Changing or stopping testosterone-lowering medication in men convicted of sexual offenses: clinical evaluation of the COSTLow-R Scale

Background: Individuals convicted of a sexual offense (ICSO) can be treated with testosterone-lowering medication (TLM) in order to support
the control of paraphilic sexual fantasies and to decrease the risk of sexual recidivism. However, due to partly severe side effects, TLM should
not be a lifelong treatment.
Aim: The aim of the current study was to further evaluate the Change or Stop Testosterone-Lowering Medication (COSTLow)-R Scale in forensic
outpatient aftercare practice. The scale was developed to assist forensic professionals in deciding on whether to change or stop TLM treatment
in ICSO.
Methods: The COSTLow-R Scale was applied retrospectively in a forensic-psychiatric outpatient institution in Hesse, Germany, on 60 ICSO. TLM
was terminated in 24 patients (40%). Moreover, 10 forensic professionals of the institution as well as an experienced working group within the
institution focusing on the treatment of ICSO, qualitatively evaluated the COSTLow-R Scale by participating in an open designed survey.
Outcomes: The COSTLow-R Scale ratings as assessed by forensic professionals were collected. In addition, a survey was performed among
these professionals about the usefulness of the scale and their practical experiences with it.
Results: A binary logistic regression analysis was conducted to ascertain the predictive power of the scale regarding the stopping of TLM. Three
items of the COSTLow-R Scale significantly predicted stopping decisions: the possibility of psychotherapy before TLM treatment, psychopathic
traits, and a substantial decrease of paraphilic severity. Thus, a decision towards stopping TLM was more likely for patients who showed greater
treatment readiness before starting TLM, lower psychopathy scores, and a higher decrease of paraphilic severity. The forensic professionals
described the scale as a good and structured tool that displays which aspects are important to consider during TLM treatment decisions.
Clinical Implications: The COSTLow-R Scale provides structure to the decision of whether to change or stop TLM and should thus be
implemented in the forensic treatment process of patients with TLM more frequently.
Strengths and Limitations: Although the small sample size limits generalizability of the findings, the present study was conducted directly in
a forensic outpatient practice and, therefore, has high external validity and a strong impact on the life and health of patients treated with TLM.
Conclusion: The results indicate that the COSTLow-R Scale can be a useful instrument facilitating the TLM decision-making process by providing
a structured compendium of criteria. Further research is still needed to evaluate the scale and to provide additional evidence for the results of
the current study.