Many people consider sexual offenders monsters—especially those who molest children—and would like nothing more than to see them castrated. Yet that is not about to happen as long as the impulse toward castration is reined in by others, including the AMA, which opposes physician participation in castration initiated for criminal punishment.

But how about giving sexual offenders chemicals that blunt their testosterone and thus dampen their sexual drive—that is,

antiandrogens?

This is actually being tried in various settings, said panelists at the annual meeting of the American Academy of Psychiatry and the Law, held last month in Vancouver, British Columbia.

Richard Krueger, M.D., of the Sexual Behavior Clinic of the New York State Psychiatric Institute in New York City works with high-risk sexual offenders. He has treated some 20 patients with antiandrogens. He reported that a clearinghouse on sexual offenders recently surveyed treatment programs for them and found that while most of the programs offer psychotherapy, a number are also using medication.

But does such treatment work? Some European studies and an Israeli one have shown some positive effects, Krueger continued. Krueger has also obtained some positive results with his own patients. One was a man who had attacked a number of people, and behavioral treatment had not stopped his urges. So his attorney wanted him to get chemical treatment, and he consented to it. That treatment helped. Another was a mentally retarded man who had lunged for the breasts or buttocks of women 10 different times in the months before Krueger saw him. A surrogate for him, as well as his family, agreed to his getting chemical treatment. It was successful.

However, abundant evidence that antiandrogens can put sexual offenders on the right road does not yet exist. Philip Candilis, M.D., of the University of Massachusetts Medical School in Worcester, said that he worries that science is not yet good enough to demonstrate that these interventions can really work. But the problem may be less that science is incapable of coming up with the answers than that there are some explosive ethical questions surrounding such research. Or as Krueger put it: "This is a very difficult area to do research in. Institutions are terrified of any adverse consequences."

For instance, he said, suppose some sexual offenders were given a chemical treatment, whereas others were given a placebo, and all subjects meanwhile lived in the community. The chemical treatment might well keep the sexual urges of those receiving it in check, yet those on placebo might once again attack during the period of study.

So why not compare the effects of antiandrogens or a placebo on imprisoned sexual offenders? Certainly, that way the offenders would be unable to victimize children or others in the community while being studied. Yet at the same time, doing research on prisoners, even those who have committed abominable offenses like child molestation, raises some ethical questions.

For example, Candilis asked, do researchers have a right to make imprisoned sexual offenders, who are perhaps mentally ill, participate in research to see whether medication works? When considering the often devastating effects of their sexual offenses on others, perhaps such forced participation would be defensible ethically, he said. In contrast, he said, societal rights must be balanced against prisoner rights.

So how about asking imprisoned sexual offenders if they would be willing to participate in antiandrogen studies? This appears to be the most prudent tack to take, speakers agreed. But even getting studies in this direction under way is no easy task, it appears.

Charles Smith, M.D., clinical director of the Mid-Hudson Forensic Psychiatric Center in New Hampton, N.Y., and his colleagues would like to conduct research on chemical treatment for sexual offenders. But first, Smith explained, they have to get their research proposals approved by the forensic institutional review board for research set up by the New York State Office of Mental Health a year and a half ago. Research proposals will be approved only if they meet a number of criteria, among them: The research can be done on prisoners so long as it cannot be done outside the prison environment; the results have to be applicable to the subjects studied; two mental health professionals must visit the participants to make sure they are capable of informed consent; and one of the professionals must not be part of the proposed investigation.

Yet the need for solid answers about whether chemical treatment can stop sexual offenders is urgent, especially now that some states are demanding or encouraging chemical treatment.

The most important state law in this area, which has set a precedent for others, was passed in California in 1996, said Thomas Gratzer, M.D., an assistant professor in the department of family medicine at the University of Minnesota in Minneapolis. Florida passed a similar law in 1997. Under a 1997 Montana law, the courts may require chemical treatment for sexual offenders. Georgia, Louisiana, and Texas also have laws regarding chemical therapy for sexual offenders.