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An important contribution: Role of ADT and endocrinologists in treating unacceptable sexual behavior
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Twenty years ago, I was asked to see a 19-year-old, mildly retarded, impulsive, powerfully built young man who had been incarcerated twice for approaching girls and frightening them terribly. His parents indicated that law enforcement would commit him to a facility for the severely retarded if they couldn’t find a doctor who would perform a medical castration. I was their last choice; they lived about 200 miles north of Los Angeles, but no physician they contacted would take responsibility for the treatment.
The boy was eager for any treatment that would keep him out of the “crazy house” (he had been there briefly before) and allow him to stay with his parents, who were eager to keep him at home. I agreed to treat him with medroxyprogesterone acetate suspension (depo-MPA), which I knew would decrease his testosterone and interfere with spermatogenesis. A clinic would give the injections.
During the past 20 years, he has worked hard on his parents’ small ranch. He has had only one questionably impulsive act. His testosterone has been maintained at about 100 ng/dL. He gained 50 lb of fat but maintained impressive musculature. He is being treated for hypertension and hyperlipidemia, and on our occasional visit, he seems to be content with his life, as are his now aged parents. The unspoken question is: What will happen when they can no longer care for him?
I believe that it is a privilege to be able to manage a situation in which both the community and the individual are protected. We applaud the development of a more humane social structure associated with advancing medical knowledge. We now see alcoholics, drug addicts and sexual behavioral pathologies as illnesses rather than antisocial expressions of free will, to the extent that the legal system permits treatment and rehabilitation in place of incarceration to achieve a more civilized world. The medical profession is obligated to accept the challenge and utilize effective therapies to both protect society and allow miscreants to function within it. Androgen deprivation therapy (ADT) is such a therapy and was well-described by Gooren in the September issue of the Journal of Clinical Endocrinology & Metabolism.
Endocrinologists should be prepared to use their knowledge and skills to this purpose, but in my experience, they are frequently unwilling to get involved. Is it a matter of experience? Is it fear of litigation? Is it an unwillingness to accept a patient whose presence induces fear and disquiet, even among physicians?
This article helps us understand all aspects of ADT and provides a standard of care for practitioners, although there remain a number of unanswered questions. Our professional ethics allow us to select our patients, but we, as a profession, have committed to care for everyone, including terrorists and murderers, and endocrinologists must fulfill their share of these responsibilities. Some of us must stand up.
Stanley Korenman, MD, is professor of medicine in the division of endocrinology, diabetes and hypertension; regulatory program director for CTSI and associate dean for ethics at the David Geffen School of Medicine at UCLA.
For more information:
- Gooren LJ. J Clin Endocrinol Metab. 2011;96:3628-3637.