The case for castration, part 2.

An expert in the treatment of sexual offenders explains why Mr. McQuay could be right.

Larry Don McQuay was once a child himself. From the innocence of youth, no doubt filled with the promise of life, he became an uncle, step-father, school bus driver, and child molester. A self-proclaimed monster who haunts the nightmares of children, fearful himself of spending eternity in hell, who is Mr. McQuay and what should we do with him?

To be sure, even the mention of castration has an ugly, jarring sound to it; it is an idea that polite people naturally shrink from. But as Mr. McQuay's own words show, there is a terrible problem out there and the ways we are currently trying to solve it aren't working. So if castration, in any form and even in combination with other measures such as counseling, strikes you as the wrong solution, keep thinking about the problem, because everyone can agree that putting people like Mr. McQuay back on the streets is crazy.

Let's be clear about the stakes here. According to the U.S. Department of Health and Human Services, approximately two out of every 1,000 children have been sexually abused, a figure that totaled 138,000 youngsters nationally in 1986. A significant percentage of this figure likely reflects the prevalence of pedophilia in a given community. Because of the driven nature of the disorder, an individual pedophile may make contact with 2 or 3 different children per week, some of the children sometimes being teenaged prostitutes. This can add up to hundreds of youngsters over a period of several years. Most pedophiles are physically nonviolent.

Let's also be clear about castration. Many people believe that castrating a sex offender is like cutting off the hand of the crook. Not so. Cutting off the penis would be like cutting off the hand of the crook, but that is not what castration is. Surgical castration involves removal of the testes only. When the penis is removed but the testes are still left intact, a man will still try to have sex. If the testes are removed, but the penis left intact, a man is far less likely to attempt to engage in sexual behavior. Removal of the testes generally decreases the desire for sexual activity, rather than affecting the capacity to perform.

The testes are the major source of testosterone production in males. It is the marked elevation in testosterone in males at the time of puberty that is associated with a marked increase in sexual desire and interest. Lowering testosterone can reduce the intensity of sexual desire.

A man can will his right arm to move. He cannot will an erection. He can get an erection by thinking certain thoughts. Tragically, for him and for the rest of us, Mr. McQuay apparently discovered that thoughts and cravings about children are what arouse him. To be afflicted with such a condition can itself be a nightmare. It is a condition that cannot be willed, legislated, or punished away. Reported rates of recidivism in the scientific literature for pedophiles not receiving treatment have varied considerably. It's difficult to know whether a given pedophile has not re-offended or simply re-offended and not been caught. Recidivism rates could, however, be as high as 65 percent. This figure makes intuitive sense: If one goes to prison because of a sexual attraction to 10-year-old boys, there is nothing about being in prison that will erase that attraction.

The good news is that lowering testosterone levels works. One Danish study reported a 4.3 percent recidivism rate over a period of up to 18 years among 117 surgically castrated sex offenders, whereas 58 noncastrated offenders were 10 times more likely to re-offend. A 7.4 percent recidivism rate was reported among 121 castrated sex offenders in Switzerland over five years compared with a 52 percent rate at the 10 year followup among men not undergoing the procedure. Yet another Danish study involving over 900 castrated sex offenders followed for periods of as long as 30 years reported a mere 2.2 percent recidivism rate.

Surgical castration, however, is neither necessary nor foolproof. Its effects can be reversed by taking testosterone. A better idea is so-called chemical castration. This involves no surgery--it consists of injections that lower testerone levels. Compliance with medications used to lower testosterone can readily be monitored because they can be given by means of periodic injections. This treatment recently made headlines. In Florida, a legislative attempt is being made to impose testosterone lowering injections upon possibly unwilling repeat offenders.

There is precedent in this country for compelling persons to undergo medical procedures without choice. At one time, because of the danger of smallpox, everyone was required to be vaccinated so that they would not pose a danger to the community. Convicted felons lose certain rights (e.g., the right to bear arms). If it were clear that a community would definitely be safer with a sexual offender's testosterone lowered, then society would likely have a right to insist that he make himself safe.

Lowering testosterone is not a cure, a guarantee, or a panacea, but it might be far more palatable to a society in which many people are squeamish about mandating surgical castration. In conjunction with psychological counseling, most testosterone-lowering treatments are effective, especially when used to help individuals who want to change. In combination--chemical castration and counseling--we've seen encouragingly low rates of recidivism; one study found a 15 percent rate, a figure which is deceptively high because the study broadly defined re-offending to include non-sexual contact, like visits to schoolyards.

Today most people still consider sexual offenses, even the many that are nonviolent, to be more a question for the legal system than one in which science and medicine can play a useful role. But like it or not, it is a fact that over 90 percent of incarcerated sex offenders sooner or later will be free. If legislation and punishment alone cannot fully solve the problem, medicine and science need to be called into action. And if society can be made safer by such means, why not use them? Mr. McQuay, we should remember, will be among us again soon.

Dr. Fred S. Berlin, an associate professor at the Johns Hopkins University School of Medicine, is director of the National Institute for the Study, Prevention and Treatment of Sexual Trauma.