Statistics on and definition of sex offenders; Paraphilics; Gene Abel studies; Exhibitionism; Crossing; Female sex offenders; Pedophilia; Internet offenders; Sexual psychopath legislation; Risk assessment; Treatment; Recidivism

Educational Objectives

The goal of this program is to improve the assessment, diagnosis, and treatment of sex offenders. After hearing and assimilating this program, the clinician will be better able to:

1. Distinguish sex offenders from sexually violent predators.

2. Assess the diagnostic and prognosticative significance of paraphilias and sexual deviancies.

3. Recognize possible negative consequences of registration and notification laws pertaining to sexual offenders.

4. Determine an offender's risk of reoffense after a conviction of a sex offense.

5. Reduce sexual desire and recidivism rates in sexual offenders through the use of pharmacologic interventions.

Summary

Sex Offenders and the Law

From the Forensic Psychiatry Review Course, sponsored by the American Academy of Psychiatry and the Law

Charles L. Scott, MD, Professor of Clinical Psychiatry, and Chief, Division of Psychiatry and the Law, Department of Psychiatry and Behavioral Science, University of California, Davis, Medical Center

Educational Objectives

The goal of this program is to improve the assessment, diagnosis, and treatment of sex offenders. After hearing and assimilating this program, the clinician will be better able to:

1.   Distinguish sex offenders from sexually violent predators.

2.   Assess the diagnostic and prognosticative significance of paraphilias and sexual deviancies.

3.   Recognize possible negative consequences of registration and notification laws pertaining to sexual offenders.

4.   Determine an offender's risk of reoffense after a conviction of a sex offense.

5.   Reduce sexual desire and recidivism rates in sexual offenders through the use of pharmacologic interventions.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Scott and the planning committee reported nothing to disclose. In his lecture, Dr. Scott presents information related to the off-label use of a therapy or product.

Background on sex offenders: comprise 10% of prisoners (two-thirds convicted of crimes against children); 75% of victims girls or women; »375,000 registered in United States (US); rape  —  reported by 12 million women in US (30% occur before 11 yr of age); perpetrators assault average of 7 victims before attracting attention

Definitions: sex offender  —  individual required to register with authorities after sex offense conviction; sexually vi­olent predator  —  sex offender with increased risk for recidivism due to diagnosed ”mental disorder”

Paraphilia: blanket diagnosis for aberrant sexual behavior; in Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR), defined as “recurrent, intense, sexually arousing fantasies, urges, or behaviors of nonhuman objects, suffering or humiliation of oneself or partner, children, or other nonconsenting adults” (lasting ³6 mo)

Proposed changes in DSM-5: suggest distinction between paraphilias and paraphilic disorders (disorders cause clinically significant hurt, harm, or distress to patient or others); nonconsenting paraphilias (eg, voyeurism, frot­teurism, rape) require specific number of victims per type of offense; proposes pedohebephilic disorder (for pe­dophilic patients with focus on pubescent and adolescent children; usage of child pornography for ³6 mo given as another criterion for diagnosis) and paraphilic coercive disorder (describes patients with sexually coercive fan­tasy or behavior and ³3 instances of forced sex with nonconsenting individual)

Abel study (1987) of sex offenders: many have high rate of offending with high number of victims (often with mul­tiple types of offenses); offenses typically involve coercion; commonly have history of nonsexual criminal of­fenses; offenders have poor insight into sexual deviancy or issues

“Crossing”: patients crossing multiple areas of deviancy (eg, touching plus nontouching offenses, victimization of both family and nonfamily, female and male victims, younger and older victims) show higher rates of recidivism; Abel study of indications with greatest crossover (1999)  —  1) bestiality (indicates hyperarousal in multiple areas); 2) public masturbation; 3) male incest pedophilia; 4) fetishism; 5) masochism

Abel study of female sex offenders (1999): found 50% less deviancy than in male offenders (however, 20% of child victims report female perpetrator); offenders with prior criminal history (eg, misdemeanor, felony, drug offense, prostitution of child) show higher rates of recidivism

Background on pedophiles: majority show heterosexual orientation; most choose familiar victims; Abel study (1989)  —  55% of victims female; nontouching offenses more commonly perpetrated on girls

Traits of sexual offenses in clerics: majority of offenders have homosexual pedophilia (unlike general population); longer delays before criminal indictment; one study indicated increased use of force (contradicted by later study)

Internet offenders: types  —  “traders” (involving trafficking in child pornography); “networking” (connecting with other offenders for purpose other than trading); grooming (in, eg, chat rooms for children or teenagers); “travelers” (offenders who travel to meet potential victims); study  —primarily comprised of men 30 to 39 yr of age; majority act only as traders

Child pornography: transmission over internet constitutes federal crime (in US); strong diagnostic indicator of pe­dophilia, but not associated with increased risk of committing hands-on offense

Legislation history: sexual “psychopath” legislation  —involved punishment and treatment; offenders subject to “in­determinate sentencing” (release conditional on therapeutic progress and feedback given to review board); pre­sumed involvement of mental illness; mentally disordered sex offender statutes  —  implemented in 30 states; identification under statutes led to hospitalization and treatment; US Supreme Court invalidated statutes involving indefinite commitment, and mandated due process for all sex offenders (rights to, eg, attorney, notice, hearing, con­front evidence, cross-examination of witnesses, offer evidence); compulsory psychiatric examination  —  upheld by Supreme Court (since commitment hearings count as civil rather than criminal cases, constitutional protections against self-incrimination do not apply); determinate sentencing  —forces authorities to release offenders after specified amount of time, regardless of risk for repeat offense; recidivism led to sexually violent predator (SVP) laws

SVP laws: allow for indefinite psychiatric commitment of offenders who have completed criminal sentences; key components  —  history of harmful sexual conduct; current mental disorder or “abnormality”; risk for future harm­ful sexual conduct; mental abnormality associated with increased risk for future danger; legal challenge arguments  —  violation of due process; equal protection (eg, sex offenders should not be subject to unique criteria for commitment); double jeopardy (eg, SVP hearings and sentencing violate protections against multiple trials for same crime); ex post facto (new laws and sentencing guidelines should not be applied to offenders currently in custody)

Community Protection Act of Washington (1990): first example of modern SVP legislation; created new civil com­mitment system for SVPs (with mental abnormalities and personality disorders included in criteria); treatment occurs only after punishment; recent history of sexual violence not required for commitment

Kansas Sexually Violent Predator Act (1994): established new procedures for civil commitment of sex offenders; defined “mental abnormality” as congenital or acquired, affecting emotional or volitional capacity, and associ­ated with predisposition to sexually violent offenses; legal challenge outcome  —  Kansas SVP act not found to vi­olate due process; act affirmed as civil instead of criminal (fewer legal protections apply); commitment without suitable treatment not found to constitute punishment; “complete lack of control” not required for commitment

Lyle case: involved laws requiring specialized treatment programs for all sex offenders in minimum security facili­ties; defendant challenged laws as violation of protections against self-incrimination (since treatment program re­quired admission of guilt and court admission of polygraph tests seeking information on unreported offenses); US Supreme Court finding  —  laws not found to violate self-incrimination

Sex offender registration and notification laws: created after public outcry over tragic and highly publicized crimes involving or possibly involving repeat sex offenders; laws require both registration of offenders and public re­lease of information on offenders; possible negative consequences  —  community notification often discourages offenders from registering; have led to identification of victims who wished to remain anonymous; avoiding reg­istration may lead to avoiding treatment (increases risk for relapse)

Common legal challenges: frequently revolve around violation of due process (eg, lack of formal hearing to assess offender's danger to community); in Connecticut, US Supreme Court ruled in favor of registries, citing convic­tion as only grounds for registration, and posting of disclaimer acknowledging that “The Department of Public Safety has not considered or assessed the specific risk of re-offense”; retroactive enforcement  —  US Supreme Court refuted ex post facto challenges (over, ie, forcing offenders to register even when convictions occurred be­fore enactment of laws), citing civil nature of registration and notification laws

Adam Walsh Child Protection Act (2006): created centralized uniform database compiled from each US state's sex offender registries; Sex Offender Registration and Notification Act provision  —  mandates registration of sexual offenders while imprisoned (ie, before release); nonincarcerated offenders must register £3 days after conviction; applies retroactively to all offenders; criminalizes failure to reregister after moving across state lines (not retroac­tively enforced); juvenile offenders 14 yr of age subject to registration and notification if specific convictions meet registration criteria; allows federal government to commit “sexually dangerous” individuals (defined as en­gaging or attempting to engage in sexually violent conduct or child molestation, or generally considered sexually dangerous)

Legal challenge outcome: US Supreme Court upheld right of Congress to authorize civil commitment of sexually dangerous persons in federal facilities (in, eg, cases in which criminal sentences have been served or defendants have been found incompetent to stand criminal trial); offenders without hands-on offenses (eg, child pornogra­phy) may be subject to indefinite involuntary commitment

Castration laws: encourage or mandate chemical (with, eg, depot medroxyprogesterone acetate [Depo-Provera]) or surgical castration as condition of release or probation; some states give immunity to providers of treatment

Evaluation of sex offenders: avoid labeling questions (eg, “you would never molest children, would you?”); review wide range of patient's possible sexual activities (speaker recommends structured and thorough list of diverse para­philias)

Identifying victim preferences: speaker emphasizes importance of risk assessment instruments when doing clinical interviews, and encourages physicians unfamiliar with instruments to collaborate with suitably trained peers

Penile plethysmography: measured as circumferential changes (used in US; requires 10% erection) or volume changes (used in Canada; increased sensitivity allows measurement of minute changes); primarily used for eval­uation of pedophiles (insufficient data on efficacy in cases of rape); not generally admissible in court; many fac­tors may affect validity; sensors measuring galvanic skin response and breathing rate attempt to detect deception and suppression of arousal; tests may include mildly suggestive imagery involving children; accuracy may vary, since many men fail to show arousal under laboratory conditions; legal challenge outcomes  —  US Ninth Circuit Court ordered reconsideration of plethysmography as requirement for probation and declared “prisoners should not be compelled to stimulate themselves sexually”

Visual reaction time: noninvasive method; special laboratory not required; commonly known as “Abel screen”; combines detailed questionnaire with computerized measurement of time spent looking at specific images in se­ries (patient moves through images by pressing button); non-nude images, including children of various ages, act as visual stimuli; recommended if plethysmography unavailable (for patients ³12 yr of age); some physicians have raised concerns about lack of standardization

Polygraph: not admissible in court; threat of polygraph often elicits confessions of additional offenses before test­ing (if negative consequences can result from deception); confronting offenders with evidence of deception on polygraphs may also elicit confessions; key uses  —determining readiness for treatment; assessing offender's nar­rative of offense; monitoring in community; study  —polygraph helped reveal information about offenses; how­ever, knowledge of future polygraph failed to prevent high-risk behavior (ie, valuable for screening and identification of offenders, but not deterrence)

Treatment and Release of Sex Offenders

Depot medroxyprogesterone acetate: used in US; reduces testosterone; associated with weight gain and hyperten­sion; generally nonfeminizing

Cyproterone acetate: used in Canada and Europe; decreases testosterone; side effects include liver dysfunction, gy­necomastia, and feminization

Other regimens: long-acting analogues of gonadotropin-releasing hormone (eg, triptorelin, leuprolide [Lupron]); initiating treatment with depot medroxyprogesterone acetate, then transitioning to stronger agents if necessary; se­lective serotonin reuptake inhibitors (may decrease sexual drive; consider in patients with symptoms characteristic of obsessive-compulsive disorder)

Risk factors associated with reoffense: offenders convicted of in-home incest show lower rates of recidivism (com­pared to pedophiles and rapists expressing interest outside home); in one study, molestation of acquaintances asso­ciated with highest rates of recidivism; in 25-yr follow-up study, extrafamilial child molesters showed greatest persistence in reoffending (higher than child rapists)

Meta-analysis of recidivism in sex offenders: included data on 28,000 offenders; subjects average 13.4% recidivism after 4 to 5 yr (slightly higher for rapists, but slightly lower for child molesters [conflicts with literature finding greater long-term persistence in molesters]); rapists showed higher risks for nonsexual violent offenses; positive plethysmography found to serve as best predictor for future recidivism (primarily with pedophilic interest)

Treatment outcomes: castration significantly lowers recidivism; combining pharmacologic, cognitive behavioral, and relapse prevention therapies improves outcomes

Speaker's opinion on SVP laws: extreme costs associated with indefinite detention may ultimately cause termina­tion of programs; many states now considering increasing determinate criminal sentences; laws must avoid psychi­atric commitment of individuals without psychiatric disorders

Pharmacologic treatment of female sex offenders: limited data available; viewed as generally effective in reducing sexual desire

Choosing actuarial risk assessment tools: consider offender and offender type, and determine which tool seems most relevant to targeted population

Acknowledgements

Dr. Scott spoke at Forensic Psychiatry Review Course, held October 18-20, 2010, in Tucson, AZ, and sponsored by the American Academy of Psychiatry and the Law. For information about upcoming Forensic Psychiatry Review Course meet­ings sponsored by the American Academy of Psychiatry and the Law, visit their website at www.aapl.org/meetings.htm. The Audio-Digest Foundation thanks Dr. Scott and the American Academy of Psychiatry and the Law for their cooperation in the production of this program.

Suggested Reading

Abel GG et al: Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law 16:153, 1988; Abel GG et al: Predicting child molesters' response to treatment. An N Y Acad Sci 528:23, 1988; Abel GG et al: Sexual arousal patterns: normal and deviant. Psychiatr Clin North Am 31:643, 2008; Busch KG et al: Looking forward in records of young adults con­victed of sexual homicide, rape, or molestation as youth: risks for reoffending. Psychol Rep 104:155, 2009; Fabian JM: Diag­nosing and litigating hebephilia in sexually violent predator civil commitment proceedings. J Am Acad Psychiatry Law 39:496, 2011; Gannon TA, O'Connor A: The development of the interest in child molestation scale. Sex Abuse 23:474, 2011; Isely PJ et al: In their own voices: a qualitative study of men abused as children by catholic clergy. J Child Sex Abus 17:201, 2008; McDermott BE et al: The predictive ability of the Classification of Violence Risk (COVR) in a forensic psychiatric hospital. Psychiatr Serv 62:430, 2011; Oliver CJ et al: A comparison of rapists and sexual murderers on demographic and selected psy­chometric measures. Int J Offender Ther Comp Criminol 51:298, 2007; Wijkman M et al: Women don't do such things! Char­acteristics of female sex offenders and offender types. Sex Abuse 22:135, 2010; Wood E, Riggs S: Predictors of child molestation: adult attachment, cognitive distortions, and empathy. J Interpers Violence 23:259, 2008.

 

Readings

Suggested Reading

Abel GG et al: Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law 16:153, 1988; Abel GG et al: Predicting child molesters' response to treatment. An N Y Acad Sci 528:23, 1988; Abel GG et al: Sexual arousal patterns: normal and deviant. Psychiatr Clin North Am 31:643, 2008; Busch KG et al: Looking forward in records of young adults con­victed of sexual homicide, rape, or molestation as youth: risks for reoffending. Psychol Rep 104:155, 2009; Fabian JM: Diag­nosing and litigating hebephilia in sexually violent predator civil commitment proceedings. J Am Acad Psychiatry Law 39:496, 2011; Gannon TA, O'Connor A: The development of the interest in child molestation scale. Sex Abuse 23:474, 2011; Isely PJ et al: In their own voices: a qualitative study of men abused as children by catholic clergy. J Child Sex Abus 17:201, 2008; McDermott BE et al: The predictive ability of the Classification of Violence Risk (COVR) in a forensic psychiatric hospital. Psychiatr Serv 62:430, 2011; Oliver CJ et al: A comparison of rapists and sexual murderers on demographic and selected psy­chometric measures. Int J Offender Ther Comp Criminol 51:298, 2007; Wijkman M et al: Women don't do such things! Char­acteristics of female sex offenders and offender types. Sex Abuse 22:135, 2010; Wood E, Riggs S: Predictors of child molestation: adult attachment, cognitive distortions, and empathy. J Interpers Violence 23:259, 2008.

 

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Scott and the planning committee reported nothing to disclose. In his lecture, Dr. Scott presents information related to the off-label use of a therapy or product.

Background on sex offenders: comprise 10% of prisoners (two-thirds convicted of crimes against children); 75% of victims girls or women; »375,000 registered in United States (US); rape  —  reported by 12 million women in US (30% occur before 11 yr of age); perpetrators assault average of 7 victims before attracting attention

Definitions: sex offender  —  individual required to register with authorities after sex offense conviction; sexually vi­olent predator  —  sex offender with increased risk for recidivism due to diagnosed ”mental disorder”

Paraphilia: blanket diagnosis for aberrant sexual behavior; in Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR), defined as “recurrent, intense, sexually arousing fantasies, urges, or behaviors of nonhuman objects, suffering or humiliation of oneself or partner, children, or other nonconsenting adults” (lasting ³6 mo)

Proposed changes in DSM-5: suggest distinction between paraphilias and paraphilic disorders (disorders cause clinically significant hurt, harm, or distress to patient or others); nonconsenting paraphilias (eg, voyeurism, frot­teurism, rape) require specific number of victims per type of offense; proposes pedohebephilic disorder (for pe­dophilic patients with focus on pubescent and adolescent children; usage of child pornography for ³6 mo given as another criterion for diagnosis) and paraphilic coercive disorder (describes patients with sexually coercive fan­tasy or behavior and ³3 instances of forced sex with nonconsenting individual)

Abel study (1987) of sex offenders: many have high rate of offending with high number of victims (often with mul­tiple types of offenses); offenses typically involve coercion; commonly have history of nonsexual criminal of­fenses; offenders have poor insight into sexual deviancy or issues

“Crossing”: patients crossing multiple areas of deviancy (eg, touching plus nontouching offenses, victimization of both family and nonfamily, female and male victims, younger and older victims) show higher rates of recidivism; Abel study of indications with greatest crossover (1999)  —  1) bestiality (indicates hyperarousal in multiple areas); 2) public masturbation; 3) male incest pedophilia; 4) fetishism; 5) masochism

Abel study of female sex offenders (1999): found 50% less deviancy than in male offenders (however, 20% of child victims report female perpetrator); offenders with prior criminal history (eg, misdemeanor, felony, drug offense, prostitution of child) show higher rates of recidivism

Background on pedophiles: majority show heterosexual orientation; most choose familiar victims; Abel study (1989)  —  55% of victims female; nontouching offenses more commonly perpetrated on girls

Traits of sexual offenses in clerics: majority of offenders have homosexual pedophilia (unlike general population); longer delays before criminal indictment; one study indicated increased use of force (contradicted by later study)

Internet offenders: types  —  “traders” (involving trafficking in child pornography); “networking” (connecting with other offenders for purpose other than trading); grooming (in, eg, chat rooms for children or teenagers); “travelers” (offenders who travel to meet potential victims); study  —primarily comprised of men 30 to 39 yr of age; majority act only as traders

Child pornography: transmission over internet constitutes federal crime (in US); strong diagnostic indicator of pe­dophilia, but not associated with increased risk of committing hands-on offense

Legislation history: sexual “psychopath” legislation  —involved punishment and treatment; offenders subject to “in­determinate sentencing” (release conditional on therapeutic progress and feedback given to review board); pre­sumed involvement of mental illness; mentally disordered sex offender statutes  —  implemented in 30 states; identification under statutes led to hospitalization and treatment; US Supreme Court invalidated statutes involving indefinite commitment, and mandated due process for all sex offenders (rights to, eg, attorney, notice, hearing, con­front evidence, cross-examination of witnesses, offer evidence); compulsory psychiatric examination  —  upheld by Supreme Court (since commitment hearings count as civil rather than criminal cases, constitutional protections against self-incrimination do not apply); determinate sentencing  —forces authorities to release offenders after specified amount of time, regardless of risk for repeat offense; recidivism led to sexually violent predator (SVP) laws

SVP laws: allow for indefinite psychiatric commitment of offenders who have completed criminal sentences; key components  —  history of harmful sexual conduct; current mental disorder or “abnormality”; risk for future harm­ful sexual conduct; mental abnormality associated with increased risk for future danger; legal challenge arguments  —  violation of due process; equal protection (eg, sex offenders should not be subject to unique criteria for commitment); double jeopardy (eg, SVP hearings and sentencing violate protections against multiple trials for same crime); ex post facto (new laws and sentencing guidelines should not be applied to offenders currently in custody)

Community Protection Act of Washington (1990): first example of modern SVP legislation; created new civil com­mitment system for SVPs (with mental abnormalities and personality disorders included in criteria); treatment occurs only after punishment; recent history of sexual violence not required for commitment

Kansas Sexually Violent Predator Act (1994): established new procedures for civil commitment of sex offenders; defined “mental abnormality” as congenital or acquired, affecting emotional or volitional capacity, and associ­ated with predisposition to sexually violent offenses; legal challenge outcome  —  Kansas SVP act not found to vi­olate due process; act affirmed as civil instead of criminal (fewer legal protections apply); commitment without suitable treatment not found to constitute punishment; “complete lack of control” not required for commitment

Lyle case: involved laws requiring specialized treatment programs for all sex offenders in minimum security facili­ties; defendant challenged laws as violation of protections against self-incrimination (since treatment program re­quired admission of guilt and court admission of polygraph tests seeking information on unreported offenses); US Supreme Court finding  —  laws not found to violate self-incrimination

Sex offender registration and notification laws: created after public outcry over tragic and highly publicized crimes involving or possibly involving repeat sex offenders; laws require both registration of offenders and public re­lease of information on offenders; possible negative consequences  —  community notification often discourages offenders from registering; have led to identification of victims who wished to remain anonymous; avoiding reg­istration may lead to avoiding treatment (increases risk for relapse)

Common legal challenges: frequently revolve around violation of due process (eg, lack of formal hearing to assess offender's danger to community); in Connecticut, US Supreme Court ruled in favor of registries, citing convic­tion as only grounds for registration, and posting of disclaimer acknowledging that “The Department of Public Safety has not considered or assessed the specific risk of re-offense”; retroactive enforcement  —  US Supreme Court refuted ex post facto challenges (over, ie, forcing offenders to register even when convictions occurred be­fore enactment of laws), citing civil nature of registration and notification laws

Adam Walsh Child Protection Act (2006): created centralized uniform database compiled from each US state's sex offender registries; Sex Offender Registration and Notification Act provision  —  mandates registration of sexual offenders while imprisoned (ie, before release); nonincarcerated offenders must register £3 days after conviction; applies retroactively to all offenders; criminalizes failure to reregister after moving across state lines (not retroac­tively enforced); juvenile offenders 14 yr of age subject to registration and notification if specific convictions meet registration criteria; allows federal government to commit “sexually dangerous” individuals (defined as en­gaging or attempting to engage in sexually violent conduct or child molestation, or generally considered sexually dangerous)

Legal challenge outcome: US Supreme Court upheld right of Congress to authorize civil commitment of sexually dangerous persons in federal facilities (in, eg, cases in which criminal sentences have been served or defendants have been found incompetent to stand criminal trial); offenders without hands-on offenses (eg, child pornogra­phy) may be subject to indefinite involuntary commitment

Castration laws: encourage or mandate chemical (with, eg, depot medroxyprogesterone acetate [Depo-Provera]) or surgical castration as condition of release or probation; some states give immunity to providers of treatment

Evaluation of sex offenders: avoid labeling questions (eg, “you would never molest children, would you?”); review wide range of patient's possible sexual activities (speaker recommends structured and thorough list of diverse para­philias)

Identifying victim preferences: speaker emphasizes importance of risk assessment instruments when doing clinical interviews, and encourages physicians unfamiliar with instruments to collaborate with suitably trained peers

Penile plethysmography: measured as circumferential changes (used in US; requires 10% erection) or volume changes (used in Canada; increased sensitivity allows measurement of minute changes); primarily used for eval­uation of pedophiles (insufficient data on efficacy in cases of rape); not generally admissible in court; many fac­tors may affect validity; sensors measuring galvanic skin response and breathing rate attempt to detect deception and suppression of arousal; tests may include mildly suggestive imagery involving children; accuracy may vary, since many men fail to show arousal under laboratory conditions; legal challenge outcomes  —  US Ninth Circuit Court ordered reconsideration of plethysmography as requirement for probation and declared “prisoners should not be compelled to stimulate themselves sexually”

Visual reaction time: noninvasive method; special laboratory not required; commonly known as “Abel screen”; combines detailed questionnaire with computerized measurement of time spent looking at specific images in se­ries (patient moves through images by pressing button); non-nude images, including children of various ages, act as visual stimuli; recommended if plethysmography unavailable (for patients ³12 yr of age); some physicians have raised concerns about lack of standardization

Polygraph: not admissible in court; threat of polygraph often elicits confessions of additional offenses before test­ing (if negative consequences can result from deception); confronting offenders with evidence of deception on polygraphs may also elicit confessions; key uses  —determining readiness for treatment; assessing offender's nar­rative of offense; monitoring in community; study  —polygraph helped reveal information about offenses; how­ever, knowledge of future polygraph failed to prevent high-risk behavior (ie, valuable for screening and identification of offenders, but not deterrence)

Treatment and Release of Sex Offenders

Depot medroxyprogesterone acetate: used in US; reduces testosterone; associated with weight gain and hyperten­sion; generally nonfeminizing

Cyproterone acetate: used in Canada and Europe; decreases testosterone; side effects include liver dysfunction, gy­necomastia, and feminization

Other regimens: long-acting analogues of gonadotropin-releasing hormone (eg, triptorelin, leuprolide [Lupron]); initiating treatment with depot medroxyprogesterone acetate, then transitioning to stronger agents if necessary; se­lective serotonin reuptake inhibitors (may decrease sexual drive; consider in patients with symptoms characteristic of obsessive-compulsive disorder)

Risk factors associated with reoffense: offenders convicted of in-home incest show lower rates of recidivism (com­pared to pedophiles and rapists expressing interest outside home); in one study, molestation of acquaintances asso­ciated with highest rates of recidivism; in 25-yr follow-up study, extrafamilial child molesters showed greatest persistence in reoffending (higher than child rapists)

Meta-analysis of recidivism in sex offenders: included data on 28,000 offenders; subjects average 13.4% recidivism after 4 to 5 yr (slightly higher for rapists, but slightly lower for child molesters [conflicts with literature finding greater long-term persistence in molesters]); rapists showed higher risks for nonsexual violent offenses; positive plethysmography found to serve as best predictor for future recidivism (primarily with pedophilic interest)

Treatment outcomes: castration significantly lowers recidivism; combining pharmacologic, cognitive behavioral, and relapse prevention therapies improves outcomes

Speaker's opinion on SVP laws: extreme costs associated with indefinite detention may ultimately cause termina­tion of programs; many states now considering increasing determinate criminal sentences; laws must avoid psychi­atric commitment of individuals without psychiatric disorders

Pharmacologic treatment of female sex offenders: limited data available; viewed as generally effective in reducing sexual desire

Choosing actuarial risk assessment tools: consider offender and offender type, and determine which tool seems most relevant to targeted population

Acknowledgements

Dr. Scott spoke at Forensic Psychiatry Review Course, held October 18-20, 2010, in Tucson, AZ, and sponsored by the American Academy of Psychiatry and the Law. For information about upcoming Forensic Psychiatry Review Course meet­ings sponsored by the American Academy of Psychiatry and the Law, visit their website at www.aapl.org/meetings.htm. The Audio-Digest Foundation thanks Dr. Scott and the American Academy of Psychiatry and the Law for their cooperation in the production of this program.

Suggested Reading

Abel GG et al: Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law 16:153, 1988; Abel GG et al: Predicting child molesters' response to treatment. An N Y Acad Sci 528:23, 1988; Abel GG et al: Sexual arousal patterns: normal and deviant. Psychiatr Clin North Am 31:643, 2008; Busch KG et al: Looking forward in records of young adults con­victed of sexual homicide, rape, or molestation as youth: risks for reoffending. Psychol Rep 104:155, 2009; Fabian JM: Diag­nosing and litigating hebephilia in sexually violent predator civil commitment proceedings. J Am Acad Psychiatry Law 39:496, 2011; Gannon TA, O'Connor A: The development of the interest in child molestation scale. Sex Abuse 23:474, 2011; Isely PJ et al: In their own voices: a qualitative study of men abused as children by catholic clergy. J Child Sex Abus 17:201, 2008; McDermott BE et al: The predictive ability of the Classification of Violence Risk (COVR) in a forensic psychiatric hospital. Psychiatr Serv 62:430, 2011; Oliver CJ et al: A comparison of rapists and sexual murderers on demographic and selected psy­chometric measures. Int J Offender Ther Comp Criminol 51:298, 2007; Wijkman M et al: Women don't do such things! Char­acteristics of female sex offenders and offender types. Sex Abuse 22:135, 2010; Wood E, Riggs S: Predictors of child molestation: adult attachment, cognitive distortions, and empathy. J Interpers Violence 23:259, 2008.

 

Acknowledgements

Dr. Scott spoke at Forensic Psychiatry Review Course, held October 18-20, 2010, in Tucson, AZ, and sponsored by the American Academy of Psychiatry and the Law. For information about upcoming Forensic Psychiatry Review Course meet­ings sponsored by the American Academy of Psychiatry and the Law, visit their website at www.aapl.org/meetings.htm. The Audio-Digest Foundation thanks Dr. Scott and the American Academy of Psychiatry and the Law for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PS410301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation