reduct on would be h ghly
speculat ve. Another methodolog cal l m tat on of the study was the lack of a compar son group of noncastrated
nd v duals.
Germany and Sw tzerland
He m and Hursch23 rev ewed many of the s gn f cant European castrat on art cles, nclud ng those by
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Langelüddeke32 n 1963 and Cornu33 n 1973. Both of these stud es were wr tten or g nally n German. He m and
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Hursch's rev ew prov
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H ghl an Engl sh translat on of the data.
Accord ng to He m and Hursch, Langelüddeke's data cons sted of an arch val rev ew of cr m nal records of 1,036
German castrated sex offenders released nto the commun ty (the cr m nal records dated back to 1953). The
castrated group cons sted of 638 males who were castrated between 1934 and 1938, 259 castrated between
1939 and 1941, and 139 castrated between 1942 and 1944. These sex offenders were released soon after
nvoluntary castrat on. The compar son group cons sted of 685 released, noncastrated sex offenders.
W th respect to sexual rec d v sm, 84 percent (n = 870) of the 1,036 castrated sex offenders had at least two
conv ct ons (numbers ranged from two to more than e ght) for sexual cr mes before castrat on. After castrat on,
the sexual rec d v sm rate for the castrated persons dropped to 2.3 percent (24 of the 1,036 castrated persons
reoffended at least once after surgery). Th s rate rose to 2.6 percent when corrected for those nd v duals who
d ed—that s, a 10 percent assessment was taken of the total sample, thus reduc ng the sample to 932 w th 24
castrated rec d v sts. The nature of the sexual cr mes (e.g., contact, noncontact, ch ld molestat on, or rape) was
not spec f ed. Ten of the rec d v sts were castrated between the ages of 20 to 30, and these offenders showed a
h gher rec d v sm rate than offenders castrated at an older age. The t me nterval for rec d v sm after castrat on
and release ranged between s x weeks and 20 years. Castrated nmates who were sent to pr son once or tw ce
had a lower rate of rec d v sm than those castrated persons w th three or more conv ct ons. N ne of the 24
castrated persons who reoffended sexually d d so f ve years after release. Twenty comm tted nonsexual offenses
n add t on to sexual cr mes. The noncastrated sex offenders had a sexual rec d v sm rate of 39.1 percent (n =
268).
He m and Hursch23 rev ewed the data of 89 nterv ewed castrated nd v duals n the Langelüddeke sample. S xty‐
f ve percent (n = 58) reported that the r l b do and potency were ext ngu shed mmed ately or soon after
castrat on, 17 percent (n = 15) reported s gn f cant fad ng followed by the ext nct on of sex dr ve, and 18 percent
(n = 16) stated that they were st ll able to have sexual ntercourse more than 20 years after castrat on. Of the 15
castrated nd v duals over the age of 50 (aged 51–70), 80 percent (n = 12) descr bed ext nct on of potency soon
after castrat on, 7 percent (n = 1) descr bed potency as obv ously weaker, and 13 percent (n = 2) descr bed
potency as st ll present or weakened sl ghtly. For those n the 31‐ to 40‐year‐old age group (n = 28), 64 percent
(n = 18) exper enced ext nct on of potency soon after castrat on, 21 percent (n = 6) descr bed obv ous weaken ng
of potency, and 14 percent (n = 4) stated that potency was st ll n effect or sl ghtly weakened. A small percentage
of the sample had somat c sequelae. N ne percent (n = 8) had subcutaneous fat t ssue s m lar to that of women,
10 percent (n = 9) had “strong” gynecomasty, and 25 percent (n = 22) developed “weak” gynecomasty. F fty‐one
percent (n = 45) of the nd v duals had soft or more compl ant sk n, 17 percent (n = 15) had weaker beard growth,
and 66 percent (n = 59) had reduced body ha r. Only one of the nd v duals developed osteoporos s. Twenty
percent (n = 18) stated that the operat on had a pos t ve nfluence on the r l ves, w th reports of feel ng calmer
and more balanced; however, 30 percent (n = 27) compla ned that s nce the operat on they were more
depressed and felt nadequate, solated, and pass ve. F fty‐two percent (n = 46) sa d they were content w th the
outcome of the operat on, wh le 26 percent (n = 23) were amb valent. The rema n ng 22 percent (n = 20)
expressed marked d scontent. 0 views
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The second study rev ewed by He m and Hursch23 was conducted by Cornu33 n 1973 n Sw tzerland. The
sample s ze of 127 castrated persons was much smaller than n Langelüddeke's study. These castrated
nd v duals were sex offenders released to the commun ty after surgery, who were evaluated at least f ve years
follow ng d scharge. The compar son group cons sted of 50 noncastrated sex offenders who refused to undergo
the procedure. The follow‐up per od ranged from 5 to 35 years. In the 121 castrated subjects assessed dur ng
follow‐up, the rec d v sm rate before the operat on was 76.86 percent. Follow ng orch ectomy, 7.44 percent (n =
9) sexually reoffended. In contrast, 52 percent (n = 26) of the compar son group sexually rec d vated w th n 10
years after castrat on was recommended to them (ma nly w th n the f rst 5 years), and the r reoffenses were often
nfluenced by alcohol. It was reported that there were no substant al d fferences between the castrated group and
the compar son group w th respect to sexual dev at on and mar tal status. However, there was contrad ctory
nformat on as to group d fferences w th regard to psych atr c d agnos s and l fe h story. The noncastrated group
may have had greater rates of d m n shed mental soundness and come from more d srupt ve fam ly
backgrounds.
S xty‐e ght of the castrated persons n the Cornu sample were later nterv ewed. S xty‐three percent (n = 43)
descr bed that l b do and potency ext ngu shed qu ckly after castrat on, wh le 26 percent (n = 18) sa d that there
was a gradual decl ne of sex dr ve. Ten percent (n = 7/68) of those castrated stated that they were able to
ach eve sexual ntercourse 8 to 20 years after castrat on. S gn f cant somat c sequelae ncluded 51 percent (n =
21/41) who were extremely overwe ght and 82 percent (n = 49/60) who developed osteoporos s. Of those
d ssat sf ed w th hav ng been castrated, 13 percent (n = 9/68) felt effem nate and mut lated, and 32 percent (n =
22/68) reported feel ng m serable after the operat on w th compla nts of depress on, rr tab l ty, and solat on. Forty
percent (n = 27/68) of the castrated group descr bed feel ng calmer, happ er, and more act ve after the operat on.
Seventy‐one percent (n = 48/68) of the subjects nterv ewed were accept ng of and content w th the dec s on to
be castrated. These nd v duals c ted the pos t ve benef ts of castrat on as hav ng decreased the r abnormal sex
dr ve, prevented the r conf nement, or mproved the poss b l ty of marr age.
Both the Langelüddeke and Cornu stud es could be cr t c zed on several methodolog cal grounds. Wh le the
Langelüddeke data offer large numbers of castrated sex offenders, the f nd ngs are l m ted by the context of the
castrat ons—that s, dur ng the Naz reg me, under wh ch the ster l zat on of so‐called undes rables was a
pract ce. An add t onal concern s that n the Langelüddeke sample, the castrated subjects had a sexual
rec d v sm rate of 84 percent pr or to the surgery, wh le the noncastrated subjects had a sexual rec d v sm rate of
39.1 percent. These rates suggest that the two groups d ffered beyond the r surg cal status. That s, the
noncastrated group appeared to be at a lower rec d v sm r sk by base rate and may not have represented an
adequate compar son group. It s poss ble that those subjects who were n the compar son noncastrated group
were not selected for castrat on because of a perce ved low rec d v sm r sk. Other than castrat on, t was unclear
whether the nd v duals n both Langelüddeke's and Cornu's stud es were treated d fferently (e.g., whether there
was a h gher level of soc al control dur ng commun ty superv s on for the castrated group). Also unknown was
whether the castrated and compar son groups came from the same t me cohorts and were followed for an equal
length of t me. Cornu's matched group cons sted of those who refused castrat on and had to endure a long
0 views sample appeared to have a h gher
per od of conf nement. In add t on, these noncastrated nd v duals n Cornu's
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rate of alcohol sm, H
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ghterbed as exh b t ng d m n shed mental soundness, and seemed to come from more
d srupt ve fam ly backgrounds than the castrated group. Further, the nature of the sex cr mes (e.g., pedoph l a,
exh b t on sm, or rape) were not spec f ed for e ther the Langelüddeke or Cornu samples.
Another study from Germany was conducted by He m.34 He exam ned the sexual behav or of 39 West German
sex offenders released from pr son after voluntary surg cal castrat on w th no follow‐up as to sexual rec d v sm.
The offenders cons sted of 12 (31%) rap sts, 12 (31%) heterosexual pedoph les, 4 (10%) homosexual
pedoph les, 4 (10%) b sexual pedoph les, 1 (3%) sexual murderer, and 6 (15%) homosexuals. Th rty‐three (85%)
offenders comm tted two or more sex cr mes pr or to castrat on. The r mean age was 49.3 years (range, 32–69).
The mean age at castrat on was 42.5 years (range, 25–59). The med an t me the offenders were n the
commun ty was 4.3 years (range, 4 months to 13 years). Th s study used quest onna res and assessed the
subjects' sexual funct on ng before and after orch ectomy. Overall, the subjects reported a stat st cally s gn f cant
decrement n the frequency of sexual ntercourse, masturbat on, and sexual thoughts after castrat on. Of the 35
subjects who exper enced co tus before castrat on, 11 of the 35 reported the ab l ty to have sexual ntercourse
after castrat on, even though the procedure had occurred several years (mean, 4.8 years; range, 1.3–9.5)
prev ously. Th s study found that castrat on had the strongest effect on sexual behav or n those who were
castrated between the ages of 46 and 59. The study s hampered by the lack of object ve assessment of sexual
funct on ng and nterest (e.g., plethysmograph) rely ng nstead on self‐report data. In add t on, the rec d v sm
rates of these castrated nd v duals were not reported.
W lle and Be er35 reported rec d v sm rates of both castrated and noncastrated appl cants to the general med cal
counsel n Germany for the per od between 1970 and 1980. In t ally, there were 104 castrated and 53
noncastrated appl cants. The noncastrated subjects cons sted of those who were not castrated because the r
appl cat ons were rejected by the author tat ve comm ss on (n = 17), they canceled the appl cat on before the
comm ss on could render a dec s on (n = 30), or they canceled the appl cat on after the comm ss on granted the
request (n = 6). Both the narrat ve and tables n th s report were not clear as to what const tuted the cr m nal
h story of the subjects—that s, whether the “offenses pr or to appl cat on for castrat on” preceded the nstant
offense or were the nstant offense. G ven th s l m tat on, we cannot prov de nformat on regard ng the sexual
rec d v sm rates pr or to appl cat on for castrat on. W lle and Be er descr bed offense type (unspec f ed as to when
they occurred) for both the castrated and noncastrated subjects. In part cular, among the castrated, 22 percent (n
= 23) were descr bed as “aggress ve” offenders (cons st ng of one nd v dual whose offense was hom c de and 22
whose offenses were rape, attempted rape, or sexual assault) and 73 percent (n = 76) as pedoph l c offenders.
Of those who were not castrated, 28 percent (n = 15) were descr bed as aggress ve offenders (cons st ng of
three nd v duals whose offense was hom c de and 12 whose offenses were rape, attempted rape, or sexual
assault) and 49 percent (n = 26) as pedoph l c offenders. In exam n ng only those subjects w th sexual offense
charges (aga n unclear as to whether th s referred to the nstant offense, pr or sex offenses, or a comb nat on),
the average number of charges was fa rly s m lar for the two groups. The castrated offenders (n = 103) had an
average of 3.27 charges and the noncastrated offenders (n = 45) had 2.87. Of note, W lle and Be er offered
confl ct ng numbers as to the offense charges of the noncastrated group, c t ng e ther s x or e ght as hav ng
comm tted no sex offense. W thout clear nformat on regard ng sexual rec d v sm rates pr or to castrat on, we
have l m ted ab l ty to compare the subjects from th s study w th known0 hviews
gh rec d v st c sex offenders.
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For purposes of assess ng rec d v sm, certa n nd v duals from both the castrated and noncastrated groups were
excluded from the analys s. They ncluded those who had no sexual offenses pr or to the appl cat on for
castrat on (n = 4), those for whom castrat on was not perm ss ble under German Law (n = 2), those who were
castrated due to psychos s (n = 2), those who were not traceable (n = 7), and those for whom there was no val d
follow‐up (n = 8). These exclus ons reduced the number to 99 castrated and 35 noncastrated appl cants. Among
the castrated group, three sexually reoffended, y eld ng a rec d v sm rate of 3 percent. Of the noncastrated
appl cants, 16 sexually reoffended, for a 46 percent rec d v sm rate.
Wh le all castrates n the W lle and Be er sample exper enced a reduct on n sexual nterest and act v ty, erot c
fantas es, and capab l ty of spontaneous or st mulated erect on after surgery, an exam nat on of the r sexual ty
f ve years after surgery revealed var ous degrees of l b do and sexual act v ty. Of a total of 81 subjects for whom
data were ava lable, the effects of castrat on on post‐surg cal sexual funct on ng at f ve years were reported.
Among the castrated nd v duals n the 30‐ to 44‐year age group, 33.3 percent (n = 16/48) could funct on
sexually; that s, 20.8 percent (n = 10/48) requ red ntens ve st mulat on, and 12.5 percent (n = 6/48) reported that
the r sexual act v ty and l b do were reduced, but not drast cally. On the other hand, n the same age group, 66.7
percent (n = 32/48) dent f ed sexual act v ty as pract cally ext nct after s x months. Among those aged 45 to 59
years, 10 percent (n = 2/20) reported sexual act v ty w th ntens ve st mulat on, 5 percent (n = 1/20) reported
nondrast c reduct on of act v ty and l b do follow ng castrat on, and 85 percent (n = 17/20) reported ext nct on of
sexual act v ty and l b do. Among castrated persons aged 60 and over, only 7.7 percent (n = 1/13) exper enced
reduced sexual capac ty, whereas 92.3 percent (n = 12/13) reported pract cally ext nct l b do and sexual act v ty.
These data underscore that castrat on was most effect ve n the reduct on of l b do and sexual act v ty among
those aged 45 years or more. Wh le castrat on rendered l b do and sexual act v ty pract cally ext nct at s x months
for two‐th rds of the youngest age group (30–44 years), one‐th rd reported the ab l ty to funct on sexually f ve
years after castrat on.
Seventy‐seven of the castrated appl cants were evaluated regard ng the r sat sfact on w th the r current s tuat on
and the surg cal procedure. Seventy‐one percent (n = 55) sa d that they were pleased, 20 percent (n = 15) sa d
that they were undec ded, and the rema n ng 9 percent (n = 7) sa d that they were d ssat sf ed. Methodolog cally,
th s study offered descr ptors of the offense types as well as a compar son group of noncastrated persons w th a
s m lar average number of sexual offenses pr or to ntervent on as the castrated group. The very low reoffense
rate n the castrated group (3%) compared w th the much h gher rate n the noncastrated group (46%) could be
argued more cred bly as be ng related to surg cal ntervent on.
Un ted States
One report from the 1952 Cal forn a leg slat ve subcomm ttee on sexual cr mes stated that 60 nd v duals had
undergone orch ectomy n San D ego County s nce 1937.25 Follow ng surgery, there was a zero percent rate of
sexual rec d v sm; that s, “the records reflect that not one of these nd v duals has comm tted a further sex
offense” (Ref. 25, p 47). However, nonsexual cr mes were comm tted n some cases. The document prov ded
l m ted nformat on on 44 conv cted sex offenders who underwent surg cal castrat on between 1937 and 1948
and were released from custody. The document was unclear as to the0per
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od of follow‐up for each nd v dual after
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orch ectomy or when
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H ghl were released nto the commun ty. It noted that a prel m nary report was f led on March
8, 1950, and as best as can be determ ned, th s date may represent the end of the follow‐up per od. However,
the report was so l m ted n explanat on that an assumpt on about the nd v duals' date of release nto the
commun ty could not be made.
Desp te the sparseness of data reported n th s leg slat ve document, t conta ned some case nformat on w th
deta ls that prov ded a p cture of the types of offenders who d d not reoffend sexually after orch ectomy. Of the 44
c ted cases, the nstant offenses for 40 nd v duals met the cr ter a for clear “hands on” sexual offenses such as
rape and/or ch ld sexual molestat on. W th respect to the demograph c breakdown of these 40 cases, the
leg slat ve document descr bed 39 as wh te and one as Mex can; 39 were employed largely n lower m ddle‐ to
m ddle‐class occupat ons, w th the one unemployed nd v dual descr bed as hav ng subnormal ntell gence.
Regard ng mar tal status, 15 were marr ed, 12 were s ngle, 7 were d vorced, 4 were separated, and 2 were
w dowed. The age range of the castrated offenders was between 24 and 72 years. The level of educat on ranged
from persons w th a second‐grade level of educat on (n = 1) to those w th a med cal degree (n = 2).
The l m ted descr pt on of the 40 offenders and the r offenses restr cts an assessment of the r r sk level pr or to
surg cal castrat on. Exam nat on of the subjects' cr m nal h story pr or to the nstant sex offense revealed that 60
percent (n = 24) of the sample had no pr or cr mes, 27.5 percent (n = 11) had a pr or sexual offense, and 12.5
percent (n = 5) had a h story of nonsexual offenses.
Th s leg slat ve report s a h ghly relevant document that descr bes and follows several conv cted sex offenders
who were surg cally castrated n the Un ted States. However, t s not read ly ava lable w th n the publ c doma n.
Therefore, spec f c nformat on from the report s presented n Table 1 for those who may want to v ew data on
the 40 nd v dual cases.
Table 1
V ew nl ne
1952 Cal forn a Leg slat ve Subcomm ttee Report: Cases of 40 Castrated Sex Offenders Who D d Not Reoffend Sexually
Summary
A summary of the sexual rec d v sm rates for the European and U.S stud es s dep cted n Table 2. The overall
rate of sexual rec d v sm follow ng castrat on s very low, rang ng between 0 and 10 percent. Parenthet cally, the
10 percent rate occurred n a small sample (n = 21) after both of the reoffend ng castrated persons were g ven
testosterone nject ons. The low sexual rec d v sm f nd ngs rema ned cons stent across the stud es, even though
they var ed n methodology and had a var ety of l m tat ons. Many of the stud es were hampered by the follow ng:
no pre‐surgery base‐rate r sk for sexual rec d v sm, lack of a true compar son group, no basel ne data regard ng
pre‐ ntervent on offend ng and offense types, or small sample s zes. Further, there was a lack of post‐surgery
corroborat on of dev ant sexual nterest v a use of pen le plethysmography, a method useful for assess ng sexual
dev ant nterest among those seek ng commun ty release.36
Table 2you like to highlight web like that?

Would V ew nl ne
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Summary of Surg cal Castrat on Stud es Regard ng Sexual Rec d v sm
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The theory underp nn ng these stud es was that the el m nat on of testosterone v a orch ectomy would lead to a
s gn f cant reduct on of sexual dev ancy, thereby assur ng safe release of sex offenders nto the commun ty.
However, these stud es d d not address d rectly whether there was an establ shed l near relat onsh p between
low or near‐absent levels of testosterone and sexual nterest, dr ve, and erect le capac ty follow ng orch ectomy.
Orch ectomy and Sexual Behav or n Test cular and Prostate Cancer Stud es
Test cular and prostate cancer stud es that exam ned sexual funct on ng among normal males after surgery offer
one body of emp r cal data by wh ch to exam ne the relat onsh p between serum testosterone levels and
behav or. These stud es, n contrast to those of surg cal castrat on of sex offenders, have the advantage of
controlled des gns that offer demonstrated markers of sex hormone level, dr ve, and funct on.
Test cular cancer occurs pr mar ly among young men. Sexual funct on ng after surg cal ntervent on n th s pat ent
populat on has been addressed by two means: erect le response n laboratory sett ngs and quest onna res.37,38
Wh le t s generally accepted that sexual dr ve and act v ty are decreased s gn f cantly follow ng b lateral
orch ectomy, the effect s not absolute. Van Basten et al.39 exam ned the effects of ntramuscular testosterone
nject ons on sexual funct on ng among seven men who underwent b lateral orch ectomy for test cular cancer.
Inject ons were g ven every three weeks, and sexual funct on was assessed by both self‐report and erect le
performance as el c ted by v sual erot c st mulat on (v deo). These assessments occurred over three per ods: one
day after nject on, a per od halfway between nject ons, and just before the next nject on. One day after the
nject on, the serum testosterone level ncreased; levels n f ve of seven pat ents were n the upper normal range
(greater than 35 nmol/L). Th s was followed by a rap d decl ne of plasma testosterone levels to below the normal
reference range (below 10 nmol/L) n s x of seven pat ents for the rema n ng two follow‐up per ods. Three of the
pat ents reported loss of l b do, decreased arousal, and erect le dysfunct on; however, th s was not ev dent on
read ngs of tumescence atta ned through v sual erot c st mulat on. Sexual funct on ng d d not appear to be
affected by fluctuat ng plasma testosterone levels. Of spec f c relevance to r sk assessments of b laterally
castrated sex offenders s the f nd ng of Van Basten et al.37 of laboratory conf rmat on of erect le capac ty n those
who self‐reported such d ff culty. These results h ghl ght the need for laboratory corroborat on of self‐reports of
d m n shed or absent sexual des re and capac ty among sex offenders who have been surg cally castrated.
In ag ng sex offender populat ons, an mportant cons derat on s whether surg cal castrat on has a cumulat ve,
and thereby more s gn f cant, mpact on sexual funct on ng among older males. One assumpt on s that as men
age, there s an assoc at on of overall testosterone reduct on w th reduced sexual funct on. Rhoden et al.40
stud ed erect le funct on and testosterone levels n 965 normal ag ng men w th a mean age of 60.7 years (age
range, 40–80); however, erect le funct on was measured only by self‐report. Th s group had var ous degrees of
reported sexual dysfunct on (11.9% severe, 6.3% moderate, 14.1% m ld to moderate, 21.5% m ld) and h ghly
var able overall testosterone levels. Wh le the mean total serum testosterone d d not vary s gn f cantly across age
groups, there was a h gher percentage of men w th subnormal testosterone levels who were n the group older
than 70 years n compar son to those n the 40 to 49 age group. Overall, the researchers found that testosterone
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was largely w th n a normal reference range n the major ty of the sample. Total serum testosterone levels were
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not assoc ated w thHreported
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med cal llness n the group older than 70 years. The overall prevalence of reported erect le dysfunct on was 53.9
percent. When exam ned by age group, the rate of erect le dysfunct on was 36.4 percent n those aged 40 to 49
years, 42.5 percent n those 50 to 59, 58.1 percent n those 60 to 69, 79.4 percent n those 70 to 79, and 100
percent n those 80 and older. The study by Rhoden et al. supported other stud es of ag ng men,41,42 wh ch
concluded that testosterone levels d d not correlate w th erect le dysfunct on.
The f nd ngs of Rhoden et al.40 have mpl cat ons for r sk assessment among older sex offenders. Sexual
dysfunct on appeared at the h ghest level n those who were older than 70. However, of those n the 60 to 69
years age group, almost 42 percent reported no erect le dysfunct on. Further, these stud es found that older men
d d not necessar ly have subnormal testosterone levels. Therefore, t should not be assumed that older men have
low testosterone levels and consequently low sexual nterest, dev ant or otherw se.
Greenste n et al.43 exam ned erect le funct on among older b laterally castrated men who were sexually
funct onal pr or to castrat on for metastat c prostate cancer. In the r group of 16 pat ents, 8 were b laterally
surg cally castrated, 2 both surg cally and chem cally castrated, and 6 only chem cally castrated. The mean age
was 67.4 years (range, 62–75). In the e ght pat ents w th surg cal castrat on only, all reported reduct on n l b do.
No pat ent reported spontaneous erect on nor had they attempted ntercourse. These same pat ents reported
strong l b do and good erect ons pr or to castrat on. A record ng dev ce measured erect le funct on dur ng the
presentat on of an erot c v deo (v sual sexual st mulat on) 4 to 59 months (average was 21 months) after
orch ectomy. Four (50%) of the surgery‐only pat ents reported funct onal erect on, wh ch was corroborated dur ng
the per od of v sual sexual st mulat on. None of the chem cally castrated men ach eved a funct onal erect on
dur ng presentat on of the v deo. However, 9 of the 10 castrated men (comb n ng the e ght surgery‐only and the
two surg cal and chem cal‐castrat on pat ents) reported poor to absent l b do after surgery. Greenste n et al.
concluded that castrat on was assoc ated w th marked reduct on n both l b do and erect le funct on, but not
un form el m nat on of capac ty.
Overall, the test cular and prostate cancer stud es d d not support a complete lack of sexual capac ty and erect le
dysfunct on follow ng b lateral orch ectomy. The major f nd ngs are summar zed as follows:
Test cular cancer pat ents who underwent b lateral orch ectomy and who rece ved ntramuscular testosterone
nject ons reported loss of l b do, decreased arousal, and erect le dysfunct on. Wh le sexual des re s un formly
reduced or el m nated by b lateral orch ectomy, the capac ty to have an erect on to sexually st mulat ng mater al
s not el m nated.
Self‐reports of lack of erect le capac ty n the test cular cancer stud es were not conf rmed by laboratory
tumescence read ngs assoc ated w th v sual erot c st mulat on.
Among b laterally castrated men w th metastat c prostate cancer who were n the r 60s, erect le funct on
measured n the laboratory demonstrated that 50 percent could ach eve a funct onal erect on after
orch ectomy.
H ghly var able overall testosterone levels were found n a large sample of noncastrated, older male non‐sex
offenders. Erect le dysfunct on was assoc ated w th ag ng, but not w0th total serum testosterone. Almost 42
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percent of those n the 60 to 69 years age group reported noOriginal
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The study by Greenste n et al.43 of castrated elderly normal men demonstrated that all e ght who were only
surg cally castrated reported reduct on n l b do and loss of spontaneous erect on. These data coupled w th the
f nd ngs of W lle and Be er35 on sex offender castrated persons aged 60 years and over, n wh ch only 1 of 13
exper enced sexual capac ty, suggest that orch ectomy may be an effect ve method of reduc ng both l b do and
sexual rec d v sm among elderly sex offenders.
Wh le orch ectomy can decrease the ntens ty of sexual mot vat on, t does not always el m nate sexual capac ty.
That s, castrated nd v duals can ach eve erect ons after surgery. The data from normal males suggest that
erect le capac ty occurred n response to st mul they found to be erot c. It could be argued that erect le capac ty
n castrated sex offenders does not mean they w ll sexually rec d vate, only that they are capable of sexual
ntercourse. However, when the arous ng st mul for the castrated sex offender rema n dev ant, then the prudent
evaluator would need to cons der erect le capac ty as a var able n sexual rec d v sm r sk.
Eth cs Ram f cat ons Regard ng Surg cal Castrat on
The nvoluntary castrat on of sex offenders of the type conducted n pre‐World War II Germany under the Naz
reg me fell clearly w th n an uneth cal realm. Many of these surger es were performed under the ausp ces of
“exper mentat on,” w th poor methodology, w th no benef t for or consent from the nd v dual, and for the purpose
of assembly‐l ne ster l zat on of undes red populat ons. Such “exper ments” were often d ff cult to d fferent ate
from frank torture. Presently, t could be argued that pr soners and mentally ll persons are two groups of
vulnerable populat ons n wh ch even “voluntary” agreement to orch ectomy may be suspect. Involuntary c v l
comm tment, such as that found under SVP/SDP laws, could be cons dered a s tuat on of h gh coerc ve potent al.
Alternat vely, some sex offenders m ght v ew castrat on as the only method of release from potent ally l fet me
comm tment to a state hosp tal or s m lar locked fac l ty. Thus, they could argue that t s uneth cal to depr ve them
of an ntervent on that m ght restore the r freedom to l ve n the commun ty.
Eth cs arguments have been promulgated both aga nst and n favor of the use of surg cal castrat on for
rec d v st c sex offend ng. These arguments nvolve compet ng eth cs obl gat ons to the nd v dual and to soc ety.
Key eth cs concepts relevant to these ssues nclude respect for nd v dual autonomy, benef cence, and just ce.
One argument aga nst the use of surg cal castrat on stems from the nd v dual's po nt of v ew. It could be argued
that a person who chooses to undergo surg cal castrat on wh le be ng restra ned n a psych atr c hosp tal (or
pr son) may not have made a fully voluntary dec s on. Rather, t m ght be more accurate to state that the
nd v dual was coerced by h s c rcumstances, g ven h s status as an nvoluntary comm ttee fac ng protracted
per ods of custody, as well as h s percept on that castrat on w ll persuade courts that he s suff c ently
nondangerous to be released nto the commun ty. Some quest on the very capac ty of a person n th s s tuat on to
choose autonomously and voluntar ly between two such onerous outcomes, thus call ng nto quest on the val d ty
of an “ nformed” dec s on to be castrated.
In the r rev ew of n ne states where chem cal and/or surg cal castrat on statutes have been enacted, Scott and
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Holmberg44 ra sed s m lar eth cs concerns as to the capac ty of conv cted sex offenders to make an nformed
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ghlcal or chem cal castrat on. Whether th s type of treatment s med cally appropr ate s
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another eth cal cons derat on. As Berl n et al.45 noted, such ntervent on may be med cally appropr ate under
narrow c rcumstances—that s, when there s ev dence that the sex offender's act ons are med ated by ntense,
obsess onal, and recurrent paraph l c urges and fantas es. In some of the states w th castrat on statutes, there s
no requ rement for a psych atr c evaluat on of the offender; therefore, the med cal appropr ateness of such
treatment cannot be determ ned.46
Add t onal debates on eth cs could be v ewed from a trad t onal med cal analys s regard ng the r sks and benef ts
of a procedure. From a r sk perspect ve, the surg cal procedure s rrevers ble, thereby reduc ng an nd v dual's
autonomy through a severe reduct on n sexual des re. It m ght also result n osteoporos s and ncreased r sk of
su c de. From a benef t perspect ve, surg cal castrat on reduces compuls ve sexual preoccupat on for some sex
offenders, may not el m nate sexual capac ty for some sex offenders, and lost des re m ght be re n t ated through
exogenous testosterone for some sex offenders.
In contrast, these reduct ons n autonomy are not un que n med c ne. Many med cal and surg cal procedures
l m t a person's future autonomy, nclud ng prophylact c mastectomy for r sk of future breast cancer, use of
Antabuse, tubal l gat on, and vasectomy. Many more med cal ntervent ons carry w th them potent al harmful
effects—for example, permanent neurolog cal damage (ant psychot c med cat on), loss of hear ng (ant b ot cs),
damage to other organs of the body (ant ‐se zure med cat ons), and death (general anesthes a). Such med cal
r sks should be cons dered n l ght of the ava lab l ty of alternat ve treatments that have demonstrated some level
of effect veness. W th respect to sex offenders, are there effect ve alternat ves to b lateral castrat on that reduce
dev ant sexual behav or? Both cogn t ve‐behav oral therapy and pharmacolog cal ntervent ons, such as spec f c
seroton n reuptake nh b tors (SSRIs), ant androgen med cat ons, and the lute n z ng hormone‐releas ng hormone
(LHRH) agon sts, have shown at least moderate levels of effect veness. Ne ther cogn t ve‐behav oral therapy nor
ant androgen treatment can be v ewed as absolute n the r reduct on of sexual rec d v sm r sk.
Some profess onal organ zat ons have taken a pos t on aga nst surg cal castrat on as an ntervent on for sex
offenders based on the ava lab l ty of ant androgen med cat ons that can ach eve s m lar results.47 However, t
could be argued that, under certa n c rcumstances, the most nvas ve treatment may be the only effect ve
alternat ve for a h gh‐r sk sex offender. Wh le ant androgen and hormonal agents are non nvas ve alternat ves,
these ntervent ons have problemat c s de effects such as we ght ga n, nausea, fem n zat on, osteoporos s, and
ncreased r sk of d abetes mell tus and deep ve n thrombos s.48,49 These s de effects may n some nd v duals
exceed those assoc ated w th surg cal castrat on. It could be argued further that surg cal castrat on s an
appropr ate alternat ve under c rcumstances when chem cal suppressants have been tr ed and d scont nued due
to ntolerable s de effects or r sk of l fe‐threaten ng cond t ons.50
Add t onal support n eth cs for castrat on for sexual offenders nvolves the assert on of cho ce to rema n offense
free n the commun ty and to be r d of aberrant and compuls ve mpulses. Based on the few publ shed castrat on
stud es conducted on sex offenders, b lateral orch ectomy was related to some success n prevent ng rec d v st c
sexual v olence. Surg cal castrat on may prov de a method of show ng the pat ent's comm tment to publ c safety
or at least h s comm tment to attempt ng to control h s dev ant sexual behav or. There may also be pos t ve
psycholog cal benef ts to the sex offender result ng from the operat on.0 In
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th s regard, Langelüddeke found that
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and Cornu found
H ghl that 71 percent of the castrated sex offenders were accept ng of and content w th
ghter
the r dec s on to be castrated.23 The qual ty‐of‐l fe cho ce n be ng free of forced nst tut onal zat on for the pr ce of
surg cal castrat on could be v ewed by some sex offenders as a val d opt on, espec ally for those who v ew
themselves as unl kely to be released g ven the r past cr mes.
Wh le beyond the scope of th s art cle, t should be noted that n add t on to the ram f cat ons n eth cs regard ng
castrat on as a method of treatment for sex offenders, legal ssues have been ra sed on ts use, nclud ng
whether th s ntervent on may be cons dered a med cally appropr ate treatment. W nslade et al.51 outl ned
c rcumstances under wh ch surg cal castrat on of pedoph les may be legally and morally defens ble. The authors
stated that proponents of castrat on must face such quest ons as whether the procedure s med cally appropr ate,
the r sks are known and m n mal and can be m t gated, there s nformed consent, there are procedural
safeguards to assure that the ncarcerated nd v dual s competent to make treatment dec s ons and elects to
undergo the surgery on a voluntary bas s and under no coerc on, and there s an outs de profess onal rev ew of
the request for castrat on.
Assess ng R sk Reduct on Among SVP/SDP Surg cal Castrates
The orch ectomy stud es h ghl ght the complex nature of sexual funct on ng n males who have undergone
b lateral removal of the testes. Men w th low or no testosterone levels were st ll able to perform sexually and
ach eve funct onal erect ons, as demonstrated n cancer stud es measur ng pen le tumescence n response to
erot c v sual st mulat on. The stud es of non‐sex‐offender males who underwent b lateral orch ectomy
demonstrated that wh le testosterone may med ate phys cal sexual arousal, t s not un formly essent al to male
sexual funct ons.
W th respect to sex offenders who underwent chem cal castrat on only, hormonal treatments such as MPA
(medroxyprogesterone acetate) or CPA (cyproterone acetate) reduced testosterone levels and affected sexual
dev ance.52–54 However, these stud es used self‐report to measure decreases n dev ant sexual dr ve, fantas es,
and behav or—a methodology w th quest onable rel ab l ty.
As Table 2 summar zes, every study that exam ned sexual rec d v sm n castrated sex offenders found a marked
reduct on n sexual offend ng (0–10 percent). Sexually V olent Predator/Sexually Dangerous Person laws use a
r sk threshold that s def ned as “l kely” or “more l kely than not” to meet the standards for comm tment.2 Thus, a
castrated sex offender may argue that h s r sk level falls somewhere between 0 and 10 percent, based on
prev ous research, and s substant ally lower than the threshold of r sk mandated by the SVP/SDP laws. Indeed,
such a probab l st c percentage of r sk range would comport w th a low‐r sk label, accord ng to one w dely used
actuar al rat ng scale for sexual rec d v sm r sk, the Stat c 99.55
Does b lateral orch ectomy prov de a substant al treatment for h gh‐r sk sex offenders that just f es uncond t onal
release of these nd v duals nto the commun ty? Three cons derat ons must be exam ned n answer ng th s
quest on. The f rst s whether the ex st ng orch ectomy data can be appl ed rel ably to h gh‐r sk nd v duals such
as those subsumed under the SVP/SDP comm tment process. The second po nt concerns whether the nd v dual
w ll have access to exogenous testosterone. The th rd cons derat on s0 the
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extent to wh ch nonhormonal factors,
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such as psycholog
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ven needs for nt macy and neurob olog cal pleasure mechan sms can potent ate
relapse.
The follow ng v gnettes are compos te portrayals of nd v duals who qual f ed for an SVP evaluat on. They are
used to llustrate the d ff cult es n apply ng the orch ectomy research to a spec f c h gh‐r sk populat on n
assess ng potent al for rec d v sm among SVP/SDP respondents pet t on ng for release based on surg cal
castrat on. Just as a part cular psychotherapeut c approach should not be v ewed as an absolutely effect ve
treatment ntervent on or a probab l st c est mate based on actuar al tools should not be the sole determ nant for
assess ng rec d v sm r sk,56 castrat on should not be the only factor used for determ n ng whether an nd v dual s
l kely to reoffend sexually. Rather, the orch ectomy data should be appl ed n conjunct on w th other factors and n
a cl n cally reasoned manner. The careful use of these data s cruc al, as there s no emp r cal ev dence on
whether the ex st ng orch ectomy f nd ngs on sex offenders s general zable to an SVP/SDP populat on.
V gnette A: The Castrated Ser al Rap st
Mr. A. was 54 years old w th an arrest h story of s x rapes and an adolescent onset of sex offend ng. Desp te
serv ng pr son terms for two of the rapes, Mr. A. comm tted a th rd set of offenses at the age of 40. In the most
recent offenses, there was an escalat on n v olence that nvolved the torture and mut lat on of an adolescent
female v ct m and of an adult female prost tute. At the t me, he was n a l ve‐ n relat onsh p w th a woman 20
years h s sen or. When Mr. A. was 51 years old and el g ble for release from pr son for these last offenses, he
was d agnosed w th the mental cond t on of Paraph l a Not Otherw se Spec f ed, found to meet the SVP cr ter a,
and thereby comm tted to a state hosp tal for treatment.
Dur ng h s SVP comm tment, Mr. A. chose not to part c pate n any form of psycholog cal treatment, nclud ng the
cogn t ve‐behav oral treatment program for sex offenders. Now 54, Mr. A. pet t oned for release on the bas s of
hav ng undergone a court‐approved b lateral orch ectomy four months prev ously.
State hosp tal notes descr bed Mr. A. as reclus ve and rema n ng verbally host le toward female staff members.
After orch ectomy, he became more rr table and pass ve and ga ned we ght. He repeatedly art culated h s v ew
that he suffered from no sexual or psycholog cal d sorder. If released, Mr. A. would not be under any parole
superv s on or other type of cond t onal release. Moreover, he now has ne ther fam ly nor f nanc al resources
ava lable to h m n the commun ty.
Mr. A. argued that h s cont nued comm tment follow ng orch ectomy was unwarranted, as he currently had no
sexual dr ve, dev ant or otherw se. A pen le post‐surg cal plethysmograph was performed, the results of wh ch
showed no s gn f cant sexual arousal n response to scenes dep ct ng sexual aggress on, to other sexual dev ant
st mul , or to normal st mul . Blood levels drawn after surgery n the state hosp tal conf rmed ns gn f cant
testosterone levels.
In assess ng Mr. A.'s r sk of sexual reoffend ng and whether he should rema n comm tted as an SVP, two ssues
related to orch ectomy are pert nent: the appl cat on of orch ectomy data to h gh‐r sk sex offenders and the mpact
of potent al access to exogenous testosterone on r sk for rec d v sm.

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Apply ng Ex st ng Castrat on Stud es to a H gh‐R sk Sex Offender
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The pre‐surgery rec d v sm r sk level of those sex offenders who underwent orch ectomy was var able across the
publ shed sex‐offender castrat on stud es summar zed n Table 2. The follow ng stud es have very l m ted
appl cab l ty to a nonpsychot c, sad st c ser al rap st such as Mr. A:
Stürup26 d d not spec f cally dent fy what type of sex cr mes the 900 men n Denmark comm tted before the r
castrat on; therefore, the data offer no d rect on on how to apply the r f nd ngs to a person such as Mr. A.
The German Langelüddeke23,32 data set also conta n a large number of subjects (n = 1,036). However, the
types of sex cr mes comm tted by the subjects before orch ectomy are not well spec f ed. Therefore, th s study
has the same l m tat ons as Stürup.26
The Sw ss data set reported by Cornu n 1973,23,33 aga n, has the same l m tat ons as noted by Stürup26 and
Langelüddeke.32
The Norweg an study conducted by Bremer31 cons sted pr mar ly of subjects who suffered from mental
retardat on or sch zophren a.
Wh le the German study reported by W lle and Be er35 s not clear as to pre‐surg cal sex offense rec d v sm
rates, t does descr be the type of offenders who underwent castrat on—that s, there was a h gh rate of
pedoph l c offenders and a low rate of aggress ve sex offenders. Consequently, t has l ttle appl cab l ty to a
v olent and ser ally sexually assault ve nd v dual such as Mr. A.
The 1952 Cal forn a leg slat ve report25 conta ns nformat on dated to 1950 for some of the sex offenders who
were castrated as deta led n Table 1. However, none of these offenders was s m lar to Mr. A. n the cr t cal
factors of the degree of v olence and repeated sexual assault. Therefore, the low‐r sk rec d v sm rates of th s
group after orch ectomy cannot be general zed rel ably to Mr. A.
The follow‐up of Hansen30 of aggress ve rap sts and others who comm tted ser ous assault ve cr mes aga nst
persons appears to be the closest f t to Mr. A. Even so, there are l m tat ons n th s study. There was no
nformat on as to the subjects' pre‐surg cal rate of sex offend ng. The sample s ze was small: 21 who were
surg cally castrated and 22 who were not. A 10 percent rate of sexual rec d v sm more than 15 years after
release occurred only after two of the released castrated offenders rece ved exogenous testosterone. However,
can data from a small European sample be used to just fy a conclus on of low r sk due to surg cal castrat on,
g ven Mr. A.'s h story and nature of offend ng? The Hansen and Lykke‐Olesen27 art cle d d not offer nformat on
as to the character st cs of the r subjects: were they s m lar to Mr. A. n escalat on of sad st c v olence; d d they
have a pattern of mult ple pr or offenses followed by cr m nal sanct on, release, and reoffense; were they offered
psycholog cal treatment that they refused; was there a support system ava lable to them after orch ectomy and
after release; and were they under superv s on after d scharge nto the commun ty? The absence of such deta ls
argues aga nst a persuas ve appl cat on of the study's low rec d v sm rates to Mr. A. Therefore, the assumpt on of
a low‐level of rec d v sm r sk for Mr. A. as supported solely on orch ectomy‐based probab l st c est mates would
not be warranted.
Access to Exogenous Testosterone as a R sk Factor
The phys cal s de effects of orch ectomy m ght lead sex offender surg cally castrated nd v duals to seek
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testosterone replacement for symptom rel ef. The Langelüddeke23,32 study of sex offenders who were castrated
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reported several
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effects after surgery, nclud ng enlarged breasts (11%), slack and flabby sk n (51%),
reduced body ha r (69%), hot flashes and vert go (42%), heart and resp ratory d sorders, n ght sweat ng or
chron c pa n (19%). Th rty‐one percent reported psycholog cal symptoms of depress on, solat on, and pass v ty
s nce the castrat on. Wh le Mr. A. exper enced some unpleasant s de effects, he m ght suffer from add t onal ones
as the years s nce the orch ectomy ncrease. It therefore s qu te poss ble that he m ght seek exogenous
testosterone for symptom rel ef. In the sample that was the “closest f t” to Mr. A., the only two castrated sex
offenders who reoffended more than 15 years after release nto the commun ty d d so subsequent to rece v ng
testosterone nject ons.
It s not nconce vable that some phys c ans bel eve that a small dose of exogenous testosterone to reduce the
s de effects of orch ectomy n sex offenders would not result n sexual reoffend ng. However, there s research
demonstrat ng that even low levels of testosterone can restore sexual capac ty. One study57 found that after
serum testosterone levels n normal males were pharmacolog cally suppressed by Lupron (a gonadotrop n‐
releas ng hormone agon st), relat vely low amounts of exogenous testosterone restored both erect le funct on and
sexual act v ty and feel ngs. Thus, for the castrated sex offender, these data would have s gn f cant mpl cat ons f
the offender were to obta n even small doses of exogenous testosterone that restored h s sexual funct on, dr ve,
and phys ology.
Clearly, there s no guarantee that Mr. A. w ll not seek exogenous testosterone; part cularly, f the s de effects
ncrease or worsen, f he t res of them, or f he develops an nterest n preserv ng the exc tement he ga ned
earl er from h s paraph l c des res. The cr t cal ssue n th s case s Mr. A.'s mot vat on n subm tt ng to a voluntary
orch ectomy. There s no ev dence that such an act on was mot vated by h s awareness of h s psych atr c
cond t on and ts relat onsh p to h s documented dangerous sexual behav or. Rather, t appears that he elected
the surgery as a means by wh ch to ga n d scharge from h s comm tment and return to the commun ty. Follow ng
orch ectomy, Mr. A. rema ned essent ally psycholog cally unchanged. He cont nued to demonstrate host l ty
toward female staff members, a tra t that could be related arguably to m sogyn st c att tudes. If released, he w ll
not be under parole superv s on or any other commun ty soc al control mechan sm. Releas ng an nd v dual such
as Mr. A., whose h story ncludes legal sanct ons w th poor respons veness, n the hope that he w ll not seek
exogenous testosterone does not appear prudent. He has exper enced s de effects from the castrat on and may,
at m n mum, seek symptom rel ef w th med cat on. Further, t could be argued that the sad st c tra ts long
exh b ted by Mr. A. are non‐testosterone‐based factors that are f rmly entrenched and present, thus render ng
h m at r sk of sexually rec d v st c behav or, desp te orch ectomy.
V gnette B: The Castrated Ser al Pedoph le
Mr. B. was a 49‐year‐old nd v dual who had l ved alone h s ent re adult l fe. H s pattern of sex offend ng began at
age 16 when he molested a young boy. S nce then, he had been placed n custody on three separate occas ons
for sex offenses aga nst f ve boys under the age of n ne. Wh le on parole at age 35, he was arrested for oral
copulat on w th three boys to whom he showed pornograph c v deos and p ctures and gave money for sexual
favors. These acts were alleged to have occurred over a s x‐month per od.
At the end of Mr. B.'s last pr son term, he was found to be an SVP and comm tted to a state hosp tal. In t ally,
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wh le n the hosp tal's sex offender treatment program, he was hes tant to d sclose but soon part c pated fully n
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the groups.Install
H s SVP comm
H ghl tment was renewed, and he has s nce completed most of the phases of the treatment
ghter
program. One year ago, he chose to undergo surg cal castrat on. S nce then, h s testosterone levels were
conf rmed as low. Currently, he v ews h mself as cured of sexual dev ancy. A pen le plethysmograph (PPG)
conducted recently conf rmed no sexual arousal n response to young boys. Mr. B., however, demonstrated
sexual arousal n response to mages of teenage boys on the PPG. S x months after orch ectomy, the hosp tal
staff found a stash of p ctures of young boys n Mr. B.'s locker that were cutouts from “fam ly‐type” magaz nes.
Mr. B. den ed that the p ctures belonged to h m.
Mr. B. has never had age‐appropr ate relat onsh ps, and dur ng group sess ons he adm tted freely to be ng afra d
of reject on by adults. He sa d that he was more comfortable w th male ch ldren. Mr. B.'s release plan s to l ve n
a fac l ty that ass sts parolees w th commun ty reentry. Staff contact w th the organ zat on revealed that they were
unaware of Mr. B.'s offense h story and dent f ed the r pr mary m ss on as prov d ng temporary shelter and job
referrals. If released from h s SVP comm tment, Mr. B. would be under no mandated commun ty superv s on, as
h s term of parole has exp red.
Orch ectomy Data Appl cat on
Of the seven castrat on data sets l sted n Table 2, s x d d not appear general zable to Mr. B. These stud es were
l m ted as to nformat on on the rate of pedoph l c offenders, ncluded only aggress ve rap sts or other ser ously
assault ve nd v duals, or d d not spec fy the nature of the sex cr me. One data set may be appl cable to Mr. B.
The study from Germany by W lle and Be er35 reported rec d v sm rates for castrated sex offenders between
1970 and 1980. The castrated sample ncluded 73 percent who were descr bed as pedoph l c offenders wh le the
noncastrated group ncluded 49 percent pedoph l c offenders. The sexual rec d v sm rate was 3 percent for all of
the castrated nd v duals, as opposed to 46 percent for all of the noncastrated persons. These f nd ngs seem to
suggest that the surg cal ntervent on was related to reduc ng sexual rec d v sm, espec ally g ven the fact that the
castrated group was composed almost ent rely of nd v duals who were sex offenders; however, the r pre‐surg cal
rate of sex offense was not spec f ed. Therefore, based on the study by W lle and Be er, t could be argued that
Mr. B.'s probab l st c r sk for sexual rec d v sm s very low ( .e., three percent). Would th s be an accurate
assessment for Mr. B.? Before mak ng such a conclus on, t s mportant to cons der other factors that rema n
sal ent to r sk of sexual rec d v sm.
Neurob olog cal Factors That Are Non‐testosterone Dependent
The reduct on or el m nat on of testosterone m ght not affect the neurotransm tters (such as dopam ne) that play
a role n the ma ntenance of sexual behav or.53,58,59 Dopam nerg c m dbra n pathways assoc ated w th the
nterpretat on of pleasure could also have relevance for sexual behav or. The mesol mb c dopam nerg c neuronal
pathway has been long descr bed as ntegral to the process ng of pleasure or reward. Th s pathway (v a the
nucleus accumbens) may play a role n nterpret ng pleasure der ved by v sual st mul . There has been emp r cal
ev dence that the m dbra n pleasure pathways are react ve to v sual st mul of a quas ‐sexual nature. For
example, one funct onal magnet c resonance mag ng (fMRI) study found that the mesol mb c dopam nerg c
pathway was select vely act vated n young heterosexual males when exposed to faces of beaut ful women. Such
0 nary‐appear
a f nd ng d d not occur when the subjects were exposed to faces of ord views ng women.60 Moreover,
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there are emerg ngHdata
Install ghl suggest
ghter ng that v sual erot c st mul are processed d fferently by normal and paraph l c
persons, w th d fferent areas of the bra n st mulated by dev ant sexual st mul .61
What mpact do v sual st mul have on sexual arousal? Cancer stud es of b laterally castrated pat ents found that
exposure to erot c v sual st mul rema ns sexually arous ng desp te the absence of testosterone.39 Although Mr.
B. d d not demonstrate any sexual arousal n response to p ctures of young boys on the post‐orch ectomy PPG,
he was aroused by mages of teenage boys desp te low testosterone levels. Th s f nd ng nd cated that h s non‐
testosterone‐based pleasure mechan sms rema n robust. In add t on, Mr. B. was found n possess on of p ctures
of young boys after surgery. Exposure to nnocuous st mul could be sexually arous ng to paraph l c males, as
one study of pedoph les found. In th s study, pedoph les adm tted to f nd ng telev s on and pr nt advert sements
us ng ch ld models sexually arous ng.62 G ven Mr. B.'s response to and possess on of p ctures of juven le males,
t could be argued that he cont nues to have pedoph l c nterests, desp te surg cal castrat on and low testosterone
levels.
An mportant factor to cons der s that the castrat on stud es of sex offenders preceded current computer
technology that offers avenues for v sual pornograph c st mul . The freedom of commun cat on w th computers
(e.g., chat rooms, and electron c ma l) could also prov de sex offenders easy access to potent al v ct ms and may
mot vate the castrated sex offender to engage n nappropr ate sexual contacts w th ch ldren or adults. Haywood
and Cavanaugh descr bed chat rooms as “open ng up new v stas for sexual dev ance” (Ref. 36, p 388).
Psycholog cal Factors
Sexual behav or s not exclus vely determ ned by sex hormones. Therefore, as w th other behav or, past
exper ences as well as needs and nterpersonal sk lls determ ne the form and ntens ty of sexual behav or, both
normal and dev ant. An nadequate capac ty to bond emot onally w th adults may lead to dev ant attract on to
underage m nors. Throughout h s l fe, Mr. B. had no age‐appropr ate partners; rather, he had a long‐stand ng
dev ant nterest n male ch ldren. Mr. B.'s proposed res dence upon release offers l ttle n the way of help ng h m
address and cope w th h s needs and mpulses. Therefore, there s a substant al l kel hood that he w ll f nd
h mself n a pos t on of l ttle soc al support, factors that are only apt to he ghten emot onal d stress.
In an exam nat on of released sex offenders, Hanson and Harr s63 found that nt macy def c ts such as lack ng
age‐appropr ate partners, emot onal dent f cat on w th ch ldren, and soc al reject on were assoc ated w th an
ncreased r sk of sexual rec d v sm. Among sex offenders, dev ant sexual fantas es have been l nked as a cop ng
mechan sm for emot ons, such as anger, depress on, and lonel ness, that become precursors to sexual
rec d v sm.64 Pre‐ex st ng def c ts n the ab l ty to form appropr ate soc al relat onsh ps as well as poor capac ty to
bond w th others may only be he ghtened by surg cal castrat on. He m and Hursch23 reported follow‐up f nd ngs
from a subsample of German castrated sex offenders and noted that almost a th rd compla ned of feel ngs of
depress on, nadequacy, and solat on after surgery. In the Sw ss sample, they reported the f nd ng that 32
percent of the castrated group compla ned of feel ng m serable after the operat on, w th some express ng
compla nts of depress on, rr tab l ty, and solat on. Wh le the rate of sexual rec d v sm was low n both groups,
these psycholog cal factors cannot be gnored as potent al r sk elements that may ncrease the l kel hood of
sexual rec d v sm. In sum, the extent of protect on aga nst sexual rec d0 vviews
sm offered by castrat on alone for Mr. B.
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appears to Install
be overest mated.
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Conclus on
The stud es of b lateral orch ectomy are compell ng n the very low rates of sexual rec d v sm demonstrated
among released sex offenders. However, as th s rev ew has underscored, the stud es are methodolog cally
subopt mal and the general zab l ty of f nd ngs to a present‐day, h gh‐r sk sex offender rema ns problemat c.
Sample general zab l ty s a cr t cal ssue that should nform the appl cat on of research f nd ngs to the nd v dual
pat ent. The process of ut l z ng research f nd ngs n cl n cal pract ce s called “ev dence‐based med c ne.” The
f nd ngs that have the greatest appl cab l ty to the nd v dual pat ent are those where that person s s m lar to
those stud ed.65 When the research sample d ffers greatly from the nd v dual pat ent, the cl n c an cannot apply
conf dently the study f nd ngs to that person. In the sex offender castrat on stud es that were rev ewed, the sexual
rec d v sm percentages were calculated from groups of h ghly var able castrated sex offenders, whose types of
sex offenses and cond t ons of release were not well spec f ed. Th s s a key shortcom ng when evaluators
attempt to apply the rec d v sm r sk percentages from these sex offender orch ectomy stud es to an SVP/SDP
sample that represents a small subgroup of extremely dangerous nd v duals.
A recurrent pattern of sex offend ng suggests the ngra ned nature of dev ant sexual nterests. Orch ectomy
alone, w thout attendant psycholog cal change, may be nsuff c ent to m t gate sexual rec d v sm n a person who
s n the commun ty and subject to temptat ons. Conversely, t may be d ff cult to measure the true extent of
reduct on of dev ant sex dr ve by use of nonhormonal treatments; that s, there s no strong emp r cal base that
the effects of cogn t ve‐behav oral treatment adm n stered n nst tut ons w ll rema n robust once the offender s
released nto the commun ty, free from soc al control. Of pr mary concern to publ c safety s that there are few
emp r cal data regard ng the rec d v sm rate of h gh‐r sk sex offenders who are surg cally castrated and released
under no commun ty superv s on. For those nd v duals who harbor entrenched pedoph l c or sad st c sexual
preoccupat ons, the removal of the testes w thout accompany ng cogn t ve‐behav oral ntervent ons may leave
potent psycholog cal r sk factors n place. Cond t onal, as opposed to absolute, release nto the commun ty allows
a safer way of mon tor ng n v vo how the h gh‐r sk sex offender copes w th stress and how he handles r sky
s tuat ons (e.g., go ng to the grocery store and see ng young boys). It could also allow for assess ng access to
exogenous testosterone v a blood tests.
As Hansen and Lykke‐Olesen27 noted, surg cal castrat on s a treatment of symptoms and not a cure. The latter
must be emphas zed, as orch ectomy n h gh‐r sk offenders may create an art f c al sense of safety. Th s s not to
suggest that the ex st ng orch ectomy data are of no value n current sex offender r sk assessment. Rather, the
r sk analys s should reflect a prudent appl cat on of the orch ectomy data to the assessment of the nd v dual sex
offender. As the v gnettes llustrate, each assessment should address some, f not all, of these four po nts:
Is the data set to be used suff c ently deta led that the cl n c an can have a h gh degree of conf dence that the
sex offender be ng evaluated s s m lar to those exam ned w th n the study sample?
Are there non‐testosterone‐dependent neurob olog cal factors present that could dr ve sexual rec d v sm?
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Are there psycholog cal r sk factors present that could ncrease sexual rec d v sm?
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What s the r sk that th s nd v dual w ll secure exogenous testosterone, f released?
The low probab l st c sexual rec d v sm rates found n the sex offender orch ectomy stud es may be appl ed under
the follow ng cond t ons: to those nd v duals for whom a persuas ve argument can be made n support of the r
s m lar ty to a sex offender orch ectomy data set; when there s no ev dence of cont nued preoccupat on w th
ch ldren or that aggress ve mater al arouses sexual pleasure; when there s a pattern of nvolvement n
ntervent ons that demonstrate awareness of psycholog cal and other r sk factors and the nd v dual appears to
have made substant al nternal and behav oral changes; and when, as a result of these and other factors, the
l kel hood of access ng exogenous testosterone s low. Under such c rcumstances, t could be concluded that the
confluence of var ables, w th orch ectomy as one, suggests that the nd v dual would not present a “l kely r sk”
and could be released nto the commun ty even w th l ttle to no superv sed control.
The current rev ew h ghl ghts the d ff cult dec s ons regard ng the eth cal use of surg cal castrat on for select
populat ons. Th s procedure, n and of tself, s not a complete treatment for sex offenders. Consequently, the
del berate evaluator should cons der carefully the mpact of b lateral orch ectomy on the reduct on of r sk n an
SVP/SDP populat on and should not we gh th s var able w th e ther an nflated or deflated degree of mportance.
Acknowledgments
The authors thank Mary Flavan, MD, for her generous ass stance as well as the anonymous rev ewers for the r
many deta led and thought‐provok ng comments.
Amer can Academy of Psych atry and the Law
References
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legal standards of “mental d sorder” and “l kely to reoffend.” J Am Acad Psych atry Law 31:471–85, 2003
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Surg cal Castrat on and Sex Offenders

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Eth cs Ram f cat ons Regard ng Surg cal Castrat on

Assess ng R sk Reduct on Among SVP/SDP Surg cal Castrates

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Access to Exogenous Testosterone as a R sk Factor

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Orch ectomy Data Appl cat on

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