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medical examiner: Health and medicine explained.

The Unkindest CutThe science and ethics of castration.

By Atul Gawande
Updated Sunday, July 13, 1997, at 3:30 AM ET

With surprisingly little fanfare, four states recently passed laws calling for castration--either chemical or surgical--of sex offenders. Last month, prompted by two prisoners who actually wanted the treatment, Texas Gov. George Bush signed a law letting judges offer castration as an option for perpetrators of sex crimes. Florida, California, and Montana have all enacted more stringent laws to order involuntary chemical or surgical castration of these criminals.

The technology for castration has evolved considerably, and there is evidence that, in some circumstances, it can dramatically reduce the likelihood a sex offender will strike again. Nonetheless, there are strong reasons that court-ordered castration is a bad idea.

Americans remain frustrated with the inability of the justice system to control rape and child molestation. Dozens of states have enacted so-called Megan's Laws requiring that the public be notified when released sex offenders move in nearby, but people complain that it doesn't help much to know that your neighbor is a pedophile if you can't do anything about it. More states are turning to doctors to solve the problem for them.

Compulsory castration has been used as a punishment for crimes in all cultures dating back thousands of years. In Europe in the Middle Ages, the "eye for an eye" philosophy of jus talionis included castration as punishment for adultery or rape. In the 20^th century, castration has been practiced in the Netherlands, Germany, Estonia, Iceland, Switzerland, and Scandinavia for rape, pedophilia, and homosexuality. After World War II, its use in Europe was dramatically scaled back, probably because of the increased awareness of humanitarian concerns prompted by the Holocaust.

More recently, research has produced powerful drugs, such as cyproproterone and medroxyprogesterone, which reversibly block testosterone production. The drugs' primary use in men is to control prostate cancer, but when injected daily or weekly they reduce testosterone to castration levels. Side effects include serious allergic reactions and the formation of blood clots that can kill patients. The drugs also appear to alter thinking enough to increase suicide rates. The Czech Republic and Germany have reintroduced castration in this modern, seemingly humane form, although only among sex offenders who volunteer for treatment.

Surgical castration is less mutilating than it once was. Orchiectomy, as it is called, is a day-surgery procedure done under local anesthesia. Each testicle is removed through a small scrotal incision similar to the kind made during a vasectomy.

Three of the four new state laws call for sentencing rapists to be castrated, but with some variations. Florida requires judges to impose either injections or orchiectomy for repeat rapists. California does the same, but only for repeat child molesters. Montana allows, but does not require, judges to impose chemical castration on offenders who commit rape or incest after even one offense, if it is particularly heinous.

Legislators argue that castration is justified and appropriate, and that by controlling sex offenders' irresistible urges to rape or molest again, the operation allows them to be released without endangering the public. Studies of the European experience suggest they could be right. Of more than 700 Danish sex offenders castrated after multiple convictions, relapse rates dropped from between 17 percent and 50 percent to just 2 percent. A Norwegian study showed the same for selected male and female sex offenders (the women had their ovaries removed). In smaller studies of cyproproterone in Scandinavia and Italy, chemical castration was equally effective in some groups of volunteer prisoners, with the most dramatic reductions among pedophiles.

These studies suggest the common argument--that rape is all about power, not sex, and therefore castration won't work--is wrong. Interestingly, a German study found that up to half of the castrated men still could have erections and sex, but their desire was weakened or even extinguished. Over 80 percent no longer masturbated; 70 percent gave up sex. As Fred Berlin, a Johns Hopkins University psychiatrist and expert on treating sex offenders, points out, castration works "mainly in those who are sexually aroused by their crime ... sadists and pedophiles." Castration takes the impulse away from those with an aberrant sexual orientation, often to their relief.

So what objection could there be to castration of sex offenders? Well, none, if it is carefully applied to the narrow group of repeat sadistic or pedophiliac rapists who accept the treatment. But the court-mandated castration proposed in Florida, California, and Montana raises serious problems.

1 The laws are wrong to apply castration indiscriminately. The studies show that castration is effective in criminals with multiple offenses, especially if they are motivated by sex. But proponents are wrongly using the data to justify mandatory application across the board. In Florida and Montana, all rapists are targeted, even though sadists and pedophiles are only a small percentage of the total. Most rapists appear to be motivated by hatred or anger, not sex. Montana lets judges order castration after just one offense. Dr. Berlin argues that the laws impose "a medical intervention in the absence of evidence that forced treatment is likely ... to be effective" and make "no effort to medically assess whether [castration] is appropriate for an individual."

2 Forced castration is difficult to administer. First, the state must find doctors willing to do the job. (Heaven's Gate members had to go to Mexico for the operation because no California doctor would perform it on them.) California's law suggests letting state workers give the injections without medical supervision, but the serious side effects, and the need to ensure that appropriate doses are given, make this approach foolhardy. It also raises the question of what to do with people who can't take the drug because of the side effects. Would they have to go back to jail? Bringing in released convicts for injections is even more difficult. The longest-lasting drug, medroxyprogesterone, still must be given weekly. Making sure that rapists and pedophiles turn up week after week for an unwanted, potentially lifelong treatment may prove impossible.

3 Forced castration is immoral. In 1985, the Supreme Court recognized this when it ruled that involuntary surgical castration constituted cruel and unusual punishment. The court may be persuaded to let chemical castration stand because it is theoretically reversible. If this line is crossed, politicians would have little to stop them from seeking forced treatments to control other behaviors, such as adultery (for which castration has historically been a punishment), prostitution, or the consumption of pornography. As medicine's arsenal expands (we already have drugs to limit libido, hunger, and depression), it is conceivable that laws could mandate even wider uses of medicines to control the population.

Many people see rapists as a special case, though, having no objections to extreme measures to stop them from raping again. The crime is so repugnant, they say, that it is hard to treat rapists as people deserving of any concern. Prisoners, after all, give up their rights for having committed such crimes. But as bioethicist Arthur Caplan points out, while "prisoners are excluded from moral life," losing the right to vote, "Americans have not reduced them to non-human status." Unlike Iran, Turkey, or Nazi Germany, the United States accepts prisoners' rights to free speech, legal representation, and health care. We still reject using prisoners for organ transplants or slave labor. Requiring castration for rape means we have decided it is acceptable to treat prisoners as less than human.

While the laws elsewhere fail to counter these fundamental objections, the narrower castration law in Texas seems more appropriate. It does not mandate castration, instead reserving it for repeat offenders who seek the treatment. Larry Don McQuay could be the first to whom it is applied. He admits to molesting children at least 240 times. Having completed his sentence for his one conviction, he is set for release. Fearing his urges, he wants orchiectomy. It should be done.