Secretary of State for Justice Shabana Mahmood is reportedly looking into a potential ‘national rollout of voluntary chemical castration for sex offenders’. The proposal is one of the recommendations outlined in the recently published Independent Sentencing Review led by former Lord Chancellor David Gauke, commissioned to investigate ‘the prison overcrowding crisis and to consider alternative punishments to custodial sentences’. According to the Review, ‘sexual offences accounted for 21% of adults serving immediate custodial sentences at the end of March 2025’. Mahmood has said that she is ‘not squeamish about taking these further measures’ to extend use of anti-libidinal interventions (ALIs)—medication that lowers recipients’ testosterone levels with the aim of reducing their recidivism risk—and that she ‘will make sure that that is what happens’. While the Gauke Review focuses on voluntary ALI use and emphasises that ‘valid, informed consent’ to interventions ‘is a key tenet of medical law in England and Wales’, Mahmood has, according to the BBC, told the House of Commons that she is ‘exploring whether mandating the approach is possible’.
Don Grubin, Emeritus Professor of Forensic Psychiatry at Newcastle University, has expressed doubts that the government would ‘get the mandatory element of it off the ground’, as well as concern that it would be unethical to do, and that doctors would be resistant. He is right that there are a number of important ethical considerations in the mix, especially—but not exclusively—if ALI use is to be made mandatory.
ALIs’ Purpose and Ethical and Legal Permissibility
One key question concerns the purpose for which ALIs are used. ALIs are an example of dual-purpose intervention, that is, an interventions that can be used either to benefit recipients, or for public protection purposes, or both.
We need to know an intervention’s purpose to measure its success. The success of therapeutic interventions in health care is measured in terms of the patient’s health and well-being. A public protective intervention’s success in contexts such as criminal justice (and—sometimes—public health and mental health) is measured against other indicators, such as the recipient’s risk to others or actual recidivism. Sometimes, interventions both benefit recipients and reduce their risk to others, but sometimes they do one and not the other. ALIs may reduce the risk of reoffending, but may not improve a sex offender’s well-being, and vice versa. Which goal are we aiming for in ALI use?
Some news reports mention the importance of potential recipients giving their valid consent to ALIs. But consent requirements are much less straightforward when an intervention is used solely for public protection, or for both therapy and the protection of others, than when the goal is solely therapeutic. It may well be ethically permissible to provide ALIs without recipient consent if public protection is one of the state’s goals. Consent requirements vary according to an intervention’s purpose; what an intervention’s purpose is has important implications for its ethical and legal permissibility, and how its permissibility should be evaluated. We don’t normally ask for recipient consent to, for example, incarceration or probation, nor for quarantine or isolation.
To determine the ethical permissibility of ALIs, it is important to clarify how benefit/harm to recipients should be understood, and how benefit/disbenefit interacts with consent. As Gauke notes in an interview with Sky News, some sex offenders may wish to have sexual desires which they themselves find problematic attenuated. But as Professor Grubin notes, ALIs may also have significant side effects. Therapeutic interventions are typically ethically permissible when they are expected to benefit recipients who give valid consent. Assuming that ALIs are indeed effective in reducing problematic sexual desires, it is plausible that some sex offenders may be benefited by such interventions, side-effects notwithstanding. But it is unclear exactly how ‘benefit’ should be understood: Is it beneficial for sex offenders to have their sexual desires attenuated? Can we be benefited by being prevented from acting in immoral ways that are consistent with our desires? Does the possible avoidance of future punishment due to further offending itself count as a benefit? Can it be beneficial also to offenders who do not consent to the intervention? And when, if ever, may it be ethically permissible to provide ALIs without benefit to the recipient? A more clearly articulated understanding of benefit is required to answer the question of permissible ALI use.
Other important questions concern legal justification. While the Independent Sentencing Review is right to note that recipient consent is central in general health law, it is less clear that this offers a complete answer to the question of ALIs’ lawfulness. My analysis of the legal framework in England and Wales shows that providing ALIs to sex offenders may be consistent with the obligations imposed on public authorities in the UK under the European Convention on Human Rights (via the Human Rights Act 1998), even when this is done without recipients’ consent. Here too, it is necessary to clarify how benefit/harm to recipients interacts with recipient consent in determining lawfulness when interventions are used for different purposes. Interventions that use medical means—as ALIs do—are usually lawful to offer to patients under English general health law because they are expected to benefit recipients. Even here, it is unclear what ‘benefit’ means—e.g. whether it is narrowly-construed clinical benefit, or some broader welfare benefit, an issue I have explored in previous work (open access). But the lawfulness of interventions whose purpose is public protection—potentially not benefitting recipients at all—is even less clear. Careful analysis is needed of how English law construes benefit for the purposes of legal justification, and whether public protective interventions are lawful on the same normative grounds as therapeutic interventions or require distinct justification. The fact that ALIs are potentially non-beneficial (depending on how we understand benefit) makes their legal status unclear (even when provided with recipient consent).
Professional Obligations
A rollout of ALIs to sex offenders—whether voluntary or mandatory—also requires careful consideration of how the ethical and legal considerations bear on the obligations of those involved in or directing provision of these interventions—both individuals and (in particular state) institutions. Professor Grubin has said that the administration of ALIs is ‘about doctors treating patients, rather than doctors doing a job for criminal justice agencies, but a side effect is that reoffending is likely to be reduced’. However, it is not clear that ALI use should always be understood primarily as ‘doctors treating patients’, in the same way as we would normally expect for therapeutic interventions. ALI use in sex offenders will often generate conflicting duties, which we must find ways to navigate. Can it be compatible with professional obligations to provide interventions that aren’t in recipients’ clinical interests if it benefits others? Do professional obligations vary according to an intervention’s purpose? How might conflicts between providers’ obligations to individual recipients and to others/society be resolved? ALIs expose tensions in the ethical and legal obligations individual and institutional providers owe to recipients and to society.
These are some of the questions I explore in a new research project investigating how we ought to understand, evaluate, and regulate interventions that can be used for either or both therapeutic and public protection purposes, including ALIs. They are questions that the government, and those involved in provision, will need to carefully consider, when deciding on whether to extend the use of ALIs with or for sex offenders.
A shorter version of this blog post is published in The Conversation.
Hi Lisa,
Thank you for the insightful piece. I found the early remark—that we can only know an intervention’s success if we know its purpose—interesting, not in cases of reducing libido, but rather, in cases of “enhancing” it. In cases of enhancement, we could use the same measures of success in terms of individual wellbeing vs. collective benefits which include public safety. Consider the following:
Sexless Humans: Imagine a world where the average sex drive of humans is that of someone who has been coercively placed on an ALI. Now imagine scientists discover a variety of libido-enhancing agents (LEA) that increase the sex drive of these individuals to that of the average human in the actual world. They find that when people take these LEAs, they report increases in wellbeing, new forms of meaning in their life and so on. However, as more and more people take LEAs, it becomes clear there are many side effects. Many people now participate in acts of sexual violence (assault, rape, trafficking), or participate in these acts indirectly, by watching others do these despicable things online.
Unlike the case of ALIs, my hypothetical case of LEAs does not involve coercion. Notwithstanding this one moral consideration, we may still ask if the LEA is successful, by what metric shall we measure its success? We might first wonder if LEAs are an enhancement in any meaningful sense. Does they actually make a person’s life go better? Let us assume that taking an LEA does promote wellbeing (although it’s not immediately clear they do). How are we to measure the success of the intervention in relation to public safety? Imagine the LEA increases the rate of sexual assault by a very modest amount—just a few percentage points—would it still be plausible to call them a success? How should we think about the doctors who prescribe LEAs, knowing that the LEA will be a/one direct cause of an act of sexual violence? In light of the side effects of LEAs, I find it difficult to describe them as successful, even if they offer some prudential value. I would think that doctors would have a strong moral obligation to withhold LEAs given the undesirable consequences of their use. We might even ask ourselves at what rate sexual violence would have to occur before we banned the use of LEAs? And we would probably be justified in wondering how much lower that number is than what actual rates of sexual violence are. To me, LEAs only seem permissible if vastly outweigh the costs, that is, that they so overwhelmingly contribute to wellbeing that we accept increases in sexual violence.
What can this tell us about the use of ALIs as corrective measures for acts of sexual violence? When ALIs are framed as a loss of something, we may feel by default that our wellbeing is lowered simply because something is being taken away. But when framed as a gain in something, especially when a gain in function is accompanied by a small, but not insignificant risk of committing acts of sexual violence, the positive effect on wellbeing is not so clear. The real badness of ALIs may not be of losing sexual desires and functioning, but rather, in the side effects of the drugs and the potentially coercive practices behind them. Maybe approaching the wellbeing question from a different angle can offer valuable insights and help us better analyze whether or not the use of ALIs as corrective measures is permissible or not.
Anyhow, hope there is at least one useful thought somewhere in here.
Best,
Jesse
Raising the spectre of these types of legal penalty to unwanted acts against another must bring to mind actual cases like Alan Turing and also the early yet wide use of Electroconvulsive therapy. The more obviously distasteful violent removal of body parts was/is sometimes seen as a suitable legal penalty for particular crimes, yet over many centuries even such awful outcomes have/did not provided a cure for the targeted social ills. They (those penalties) reflect more of a desired or favoured method of response.
Regulations do become focused on offence rather than gender, so a requirement arises to consider the penalties for both male and female sex offenders. Historically surgical interventions have been favoured when looking to lower the sex drive in the female gender (generally religiously or culturally based.) because of the issue of procreation, so chemical responses may not be a feasible route.
Societies define their own boundaries, creating legal wrongs where seen necessary to maintain or move those boundaries, and determine categories of punishment which could be perceived as constrained by proportionality or appropriateness along the way. Yet even in what are perceived as enlightened societies, punishments as often determine crime.
It is not an ability to cause dialogue which advances, even when dialogue, for immediately perceived benefit becomes coerced into social narrative, as presentations of black and white perceptions of goodness/badness/right/wrong which more profoundly affect progress are over time amorphously centered.