Chemical castration: the soft option?

Chemical castration: the soft option?

 

More than 100 British sex offenders have volunteered for 'chemical castration'. But do the drugs make them harmless?

Barry was sentenced to life in prison in 1976 for murdering a man, a random stranger who'd refused him a light for his cigarette. He didn't think of himself as a sex offender. He is a voyeur – "That's my thing. I like to look" – and has never been convicted of a sexual offence.

"But no woman, no girl, was safe if I was in a room with them. It could be any girl, from the age of 13 to 60 –  I would ensure that I would be sat in a position where I could see up her skirt. Or if she's wearing trousers, I'd be stood where I could see down her top. I couldn't be in the company of a woman without trying to see what I could see, constantly thinking, 'I wonder what knickers she's got on. I wonder what type they are. I wonder what colour they are. What can I see?' I couldn't think of anything else, 24 hours a day, seven days a week, from the moment I woke up to the moment I went to sleep."

On the two occasions Barry was released on licence, he would spend his day scouting town for locations to see up skirts or down tops, and bought goggles to see underwater at his local swimming pool. "Then I would go back to my room in the hostel, where I would write down what I'd seen, but changing it to where the woman was compliant and showing me her underwear on purpose. I would then undress and I would masturbate three or four times. And this was every single day."

The first time Barry was released, after serving almost 12 years, he took a shine to a 16-year-old colleague at the chip shop where he worked. "I plucked up the courage to ask her out. Consciously, the idea was to take her out – meal, a few drinks, escort her home. Subconsciously, the idea was to get her absolutely well and truly drunk, incapable of stopping me getting what I wanted. And that was, I wanted to see her underwear."

All through the evening, he says, "My mind was working overtime, trying to work out when would be the best time to get what I wanted. But my plan was having to change all the time, because things were happening that were not under my control." She'd surprised him by coming on a moped, and was about to ride off at the end of the night, "So I'm thinking, 'I've got to do something now to stop her going anywhere.' " He persuaded her to follow him to a secluded spot hidden by bushes, where he kissed her. He says she smiled.

"And I thought, 'This is my opportunity.' I said, 'I'm not going to touch you. I'm not going to do anything to you. All you've got to do is just undo your zip and pull open your jeans.' But the smile disappeared from her face."

She tried to escape, he grabbed her, they struggled, she screamed, he let her go and she was gone. Arrested within the hour, "I lied, I bullshitted, I said I hadn't a clue what had gone on, and I kept to that." He'd only wanted to see her underwear, he told himself. "But if I'd managed to catch her the second time she ran," he admits quietly, "in order to stop things, it would have been another murder." He'd been free for just 13 months.

Convicted of common assault and returned to jail, Barry was re-released on licence almost three years later, and lasted just over two years before a woman he'd befriended through AA – he is an alcoholic – complained to his probation officer that he'd become sinister and unnerving, and she feared he might murder her. In 1994 he was returned to jail, and has been there ever since.

Barry was astonished when HMP Dartmoor enrolled him on a sex offender treatment programme (SOTP). "As far as I was concerned, I wasn't doing any harm, just looking. That's all I do. It's natural for a man to look." The SOTP was a revelation. "I really had to step back from everything I knew about my life. I realised the voyeurism is a sex offence. It's invading a woman's personal space without her permission."

The trouble was, while the SOTP had made him see he had a problem, it didn't do anything to solve it. "Even though I felt guilty, it still didn't matter. It was an addiction –  I couldn't do anything about it. I wanted to change my behaviour – I knew that it was wrong – but even after all of the programmes that I'd done, still nothing seemed to work."

So when a prison doctor offered him a pill that might take away his sex drive, "I didn't think twice. I jumped at it. And I haven't looked back."

Chemical castration, as it's popularly known, has been practised all over the world for more than 50 years. Clinicians prefer the term "anti-libidinal psychopharmacological intervention", and it consists of treating sex offenders with drugs that fall into two broad categories.

For patients with obsessive sexual fantasies, antidepressants from the family of SSRIs that includes Prozac, often prescribed to treat obsessive compulsive disorder, can help them control their sexual thoughts. The second and more radical approach is an anti-androgen drug, such as leuprorelin, which reduces testosterone levels to those of a prepubescent boy, and makes the patient impotent. In some countries – Poland, Russia, parts of the US – the treatment is mandatory for those convicted of sexual offences against children, but its voluntary use is more widespread, and has been introduced in Germany, France, Sweden and Denmark. Research from Scandinavia has reported a drop in reoffending rates from 40% to between zero and 5%.

In 2007, trials were proposed in prisons in England and Wales, since when roughly 100 sex offenders have volunteered for treatment. Professor Don Grubin, a criminal psychiatrist, has been overseeing the referrals, and early last year he announced that a pilot regional clinic had been established at HMP Whatton, near Nottingham, where a concentration of volunteers could be studied closely.

Every one of the 800 or so men in Whatton is a sex offender, making the category C jail Europe's largest sex offender rehabilitation centre. Prisoners must apply to be transferred there, and admission of guilt is a condition of entry. The jail operates six different SOTPs, all based on cognitive behavioural therapy, each tailored to different needs, such as learning disabilities, delivered alongside other behaviour and resettlement programmes.

"But there are some," explains Karen Thorne, a forensic psychologist at Whatton, "who really have problematic behaviour – quite sexually preoccupied men – and that causes difficulties for the staff managing them." The SOTPs are difficult to teach to inmates who "can be rubbing up against members of staff, or you can tell are physically aroused, or will excuse themselves on the pretext of going to the toilet. There's all kinds of things which make alarm bells ring."

So far more than 50 prisoners have volunteered for the treatment, and an early evaluation last summer was encouraging. Volunteers are treated with SSRIs first, but a minority such as Barry have advanced to anti-androgens, and both groups reported a significant reduction in sexual preoccupation, arousal and masturbation.

But a reduced libido will not necessarily translate into reduced reoffending, and in the absence of double blind randomised trials the data remains inconclusive. Such trials would be difficult to conduct with sex offenders, not least because the side-effects of anti-androgens are so marked, making it obvious who'd received the drug as opposed to the placebo. Breast growth, hot flushes, heart problems and osteoporosis make anti-androgens, as Professor Grubin has said, "a pretty heavy-duty measure to prevent reoffending".

The governor of Whatton, Lynn Saunders, is well aware that public fears can lead to alarmist misreporting of any treatment. "But I do want people to know about this. We're trying to stop the people we lock up from doing this again. That's the key thing for me. The majority of them will get out and will possibly be living next door to you or me. That's my bottom line. We need to make sure they are as safe as possible to live next door to you or me or your children."

It's fair to say that Barry would not have been most people's ideal next-door neighbour. When we meet in the prison chapel, he speaks slowly, with the unself-conscious candour of a group therapy veteran. Now in his 50s, he has an unwavering gaze and holds himself unusually still. Had we met before he began treatment, he says, "You would not have liked me. You would have felt very uncomfortable in my presence."

Barry began treatment with an SSRI, but after about 10 weeks his old thoughts began coming back, so he asked for the anti-androgen. He says he didn't suddenly wake up one day feeling like a different person, but now, many months into treatment, the change he reports is extraordinary.

"These pills have actually given me the chance to take a step back and think, 'Hang on, you don't want to go down that road again.' I can watch a TV programme simply for what it is, without hoping the presenter would part her legs so I could see up her skirt." He still has "the odd slip" but is functionally impotent now. "I get the stirrings, but nothing else." His entire relationship with the world has changed. "Because my head isn't full of sex all the time, I'm able to speak to people. How I used to manage even the mundane things – walk, talk, sleep – I don't know."

 Above all, the drugs have created space in his head for change. "Without the drugs, I wouldn't stand a chance. With the drugs, it's helped me to have a clear mind. I don't want to see every woman as a sexual object; I want to see her for who she is. I've never been able to do that before. It's always been me, me, me."

Most of Whatton's volunteers report similarly impressive results without even taking anti-androgens. Mark, in his mid-30s, is being treated with an SSRI, following a conviction in 2007 for inciting a 14-year-old girl to have phone sex with him. She lived two doors away and thought she was talking to a 15-year-old boy; they'd been texting and talking for more than a year before he was caught. It was his first conviction, and he says it was his first offence, but Mark's sexual obsession with underage girls had taken over his life. Terrified of being found out, tormented by self-disgust, at the time of his arrest he was isolated, paranoid and profoundly depressed.

Less obviously institutionalised than Barry, he also seems more troubled by how his story may affect me. He strikes me as heartbreakingly lonely, and says his victim's name with a tenderness that would probably enrage me were she my daughter or sister, but I suspect is his way of trying to acknowledge the harm he knows he has done.

"When I was thinking about sex, I didn't like what I was thinking, so it was like a circle of depression. I was depressed about what I was thinking, so I would masturbate, then I would feel depressed about that, too, so it would be a vicious circle." He'd never even heard of an SOTP when he was sentenced, but signed up straight away, and was still so frightened of reoffending that when an antidepressant was offered, he decided to give it a try.

"The biggest thing is that it's taken the weight off my shoulders. In my head I do feel, still, I have an attraction to young girls. Before, it was almost like I was trapped. I was always controlled by my urges to masturbate, but now I don't. Now when I'm masturbating, if I start thinking about that, I can stop, I can make myself move away and think about something else. The drugs have cleared my head away from all the junk."

It's not a miracle cure, he stresses. "I have to put in the effort, just as much as I normally would. It's just that now the drugs are giving me that helping hand – almost like a push – so I can try and be… I was going to say 'normal', but just try and be me – the person I wanted to be in the first place."

Dr Adarsh Kaul isn't surprised by these prisoners' accounts. The consultant forensic psychiatrist has been treating sex offenders with drugs for more than 20 years, but until now almost all had been referred only after their release. He thinks the Scandinavian reports of a dramatic drop in reoffending "sound about right", and the cost of the treatment is startlingly low: Whatton spends about £2.5m every year on SOTPs, whereas the drugs programme costs just £20,000. But if it's really so successful and inexpensive, why hasn't it been made compulsory?

"Compulsion, in pragmatic and practical terms, is not easy. It's not always easy to monitor compliance when it is a compulsory thing." Anti-androgens, Kaul concedes, can be administered by injection – but SSRIs cannot. "And equally, there is the human rights lobby who would say that is not the right thing to do. So we have taken the pragmatic solution, and I think the proof is that what we have seen is most of the people, by working with them, they can see the benefits, and hence they are much more likely to comply."

The ethical objections to compulsory medication that can have such serious side-effects are self-evident, but Kaul claims these have been overstated. He has yet to encounter a case of osteoporosis, and breast enlargement can be corrected with minor surgery. A small number of prisoners have chosen to withdraw from treatment, but only a fraction, he says, have stuck with that decision. Most, he says, asked to stop because they believed they were cured, "A bit like people do with antibiotics – they stop taking them as soon as they feel better." Three months later, "They come back and say, 'You know what? I was wrong. Can I go back on it, please?' "

But critics dispute the efficacy of the treatment, and challenge its fundamental premise. "Sex offending is often not about sex at all, but about violence and domination," Frances Crook, director of the Howard League for Penal Reform, has argued. "The drugs used will not affect those attitudes. Some men may inflict other types of deviant behaviour on victims if they are unable to perform sexually due to the drugs. Most sex offending on adults is more closely related to violence and domination than to lust. I am not convinced that a pharma intervention gets to grips with the psychological triggers for offending."

Dr Kaul sighs wearily. "These people will make these comments because they like simple answers. The answers are not simple. All sex offending is not just about sex, nor just about power, nor just about control, nor just about anything. These are very simplistic views on the nature of the problem. The world of the sex offender is not like that. That world is complex, and for complex problems you need complex solutions. For some of them, part of that complex solution is medication."

Could the critics not at least be on to something, though? If some men respond to antidepressants, but others need anti-androgens to control testosterone, doesn't this tell us something about the underlying explanations? In crude terms, does the first category's offending stem from personality problems, and the second's from sexual dysfunction?

"I think it's fair to say that we don't think we understand these things well enough yet, and part of the reason is because we don't treat enough people," Kaul says. "But very interestingly, none of the people that we have treated – not one – has a high testosterone level. None has had levels higher than the upper limit of the normal range. So it is not just about testosterone levels; it is also something about that particular individual's sensitivity to it in his brain."

It may be a misapprehension that sex offenders are testosterone-crazed, but there is no doubt that they can be manipulative liars. How can we be sure that the medication works when we ultimately have only their word for it? "For me, it wouldn't be the fact that I'm lying to the authorities," Barry insists. "It would be that I'm lying to myself. No, no, no." But until he gets out of jail, there's no way of knowing.

"I can make a facetious comment, which is that I could name some politicians who are more plausible and manipulative than sex offenders," Kaul points out with a wry smile. "But absolutely, you're right. There is no argument I can give to those who say, 'What's the proof?' We haven't got the proof in real life because we haven't followed these people up to see what actually happens out there. They are still in prison."

And a lot of them will stay there until a parole board decides they no longer pose a danger. More than 100 of Whatton's inmates are lifers, and 300 more are serving indeterminate sentences – IPPs – which will last for as long as the authorities see fit. Introduced in 2003, IPPs were originally intended to be issued only in exceptional circumstances, but now account for up to 7% of the prison population. Governor Saunders acknowledges the controversy around them. "But I have to say – and I think I am fairly liberal in my attitude – I haven't come across anyone [serving an IPP] in this prison who I didn't think should have an IPP. Not one."

Mark's IPP sentence set a 20-month minimum tariff, but he has served more than five years. Since volunteering for drug treatment, he has had a parole hearing, but it was rejected. "They said they weren't 100% sure the drugs were working, and weren't 100% sure that the statistics prove they're any good anyway. I'm not going to lie: I was angry. I know it's never going to be, 'Well I'll take this tablet and I'll never offend again'. It's never going to be like that. It's always going to be on me to take the tablet and carry on doing what I'm doing to change myself. But for a parole board just to almost dismiss it, as if it was just me taking the drugs because it looks good… well, that's completely wrong. I'm taking them because they work. If a parole board doesn't want to believe that, then fine. But I'll carry on taking them, and maybe one day they'll see they were wrong."

But the parole question is even more complicated than Mark imagines, for the board isn't supposed to be told if a prisoner is receiving drug treatment. On the face of it, the injunction seems baffling, for how could a parole board begin to make sense of, say, Barry's account of a radical transformation, if he's not allowed to tell them how it's happened? In the absence of that information, his claims would sound completely ludicrous.

"I think they should absolutely have the information," Kaul says firmly. "And then it's up to them to weigh it up. That's their job." The dilemma, Karen Thorne explains, comes when a prisoner has tried the drugs and seen no improvement. "Where does that leave us with providing information to the parole board?" If an unsuccessful outcome could count against them, prisoners may be afraid to give the treatment a try.

Would a parole board be right to infer high risk from an unsuccessful outcome? Nobody knows. But far from making drug treatment a uniquely unknown or risky quantity, Kaul argues, the same uncertainty applies to almost every other intervention. For all our anxiety about sex offenders – and more than 10,000 are currently in prison – we still don't really know what determines their chance of reoffending when they get out.

"People don't seem to ask, 'Are we being manipulated?', when you get a good report from an SOTP. But you can equally manipulate an SOTP, and yet that doesn't stop it being presented as the gold standard. The same could be said about anything; patients can manipulate their psychologist or psychiatrist." Even an admission of guilt, in which parole boards place such unquestioning faith, might in fact have no bearing at all on the likelihood of reoffending, he adds. "It's just an assumption."

"For me," Mark says, "if I come off these drugs and commit an offence, I will never be able to say at least I did my best – because I didn't. But now I'm on these, it doesn't matter what anyone else says – I know I'm trying everything. And if this helps, then it helps. I just want to have a normal life, and that normal life doesn't include thinking about sex and children."