Ethical evaluation of urology specialists’ knowledge and attitudes on the application of medical (chemical) castration for sexual offenders: a perspective from Turkey

Abstract

Background

Court-ordered medical (chemical) castration has pre-occupied Türkiye’s legal and medical communities since the short-lived 2016 by-law that named urologists as key implementers. How do the very physicians expected to administer the intervention actually view it? This nationwide survey probes urology specialists’ knowledge, ethical reasoning and practical attitudes toward medical castration for sexual offenders.

Methods

A nationwide, cross-sectional online survey was conducted between April 2020 and October 2024. A 53-item questionnaire covering sociodemographic data, knowledge, ethical attitudes, and evaluative propositions about medical castration was distributed via professional mailing lists and direct e-mails. A total of 121 urology specialists participated. Data were analyzed with SPSS 26; descriptive statistics, Pearson χ², Fisher–Freeman–Halton exact tests, and Monte Carlo simulations were used, with significance set at p < 0.05.

Results

Just 47/121 (38.8%) could accurately cite the legal basis for medical castration; 33/121 (27.3%) reported detailed procedural knowledge. Legal awareness correlated with ≥ 11 years’ practice (χ² = 10.14, p = 0.039) and prior medical-ethics coursework (χ² = 9.17, p = 0.034). While roughly seven in ten (71.9%) felt the option should exist in principle, only 24/121 (19.8%) endorsed mandatory application. A slim majority (53/121; 43.8%) insisted on written offender consent, and 96/121 (79.3%) would mandate pre-treatment counselling on adverse effects. More than half (62/121; 51.2%) feared “medicalising” criminal punishment, and nearly two-thirds voiced concern about becoming agents of the penal system. Support was uneven: higher among academics holding associate professorships (p = 0.012) and in the Marmara region (p = 0.005), yet markedly lower among physicians with children (p = 0.040).

Conclusion

Urology specialists in Türkiye exhibit a nuanced, often ambivalent stance: many view medical castration as potentially useful but emphasize voluntariness, informed consent, and multidisciplinary follow-up. Limited legal familiarity and substantial ethical reservations highlight the need for clearer legislation, strengthened ethics education, and alignment with international human-rights standards before wider implementation can be contemplated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-026-01495-3.

Introduction

Sexual offenses constitute one of the most severe forms of violence, violating both physical and psychological integrity, and their prevention requires not only punitive but also preventive strategies [1]. Data from the World Health Organization indicate that sexual violence represents a major global public health problem, particularly affecting women and children [2, 3]. In Turkey, the increasing trend in sexual crimes against bodily autonomy has prompted legislators and healthcare professionals to discuss alternative intervention strategies [4].

Among these strategies, medical (chemical) castration seeks to reduce the risk of reoffending by suppressing sexual urges through hormonal treatment [5]. Although this intervention is reversible, it directly affects reproductive capacity and hormonal balance, making it a subject of intense debate in the context of medical ethics, human rights, and the principle of voluntariness [6, 7].

In 2016, a regulation in Turkey—later suspended—introduced court-mandated medical castration for sexual offenders, thereby raising ethical concerns regarding physicians’ responsibilities, particularly urology specialists who would be directly involved in the procedure [8, 9]. However, studies examining these specialists’ knowledge and ethical attitudes toward the practice remain limited in the literature [10].

This study aims to investigate the knowledge, attitudes, and ethical evaluations of urology specialists in Turkey regarding medical castration. Additionally, by incorporating the principles of voluntariness, informed consent, and feminist bioethics, the study seeks to provide a comprehensive framework that extends beyond individual considerations to encompass broader societal dimensions [11, 12]. This approach aspires to contribute not only to ethical debates but also to the re-examination of legal frameworks, health policies, and clinical practices [13].

The ethical evaluation of chemical castration is significant not only in the context of the individual doctor–patient relationship but also in the broader interaction between the healthcare system and the criminal justice mechanism [14]. In this context, the physician’s role shifts from being a provider of therapeutic care to an agent contributing to state-enforced punishment. This shift aligns with discussions framed by international ethical documents such as the World Medical Association’s declarations rejecting physician participation in punitive measures and the Oviedo Convention on Human Rights and Biomedicine [15, 16].

The 2016 Turkish regulation, although later annulled by the Council of State, defined chemical castration as a form of “treatment” and mandated its application to convicted offenders by court order [8]. However, the conflation of treatment with punishment creates ethical ambiguity regarding the true nature of the intervention. This ambiguity raises critical questions about physicians’ professional autonomy, the validity of informed consent, and how voluntariness can be ensured in a coercive setting [17].

The unique contribution of this study lies in placing the perspectives of urology specialists at the center of the ethical debate. These specialists possess the pharmacological expertise necessary to administer chemical castration and are therefore pivotal in shaping policies and informing clinical decision-making [10, 18]. Their knowledge, ethical concerns, and awareness of feminist bioethical principles hold significant potential for influencing policy development and clinical practice [19].

A feminist bioethical perspective enriches this analysis in two key ways. First, it emphasizes that sexual offenses cannot be fully explained by individual psychopathology alone but are deeply rooted in patriarchal structures, gender inequalities, and cultures of violence [12, 20]. Second, it critiques chemical castration for individualizing and medicalizing the problem, thereby failing to address structural inequities and overshadowing broader social solutions [21, 22]. This perspective allows the study to expand the ethical discourse beyond punitive approaches and to contribute to preventive, socially grounded policy frameworks.

Methods

Study design

The reporting of this study was guided by the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) recommendations.

This study was conducted as a descriptive research to evaluate medical castration practices for sexual offenders from a medical ethics perspective and to determine the knowledge and attitudes of urology specialists on this issue.

Study population and sample

The study population consisted of urology specialists actively practicing in Turkey. As of 2020, which marked the beginning of the survey study, personnel distribution records of the Ministry of Health indicated that 1,704 urology specialists were actively employed within the Ministry of Health system in Türkiye. According to data obtained from the Council of Higher Education, there were also 557 academic urology specialists working at universities, including 274 professors, 126 associate professors, 149 assistant professors, and 8 lecturers. Precise numerical data regarding urology specialists employed in the private sector could not be obtained. Data obtained from the Ministry of Health, universities, and professional associations indicated that these specialists were distributed across public, academic, and private sectors. The questionnaire was disseminated to the entire population via association mailing lists and individual emails without applying a sampling method. Invitations were disseminated through national professional mailing lists and direct e-mail communication. Due to the circulation-based distribution strategy, the exact number of physicians who received the invitation could not be determined precisely; therefore, a formal response rate could not be calculated. Ultimately, 121 urology specialists responded and were included in the study.

Data collection tool

The study commenced following the approval of the Clinical Research Ethics Committee of Kırşehir Ahi Evran University Faculty of Medicine, granted on 10 March 2020 with decision number 2020-04/22, confirming that the research posed no ethical or scientific concerns. Part of the data collection period coincided with the COVID-19 pandemic, which led to lower participation rates and the expiration of the initial approval period. Although the survey was administered online, the COVID-19 pandemic period significantly affected physicians’ professional workloads, emotional burdens, and accessibility. These extraordinary circumstances may have contributed to lower participation rates and prolonged the data collection period. At the same time, the pandemic context may also have influenced how physicians reflected upon state authority, bodily intervention, vulnerability, and professional responsibility — themes that are deeply intertwined with the ethical dimensions of medical castration. Consequently, an extension was requested and granted by the ethics committee, allowing data collection to continue until 2024.

Research data were collected through a questionnaire developed by the researchers based on a comprehensive literature review. The questionnaire was developed following an extensive review of the literature on medical castration, sexual offending, bioethics, human rights, and professional responsibility. Because the subject intersects medicine, law, ethics, and social policy, the questionnaire was intentionally designed to explore not only factual awareness but also ethical sensitivities and professional reflections. Prior to dissemination, the questionnaire was evaluated by scholars in urology and medical ethics with regard to clarity, conceptual coherence, and relevance to the Turkish context. The instrument consisted of 53 questions designed to assess urology specialists’ knowledge and ethical attitudes regarding the application of medical castration in sexual offenders. The questionnaire was not subjected to a formal psychometric validation process. At present, there is no previously validated Turkish instrument specifically addressing physicians’ ethical attitudes toward medical castration. Rather than presenting the questionnaire as a standardized scale, the questionnaire was approached as an exploratory tool intended to illuminate a complex and underexamined ethical field.

The questionnaire comprised four main sections:

• Sociodemographic Characteristics (11 items): Age, gender, marital status, parenthood, academic title, years of professional experience, type of institution, geographical region of practice, subspecialty interest in urology, and whether the respondent had received medical ethics and/or clinical ethics training during undergraduate or postgraduate education.

• Knowledge Assessment (10 items): Questions evaluating understanding of medical castration, including its definition, legal framework, indications, and professional groups authorized to perform the procedure.

• Ethical Attitudes (10 items): Questions assessing physicians’ perspectives on ethical principles, patient rights, and professional responsibilities related to the intervention.

• Opinions and Evaluations (22 items): Statements exploring participants’ personal opinions and general assessments of medical castration practices.

At the end of the questionnaire, a global rating item was included, asking participants: “Considering the overall questionnaire, how would you rate it on a scale of 1 to 10?”

Data were collected online using the Google Forms^® platform. Urology specialists across Turkey were contacted through professional associations and individual email invitations to encourage participation. The survey was conducted anonymously through Google Forms^®, and no personally identifiable information was collected at any stage of the study. Before participation, respondents were informed about the purpose of the research, the voluntary nature of participation, and the confidentiality of the data. The introductory section of the questionnaire provided detailed information about the study’s objectives and significance, and informed consent was obtained digitally via a “agree / disagree” option. Data collection was conducted between April 2020 and October 2024, and a total of 121 urology specialists completed the survey.

Data analysis

The data obtained in this study were analyzed using SPSS version 26.0 (Statistical Package for the Social Sciences, IBM Corp., Armonk, NY, USA). Descriptive statistical methods were employed to summarize participants’ characteristics and their knowledge and attitudes toward medical castration. Frequencies (n), percentages (%), means, and standard deviations were calculated for descriptive purposes.

Relationships between categorical variables were assessed using the Pearson Chi-square test. In cases where the expected cell frequencies were less than five, the Fisher–Freeman–Halton test and Monte Carlo simulation methods were applied, and the resulting p-values were reported. Findings were interpreted within a 95% confidence interval, and a p-value of < 0.05 was considered statistically significant.

Accordingly, statistically significant associations should be interpreted cautiously and not as evidence of causal relationships.

Results

This study aimed to evaluate the application of medical castration in sexual offenders from a medical ethics perspective and to assess the knowledge and attitudes of urology specialists regarding this issue. The findings obtained are presented under four main subheadings in accordance with the scope of the study.

Analysis of sociodemographic data

The sociodemographic characteristics of the 121 participating urology specialists are summarized in Table 1. The majority of participants were male (99.2%) and married (90.1%), with 81.8% having children. The predominance of male participants largely reflects the demographic composition of the urology profession in Türkiye, where female urologists remain underrepresented. Age distribution revealed that most respondents were within the 30–40 (31.4%) and 41–50 (31.4%) year age groups. In terms of academic title, more than half were specialist physicians (53.7%). Regarding professional experience, the highest proportion belonged to those with more than 25 years of practice (29.8%).

Table 1.

Demographic Characteristics of Participants (n = 121)

Variable	Category	n (%)
Age	< 30	7 (5.8)
	30–40	38 (31.4)
	41–50	38 (31.4)
	51–60	21 (17.4)
	> 61	17 (14.0)
Gender	Female	1 (0.8)
	Male	120 (99.2)
Marital Status	Married	109 (90.1)
	Divorced	8 (6.6)
	Single	4 (3.3)
Parental Status	Yes	99 (81.8)
	No	22 (18.2)
Academic Title	Specialist	65 (53.7)
	Assistant Professor	12 (9.9)
	Associate Professor	26 (21.5)
	Professor	18 (14.9)
Professional Experience (years)	1–5	12 (9.9)
	6–10	20 (16.5)
	11–15	21 (17.4)
	16–20	15 (12.4)
	21–25	17 (14.0)
	> 25	36 (29.8)
Institution	State Hospital	25 (20.7)
	Training and Research Hospital	33 (27.3)
	City Hospital	7 (5.8)
	University Hospital	32 (26.4)
	Private Hospital	12 (9.9)
	Private Clinic	12 (9.9)
Region of Practice	Marmara	41 (33.9)
	Aegean	15 (12.4)
	Mediterranean	11 (9.1)
	Central Anatolia	34 (28.1)
	Black Sea	12 (9.9)
	Eastern Anatolia	6 (5.0)
	Southeastern Anatolia	2 (1.7)
Subspecialty in Urology	Endourology	48 (39.7)
	Uro-oncology	29 (24.0)
	Andrology	17 (14.0)
	Urogynecology	8 (6.6)
	Pediatric Urology	7 (5.8)
	Reconstructive Urology	5 (4.1)
	Transplantation	7 (5.8)
Undergraduate Ethics Training	Yes	90 (74.4)
	No	22 (18.2)
	Not sure	9 (7.4)
Postgraduate Ethics Training	Yes	23 (19.0)
	No	78 (64.5)
	Not sure	20 (16.5)
Overall Questionnaire Rating	Mean ± SD	7.44 ± 1.92

Geographically, most participants were practicing in the Marmara (33.9%) and Central Anatolia (28.1%) regions. The most common workplace settings were training and research hospitals (27.3%) and university hospitals (26.4%). Endourology (39.7%) was the most frequently reported subspecialty interest, followed by uro-oncology (24.0%) and andrology (14.0%).

Regarding ethics education, 74.4% of participants reported having received ethics training at the undergraduate level, whereas only 19.0% had postgraduate ethics education. The overall mean rating for the questionnaire provided by participants was 7.44 ± 1.92 points.

Analysis of responses to knowledge questions

Table 2 presents the participants’ knowledge regarding medical castration. Only 38.8% of the participants reported being aware of the punishment of sexual crimes in Türkiye, while 27.3% stated that they had knowledge about medical castration. Furthermore, merely 9.9% indicated that they were aware of the existence of such a regulation in the Turkish Penal Code. Similarly, awareness of the related regulation published in the Official Gazette dated 26 July 2016 was also quite low, at 10.7%. These findings indicate that awareness of the relevant legislation and regulations is limited.

Table 2.

Knowledge status of participants regarding the application of medical castration

Statement	Response	n (%)
1. Are you aware of the punishment of sexual crimes in Türkiye?	Yes	47 (38.8)
	No	74 (61.2)
2. Do you have knowledge about the application of medical castration for sexual offenders?	Yes	33 (27.3)
	No	88 (72.7)
3. Are you aware that there is an article regarding medical castration of sexual offenders in the Turkish Penal Code?	Yes	12 (9.9)
	No	38 (31.4)
	I do not remember	71 (58.7)
4. Are you aware of the regulation No. 29,782 published in the Official Gazette on 26 July 2016?	Yes	13 (10.7)
	No	82 (67.8)
	I do not remember	26 (21.5)
5. For what purpose do you think the method of medical castration in sexual crimes was developed?	For therapeutic purposes	45 (37.2)
	For punitive purposes	69 (57.0)
	No opinion	7 (5.8)
6. In your opinion, under what scope should medical castration be evaluated in sexual offenders?	Punishment	44 (36.4)
	Medical treatment	22 (18.2)
	Both punishment and medical treatment	55 (45.5)
7. Which of the following fields do you think medical castration is associated with in sexual offenders?	Medicine	101 (83.5)
	Law	100 (82.6)
	Ethics	89 (73.6)
	Psychology	65 (53.7)
	Sociology	59 (48.8)
8. Which ethical principle(s) is/are most closely related to medical castration in sexual offenders?	Justice	76 (62.8)
	Non-maleficence	78 (64.5)
	Beneficence	66 (54.5)
	Respect for autonomy	29 (24.0)
	Privacy	18 (14.9)
9. Who should be the practitioners of medical castration?	Urologists	84 (69.4)
	Endocrinologists	58 (47.9)
	Psychiatrists	46 (38.0)
	Family physicians	7 (5.8)
	Should not be applied / Undecided / Other	7 (5.8)
10. Have you encountered such a case during your professional life?	Yes	12 (9.9)
	No	109 (90.1)

The majority of participants (57.0%) perceived medical castration as being developed primarily for punitive purposes. Regarding the scope of the practice, the highest response rate (45.5%) was for the statement “both punishment and medical treatment,” suggesting that participants perceive medical castration not solely as a therapeutic intervention but also as a punitive measure.

A substantial proportion of participants considered medical castration to be associated with multiple disciplines such as medicine (83.5%), law (82.6%), ethics (73.6%), and psychology (53.7%), reflecting the multidimensional nature of the issue. In the context of ethical principles, the most frequently cited were non-maleficence (64.5%) and justice (62.8%). Considering that medical castration directly affects human rights and bodily integrity, the emphasis on these two principles is meaningful.

Regarding the professionals deemed responsible for implementing the procedure, urologists were most frequently indicated (69.4%), followed by endocrinologists (47.9%) and psychiatrists (38.0%). Finally, only 9.9% of the participants reported having encountered such a case during their professional practice, suggesting that while rarely encountered in the field, the issue remains ethically and legally significant.

Analysis of responses to attitude questions

Participants’ attitudes toward the application of medical castration are presented in Table 3. A substantial proportion of participants (71.9%) agreed with the statement, “Medical castration should be applied to individuals convicted of sexual offenses.” However, the proportion agreeing that this intervention should be mandatory was markedly lower (19.8%), with 69.4% expressing disagreement. These findings indicate that although most participants view medical castration positively in principle, they consider its implementation to require individual consent.

Table 3.

Participants’ attitudes toward the application of medical castration

Statement	Response	n (%)
1. Medical castration should be applied to individuals convicted of sexual offenses.	Agree	87 (71.9)
	Disagree	24 (19.8)
	No opinion	10 (8.3)
2. Medical castration should be mandatory in sexual offenses.	Agree	24 (19.8)
	Disagree	84 (69.4)
	No opinion	13 (10.7)
3. Medical castration should not be applied without the offender’s consent.	Agree	53 (43.8)
	Disagree	52 (43.0)
	No opinion	16 (13.2)
4. Medical castration without consent constitutes torture and ill-treatment.	Agree	40 (33.1)
	Disagree	73 (60.3)
	No opinion	8 (6.6)
5. Medical castration should be applied to individuals convicted of sexual crimes.	Agree	79 (65.3)
	Disagree	27 (22.3)
	No opinion	15 (12.4)
6. In your opinion, which of the following human rights is medical castration closely associated with? *	Right to life, health, and bodily integrity	93 (76.9)
	Prohibition of torture and ill-treatment	43 (35.5)
	Right to respect for private and family life	42 (34.7)
	Right to marry	12 (9.9)
	Other	19 (15.7)
7. Individuals subjected to medical castration should be informed about potential side effects.*	Should be informed	96 (79.3)
	Should not be informed	21 (17.4)
	No opinion	4 (3.3)
8. Sentence reduction should not be applied to those who refuse medical castration.	Yes	42 (34.7)
	No	68 (56.2)
	No opinion	11 (9.1)
9. Medical castration should be performed by physicians.	Yes	82 (67.8)
	No	26 (21.5)
	No opinion	13 (10.7)
10. It is appropriate to use a medically developed therapeutic method as part of penal execution.	Appropriate	73 (60.3)
	Not appropriate	32 (26.4)
	No opinion	16 (13.2)

*Multiple responses were allowed

Among urologists, 43.8% agreed with the statement, “Medical castration should not be applied without the consent of the offender,” whereas 43.0% disagreed. Similarly, 33.1% agreed with the statement, “Medical castration without consent constitutes torture and ill-treatment,” while 60.3% disagreed.

The proportion of participants who believed that medical castration should be applied to individuals convicted of sexual crimes was 65.3%. In addition, a significant majority associated the intervention with fundamental human rights such as the right to life, health, and bodily integrity (76.9%). Furthermore, notable proportions related it to the prohibition of torture and ill-treatment (35.5%) and the right to respect for private and family life (34.7%).

A large majority of participants (79.3%) emphasized that individuals subjected to medical castration should be informed about potential side effects, reflecting a strong sensitivity to ethical principles. However, only 34.7% of participants agreed that individuals refusing medical castration should not benefit from sentence reductions, indicating limited support for punitive consequences in such cases. Finally, 67.8% of participants stated that the procedure should be performed exclusively by physicians. Moreover, 60.3% agreed that a method originally developed for therapeutic purposes could be used within the framework of penal execution, suggesting that participants perceive medical castration as having both punitive and therapeutic dimensions.

Analysis of responses to proposition questions

Table 4 presents the participants’ responses to propositions regarding the application of medical castration. The findings indicate that while overall support for medical castration is high, this support is conditional and critical in nature. A total of 71.9% of participants supported its application for public order and safety, yet an equal proportion stated that the intervention would only be valuable if combined with cognitive and behavioral therapy. Furthermore, 79.3% of participants emphasized that the procedure should be monitored through structured programs conducted by psychologists and social workers. These results reflect an interdisciplinary and rehabilitative approach shaped by ethical considerations.

Table 4.

Participants’ propositions regarding the application of medical castration

Statement	Response	n (%)
1. Do you agree that when medical castration is performed without patient consent, its deterrent effect decreases?	Agree	43 (35.5)
	Disagree	64 (52.9)
	No opinion	14 (11.6)
2. Instead of imprisonment, conditional release with medical castration is appropriate for sexual offenders.	Agree	25 (20.7)
	Disagree	89 (73.6)
	No opinion	7 (5.8)
3. To reduce prison overcrowding, is it appropriate to release sexual offenders after non-consensual medical castration?	Agree	14 (11.6)
	Disagree	91 (75.2)
	No opinion	16 (13.2)
4. There should be an age limit for medical castration.	Agree	21 (17.4)
	Disagree	86 (71.1)
	No opinion	14 (11.6)
5. What should the age limit be?	18 and above	15 (12.4)
	18–25	3 (2.5)
	26–65	5 (2.5)
	65 and above	3 (2.5)
6. Medical castration will be effective in treating paraphilias (sexual deviations).	Agree	69 (57.0)
	Disagree	33 (27.3)
	No opinion	19 (15.7)
7. In light of scientific findings suggesting a genetic basis for paraphilias, surgical sterilization should also be added as an additional procedure.	Agree	55 (45.5)
	Disagree	41 (33.9)
	No opinion	25 (20.7)
8. Applying medical castration to sexual offenders may make them more respectful of others’ sexual autonomy.	Agree	56 (46.3)
	Disagree	44 (36.4)
	No opinion	21 (17.4)
9. Medical castration cannot replace imprisonment and is unnecessary.	Agree	34 (28.1)
	Disagree	72 (59.5)
	No opinion	15 (12.4)
10. Medical castration should be included in the law and applied to all sexual offenders, voluntary or not.	Agree	63 (52.1)
	Disagree	44 (36.4)
	No opinion	14 (11.6)
11. Medical castration only reduces drive and libido, not the underlying deviance; thus, it is not a fully deterrent punishment.	Agree	86 (71.1)
	Disagree	19 (15.7)
	No opinion	16 (13.2)
12. Medical castration is not an appropriate penalty/treatment due to its mental and physical side effects.	Agree	30 (24.8)
	Disagree	70 (57.9)
	No opinion	21 (17.4)
13. Do you think medical castration prevents recidivism (re-offense of sexual crimes)?	Agree	61 (50.4)
	Disagree	34 (28.1)
	No opinion	26 (21.5)
14. When medical castration ends after the sentence, recidivism may increase.	Agree	63 (52.1)
	Disagree	32 (26.4)
	No opinion	26 (21.5)
15. Regarding the use of medical castration for eugenics purposes.	Agree	27 (22.3)
	Disagree	67 (55.4)
	No opinion	27 (22.3)
16. Do you think medical castration violates Article 3 of the European Convention on Human Rights (prohibition of torture and inhuman or degrading treatment)?	Agree	37 (30.6)
	Disagree	71 (58.7)
	No opinion	13 (10.7)
17. Medical castration should be applied to sexual offenders to ensure public order and safety and protect future generations.	Agree	87 (71.9)
	Disagree	25 (20.7)
	No opinion	9 (7.4)
18. Medical castration is valuable only if supported by cognitive and behavioral therapy.	Agree	87 (71.9)
	Disagree	21 (17.4)
	No opinion	13 (10.7)
19. Medical castration medicalizes sexual violence and turns physicians into agents of punishment.	Agree	62 (51.2)
	Disagree	50 (41.3)
	No opinion	9 (7.4)
20. Structured programs with psychologists and social workers should follow medical castration for sexual offenders.	Agree	96 (79.3)
	Disagree	15 (12.4)
	No opinion	10 (8.3)
21. Sexual assault is an act rooted in gender inequality aimed at controlling, punishing, or humiliating the victim.	Agree	71 (58.7)
	Disagree	26 (21.5)
	No opinion	24 (19.8)
22. Recognizing that sexual assault stems from gender inequality is important for developing solutions.	Agree	82 (67.8)
	Disagree	19 (15.7)
	No opinion	20 (16.5)

Regarding its therapeutic potential, 57.0% of participants believed medical castration would be effective in treating paraphilic disorders, whereas 50.4% thought it would reduce recidivism rates. However, 71.1% expressed the view that medical castration merely reduces sexual drive and libido without eliminating deviant tendencies, and therefore cannot serve as a fully deterrent penalty. In line with this, 59.5% of participants stated that the intervention could not substitute for criminal punishment.

From an ethical perspective, 51.2% of participants agreed with the critique that medical castration medicalizes punishment and transforms physicians into agents of the penal system. Additionally, 30.6% considered the procedure to be in violation of Article 3 of the European Convention on Human Rights (prohibition of torture and inhuman or degrading treatment).

In terms of gender dynamics, 58.7% of participants identified sexual assault as rooted in gender inequality, and 67.8% highlighted the importance of this perspective for developing effective solutions. These findings suggest that participants are sensitive not only to biological aspects but also to socio-cultural and structural determinants of sexual violence.

Additional analyses

Table 5 examines the relationships between participants’ knowledge levels regarding medical castration and their demographic characteristics. All questions concerning knowledge and demographic features were included in the analysis, and only statistically significant results are presented.

Table 5.

Comparison of Participants’ Knowledge About Medical Castration with Their Descriptive Characteristics

	Years of Professional Experience
Question 1	1-5	6-10	11-15	16-20	21-25	>25	Total
Yes	4	3	13	4	6	17	47
No	8	17	8	11	11	19	74
Total	12	20	21	15	17	36	121
χ² (p)		χ² = 11,732, p = 0,039
	Institution of Employment
Question 1	State Hospital	Ministry of Health Training and Research Hospital	City Hospital	University Hospital	Private Hospital	Private Clinic	Total
Yes	10	8	1	17	8	3	47
No	15	25	6	15	4	9	74
Total	25	33	7	32	12	12	121
χ² (p (MC %95))*		χ² = 11,874 p = ,034 (95% GA: 0,030–0,037)
	Status of Receiving Medical and/or Clinical Ethics Education During Undergraduate Period
Question 1	Yes	No	I don’t remember	Total
Yes	38	9	0	47
No	52	13	9	74
Total	90	22	9	121
χ² (p (MC %95))*		χ² = 6,790 p = ,034 (95% GA: 0,031–0,038)
	Years of Professional Experience
Question 2	1-5	6-10	11-15	16-20	21-25	>25	Total
Yes	1	3	8	2	3	16	33
No	11	17	13	13	14	20	88
Total	12	20	21	15	17	36	121
χ² (p (MC %95))*		χ² = 11,554 p = ,037 (95% GA: 0,033–0,040)
	Marital Status
Question 3	Married	Divorced	Single	Total
Yes	11	1	0	12
No	30	4	4	38
I don’t remember	68	3	0	71
Total	109	8	4	121
χ² (p (MC %95))*		χ² = 9,552 (p = 0,024 (0,021-0,027))
		Academic Title
Question 4		Specialist Dr.	Assistant Professor Dr.	Associate Professor Dr.	Professor	Total
Yes		5	0	7	1	13
No		42	12	16	12	82
I don’t remember		18	0	3	5	26
Total		65	12	26	18	121
χ² (p (MC %95))*			χ² = 13,499 (p = 0,021 (95% GA: 0,018-0,023))
		Status of Receiving Medical and/or Clinical Ethics Education During Postgraduate Period
Question 4		Yes	No	I don’t remember	Total
Yes		1	11	1	13
No		19	54	9	82
I don’t remember		3	13	10	26
Total		23	78	20	121
χ² (p (MC %95))*			χ² = 11,874 p = ,034 (95% GA: 0,030–0,037)
		Academic Title
Question 5		Specialist Dr.	Assistant Professor Dr.	Associate Professor Dr.	Professor	Total
Yes		17	6	9	13	45
No		43	6	15	5	69
I don’t remember		5	0	2	0	7
Total		65	12	26	18	121
χ² (p (MC %95))*			χ² = 13,150 (p = 0,022 (95% GA: 0,019-0,025))
		Academic Title
Question 6		Specialist Dr.	Assistant Professor Dr.	Associate Professor Dr.	Professor	Total
Punishment		29	4	9	2	44
Medical Treatment		8	5	6	3	22
Punishment and Medical Treatment		28	3	11	13	55
Total		65	12	26	18	121
χ² (p (MC %95))*			χ² = 13,744 p = 0,032 (95% GA: 0,029–0,035)

*As the assumptions of the Pearson Chi-square test were not met, the Fisher-Freeman-Halton exact test and Monte Carlo simulation p-value were used

Question 1: “Awareness of the punishment of sexual crimes in Türkiye” was significantly associated with years of professional experience (p = 0.039), institution of employment (p = 0.034), and taking an ethics course during undergraduate education (p = 0.034). Participants with more than 25 years of experience and those working in university hospitals demonstrated higher knowledge levels; additionally, individuals who had received undergraduate ethics education were also more knowledgeable.

Question 2: “Awareness of the application of medical castration to sexual offenders” was likewise significantly associated with years of professional experience (p = 0.037), with knowledge levels increasing alongside experience.

Question 3: “Awareness of the article on medical castration in the Turkish Penal Code” showed significant differences according to marital status (p = 0.024), with married participants being more knowledgeable.

Question 4: “Awareness of the regulation published in the Official Gazette on 26 July 2016” was significantly associated with academic title (p = 0.021) and postgraduate ethics education (p = 0.034).

Furthermore, participants’ responses to Question 5: “Purpose of developing medical castration” and “Scope of its application” differed significantly by academic title, with professors more frequently endorsing the view that it should combine punishment and treatment (p = 0.032).

These findings suggest that knowledge and perceptions of medical castration are influenced by various demographic and professional factors, including years of experience, workplace, exposure to ethics education, and academic rank.

Table 6 presents the comparison of participants’ attitudes toward medical castration based on their demographic characteristics. The findings indicate that responses to Question 4: “Medical castration without consent constitutes torture and ill-treatment” significantly differed by region of employment (p = 0.010) and ethics education status (p = 0.043). Participants who had received ethics education were more likely to agree with this statement.

Table 6.

Comparison of Participants’ Attitudes Towards Medical Castration According to Their Descriptive Characteristics

Soru 4	Region of Employment
	Marmara Region	Aegean Region	Mediterranean Region	Central Anatolia Region	Black Sea Region	Eastern Anatolia Region	Southeastern Anatolia Region	Toplam
Agree	13	10	3	7	7	0	0	40
Disagree	24	5	7	26	5	5	1	73
No Opinion	4	0	1	1	0	1	1	8
Total	41	15	11	34	12	6	2	121
χ² (p (MC %95))*		χ² = 22,374 (p = 0,010 (95% GA: 0,007 − 0,012))
	Status of Receiving Medical and/or Clinical Ethics Education During Undergraduate Period
Soru 4	Yes	No	I don’t remember	Toplam
Agree	30	9	1	40
Disagree	55	13	5	73
No Opinion	5	0	3	8
Total	90	22	9	121
χ² (p (MC %95))*		χ² = 8,711 p = ,043 (95% GA: 0,038–0,048)
	Academic Title
Soru 7	Specialist Dr.	Assistant Professor Dr.	Associate Professor Dr.	Professor	Toplam
Should be done	51	6	22	17	96
Should not be done	11	6	4	0	21
No Opinion	3	0	0	1	4
Total	65	12	26	18	121
χ² (p (MC %95))*		χ² = 12,526 (p = 0,024 (95% GA: 0,020 − 0,027))
	Region of Employment
Soru 8	Marmara Region	Aegean Region	Mediterranean Region	Central Anatolia Region	Black Sea Region	Eastern Anatolia Region	Southeastern Anatolia Region	Toplam
Yes	15	8	3	5	8	3	0	42
No	22	7	4	27	4	3	1	68
No Opinion	4	0	4	2	0	0	1	11
Total	41	15	11	34	12	6	2	121
χ² (p (MC %95))*		χ² = 25,763 p = 0,002 (95% GA: 0,001–0,003)
	Status of Receiving Medical and/or Clinical Ethics Education During Undergraduate Period
Soru 9	Yes	No	I don’t remember	Toplam
Yes	62	16	4	82
No	22	2	2	26
No Opinion	6	4	3	13
Total	90	22	9	121
χ² (p (MC %95))*		χ² = 9,013 p = ,039 (95% GA: 0,034–0,044)

*As the assumptions of the Pearson Chi-square test were not met, the Fisher-Freeman-Halton exact test and Monte Carlo simulation p-value were used

Responses to Question 7: “Individuals subjected to medical castration should be informed about potential side effects” differed significantly by academic title (p = 0.024), with specialist physicians and professors placing greater emphasis on the necessity of such information.

Attitudes toward Question 8: “Sentence reduction should not be applied to those who refuse medical castration” also differed significantly by region of employment (p = 0.002).

Furthermore, responses to Question 9: “Medical castration should be performed by physicians” differed significantly by both academic title (p = 0.024) and ethics education status (p = 0.039), with specialist physicians and participants who had received ethics education more likely to agree with this statement.

These findings suggest that ethics education and professional position play a significant role in shaping attitudes toward ethically contentious interventions such as medical castration.

Table 7 presents participants’ responses to various propositions concerning the ethical, medical, penal, and social dimensions of medical castration, analyzed according to variables such as academic title, ethics education, parental status, years of professional experience, age group, and type of institution.

Table 7.

Comparison of Participants' Statements on Medical Castration According to Demographic Characteristics

	Academic Title
Question 3	Specialist				Assistant Professor	Associate Professor	Professor	Total
Agree	4				3	5	2	14
Disagree	50				9	21	11	91
No Opinion	11				0	0	5	16
Total	65				12	26	18	121
χ² (p (MC %95))					χ² = 14.337 (p = 0.013 (95% CI: 0.010-0.016))
	Status of Receiving Medical and/or Clinical Ethics Education During Undergraduate Period
Question 6	Yes				No	I Do Not Remember		Total
Agree	59				8	2		69
Disagree	20				9	4		33
No Opinion	11				5	3		19
Total	90				22	9		121
χ² (p)					χ² = 11.189 p = 0.025
	Status of Receiving Medical and/or Clinical Ethics Education During Undergraduate Period
Question 7	Yes				No	I Do Not Remember		Total
Agree	48				6	1		55
Disagree	28				11	2		41
No Opinion	14				5	6		25
Total	90				22	9		121
χ² (p)					χ² = 17.817 p = 0.004
	Status of Having Children
Question 8	Yes				No			Total
Agree	45				11			56
Disagree	33				11			44
No Opinion	21				0			21
Total	99				22			121
χ² (p)					χ² = 6.122 p = 0.040
	Academic Title
Question 9	Specialist				Assistant Professor	Associate Professor	Professor	Total
Agree	22				0	8	4	34
Disagree	34				11	18	9	72
No Opinion	9				1	0	5	15
Total	65				12	26	18	121
χ² (p (MC %95))					χ² = 15.150 (p = 0.012 (95% CI: 0.009-0.014))
		Academic Title
Question 10		Specialist			Assistant Professor	Associate Professor	Professor	Total
Agree		28			10	19	6	63
Disagree		28			1	6	9	44
No Opinion		9			1	1	3	14
Total		65			12	26	18	121
χ² (p (MC %95))					χ² = 14.174 (p = 0.020 (95% CI: 0.016-0.023))
		Status of Receiving Medical and/or Clinical Ethics Education During Postgraduate Period
Question 10		Yes			No	I Do Not Remember	Total
Agree		12			44	7	63
Disagree		10			28	6	44
No Opinion		1			6	7	14
Total		23			78	20	121
χ² (p)					χ² = 13.489a p = ,009
		Special Interest Area in Urology Practice
Question 11		Uro-oncology			Endourology	Andrology	Urogynecology	Pediatric Urology	Reconstructive urology	Transplantation	Total
Agree		19			37	13	4	3	5	5	86
Disagree		4			10	1	3	1	0	0	19
No Opinion		6			1	3	1	3	0	2	16
Total		29			48	17	8	7	5	7	121
χ² (p (MC %95))					χ² = 19.917 (p = 0.023 (95% CI: 0.019-0.027))
				Years of Professional Experience
Question 12				1-5	6-10	11-15	16-20	21-25	>25		Total
Agree				4	5	4	0	8	9		30
Disagree				7	9	16	11	4	23		70
No Opinion				1	6	1	4	5	4		21
Total				12	20	21	15	17	36		121
χ² (p (MC %95))					χ² = 22.104 p = ,009 (95% CI: 0.006–0.011)
			Region of Employment
Question 12			Marmara Region		Aegean Region	Mediterranean Region	Central Anatolia Region	Black Sea Region	Eastern Anatolia Region	Southeastern Anatolia Region	Total
Agree			13		10	3	7	7	0	0	40
Disagree			24		5	7	26	5	5	1	73
No Opinion			4		0	1	1	0	1	1	8
Total			41		15	11	34	12	6	2	121
χ² (p (MC %95))					χ² = 25.406 (p = 0.005 (95% CI: 0.003-0.006)
			Academic Title
Question 13			Specialist		Assistant Professor	Associate Professor	Professor				Total
Agree			26		10	17	8				61
Disagree			23		1	7	3				34
No Opinion			16		1	2	7				26
Total			65		12	26	18				121
χ² (p (MC %95))					χ² = 14.083 (p = 0.025 (95% CI: 0.021-0.029))
			Region of Employment
Question 13			Marmara Region		Aegean Region	Mediterranean Region	Central Anatolia Region	Black Sea Region	Eastern Anatolia Region	Southeastern Anatolia Region	Total
Agree			17		7	2	23	6	5	1	61
Disagree			14		8	1	7	3	0	1	34
No Opinion			10		0	8	4	3	1	0	26
Total			41		15	11	34	12	6	2	121
χ² (p (MC %95))					χ² = 28.335 (p = 0.002 (95% CI: 0.001-0.003))
			Age
Question 14			<30		30-40	41-50	51-60	>61	Total
Agree			3		20	27	8	5	63
Disagree			3		12	6	4	7	32
No Opinion			1		6	5	9	5	26
Total			7		38	38	21	17	121
χ² (p)					χ² = 16.693a (p = 0.033) The heading "Region of Employment" should appear as an independent row, consistent with the formatting used for the other section headings in the table. As we were unable to make this formatting adjustment within the table, we kindly request that this correction be made during the production process
Question 16			Marmara Region		Aegean Region	Mediterranean Region	Central Anatolia Region	Black Sea Region	Eastern Anatolia Region	Southeastern Anatolia Region	Total
Agree			17		6	1	8	5	0	0	37
Disagree			22		9	7	23	5	3	2	71
No Opinion			2		0	3	3	2	3	0	13
Total			41		15	11	34	12	6	2	121
χ² (p (MC %95))					χ² = 19.924 (p = 0.033 (95% CI: 0.028-0.037))
			Years of Professional Experience
Question 18			1-5		6-10	11-15	16-20	21-25	>25		Total
Agree			8		16	10	12	9	32		87
Disagree			2		3	7	2	4	3		21
No Opinion			2		1	4	1	4	1		13
Total			12		20	21	15	17	36		121
χ² (p (MC %95))					χ² = 16.697 p = ,044 (95% CI: 0.039–0.049)
			Status of Receiving Medical and/or Clinical Ethics Education During Postgraduate Period
Question 18			Yes		No	I Do Not Remember					Total
Agree			16		61	10					87
Disagree			6		11	4					21
No Opinion			1		6	6					13
Total			23		78	20					121
χ² (p)					χ² = 11.804ap = ,019
			Institution of Employment		This row should be formatted as a single, merged row rather than being divided into multiple cells. As we were unable to make this formatting correction ourselves, we kindly request that it be adjusted during the production/typesetting process
Question 21			State Hospital		Training and Research Hospital (MoH)	City Hospital	University Hospital	Private Hospital	Private Clinic		Total
Agree			17		16	4	21	7	6		71
Disagree			7		4	1	5	4	5		26
No Opinion			1		13	2	6	1	1		24
Total			25		33	7	32	12	12		121
χ² (p (MC %95))					χ² = 17.191p = ,044 (95% CI: 0.038–0.049)

Question 3: “Implementing medical castration without consent to reduce prison overcrowding” differed significantly by academic title (p = 0.013), with specialist physicians predominantly opposing this proposition. Responses to Question 4: “There should be an age limit for medical castration” and Question 6: “Medical castration is effective in the treatment of paraphilia” differed significantly according to undergraduate ethics education (p = 0.025 and p = 0.004, respectively), with participants who had received ethics education adopting a more cautious stance.

Responses to Question 8: “Sentence reduction should not be applied to those who refuse medical castration” varied by parental status (p = 0.040), with participants who have children showing stricter attitudes toward this issue. Responses to Question 9: “Medical castration should be performed by physicians” and Question 10: “It should be included in the law and applied to all offenders, voluntary or not” differed significantly according to academic title (p = 0.012 and p = 0.020) and postgraduate ethics education (p = 0.009), revealing that specialist physicians were more critical of such coercive and punitive approaches.

Additionally, responses to the eugenics-oriented proposition in Question 3: “If paraphilia is genetic, surgical sterilization should also be applied” showed significant differences according to urology subspecialty (p = 0.023). Responses to Question 1: “Medical castration only suppresses sexual drive and does not provide full deterrence”, Question 12: “It is not an appropriate method due to mental and physical side effects”, Questions 13–14: “Does it prevent recidivism?”, Question 15: “Application for eugenic purposes”, Question 16: “Whether it violates Article 3 of the European Convention on Human Rights”, Question 17: “Applicability to protect future generations”, Question 18: “Meaningful only if supported by psychotherapy”, Question 19: “Medicalization of punishment turning medicine into an instrument of penal enforcement”, and Question 20: “Necessity of follow-up by specialized multidisciplinary teams” also demonstrated significant differences according to years of professional experience (p = 0.009–0.044), region of employment (p = 0.002–0.033), age group (p = 0.033), postgraduate ethics education (p = 0.019), and type of institution (p = 0.044). These findings indicate that perspectives on medical castration—a multifaceted and controversial issue are shaped not only by ethical knowledge but also by variables such as professional experience, education, field of specialization, and broader social sensitivities.

Table 8 examines the comparison between participants’ knowledge of and attitudes toward medical castration. A significant association was found between awareness of the punishment of sexual crimes in Türkiye and the attitude toward the applicability of a medical method as part of penal execution (χ² = 7.396; p = 0.025). Similarly, there was a significant relationship between knowledge about the application of medical castration and the view that medical castration should be applied to individuals convicted of sexual offenses (χ² = 7.812; p = 0.027).

Table 8.

Comparison of Participants’ Knowledge and Attitudes Regarding Medical Castration

Knowledge Question 1		Attitude Question 9
		Yes	No	No Opinion			Total
Yes		26	16	5			47
No		56	10	8			74
Total		82	26	13			121
χ² (p)			χ² = 7,396 p = ,025
		Attitude Question 1
Knowledge Question 2		Agree	Disagree	No Opinion			Total
Yes		19	12	2			33
No		68	12	8			88
Total		87	24	10			121
χ² (p)			χ² = 7,812 p = ,027
		Attitude Question 2
Knowledge Question 3		Agree	Disagree	No Opinion		Total
Yes		3	5	4		12
No		11	24	3		38
I don't remember		10	55	6		71
Total		24	84	13		121
χ² (p (MC %95))			χ² = 10,172 p= ,026 (95% GA: 0,022–0,030)
	Attitude Question 1
Knowledge Question 6	Agree		Disagree	No Opinion	Total
Punishment	23		16	5	44
Medical Treatment	18		2	2	22
Punishment and Medical Treatment	46		6	3	55
Total	87		24	10	121
χ² (p (MC %95))			χ² = 13,532 p= ,005 (95% GA: 0,003–0,007)
	Attitude Question 5
Knowledge Question 6	Agree		Disagree	No Opinion	Total
Punishment	17		19	8	44
Medical Treatment	18		1	3	22
Punishment and Medical Treatment	44		7	4	55
Total	79		27	15	121
χ² (p (MC %95))			χ² = 13,532 p= ,005 (95% GA: 0,003–0,007)

In addition, awareness of the existence of legal provisions regarding medical castration in the Turkish Penal Code was significantly associated with the attitude that medical castration should be mandatory (χ² = 10.172; p = 0.026; 95% CI: 0.022–0.030). Moreover, participants’ knowledge of whether medical castration should be considered as punishment, treatment, or both showed significant associations with both the belief that this intervention is necessary and the view that it should be applied to offenders (χ² = 13.532; p = 0.005 for both; 95% CI: 0.003–0.007).

These findings indicate that knowledge levels regarding medical castration significantly influence individuals’ ethical evaluations and attitudes toward its implementation.

Discussion

This study represents one of the first comprehensive investigations examining the knowledge, ethical evaluations, and attitudes of urology physicians in Türkiye regarding the use of medical (chemical) castration in sexual offenses. The findings reveal that the majority of physicians are unaware of the legislation on the punishment of sexual crimes, yet their ethical attitudes toward this practice are multifaceted and heterogeneous. This carries critical implications for both clinical practice and policy-making.

The findings of this study reveal a substantial degree of ethical ambivalence among urology specialists. Rather than reflecting a unified ethical position, physicians appeared divided between concerns regarding public safety and the protection of individual autonomy, bodily integrity, and human rights. This fragmentation suggests that medical castration continues to occupy an ethically unstable position within contemporary medical practice in Türkiye.

Only 38.8% of participants reported being aware of the legal framework concerning sexual crimes in Türkiye, and 27.3% had knowledge of medical castration. The fact that the 2016 regulation, which defined the procedures and principles of implementation, was known by merely 10.7% indicates a considerable gap between clinicians and the legal framework. Similar findings have been reported in surveys conducted in the United States by Meyer and Cole [23] and in Korea by Lee and Cho [24], where physicians likewise demonstrated limited awareness of the relevant legislation.

Knowledge levels were found to increase with years of professional experience and academic rank, suggesting that senior physicians are more exposed to legal processes. Moreover, physicians working in university hospitals and those who had taken an ethics course during undergraduate training demonstrated higher awareness, underscoring the role of education in shaping knowledge. The WFSBP biological treatment guidelines [25] recommend mandatory and ongoing ethics education for clinicians involved in the treatment of sexual offenders; the present findings support this recommendation.

Survey results also demonstrated that 71.9% of physicians considered medical castration necessary for public safety; however, 69.4% opposed making it mandatory. This ambivalence reflects the tension between collective welfare and individual autonomy. While 43.8% of respondents agreed that medical castration without consent is unacceptable, 43.0% disagreed, revealing a profound ethical division among clinicians. Similar findings were reported by Berlin [26] and Thibaut et al. [25], both of whom emphasized that the principle of consent represents a critical ethical threshold in debates on medical castration.

Article 3 of the European Convention on Human Rights prohibits torture and inhuman or degrading treatment, rendering mandatory chemical castration controversial in several European countries [27]. Between 1938 and 1968, castration of sex offenders in the Netherlands was carried out under both voluntary and “therapeutic” justifications. Although presented as a treatment aimed at preventing recidivism, the notion of voluntariness was often problematic; many offenders agreed to the procedure under pressure, hoping for lighter sentences or the possibility of parole. Archival records indicate that hundreds of individuals underwent surgical castration, with physicians functioning more as agents of the penal system than as therapeutic providers. The practice was driven more by social control and prevailing moral norms than by medical necessity and, when assessed against contemporary ethical standards, it conflicts with principles of informed consent, voluntariness, and human rights [28]. In Türkiye, the now-suspended regulation allowed the procedure to be implemented without the convicted person’s consent, raising concerns over compatibility with international ethical standards.

From a feminist bioethical perspective, sexual crimes are viewed not merely as individual pathology but as rooted in gender inequality and patriarchal power relations [29]. This perspective criticizes chemical castration for focusing on individual impulses rather than addressing the structural causes of sexual violence, thus medicalizing the problem. In our study, 58.7% of participants acknowledged that sexual assault is grounded in gender inequality, suggesting physician awareness of the sociocultural dimensions of these crimes. Nevertheless, clinical decision-making largely remained framed within punitive and biomedical paradigms. Feminist approaches call for this balance to be reconsidered in favor of victims’ rights and broader social transformation [30].

In the United States, states such as California, Florida, and Iowa implement chemical castration as a parole condition for specific sexual offenses [31]. These practices are generally conditional upon serving the remainder of the sentence in the community under supervised release; if the offender refuses the treatment, they continue serving their sentence in prison. In South Korea, mandatory chemical castration has been applied by court order for sexual crimes against children since 2011 [24]. Türkiye’s regulatory framework is ambiguous, straddling voluntarism and coercion, which deepens the ethical debate.

Importantly, these findings should not be interpreted merely as reflections of individual clinical preferences. Rather, they may indicate broader professional uncertainty regarding the role of physicians within interventions that simultaneously intersect with punishment, treatment, state authority, and social protection. In this regard, the suspended 2016 Turkish regulation occupies a central place within this ethical uncertainty, as it intensified debates concerning medicalization of punishment, voluntariness, and the ethical boundaries of physician participation in penal practices.

A significant association was found between knowledge levels and attitudes in this study. Participants who were aware of the legislation were more inclined to support voluntary rather than mandatory implementation, suggesting that knowledge shapes ethical judgments. Physicians with undergraduate or postgraduate ethics training exhibited greater caution and a stronger human rights orientation, indicating that ethics education can enhance ethical sensitivity. This finding highlights the need to strengthen ethics education both in pre-service and in-service training [32].

Medical castration is not solely a biological intervention; it encompasses ethical, legal, and social dimensions. Implementation should not be confined to pharmacological treatment alone but must adopt a multidisciplinary approach incorporating psychotherapy, social rehabilitation, and legal oversight [25]. Furthermore, reinforcing the principle of consent and eliminating mandatory applications is essential from both ethical and human rights perspectives. It is recommended that legislation be aligned with the Council of Europe’s Oviedo Convention and World Medical Association guidelines [27, 33].

The principle of non-maleficence is one of the most fundamental and historically established concepts in medical ethics and is expressed by the maxim “first, do no harm” (primum non nocere) [34]. This principle encompasses not only the physician’s responsibility to provide benefit but also their obligation to foresee, prevent, and minimize potential harm to the patient and society. Although chemical castration has been introduced in some legal systems as a treatment or conditional release measure due to its potential to reduce the risk of recidivism in sexual crimes, it generates intense ethical debates under this principle when its biological and psychosocial adverse effects are considered. In this study conducted among urology specialists in Türkiye, the findings indicate that a significant proportion of participants lack sufficient knowledge about the legal framework of the practice, with uncertainties regarding voluntariness and deficiencies in informed consent processes raising questions about how the principle of non-maleficence is reflected in clinical practice.

The agents used in chemical castration—such as medroxyprogesterone acetate, cyproterone acetate, and gonadotropin-releasing hormone (GnRH) analogues—suppress testosterone production to reduce sexual drive. However, this suppression can lead to severe medical side effects in the long term. The literature frequently reports complications such as osteoporosis, muscle mass loss, increased adiposity, elevated cardiovascular disease risk, anemia, hot flashes, decreased libido, erectile dysfunction, and depression [23, 24]. A 2023 review noted that GnRH agonists, particularly in older men, increase cardiometabolic risk, whereas newer GnRH antagonists such as relugolix appear safer in this regard [35]. These findings indicate that physicians must place side-effect profiles at the center of ethical decision-making when selecting pharmacological agents.

Another key finding of our study is the low awareness among specialists regarding informed consent processes. The principle of non-maleficence requires not only the prevention of biological harm but also the avoidance of psychological and ethical harm. When consent is linked to sentence reduction or conditional release, it becomes questionable whether individuals are making decisions based on their truly free will. A 2024 ethical analysis by The Hastings Center highlighted that consent obtained in such a context could be considered “coercive” and compromise the validity of informed consent [36]. This observation aligns with the perspectives of specialists in our study, who emphasized that “voluntariness appears present but is actually under pressure,” extending the concept of harm beyond its biological dimension.

Psychosocial harms constitute another critical aspect of chemical castration. Effects such as loss of libido, altered perceptions of masculinity, depressive mood, and social stigma can leave lasting marks on the individual’s mental health. A 2024 Canadian analysis suggested that chemical castration may produce a “hidden injustice” not only at the individual level but also at structural and societal levels, reinforcing social exclusion rather than promoting offender rehabilitation [37]. This finding parallels our participants’ perception of chemical castration as “a punitive measure rather than a treatment.”

The feminist bioethics perspective emphasizes that harm should be assessed not only in biological terms but also within the context of gender and power relations. Maureen Sander-Staudt argues that ethical decisions in feminist bioethics should be made by considering relational autonomy, power imbalances, and the broader social context rather than focusing solely on individual autonomy [38]. In this regard, the practice of chemical castration, which is predominantly applied to male offenders, may reproduce patriarchal norms; limiting victims’ expectations of justice to biological control risks overlooking the societal dynamics of violence. This approach critiques the reduction of chemical castration to an issue of individual pathology and advocates for a broader interpretation of non-maleficence that incorporates societal harms as well [37, 38].

Additionally, the principle of non-maleficence underscores the importance of long-term monitoring requirements for this intervention. Our study revealed that most specialists did not adopt a standardized approach to follow-up processes. However, current clinical recommendations highlight the necessity of regular bone mineral density assessments, cardiovascular risk evaluations, endocrinological follow-up, and psychiatric support for individuals undergoing chemical castration [35]. The absence of such systematic monitoring protocols undermines the ethical execution of the intervention and exacerbates related ethical concerns.

The ethical evaluation of chemical castration within the framework of the principle of non-maleficence requires a comprehensive consideration of its physical side effects, psychosocial traumas, the degree of voluntariness in consent, and gender-based injustices. The expert opinions presented in our study are consistent with the ethical debates in the international literature, demonstrating that this intervention must be assessed not only in clinical terms but also in its political, legal, and social implications. Therefore, chemical castration can only be aligned with the principle of non-maleficence if it is implemented under strict ethical oversight, with comprehensive information, continuous monitoring, and a multidisciplinary approach.

These findings demonstrate that ethical concerns surrounding chemical castration extend far beyond pharmacological side effects alone. The intervention also creates moral tension regarding coercion, professional responsibility, social stigma, and the transformation of medicine into a potential instrument of penal control.

The principle of beneficence entails not only refraining from causing harm but also the physician’s responsibility to produce positive outcomes for both the patient and society [34]. In controversial interventions such as chemical castration, this principle plays a critical role in demonstrating potential benefits and balancing them against possible harms. In our study, the views of urology specialists in Türkiye emphasized the potential of chemical castration to reduce recidivism and enhance public safety, while also expressing significant reservations that such benefits can only be realized through ethically sound processes and appropriate clinical follow-up.

The literature provides evidence that chemical castration can markedly reduce sexual offense recidivism. In the classic study by Meyer and Cole, the reoffending rates of sexual offenders receiving hormonal treatment were significantly lower than those of untreated offenders [23]. More recent data support these findings; a 2024 review reported that chemical castration, particularly when combined with psychotherapy, could reduce the risk of reoffending by up to 30% [39]. This demonstrates that the intervention holds potential not only for individual benefit but also for enhancing community safety.

However, another important finding of our study is that specialists tend to evaluate benefit predominantly within the framework of “protecting society,” often relegating the individual patient’s welfare to a secondary position. This tendency may limit the principle of beneficence to a one-dimensional “public good” approach. In contrast, Beauchamp and Childress’s ethical framework emphasizes that beneficence requires a balanced consideration of both individual and societal interests [34]. From this perspective, beneficence encompasses not only the prevention of reoffending but also the offender’s psychological rehabilitation, quality of life, and reintegration into society.

The feminist bioethics perspective does not confine the notion of benefit to clinical improvement or public safety alone; it also includes respect for individual dignity, relational autonomy, and the reduction of gender inequalities [38]. According to this view, chemical castration programs that target only individual pathology while disregarding structural causes of violence may fail to produce genuine societal benefit in the long term. In our study, a significant proportion of specialists perceived chemical castration as a “punitive” measure, a finding that parallels the reductionist approach criticized within feminist ethical frameworks.

Another dimension of beneficence is the integration of chemical castration with other therapeutic modalities. Current guidelines highlight that chemical castration should not be implemented in isolation but rather combined with psychotherapy, cognitive-behavioral therapy, and social rehabilitation programs [25, 36]. Such a holistic approach not only supports the prevention of reoffending but also renders the treatment process more ethically defensible. Our study, however, revealed that most specialists viewed chemical castration as an independent intervention, with psychosocial support mechanisms rarely being considered.

Nevertheless, the principle of beneficence often generates tension between public interest and individual rights in practice. A 2024 report by The Hastings Center emphasized that mandatory treatments justified by public safety concerns lose ethical legitimacy when they disregard individual rights [36]. In this regard, our findings underscore that voluntariness is a critical element in balancing benefit and harm, and that compulsory interventions may undermine the ethical validity of perceived benefits.

The ethical evaluation of chemical castration in the context of beneficence requires a balanced consideration of multidimensional benefits, including reducing recidivism, ensuring public safety, supporting the individual’s psychosocial recovery, and addressing gender inequalities. The findings of this study suggest that the evaluations of urology specialists in Türkiye align with international ethical debates, while also highlighting the need to redefine beneficence in a way that encompasses not only public safety but also individual rights and dignity. For chemical castration to provide genuine benefit, ethically grounded protocols based on voluntariness, comprehensive treatment programs, and long-term monitoring must be developed.

The principle of autonomy refers to the right of individuals to make informed and voluntary decisions regarding their own bodies and lives [34]. In medical ethics, every person has the right to accept or refuse a medical intervention—this right becomes especially critical in cases involving interventions with significant consequences. For an ethically legitimate implementation of chemical castration—a procedure with substantial biological and psychosocial effects—the individual’s consent must be obtained free from coercion, based on adequate information, and exercised through genuine free will. In our study, a significant number of urology specialists in Türkiye reported that chemical castration is often presented as an option in exchange for sentence reduction or conditional release, rather than as a truly voluntary choice. This raises concerns that, despite appearing consensual, such practices may constitute a violation of autonomy.

Similar concerns are reflected in the international literature. According to a 2024 analysis by The Hastings Center, offering chemical castration as an alternative to incarceration undermines the ethical validity of consent, due to the inherently coercive nature of such offers [36]. Given that the decision-making capacities of individuals deprived of liberty are shaped by highly structured systems, the concept of “conditional consent” becomes ethically problematic. This aligns with the expert opinions in our study, which suggest that voluntariness may exist only superficially, while the individual’s autonomous will is in fact constrained.

Ensuring autonomy requires more than the absence of external coercion. Individuals must possess adequate knowledge of the procedure, have the mental capacity to evaluate their options, and understand the consequences of their decisions [34]. However, in our study, only 10.7% of specialists reported being familiar with the legislation governing chemical castration, and many indicated that the informed consent process is not standardized in practice. This lack of knowledge and standardization not only violates physicians’ ethical responsibilities but also undermines the rights of the individuals involved.

Recent empirical studies show that ethics education can positively influence attitudes toward respecting autonomy. A 2024 study in Germany found that medical students who had received ethics training showed greater sensitivity to the issue of consent in medical interventions involving incarcerated individuals [40]. Similarly, in our study, physicians with ethics training demonstrated a more cautious stance toward chemical castration and exhibited a greater concern for human rights. This finding underscores the need for enhanced ethical awareness to effectively uphold the principle of autonomy in practice.

Feminist bioethics, meanwhile, interprets autonomy not merely as an individual capacity for decision-making but as something shaped by relational and structural conditions. Autonomy requires not only “informed consent,” but also an assessment of how free the individual is from societal and institutional pressures [41]. From this perspective, the punitive system surrounding male sexual offenders may suppress their decision-making capacity and thus weaken their autonomy. Reports from our study—such as examples of “consent given to escape punishment”—clearly reflect this structurally coercive environment.

Furthermore, even when consent is voluntarily given, the irreversible or long-term effects of chemical castration increase the physician’s ethical obligation to ensure respect for autonomy. In a 2011 study, Gooren LJ reported that GnRH agonists may cause long-term cognitive changes, which could impair an individual’s decision-making capacity over time [42]. This finding highlights that respect for autonomy must be maintained throughout the entire treatment process, and not merely during the initial consent phase.

An ethical evaluation of chemical castration in the context of autonomy must go beyond the question of whether consent was given; it must also assess the extent to which that consent was free, informed, and sustainable over time. The expert opinions presented in our study align with international ethical debates, emphasizing that autonomy must be preserved not only procedurally but also relationally and contextually. Accordingly, chemical castration can only be considered consistent with the principle of autonomy when the consent process is conducted in an environment free from coercion, with transparent information and respect for structural vulnerabilities.

From a broader bioethical perspective, the concept of autonomy in this context should not be reduced solely to procedural consent. Instead, autonomy must also be evaluated relationally, taking into account institutional pressure, incarceration conditions, and structural vulnerabilities that may compromise free decision-making.

The principle of justice, in the context of medical ethics, refers to acting equally and fairly toward individuals, ensuring equitable distribution of resources, and guaranteeing equal access to fundamental rights [34]. This principle encompasses not only the fair delivery of healthcare services but also the promotion of social justice in terms of punishment, rehabilitation, and human rights. In evaluating ethically controversial practices such as chemical castration, the principle of justice plays a critical role at both the individual and societal levels. In our study, a significant portion of the participating urologists stated that chemical castration is implemented not as a treatment but as a punitive measure—raising ethical concerns regarding its alignment with the principle of justice.

The fact that chemical castration is applied predominantly to specific offender groups, particularly male sex offenders, has raised ethical concerns about its potentially selective and discriminatory nature. Literature indicates that targeting only certain categories of offenders for this intervention undermines the equality aspect of justice [43, 44]. In our study, some participants similarly noted that the practice focuses almost exclusively on “male sexuality,” with no systematic approach developed for female offenders or other types of sexual crimes. This finding points to a gender-based imbalance in both penal and medical interventions.

Moreover, socioeconomic inequalities also appear to influence the implementation of chemical castration. It has been noted in the literature that individuals with limited financial means are more likely to accept the procedure in order to obtain sentence reductions, while those with stronger social support systems are more likely to refuse it [25]. This situation raises concerns about the exploitation of the vulnerability of incarcerated individuals and questions the ethical alignment of the practice with the principle of justice.

Justice also requires equal access to treatment. However, in our study, the majority of experts reported significant disparities in the implementation protocols of chemical castration. While some institutions provide multidisciplinary follow-up, others restrict the process to pharmacological treatment alone. This inconsistency, stemming from a lack of national standardization, results in different treatment based on institutional or physician-specific factors, and such disparities violate the principle of justice [24].

In addition, the ethical literature increasingly considers the sustainability aspect of the justice principle. For an intervention to be considered just, it must not only be fair at the outset but also account for its long-term effects on the individual. A 2024 ethical analysis highlighted that long-term use of GnRH agonists can lead to bone demineralization, cognitive impairment, and psychiatric side effects—yet these effects are not systematically monitored [45]. This highlights the necessity of not only equitable access to treatment but also equitable access to post-treatment care and support systems.

The ethical validity of chemical castration under the principle of justice cannot be assessed solely through legal frameworks and procedures. It must also be evaluated in light of multidimensional criteria such as gender, class, access to healthcare, access to information, and equitable participation in treatment. The expert opinions in our study revealed that chemical castration is often used with a punitive intent and lacks a standard, equitable, and ethically grounded protocol. Therefore, chemical castration can only be considered compatible with the principle of justice when it is implemented alongside comprehensive ethical evaluation, respect for individual rights, transparent procedures, and policies that address structural inequalities.

This study is significant as it represents the first comprehensive survey conducted among urology physicians in Türkiye. Inclusion of participants from various regions and institutions enhances the representativeness of the results. However, the study exclusively included urology specialists, and the exclusion of other disciplines such as psychiatry, endocrinology, and forensic medicine represents a significant limitation.

Limitations of the study

This study was conducted with the participation of urology specialists reached via email in an online setting. The limitations of the study can be summarized as follows:

1. High frequency of survey distribution: The widespread circulation of multiple survey studies in the healthcare field via email may have reduced the visibility of this study or led to limited interest in participation.

2. Unreachable physician groups: It was not possible to reach urology specialists working in the private sector who were neither employed by the Ministry of Health nor universities, and who were not members of any urological association.

3. Restrictions on conference dissemination: Although efforts were made to share the online survey during national urology congresses attended by numerous specialists, the request was declined by the association secretariat due to negative past experiences.

4. In addition, the inability to calculate a formal response rate due to the circulation-based distribution strategy represents another methodological limitation of the study.

Conclusion

Chemical castration represents not only a biomedical intervention but also a complex ethical, legal, and sociopolitical issue positioned at the intersection of punishment, treatment, public safety, and human rights. The findings of this study demonstrate substantial ethical ambivalence among urology specialists in Türkiye, particularly regarding voluntariness, informed consent, bodily autonomy, and the physician’s role within potentially punitive medical practices.

Although many participants considered chemical castration potentially beneficial for reducing recidivism and protecting society, significant concerns emerged regarding coercion, professional responsibility, human-rights compatibility, and the medicalization of punishment. These findings suggest that physicians do not approach chemical castration from a unified ethical perspective; rather, their attitudes reflect broader tensions and uncertainties within contemporary medical and legal discourse.

Accordingly, any future implementation framework should be grounded in voluntariness, transparent informed consent procedures, multidisciplinary evaluation, long-term monitoring, and strict ethical oversight. In addition, strengthening ethics education and developing nationally standardized protocols may contribute to more ethically consistent clinical approaches.

Future qualitative and interdisciplinary studies are needed to further explore physicians’ moral experiences, ethical dilemmas, and professional responsibilities regarding medical castration in sexual offenses.

Accordingly:

1. Clear legal framework: The intervention is acceptable only within a strictly defined scope grounded in voluntary consent, rigorous medico-ethical monitoring, and explicit limits on duration and indication.

2. Multidisciplinary decision-making: Case-by-case assessments must involve boards that include urology, endocrinology, psychiatry, forensic medicine, and ethics experts.

3. Rehabilitation-focused programmes: Hormonal treatment alone is insufficient; it must be integrated with psychotherapy, behavioural interventions, and social-support mechanisms.

4. Ethics and human-rights education: Strengthening physicians’ ethical literacy is vital to safeguard professional autonomy—including the right to conscientious objection—when faced with coercive demands.

5. Feminist and societal lens: Policy packages should address patriarchal structures and gender inequality rather than reducing sexual violence to individual pathology.

In this way, public safety can be promoted without turning medicine into a punitive instrument, preserving a balanced protection of the victim’s quest for justice and the offender’s fundamental rights.

Abbreviations

WFSBP

World Federation of Societies of Biological Psychiatry

GnRH

Gonadotropin-Releasing Hormone

Authors’ contributions

MD: Conceptualisation, Methodology, Formal Analysis, Writing-Original draft preparationNÖB: Conceptualisation, Methodology, Formal Analysis, Writing-Original draft preparation.

Funding

There is no financial support for his study.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

This study is based on the doctoral dissertation completed by Mümtaz Dadalı in the field of History of Medicine and Ethics. This study was approved by the Kırşehir Ahi Evran University Clinical Research Ethics Committee on march 10, 2020, under decision number 2020-04/22.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.