Rationale for Depo-Provera Treatment of Sex Offenders (Paraphiliacs). Studies begun at Johns Hopkins in 1966 have shown that sex offenders or paraphiliacs, for example, pedophiliacs treated with the antiandrogenic hormone, Depo-Provera, plus counseling have gained in self-regulation of sexual behavior. Depo-Provera suppresses or lessens the frequency of erection and ejaculation and also lessens the feeling of libido and the mental imagery of sexual arousal. For the pedophiliac, for example, there will be decreased erotic “turn-on” to children. Metaphorically, the sex offender has “a vacation” from his sex drive, during which time conjunctive counseling therapy can be effective.

Antiandrogenic Effect of Depo-Provera. Depo-Provera, a long-acting, injectable form of medroxyprogesterone acetate manufactured by Upjohn, is a synthetic progestin that is classified pharmacologically as an antiandrogen. Antiandrogen inhibits the release of androgen, the so-called male hormone, from the testicles. Some progestinic hormone is normally present in the male body, but at a very low level. Increasing the level allows progestin to compete with androgen and to take over. Androgen is a sexual activator. Progestin in the male is sexually inert. It therefore induces a period of sexual quiescence in which the sex drive is at rest.

Mode of Endocrine Action. In terms used by endocrinologists, Depo-Provera inhibits, through its effect upon neural pathways in the sexual system of the brain, the release of luteinizing hormone (LH) from the pituitary gland. LH is the chemical messenger that normally stimulates the testicles to produce androgen. Hence, the ultimate effect of Depo-Provera is to reduce the level of androgen, especially testosterone, in the blood stream. Typically, in the adult male, Depo-Provera reduces the blood level of testosterone to that of a normal prepubertal boy (from approximately 575 nanograms/100 milliliters to 125 nanograms/100 milliliters).

Brain Effect. In addition to lowering the level of testosterone, Depo-Provera, like all progestinic hormones, acts on the brain as an anesthetic if given in huge doses. In small doses, as in the treatment of sex offenders, the influence on sexual pathways in the brain, though mild, has the great advantage of being sexually calming or tranquilizing. The patient feels relief from an urge that was formerly insistent, commanding, and not subject to voluntary control.

Peripheral Physiological Effects. Depo-Provera, through decreasing the testosterone level, temporarily decreases penile erection and ejaculation and the production of sperm (spermatogenesis). In addition, the sexual accessory organs, the prostate and seminal vesicles, temporarily shrink. Occasionally, increased drowsiness, and weight gain have been reported as minor side effects.

Reversibility of Changes. All of the changes attributed to the medication are reversible upon cessation of treatment; within 7-10 days erectile and ejaculatory capacity begin to return, along with the subjective experience of more sexual drive.

Dosage Level. Tailored for the specific patient, intramuscular injections of Depo-Provera range from 100 milligrams to 500 milligrams (1.0 to 5.0 milliliters) every 7 days. The typical weekly maintenance dosage of Depo-Provera for sex offenders is 300 milligrams. For taller, heavier patients, the maintenance dosage may be as high as 500 milligrams, and the highest dosage used is 600 milligrams per week.

Hormonal Monitoring. Hormonal measures of testosterone and LH (luteinizing hormone) initially can he monitored monthly or bimonthly, and later quarterly, to gauge the effectiveness of the dosage. The recent application of radioimmunological techniques to the assay of testosterone and LH has made such endocrine monitoring precise, reliable, rapid, and relatively inexpensive, as compared to prior methods.

No Increased Tolerance. The patient does not require a progressively increasing dosage, because there is no tolerance build-up to Depo-Provera.

Comparison with Surgical Castration. Prior to the discovery, manufacture, and medical use of antiandrogen, the method of reducing the level of testosterone in men was surgical castration. Used in many societies throughout history, castration is disfavored in contemporary American legal-medical management of sex offenders. Obviously, surgical castration is irreversible. It is also less effective than hormonal antiandrogenic therapy.

Behavioral Effects of Depo-Provera Treatment. In many cases, it is possible for patients to be weaned off Depo-Provera. Since the weaning is a step-by-step lowering of the hormone dosage, it is possible for the patient to discover how completely he has become relieved of the tendency to engage in the offending behavior, both in actuality and in imagination. In many cases, there is long-lasting remission, so that the patient is no longer compelled to commit sex offenses, but is enabled to have a sex life with a socially suitable consenting partner instead. Some patients prefer to continue on a low, maintenance dosage of the medication so as to ensure a maximal guarantee of no relapse. Those patients who establish a strongly pair-bonded relationship with a permanent partner appear to be additionally guaranteed against relapse. The counseling component of treatment facilitates this achievement and is essential.

Compliance. Some patients, as in all specialities of medicine, are more faithful than others in adhering to medication schedules. Some overly confident patients drift into noncompliance. Other patients neglect specific instructions about their medication schedule. For this reason, it is advisable that as a condition of probation or parole, supervision be legally required so as to ensure strict compliance in adhering to the treatment schedule.

Statistical Assessment. Sex offenders treated with Depo-Provera at Johns Hopkins are kept in long-term follow-up. A dozen have now been followed for between 5 and 13 years. Of this group, 9 have proved able to self-regulate their sexual behavior, and 3 have had relapses correlated with noncompliance. Improvement follows resumption of treatment.

Counseling Therapy. Counseling sessions are provided weekly, at first, and then spaced to once a month. These sessions enable the patient to establish a new life-style. The fundamental impairment in paraphilia (sex-offending) is not of sexual function, but of love, attraction, and pair-bonding. It is this impairment that responds to counseling therapy. In true homosexual pair-bonding, the defining characteristic is unyielding inability to fall in love with an opposite, but not same sex partner.