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Introduction: Different clinical guidelines suggest using testosterone-lowering medications (TLM) in sex offender treatment in addition to psychotherapy. Within Germany, there are two officially approved agents. So far, no current data exist about the routine use of TLM in a clinical context., Aim: The present observational study evaluates the frequency of the prescription of TLM and other medications in sex offender treatment in German forensic-psychiatric institutions. Experts are asked about the observed effects and side effects of TLM., Method: The heads of all 69 German forensic-psychiatric hospitals and outpatient clinics were asked to fill out a questionnaire assessing offender characteristics and treatment methods in use., Main Outcome Measures: Main outcome measures were the number of patients being treated with TLM and other pharmacological agents for reducing sexual drive. Further effects and side effects of the agents were evaluated., Results: Thirty-two participating institutions reported on 3,963 patients, 611 of them being sex offenders (15.4%). Most sex offenders had been convicted for child sexual abuse (39.8%) or a sexual assault/rape (37.6%). Almost all sex offenders were treated psychotherapeutically and 37% were receiving an additional pharmacological treatment. Of all the sex offenders, 15.7% were treated with TLM; 10.6% were treated with a gonadotropin-releasing hormone agonist; and 5.1% were treated with cyproterone acetate. Of these, 26.0-75.4% showed improvements in such outcomes as reduction of frequency and/or intensity of sexual thoughts. The remaining 21.3% of sex offenders who received a pharmacological agent were treated with selective serotonin reuptake inhibitors (11.5%) or antipsychotic medications (9.8%)., Conclusions: TLM are a frequently used addition to psychotherapy in sex offenders. In light of the lack of controlled clinical trials and the many side effects, benefits and risks should always be thoroughly assessed., (© 2012 International Society for Sexual Medicine.)

A sample of 528 successive admissions to the Phoenix Program, a voluntary inpatient treatment program for sex offenders, was studied in regards to serum prolactin levels. Serum prolactins were obtained as part of a battery of endocrine tests. A substantial number of patients had prolactin levels above the normal range, i.e., 21.0 microg/L. In this sample, fully 10.0% of the men showed elevated prolactin levels (the maximum being 41.0 microg/L), compared with an expected 2.5% according to laboratory norms. None of these individuals had clinical manifestations of prolactinoma. The significance of this increased rate of hyperprolactinemia in this sample of sexual offenders is unclear. There was a negative correlation with age and no correlation with other endocrine tests.

Forty men, ages 16 to 78 years, with sex-offending behavior, were treated with combined medroxyprogesterone acetate (MPA), group therapy, and individual psychotherapy. Twenty-three are pedophiles; seven, rapists; and 10, exhibitionists. Five had sex-offending behavior that began after head trauma. The duration of MPA therapy, usual intramuscular dose 400 mg/wk, ranged from six months to 12 years, usually more than two years. These men were compared with a control group of 21 men who refused MPA therapy. They had similar types of sex-offending behavior and were treated with psychotherapy alone with follow-up for a period that ranged from two to 12 years. MPA-related side effects included excessive weight gain, malaise, migraine headaches, severe leg cramps, elevation of blood pressure, gastrointestinal complaints, gallbladder stones, and diabetes mellitus. Of the 40 individuals who took MPA, 10 are still on therapy. Eighteen percent reoffended while receiving MPA therapy; 35 percent reoffended after stopping MPA. In contrast, 58 percent of the control patients, who refused and never received MPA, reoffended. Patients defined as regressed were much more likely to reoffend off therapy than the patients defined as fixated. Other risk factors for reoffense include elevated baseline testosterone, previous head injury, never forming a marriage relationship, and alcohol and drug abuse. In spite of significant medical side effects, maintenance MPA offers benefit for the compulsive sex offender by reducing the reoffense rate.

Forty-eight male patients with long-standing histories of deviant sexual behavior received medroxyprogesterone acetate and milieu therapy for up to 12 months. Forty subjects responded positively, all within 3 weeks, with diminished frequency of sexual fantasies and arousal, decreased desire for deviant sexual behavior, increased control over sexual urges, and improvement in psychosocial functioning. Improvement in deviant sexual behavior and psychosocial functioning was maintained after treatment ended, and there was no evidence of permanent physiological changes. The author suggests that medroxyprogesterone acetate associated with counseling may be the treatment of choice for patients with long-term deviant sexual behavior. He discusses the ethical issues involved.