The Anatomy of Violence
Page 36
Recidivism rates for sexual offenses over the eleven-year post-release period were 3 percent in castrated offenders compared with 46 percent in the non-castrated offenders—a dramatic fifteenfold difference. The 3 percent reconviction rate in castrated sex offenders is consistent with rates found in other studies that have not been as rigorous as that of Wille and Beier. Rates of reconviction in castrated sex offenders from these ten other castration studies range from 0 percent to 11 percent, with a median of 3.5 percent. These data provide further support for considerably lower reconviction rates in castrated sex offenders. Bear in mind that 70 percent of castrates in Wille and Beier’s study were satisfied with their treatment. It’s certainly not a panacea for pedophilia and other sexual offences, but should it be entirely ruled out if appropriate safeguards can be guaranteed?
What about the wider literature? One review of 2,055 castrated European sex offenders showed recidivism rates ranging from 0 percent to 7.4 percent over a period of twenty years,35 results very similar to those in the Wille and Beier study. Yet another review, by Linda Weinberger, a professor of clinical psychiatry at USC, documents the low incidence of sexual recidivism following physical castration in many different countries, commenting that “the studies of bilateral orchiectomy are compelling in the very low rates of sexual recidivism demonstrated among released sex offenders.”36 At the same time she cautions that it is hard to generalize to present-day high-risk offenders, and recognizes the ethical difficulties. However, a commentary on this review cautions that it is important not to underestimate the potential importance of castration when considering the release of an offender.37
It sounds grotesque, doesn’t it? The holier-than-thou among you will be wringing your hands in horror at the barbarity of this surgical intervention. But you don’t have to live your life as a pedophile in a top-security prison, do you? You don’t have to face the daily taunts—and danger of being raped—that these men face. You don’t have your mug shot on the Web for all to see after your release so that people know exactly where you live. You don’t have to be responsible for controlling sexual urges that are very difficult to contain. Shouldn’t people like Pavel at least be given the option of castration under conditions guaranteed to have no external coercion?
Fortunately—or perhaps unfortunately, depending on your perspective—there are less drastic methods of dealing with sexual offenders: chemical castration. Here anti-androgen medication is given to reduce testosterone—and hence lower both sexual interest and performance. In the United States medroxyprogesterone—or Depo-Provera—is used to increase circulating progesterone. In the United Kingdom and Europe, cyproterone acetate is used, which competes with testosterone at androgen receptors in the brain. Other medications include leuprolide, goserelin, and tryptorelin. In all cases, they reduce testosterone to prepubertal levels.
Nobody actually doubts that these medications significantly reduce sexual interest and performance. Yet again, the methodological and scientific issue is whether they reduce re-offending. Friedrich Lösel at the Institute of Criminology at Cambridge University conducted a meta-analysis and concluded that the effects of chemical castration are actually stronger than with other treatment approaches, a very telling result.38
Because it is somewhat less controversial than physical castration, chemical castration is offered in Britain, Denmark, and Sweden on a voluntary basis to sex offenders. Nevertheless, policy became tougher in Poland since 2009, when offenders who rape either a child under the age of fifteen or a close relative have to undergo chemical castration after release from prison.39 This came about in part after a man was accused of having two children with his young daughter—akin to the case of Josef Fritzl in Austria. Eighty-four percent of the Polish population supported the policy.40 In South Korea, a new law was put into effect in July 2011 that allows judges to sentence offenders who have committed crimes against children under sixteen to receive chemical castration. In Russia, chemical castration can be recommended by a court-appointed forensic psychiatrist for those who have attacked children under the age of fourteen.41
In the United States, at least eight states have had laws on chemical castration ever since it was introduced into the Penal Code of California in 1996. In both California and Florida, treatment with Depo-Provera is mandatory for repeat sex offenders and may also be used in some cases with first-time offenders, such as those who have committed a sex crime against children under the age of thirteen. In California, treatment is administered by the Department of Corrections and must begin a week before the parolee is released. It must be continued until the Department of Corrections deems that the offender no longer needs treatment.42 In Wisconsin, the Department of Corrections can prevent the release of a child sex offender if he refuses to undergo chemical castration.43 Texas, like Germany, allows surgical castration on a voluntary basis, and, as with Germany, safety procedures are put in place. Offenders must be older than twenty-one, have at least two prior sex-offense convictions, have undergone at least eighteen months of other treatment, and also understand the side effects of the surgery.
The debate is heated. The American Civil Liberties Union argues that chemical castration violates sex offenders’ constitutional rights that pertain to privacy, due process, and equal protection, and the Eighth Amendment’s ban on cruel and unusual punishment. Others argue that with appropriate controls the treatment is in the best interest of both the individual and society. One editorial in the British Medical Journal argued that doctors should avoid becoming agents of social control, and documented the potential side effects of castration, including osteoporosis, weight gain, and cardiovascular disease. At the same time, this editorial argued that when the individual has sexual urges that are hard to control, biological treatment makes sense. The editorial argued that anti-androgen drugs are effective and that offenders are capable of making an informed choice on whether or not to take the drugs. Furthermore, it went on, while some argue that freedom of choice may be lost when the prisoner has to choose between long-term detention and drugs, prisoners should be given a choice, and preventing this choice borders on the ethically questionable.44
You can answer the question yourself. Imagine you are a sex offender in prison with murderers, rapists, and psychopaths. Would you like to be allowed a choice—a choice between long-term detention, or chemical castration and release?
Nobody is coercing you right now in pondering the answer. You are free to decide. I know what I’d want. I think if you had spent four years in top-security prisons as I have you’d want to be allowed to make a decision and you would want chemical castration. Or perhaps you think that sex offenders are beneath contempt and should rot in hell.
One of the problems with chemical castration is that it affects our right to reproduce. It goes against our evolutionary makeup and mind-set. There is another alternative. What if we stay with the medical model for treatment of offenders but we do not compromise their ability to have children? We’ll take a journey to explore this further.
FLIGHT 714: THE ADVENTURES OF TINTIN
You never know what might happen when you get on a plane. Every time I walk down that gangway, images of unforeseen disasters flit through my mind. But before I go on, let me introduce you to my boyhood hero, Tintin. This sixteen-year-old newspaper reporter was the invention of Hergé, a Belgian writer and cartoonist who was an important influence not just on myself but also on Andy Warhol.45 Tintin’s life revolves around writing crime stories and traveling internationally to solve mysteries. He is a boyish, avant-garde swashbuckler who pushes the envelope on puzzles to stop crime—and has fun at the same time. I was brought up with Tintin as a boy. I bought all the Tintin books. I tracked down Hergé in person and got him to sign several of my books, including Flight 714. And here I am today, a boy trapped in an adult’s body, writing about the causes of crime and traveling the world to stop it.
Now to Flight 714—the penultimate story in the twenty-three-volume Tintin series. Tin
tin is in the tropics in Jakarta and catching a plane to Sydney with an eccentric millionaire. A fight breaks out and the plane gets hijacked by terrorists. The criminals want the millionaire to spill his bank account number. He’s injected with a truth drug by the dastardly Dr. Krollspell—a sort of Josef Mengele parody—under the orders of his evil boss, Roberto Rastapopoulos. That’s where the medication comes in.
Now cut to my story. As with Tintin it begins benignly enough. I got on board United flight 895 bound to another tropical country—Hong Kong—on Thursday, July 17, 2007. I settled into my bulkhead aisle seat, had my dinner, and then sank into reading Jonathan Kellerman’s Rage. An academic detective crime story, of course. And that’s when it happened.
There was an urgently ominous announcement: “We have a situation. If there is a doctor or—[pause]—a psychologist on board, could you please make yourself known to the flight attendant.”
I got a queasy feeling and it wasn’t my dinner. Usually they want a doctor, but they also said “psychologist.” Well, I might be a psychologist, but I’m also a wimp. The truth is that just before that announcement I heard a racket coming from the section ahead of me past the toilets on the port side. It had distracted me from my book. Then two flight attendants zipped past me. Even more yelling. Maybe Rastapopoulos was on board.
I took a look back up the long aisle behind me to check the passenger seat lights. Come on. Surely there had to be a doctor on board. Was anyone coming to the rescue? But the aisle lights were as dark as a graveyard. I turned back in my seat and began to feel a bit desperate. It seemed like the sort of thing Jonathan Kellerman could solve. He’s a psychologist as well as a best-selling crime writer. Maybe he was on board? Maybe there was a Dr. Krollspell lurking in the wings. I looked behind me again. All I could see was a sea of faces looking up the aisle at me to see what was going on beyond me.
Think, Raine, think, you idiot. I thought it through carefully. I decided on the only sensible, professional, and responsible course of action for a professor in criminology. I kept reading Kellerman.
You know what, though? You look up from your book, gaze into space, and say to yourself, “You cowardy custard.” Emotional quicksand was quickly covering me in a suffocating swathe of guilt. I looked around again. Not a blinking sausage, no cavalry. I wasn’t the only wimp. Okay, to hell with it, here goes. I rang my bell.
There certainly had been a brawl. I walked with the flight attendant up to the front, where a scuffle was still taking place between a male flight attendant and a passenger. My escort gave me a comprehensive, articulate, and professional appraisal of the situation: “He just went nuts and whacked the woman next to him!” I was behind the desperado, so I pinned his arms behind his back while the attendant whipped his tie off. In a jiffy we’d tied the assailant’s arms behind his back. The woman was still yelling, but we ignored her, as it was all Chinese. We shoved our prisoner into a window seat. I jammed myself beside him, with the steward next to me to block up the aisle seat. We had secured the situation.
The next thing I know the steward had me switch seats because the pilot wanted to talk to me. They brought me to the cockpit. And that’s where the cool bit began and I got to feel like I was Tintin. They wanted to patch me through on the intercom to an MD on the ground. The pilot got out of his seat, I jumped into it, and he instructed me on how to work the communications system. Have you seen Steven Spielberg’s movie The Adventures of Tintin? Remember when Tintin is in the pilot’s seat? The confined space. The instrument panel dazzling your eyes at one level. Then you gaze out of the cockpit window and you’re floating on those fluffy white clouds. So very much at peace, so Tintinesque, gliding up there in heaven above the hot struggles of the poor. It’s what a British Airways ex-accountant always wanted.
The duty doctor down below snapped me out of it. He knew I was an expert on violence and a psychologist. What’s my professional evaluation of the level of danger to other passengers? How can we secure the situation? I say we can deal with it by giving the guy a hefty dose of my Temazepam—a short-acting benzodiazepine. I always bring it on board international flights because I have trouble sleeping on planes due to the noise at night—you know—owing to having my throat cut that night in Turkey. I suggest a good dose, 30 milligrams. The doctor thinks 15 milligrams. We ended up with the 15 milligrams—and that did help calm the villain down. Then we made an emergency landing in Anchorage so that security forces could board the plane and offload the blighter.
I have to say I felt pretty good about it. As the other passengers lined up to land in Hong Kong, I was slapped on the back by the copilot and applauded. United flew me business class for the rest of my round-the-world journey. All in a day’s work as a criminologist, I said. Yup, my boyhood Tintin dreams had finally come true.
But back to medication. It really does arrest aggression. Unlike in the case of flight 895 I’m not talking about sedation to quell violence. We’ve witnessed major advances in psychopharmacology together with substantive evidence that some medications are surprisingly effective in reducing aggressive and violent behavior.
Let’s start with children. What’s the most common cause of children under the age of nine being referred for psychiatric services? It’s none other than behavior problems.46 The majority of these hospitalized children are receiving medication to treat aggression.47 Clinical practice is backed up by surprisingly strong empirical support for the effectiveness of drugs as an intervention for childhood aggression. A meta-analysis of forty-five randomized, placebo-controlled trials conducted in children by Elizabeth Pappadopulos48—not to be confused with Rastapopoulos—has shown that medications are surprisingly effective in treating aggression, with an overall effect size of 0.56—which is of medium size in terms of the strength of the relationship.49
A wide variety of medications have been found to be effective in reducing aggression. The most effective are the newer generation of antipsychotics,50 which show a large effect size of .90.51 Stimulants like methylphenidate are also very effective, with an effect size of .78.52 Mood stabilizers have a medium effect size of .40, while antidepressants have a small-to-medium effect size of .30. The same story that we see in children holds true in adolescents.53 Two meta-analyses of drug treatments of aggression in juveniles, together with other reviews and meta-analyses of drug efficacy with aggression and antisocial behavior in child and adolescent populations all show the same story.54, 55, 56 What’s clear is that drug treatment is effective in reducing aggression across a wide range of psychiatric conditions in childhood and adolescence—including ADHD, autism, bipolar disorder, mental retardation, and schizophrenia.57
How does medication compare to nonmedical treatment of aggressive and violent behavior? My colleague Tim Beck, in my department at the University of Pennsylvania, originally developed cognitive-behavior therapy, which is widely effective in treating a whole range of clinical disorders. It is the most effective and well-accepted treatment for aggression. The overall effect size? Conservatively it is .30.58 So the overall effect sizes obtained for medications compare very well to the best psychosocial interventions.59 Indeed, effect sizes for atypical antipsychotics and stimulants if anything exceed the best non-pharmacological treatments.
Skeptics will scrutinize this claim assiduously and can come up with a reasonable retort. Perhaps the medications are treating other conditions like depression, ADHD, and psychosis that aggressive children also have, and that accounts for the reduction in aggression. For example, children with psychosis get crazy ideas into their heads about other kids picking on them, so they strike out in a defensive, aggressive rage. So yes, risperidone works well in reducing the aggression because it’s cutting out the craziness—one cause of the aggression. However, many studies have clearly demonstrated the effectiveness of medications with children coming to the clinic primarily with antisocial/aggressive behavior rather than psychosis.60 Meta-analyses of the literature also show that stimulants reduce aggression independent o
f their effect in reducing ADHD symptoms.61 There is even evidence that stimulants and atypical antipsychotics are effective in reducing aggression in preschoolers.62 It’s a bitter pill for many criminologists and psychologists to swallow, but medications do work in controlling and regulating aggression in children and adolescents.
Can medications work too in quelling outbursts in adults? Surprisingly, there is much less research here, probably because once you become an adult and are violent, you are viewed as evil and we lock you up. We don’t want to help you anymore. A double-blind, placebo-controlled, randomized trial allocated impulsive aggressive male community volunteers to one of three anticonvulsants.63 All three medications significantly reduced aggressive behavior.64 The same result has been found in several randomized controlled trials for treating impulsive forms of aggression in prisoners.65
Why on earth would anticonvulsants, normally used to stop epileptic seizures, work with reducing aggression? We know these medications have a calming effect on the limbic regions of the brain—particularly the amygdala and hippocampus, where epileptic seizures begin. We saw earlier that impulsive, emotional murderers have excessive activation of these limbic subcortical regions, so anticonvulsants may help reduce their impulsive emotional rage attacks by calming their emotional limbic system.
LET THEM EAT CAKE