Sex Offenders

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SEX OFFENDERS
Identification, Risk Assessment,
Treatment, and Legal Issues

Edited by

Fabian M. Saleh, MD
Albert J. Grudzinskas, Jr., JD
John M. Bradford, MD
Daniel J. Brodsky, LLB

1
2009

3
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Library of Congress Cataloging-in-Publication Data
Sex offenders : identification, risk assessment, treatment, and legal
issues / edited by Fabian M. Saleh ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-517704-6
1. Sex offendersMental health. 2. Psychosexual disordersTreatment.
3. Sex offenders. 4. Sex crimes. 5. Paraphilias. 6. Psychosexual disorders.
I. Saleh, Fabian M., 1965[DNLM: 1. Sex Offenses. 2. Paraphilias. W 795 S51813 2008]
RC560.S47S483 2008
616.85836dc22
2008028745

1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper

Foreword

Twenty years ago, it would have been difficult to imagine that the problems created by sex offenders would
be high-profile issues on the public policy agenda. The past decade, however, has seen furious legislative
activityat both the state and federal levelsaddressing sex offenders, and the controversies created by these
initiatives can be found on the front pages of newspapers around the country. Contentious public hearings
about these issues have become routine, and professional and lay groups expend considerable time and
resources supporting or fighting assorted policy initiatives.
Consider the knotty issues raised by debates about what to do with sex offenders. Should states adopt civil
commitment statutes, of the type repeatedly upheld as constitutional by the U.S. Supreme Court, that redefine
offenders as mentally ill and subject them to indefinite confinement in secure treatment facilities? Or is this
a misuse of the mental health treatment system to deal with a problem better handled by the courts and the
correctional system? How much of the data that every state now collects on the whereabouts of released sex
offenders should be available to the public? Do we all have a right to know about the former sex offenders in
our midst, or do such laws merely provide a patina of reassurance, without making us or our children materially
safer? And is their major consequence to make it impossible ever to reintegrate persons who have committed
sex offenses into the community?
Why are these issues in the forefront of public consciousness today, when a few decades ago they were largely
ignored? The undoubtedly complex answer to this question begins with a seemingly unrelated development:
the movement in the last quarter of the twentieth century away from indeterminate sentencing and toward
fixed, determinate prison terms for crimes. Indeterminate sentencing, the legacy of an earlier era in corrections
during which the mantra was to punish the offender, not the crime, was geared toward a rehabilitative model
of corrections, under which prisoners would be detained as long as necessary to reduce their proclivities for
recidivism. Hence, under the indeterminate approach there was no necessary correlation between the severity
of an offense and the punishment imposed. Discharge was dependent on whether a parole board or similar
entity deemed the prisoner ready to reenter society. Sex offenders in particular, who always evoke primal fears,
were susceptible to being held for very long periods, or at least until there was every reason to believe that they
would not offend again.
But the results of efforts to rehabilitate offenders, whatever the approach taken, were not impressive, and a
countertrend developedtypified by the federal sentencing guidelines adopted in the mid-1980sto punish
the crime, not the offender. According to this directive, sentences were graded by the severity of the offense,
regardless of the characteristics of the offender, and judges discretion was usually cabined within a fixed
range of options. Now the dominant model, determinate sentencing implies that in all but the most extreme
circumstances the offender will some day be released, and that day is often much sooner than many members

vi FOREWORD

of the general public might think. With an increasing return flow of sex offenders to the community not many
years after their conviction and imprisonment, it was inevitable that horrific crimes would occur and that there
would be public outcry for a remedy.
Once sex offenders were on the radar screens of reporters and politicians, it took little effort to stir up
powerful concerns about the safety of the citizenry, especially children. The first consequence was the adoption of the civil commitment statutes that are denoted sexually violent predator laws or similar appellations.
In the public policy aviary, these are odd birds. They are meant to take effect when a prisoner who committed
an offense that falls within their scope (usually a crime involving violence, but sometimes with considerable
flexibility as to how violence is defined) is about to be released from prison. At that point, the statutes allow
the prisoner to be examined for evidence of mental disorder, and to be subject to indefinite confinement in a
secure facility if both disordered and deemed likely to offend again. However, the definitions of disorder are
substantially circular, resting on impairment in the ability to control sexual impulses, which can be proved
largely by the prisoners conviction of the offense for which he was imprisoned. And the liabilities of concluding that a sexual offender will never repeat his crime make it difficult to avoid committing offenders about
whom any doubts exist and even harder to release them once initially confined.
Moreover, by focusing attention on persons about to be released, the statutes ratify the current approach of
ignoring the possibility of treatment in prison, when offenders are arguably more amenable to successful intervention. Thus, 10 or 20 years after conviction and incarceration, current policies suddenly manifest a desire to
provide treatment to persons who could usefully have been receiving treatment all along. And this is accomplished in a context in which the difficulty of winning release probably diminishes the perceived incentives
for offenders to cooperate. It is hard to avoid the conclusion that many of the advocates of the new generation
of civil commitment statutes are using the treatment rationale to provide constitutional cover for holding on
to sex offenders as long as they live. The foreseeable consequence of these statutes is now upon us: states are
finding that they have created extremely expensive detention facilities that are rapidly filling with offenders for
whose discharge no one is willing to take responsibility. Pressure is already growing to expand existing facilities
or to build new ones, and the costs continue to mount. It seems only a matter of time before a pendulum swing
brings us to a reconsideration of this costly mistake.
Meanwhile, for those offenders who do return to the community, we have created a system of registration
and tracking that essentially involves lifetime oversight. But again, rather than this information being used to
provide meaningful rehabilitation and support, it is instead posted on the Internet or taped onto neighborhood
lampposts in a manner designed to stir fear even among the most rational citizens. What is one to do, after all,
when one is informed by a state agency that a convicted sex offender has moved in next door, down the street,
or into an apartment building that ones child passes on the way to school? As if the resulting uproar is not
enough to ensure that released sex offenders will find it impossible to reintegrate into almost any community,
municipalities are passing ordinances restricting them from living near schools and other facilities, creating
offender-free zones that in many cases encompass most or all of the jurisdictions residential areas. Although
homeowners arguably might have an equally strong interest in knowing when a released house breaker has
moved into their community, the laws that enable or require disclosure of such information are uniformly
limited to sex offenders.
If the phrase moral panic has any legitimate application in the early twenty-first century, it is to the
rampant fear mongering that has led to consistently counterproductive policies for addressing the difficult
problems raised by people who commit sexual offenses. What is needed today is soundly reasoned policy based
on real dataand that is where efforts such as those embodied in this book come into play. The escape route
from the current policy quagmire wends its way through solid research on the phenomenology, assessment,
treatment, and risk assessment of persons who commit sexual offenses. It is worth considering briefly what each
of those bodies of work might foreseeably encompass.
There is a tendency to talk about sex offenders and the problems they create as if every person who commits
a sexual offense is similar to every other. Yet, offenders differ in ways that may have significant implications
for treatment and the risk of recidivism, including the presence of substance abuse and concomitant mental

FOREWORD

vii

illness, mental retardation, and personality disorders. Juvenile sex offenders, who may still be at an early
stage of psychosocial development, often need to be differentiated from older perpetrators of similar crimes.
Assessment approaches, addressed by a number of chapters in this book, must be developed so as to permit us
to distinguish among groups of offenders with different potentials for treatment and varying likelihoods of reoffense. Until we have a better grasp of the epidemiology of sexual offenses and the motivations of the persons
who commit them, along with a clearer understanding of the varying pathways to offending, we will be left
with a Procrustean approach to management that holds little hope of advancing the current state of prevention
and treatment.
More effective treatments of paraphilias and related phenomena stand at the top of the wish list of anyone
involved with this population. Although not all sexual offenses reflect underlying disorders, many do, and the
ongoing controversy about treatment effectiveness bespeaks the need for a much stronger evidence base on
treatments that are likely to succeed with the offender population. Indeed, in a world of rational policy development, the money now being spent on expensive sex offender commitment facilities would be allocated instead
to an intensive program of research on treatments for these problems. Only when clear-cut evidence was at
hand of real-world effectiveness population might it make sense to invest in long-term treatment facilities, and
then only if treatment could not safely be rendered in the community. And even if states felt the imperative
which it is clear that they doto confine sex offenders under the guise of providing effective treatment, in that
same rational world substantial investments in treatment research would be made alongside the expenditures
for new staff and facilities. Yet, not only is this not the case, but the politically sensitive nature of sexual offenses
and possible interventions makes it particularly difficult to obtain funding and to conduct such studies, especially in the United States. It is worth saying again: the only hope for escaping the legal, ethical, and political
tangle associated with sex offenders is the development of effective treatment, which should be an absolute
policy priority.
Along with studies of treatment, of course, must come improved methods of assessing the future risk
presented by persons who have committed sexual offenses. In fact, without such measures it may be impossible to know when treatment has been effective. Like most areas of clinical risk assessment, sexual violence
risk assessment has been hampered by approaches that rely largely on static variables. Thus, while it is becoming increasingly possible to identify persons in high-risk groups on the basis of their past behavior and fixed
characteristics, it remains difficult to adjust risk predictions according to the presumed impact of treatment.
For meaningful risk assessment to be paired with effective treatment, it will need to include variables that are
subject to modification and that have been shown to affect risk accordingly. Several of the more promising
biological measures are discussed in this book, but it is clear that this too needs to be the focus of an assertive
research strategy.
The chapters that follow provide a thorough overview of the state of the art in dealing with sexual offenders:
from phenomenology to biology, from assessment to treatment, and including a variety of special populations.
If we are serious about dealing with the real dilemmas of sexual offenders and their crimes, we will use this
work as a launching pad for the development of research and clinical approaches that can undergird rational
policy for this extremely challenging population.
Paul S. Appelbaum MD
Elizabeth K. Dollard, Professor of Psychiatry, Medicine, and Law
Department of Psychiatry
Columbia University College of Physicians & Surgeons; and
Director, Division of Law, Ethics, and Psychiatry
New York State Psychiatric Institute

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Contents

Contributors

xiii

Part IIntroduction
1. Perspectives on Sex and Normality 3
Peter J. Fagan
2. Phenomenology of Paraphilia: Lovemap Theory 12
Gregory K. Lehne
Part IINeurobiology/Neuropsychology
3. Neuropsychological Findings in Sex Offenders
Ron Langevin

27

4. The Neurobiology of Sexual Behavior and the Paraphilias

John M. Bradford and J. Paul Fedoroff

36

Part IIIAssessment and Diagnosis

5. Violence Risk Assessment 49
Debra A. Pinals, Chad E. Tillbrook, and Denise L. Mumley
6. The Use of Actuarial Risk Assessment Instruments in Sex Offenders 70
Gina M. Vincent, Shannon M. Maney, and Stephen D. Hart
7. Laboratory Measurement of Penile Response in the Assessment
of Sexual Interests 89
J. Paul Fedoroff, Michael Kuban, and John M. Bradford

x CONTENTS

8. Visual Reaction Time: Development, Theory, Empirical Evidence,

and Beyond 101
Gene G. Abel and Markus Wiegel
9. Mental Illness and Sex Offending 119
Fred S. Berlin, Fabian M. Saleh, and H. Martin Malin
10. The Assessment of Psychopathy and Response Styles in Sex Offenders
Michael J. Vitacco and Richard Rogers

130

11. The Role of Personality Disorder in Sexual Offending 144

Roy J. OShaughnessy
Part IVTreatment
12. Psychological Treatment of Sexual Offenders 159
William Marshall, Liam E. Marshall, Geris A. Serran, and Matt D. OBrien
13. Orchiectomy 171
Richard B. Krueger, Michael H. Wechsler, and Meg S. Kaplan
14. Pharmacological Treatment of Paraphilic Sex Offenders 189
Fabian M. Saleh
Part VJuveniles
15. Forensic Evaluations of Juvenile Sex Offenders
Charles Scott

211

16. Juvenile Sexual Offenders: Epidemiology, Risk Assessment,

and Treatment 221
Ernest Poortinga, Stewart S. Newman, Christine E. Negendank,
and Elissa P. Benedek
17. Juveniles Who Sexually Offend: Psychosocial Intervention
and Treatment 241
Jeffrey L. Metzner, Scott Humphreys, and Gail Ryan
Part VISpecial Populations
18. Substance Abuse and Sexual Offending 265
Peer Briken, Andreas Hill, and Wolfgang Berner
19. Female Sexual Offenders 276
Wolfgang Berner, Peer Briken, and Andreas Hill
20. Professionals Who Are Accused of Sexual Boundary Violations
Stephen B. Levine and Candace B. Risen

286

CONTENTS

21. Stalking 295

Ronnie B. Harmon
22. Child Pornography and the Internet 302
L. Alvin Malesky, Jr., Liam Ennis, and Carmen L. Z. Gress
23. Sexual Abuse by Clergy 324
Graham Glancy and Michael Saini
24. Manifestations of Sexual Sadism: Sexual Homicide, Sadistic Rape,
and Necrophilia 340
Stephen J. Hucker
25. Persons with Intellectual Disabilities Who Sexually Offend 353
Dorothy Griffiths and J. Paul Fedoroff
Part VIIForensics
26. Forensic Considerations 379
Rusty Reeves and Richard Rosner
27. Sexual Predator Laws and their History 386
Albert J. Grudzinskas, Jr., Daniel J. Brodsky, Matt Zaitchik, J. Paul Fedoroff,
Frank DiCataldo, and Jonathan C. Clayfield
28. Community-Based Management of Sex Offenders: An Examination
of Sex Offender Registries and Community Notification in the United States
and Canada 412
Lisa Murphy, Daniel J. Brodsky, S. Jan Brakel, Michael Petrunik,
J. Paul Fedoroff, and Albert J. Grudzinskas, Jr.
29. Ethical Issues in the Treatment of Sex Offenders
Howard Zonana and Alec Buchanan
30. Commentary 441
James C. Beck
Index 447

425

xi

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Contributors

Gene G. Abel, MD
Professor, Department of Psychiatry, Emory University and Morehouse School
of Medicine; Director, Behavioral Medicine Institute of Atlanta, Atlanta, GA
James C. Beck, MD, PhD
Professor of Psychiatry, Harvard Medical School; Associate Chief, Law and Psychiatry Service,
Massachusetts General Hospital, Boston, MA
Elissa P. Benedek MD
Adjunct Professor, Department of Psychiatry, University of Michigan School
of Medicine, Ann Arbor, MI
Fred S. Berlin, MD, PhD
Associate Professor, Department of Psychiatry and Behavioral Sciences,
The Johns Hopkins University School of Medicine, Baltimore, MD
Wolfgang Berner, MD
Professor and Director, Insititute for Sex Research and Forensic Psychiatry, Center of Psychosocial
Medicine, University Medical Center Hamburg-Eppendorf,Hamburg, Germany
John M. Bradford, MB ChB, DPM, FFPsych, FRCPsych, DABPN, DABFP, FAPA,
FACPsych, FCPA
Professor and Head, Division of Forensic Psychiatry, Faculty of Medicine and Professor, School
of Criminology, University of Ottawa, Ottawa, ON; Professor of Psychiatry, Faculty of Medicine,
Queens University, Kingston, ON; Associate Chief (Forensic), Royal Ottawa Health Care Group,
Ottawa, ON, Canada. Honorary Titles: Fellow of the Royal College of Psychiatrists (UK);
Distinguished Fellow, American Psychiatric Association; Fellow, American College of Psychiatrists
S. Jan Brakel, JD
Adjunct Professor of Law, DePaul University College of Law; Director of Legal Research,
Isaac Ray Center, Inc., Chicago, IL

xiv CONTRIBUTORS

Peer Briken, MD
Assistant Professor of Pychiatry and Psychotherapy, Institute of Sex Research
and Forensic Psychiatry, University Medical Centre, Hamburg, Germany
Daniel J. Brodsky, LLB
Criminal Defence Lawyer, Toronto, ON, Canada
Alec Buchanan, MD
Associate Professor, Department of Psychiatry, Yale University School
of Medicine, New Haven, CT
Jonathan C. Clayfield, MA, LMHC
Project Director II, Department of Psychiatry, University of Massachusetts
Medical School, Worcester, MA
Frank DiCataldo, PhD
Assistant Professor, Department of Psychology, Roger Williams University, Bristol, RI;
Director, Forensic Evaluation Service, NFI Massachusetts
Liam Ennis, PhD
Assistant Clinical Professor, Department of Psychiatry, Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, AB, Canada
Peter J. Fagan, PhD
Associate Professor of Medical Psychology, Department of Psychiatry and
Behavioral Sciences, The Johns Hopkins University School of Medicine; Director of Research,
Johns Hopkins HealthCare LLC, Baltimore, MD
J. Paul Fedoroff, MD
Associate Professor, Department of Psychiatry, Institute of Mental Health Research,
University of Ottawa; Director, Sexual Behaviors Clinic, Integrated Forensic Program,
Royal Ottawa Mental Health Care Group, Ottawa, ON, Canada
Graham Glancy, MB, ChB, FRCPsych, FRCPC
Assistant Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto,
Toronto, ON, Canada
Carmen L. Z. Gress, PhD
Adjunct Professor, Department of Educational Psychology,
University of Victoria, BC, Canada
Dorothy Griffiths, PhD
Associate Dean, Faculty of Social Sciences, Brock University,
St. Catharines, ON, Canada
Albert J. Grudzinskas, Jr., JD
Clinical Associate Professor and Coordinator of Legal Studies, Department of Psychiatry,
University of Massachusetts Medical School, Worcester, MA

CONTRIBUTORS

Ronnie B. Harmon, MA, MPhil

Clinical Assistant Professor, Department of Psychiatry, New York University School
of Medicine, New York, NY
Stephen D. Hart, PhD
Professor, Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
Andreas Hill, MD
Assistant Professor of Psychiatry and Psychotherapy, Institute of Sex Research
and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf,
Hamburg, Germany
Stephen J. Hucker, MB, BS, FRCPC, FRCPsych
Professor of Psychiatry, Law & Mental Health Program, University of Toronto;
Consulting Forensic Psychiatrist, Sexual Behavior Clinic,
Centre for Addiction and Mental Health, Toronto, ON, Canada
Scott Humphreys, MD
Instructor, Department of Forensic Psychiatry, University of Colorado Denver School
of Medicine, Denver, CO
Meg S. Kaplan, PhD
Associate Clinical Professor, Department of Psychiatry, Columbia University
College of Physicians and Surgeons; Director, Sexual Behavior Clinic,
New York State Psychiatric Institute, New York, NY
Richard B. Krueger, MD
Associate Clinical Professor, Department of Psychiatry, College of Physicians
and Surgeons, Columbia University; Associate Attending Psychiatrist,
New York-Presbyterian Hospital, New York, NY
Michael Kuban, Msc, MEd
Laboratory Coordinator, Clinical Sexology Services,
Center for Addiction and Mental Health, Toronto, ON, Canada
Ron Langevin, PhD
Associate Professor, Department of Psychiatry,
Faculty of Medicine, University of Toronto; Director, Juniper Associates,
Toronto, ON, Canada
Gregory K. Lehne, PhD
Assistant Professor of Medical Psychology, Department of Psychiatry and
Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
Stephen B. Levine, MD
Clinical Professor of Psychiatry, Case Western Reserve
University School of Medicine, Beachwood, OH; Co-director, Center for Marital
and Sexual Health, University Hospital of Cleveland, Cleveland, OH

xv

xvi CONTRIBUTORS

H. Martin Malin, PhD, MA, MFT

Professor, Department of Clinical Sexology, Institute for Advanced Study
of Human Sexuality; Research Associate, National Institute for the Study,
Prevention, and Treatment of Sexual Trauma, Benicia, CA
L. Alvin Malesky, Jr., PhD
Assistant Professor, Department of Psychology, Western Carolina University,
Cullowhee, NC
Shannon M. Maney, MA (Clinical Psychology), MA (Forensic Psychology)
Project Manager, Department of Psychiatry, University of Massachusetts Medical School,
Worcester, MA
Liam E. Marshall, MA
Research Director, Rockwood Psychological Services, Kingston, ON, Canada
William Marshall, PhD, OC, FRSC
Emeritus Professor, Department of Psychology, Queens University; Director,
Rockwood Psychological Services, Kingston, ON, Canada
Jeffrey L. Metzner, MD
Clinical Professor, Department of Psychiatry, University of Colorado Denver School
of Medicine, Denver, CO
Denise L. Mumley, PhD
Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School;
Forensic Psychologist, Forensic Science, Worcester State Hospital, Worcester, MA
Lisa Murphy
Masters of Criminology Applied (MCA) Candidate
Department of Criminology, University of Ottawa, Ottawa, ON, Canada
Christine E. Negendank, MD
Adult and Forensic Psychiatrist, Department of Psychiatry, University Of Michigan School
of Medicine, Ann Arbor, MI; Staff Psychiatrist, Washtenaw County Community Support
and Treatment Center, Ypsilanti, MI
Stewart S. Newman, MD
Assistant Clinical Professor, Department of Psychiatry, Oregon Health & Science University
School of Medicine, Portland, OR
Matt D. OBrien, BSC (Hons), MA, MSC
Therapist, Rockwood Psychological Services, Kingston, ON, Canada
Roy J. OShaughnessy, MD
Clinical Professor and Head of Forensic Program, Department of Psychiatry, Faculty
of Medicine, University of British Columbia, Vancouver, BC, Canada
Michael Petrunik, PhD
Professor (Adjunct), Department of Criminology, University of Ottawa, Ottawa, ON, Canada

CONTRIBUTORS

Debra A. Pinals, MD
Associate Professor and Director of Forensic Education, Department of Psychiatry,
University of Massachusetts Medical School, Worcester, MA
Ernest Poortinga, MD
Adjunct Clinical Assistant Professor, Department of Psychiatry,
University of Michigan School of Medicine; Forensic Psychiatrist, Michigan Center
for Forensic Psychiatry, Ann Arbor, MI
Rusty Reeves, MD
Clinical Associate Professor, Department of Psychiatry, University of Medicine and
Dentistry of New Jersey, Robert Wood Johnson Medical School, Trenton, NJ
Candace B. Risen, MSW
Assistant Clinical Professor of Social Work, Department of Psychiatry,
Case Western Reserve University School of Medicine, Cleveland, OH; Co-director,
Center for Marital and Sexual Health, Beachwood, OH
Richard Rogers, PhD, ABPP
Professor, Department of Psychology, University of North Texas, Denton, TX
Richard Rosner, MD
Clinical Professor, Department of Psychiatry, New York University School of Medicine;
Medical Director, Forensic Psychiatry Clinic, Department of Psychiatry,
Bellevue Hospital Center, New York, NY
Gail Ryan, MA
Assistant Clinical Professor, Department of Pediatrics, University of Colorado
Denver School of Medicine, Denver, CO
Michael Saini, PhD, MSW, RSW
Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto,
Toronto, ON, Canada
Fabian M. Saleh, MD
Assistant Professor of Psychiatry, Harvard Medical School;
Law & Psychiatry Service, Massachusetts General Hospital, Boston, MA
Charles Scott, MD
Professor of Clinical Psychiatry and Chief, Division of Psychiatry and the Law, Department
of Psychiatry and Behavioral Sciences, University of California, Davis School
of Medicine, Sacramento, CA
Geris A. Serran, PhD, CPsych
Clinical Director, Sex Offenders Treatment Programs, Rockwood Psychological
Services, Kingston, ON, Canada
Chad E. Tillbrook, PhD
Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School;
Forensic Psychologist, Forensic Service, Worcester State Hospital, Worcester, MA

xvii

xviii CONTRIBUTORS

Gina M. Vincent, PhD

Assistant Professor, Department of Psychiatry and Center for Mental Health Services
Research, University of Massachusetts Medical School, Worcester, MA
Michael J. Vitacco, PhD
Associate Director of Research, Department of Psychology, Mendota
Mental Health Institute, Madison, WI
Michael H. Wechsler, MD
Assistant Professor of Clinical Urology, Department of Urology, College
of Physicians & Surgeons, Columbia University; Attending, New York
Presbyterian Hospital, New York, NY
Markus Wiegel, PhD
Therapist, Behavioral Medicine Institute of Atlanta, Atlanta, GA
Matt Zaitchik, PhD, ABPP
Associate Professor, Department of Pscyhology,
Roger Williams University, Bristol, RI.
Howard Zonana, MD
Professor, Department of Psychiatry, Yale University School of Medicine;
Clinical Professor (Adjunct) of Law, Yale University Law School, New Haven, CT

Part 1

Introduction

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Chapter 1

Perspectives on Sex and Normality

Peter J. Fagan

In his annual lecture to second year medical students,

Dr. Fred Berlin describes an interview he had, early
in his career, with a man whom he was evaluating
following the mans arrest for child sexual abuse.
Halfway through the interview, the arrested man
interrupted Dr. Berlins questions and said,

North America, symbolized by the status awarded

to the medical profession. The evaluees society was
composed of all those who would espouse the benefits of consensual sexual relationships between and
among men and boys.
For many individuals, the response to the question
posed would involve a reference to normality: the
religious ceremony of circumcision with its infliction
of pain on an unconsenting infant is normal (therefore a good act or at least morally neutral act); the
act of kissing an unconsenting childs penis for the
purpose of sexual gratification is abnormal (therefore
wrong). In this type of response, the use of normal
and abnormal is descriptive, not explanatory. It
does not, therefore, advance a rational understanding about the behaviors of adults and children, in
one case religiously motivated, in the other erotically
motivated.
The question of Dr. Berlins patient reveals not
only the dramatic gulf that exists between NAMBLA
and the majority culture in the United States, but

You know, Doctor, your society takes a newborn

baby boy; gathers family and friends, takes a knife
and without any anesthesia cuts skin off the tip of
his penis. This is accepted as a religious act. I bend
over and kiss that same penis, and I am arrested as
a child sexual abuser. Can you explain that to me?
(Berlin, 2000).
The man in Dr. Berlins story was a member of
the North American Man/Boy Love Association
(NAMBLA), an organization whose website describes
its goal, to end the extreme oppression of men and
boys in mutually consensual relationships. The
society referred to was the mainstream culture in
3

4 INTRODUCTION

suggests that there may be similar, if perhaps not

as graphically stated, differences about the cultural
legitimacy or ethical morality of certain sexual behaviors among individuals and groups, not only in North
America, but also throughout the world. The Internet
with its instantaneous sharing of sexual fantasies,
the migration of peoples across traditional national
boundaries, and a growing awareness of cultural diversity forces people to recognize that the evaluation of
sexual behaviors by different groups and cultures and
by different individuals within the same society is varied, sometimes extremely so.
Frequently the clashing of views about sexual
behaviors, including those classified as sexual offenses
by a jurisdiction, is framed in terms of normality versus non-normality. Its just not normal for a person
to (reader supply here whatever the sexual behavior
is in dispute). At this point, the discussion usually
revolves around what is normal sexual behavior.
The revolving discussion then becomes a devolving
debate because the parties typically cannot agree on
what is normality for sexual behaviors.
This chapter enters the discussion/debate by examining the question of normality and sexual behavior.
The chapter will not satisfy the reader who wants two
lists, one for normal sexual behaviors and one for
non-normal or abnormal sexual behaviors. Rather,
the chapter will seek to provide a structure within
which discussants (presumably all of us) may advance
our understanding of normality and sexual behaviors
on a mutually agreed on rational basis, identifying
the perspective from which we are speaking.
The structure of the chapter is that of the four
perspectives of psychiatry first elaborated by McHugh
and Slavney (1998) and later applied to sexual disorders by the author (Fagan, 2003). The four perspectives of disease, dimension, behavior, and life story
provide a methodological framework for discussing
and hopefully advancing the answer to the questions
about normality and sexual behaviors.
The chapter, then, will describe briefly the essential features of each perspective and then apply the
perspective to the discussion of normality and sexual
behaviors. In the conclusion, we shall urge readers
to employ all four perspectives in this discussion
with the belief that doing so will not only inform
their responses to the question about normality and
sexual behaviors but also lend an often needed quality of civility to the discussion turned debate about
this topic.

SE X UA L NOR M A LIT Y A ND THE

DISE ASE PER SPECT I V E

Viewing sexual behaviors through the disease perspective is to inquire whether the behavior is the
product of a disease process in the body. The logic of
the disease perspective is categorical: the individual
either has the disease or not. If the individual is positive for the disease, the question then is whether the
sexual behaviors in question are a result of the disease state. For example, the hypersexual behaviors of
bipolar disorder are often the result of the affective
illness. While the individual may have had a diathesis toward the particular form of the behavior, the
actual expression of the sexual behavior is directly
caused by the impairment of social judgment and
the increased libido in bipolar illness. An individual
with moderate bipolar disorder may make seductive
or sexually harassing comments to fellow workers.
While the behavior may be consistent with his or
her sexual orientation, the frequency and intensity
of the comments are inconsistent with the behavior of the individual before the onset of the affective
illness.
Assessing the normality of sexual behaviors from
the disease perspective is a judgment of whether a
person has a disease that is an etiologic factor in the
expression of that persons behaviors. Normality in the
disease perspective will be referred to with terms such
as abnormal and disordered. The hypersexual
behaviors of the individual with bipolar illness would
rightly be labeled abnormal, not only because they
are not normative for the individual, but because they
are accurately seen as a behavioral manifestation of
the disease. Another term that can be used in the disease perspective is addictive sexual behavior when
the disease origins of the behavior are elaborated
(Goodman, 1992).
On further examination, however, the disease perspective in some cases is not completely categorical in
which a simple yes or no can be given to the question, Does the individual have the disease? Many
diseases such as hypertension and adult onset diabetes
are the result of application of dimensional features.
Exceeding certain values (which may change according to practice guidelines) results in the naming of
the condition as a disease. Also, the changes in bodily
functions that are the result of normal aging versus
disease process also challenge a simple categorical
application of the disease perspective.

PERSPECTIVES ON SEX AND NORMALITY

Applied to sexual normality, the application of a

dimensional component to the disease perspective
is apparent in questions relating to intelligence and
sex hormone levels. Both intelligence and hormonal
milieu can affect the expression of sexual behaviors.
In general, low intelligence or a dementia may result
in poor social judgment and/or disinhibition while
androgen levels are associated with sexual drive
in men and women. Both are somatic conditions
that may independently or in consort cause sexual
behaviors to occur. Separately they may not be considered a disease, for example, an I.Q. of 85 and a
serum testosterone level of 850 (250 to 750 range).
However, because of the multidetermined nature
of the interaction of these somatic conditions and
the environmental factors in which the individual
may be sexually stimulated, it is not always simple to
establish a primarily somatic causal role in the sexual behaviors. But if the interaction of somatic factors producing sexual behaviors can be established
with a clinical level of certainty, then the disease
perspective would suggest that the sexual behaviors
are abnormal.
In summary, the disease perspective addresses
the question of normality by assessing whether the
sexual behavior in question is a product of a disease
state. Many times, this can be accomplished with a
high degree of clinical certainty, for example, bipolar disorder in hypersexuality and hypogonadism in
hyposexuality. In other situations where there may
be an interaction between somatic and environmental factors, the use of the disease perspective may be
necessary but not sufficient to address the question of
sexual normality. Other perspectives, especially the
dimension perspective, are often required to supplement the disease perspective.

SE X UA L NOR M A LIT Y A ND THE

DIMENSION PER SPECT I V E

The dimension perspective addresses sexual normality quantitatively by measuring the behavior in question. The dimension perspective counts the frequency
and/or measures the duration and intensity of the sexual behavior. It then compares these measures to sampling of other subjects or population before returning
its verdict of normality or non-normality. Whereas
the logic of the disease perspective is in the main category (a person has or does not have the disease), the

logic of the dimension perspective is measurement

(count, degree, ratio).
With measurement as the logic of the dimension
perspective, the discussion of normality versus abnormality is largely about the arbitrary cutoffs on each
tail of the distribution curves. For example, with a
predetermined two-tail alpha of 0.025, if a behavior
is practiced by only 2% of the population, then that
behavior might be considered statistically not normal, therefore statistically abnormal. But if it were
practiced by 3% of the population, then by that same
measurement logic the arbitrary cutoffs would indicate that the sexual behavior in question is normal.
Indeed even the term paraphilic mirrors this distinction between the extremes and the central normality.
Its Greek entomology, para along side of suggests
that it occurs along the side of normal or normophilic sexual behaviors.
Employing the dimension perspective to measure a construct and the occurrence of which one
assumes to be normally distributed in the population
(a false assumption for sexual offenses), one can, by
setting a point at the extremes of the normal curve,
label the measured construct as normal or abnormal. A blood pressure of 200/120 is abnormal for a
30-year-old man; similarly a daily frequency of 10
orgasms is abnormal for him. But 10 years without an
orgasm during wake state would not be abnormal for
a 30-year-old man who happens to be an observant
celibate monk. Thus, in the dimension perspective
the terms normal and abnormal relate to statistical normality within a specific population. They do
not address the questions of value. Value relating to
the meaning of the behaviors in the context of the
life of the individual requires the life story perspective
while further qualitative descriptors of the behavior
employ the behavior perspective.
Those who argue for the normality of a selected
sexual behavior on the grounds that it is practiced
by predetermined percentage of the population are
employing the dimension perspective. In recent years,
the Internets sexual oriented websites and western
cultures increased permissiveness about discussing
sexual behaviors has given sexual minorities fodder
for their assertion of sexual normality. Those who
would disagree rarely argue about the choice of the
measurements cutoff. They resort to other perspectives, largely the life story perspective with its stress
on values, to counter the claims of normality. The
debate ends with each side arguing from different

6 INTRODUCTION

perspectives and, without consciously doing so, talking past one another. Normality in the dimension
perspective is not a value judgment. It is a statistical
measurement.

NOR M A LIT Y: FOR M V ER SUS F U NCT ION

The distinction of form and function is a component

of each of the four perspectives but needs to be considered, especially in any discussion of the dimensional measurement of normality of sexual behaviors.
The form of a behavior consists of the quantifiable
descriptors of the behavior. The form is the what of
the behavior: the physical and mental activity as well
as its manner of expression in terms of frequency,
intensity, and duration. The function of a behavior
is the purpose that the behavior plays in the life of
the individual, the why of the activity. Function is
attributed to the behavior by the individual or by the
observers; form is constitutive of the behavior.
An example of the form versus function distinction
applied to exhibitionism might clarify the distinction.
The form of exhibitionism consists of an individual
intentionally exposing his or her genitals or erotogenic parts of the body to an unconsenting individual and, at some point, becoming sexually aroused
by the experience. The function of exhibitionism is
often multidetermined: assertion of gender; aggression at object of exposure; enjoyment of risk-taking;
attempt to seduce. If they conduct a sufficiently rigorous inquiry, independent observers should be able
to have fairly high inter-rater reliability on the form of
a specific behavior. There will be less agreement on
function, however, because the observers are attributing to the subject psychological need and motivation regarding the behavior. And as the many schools
of psychological theory attest to, there can be many
rational, coherent, and, at times, contradictory understandings regarding human motivation.
The issue of discussing normality in terms of form
and function has a caveat: there may not be concurrence between form and function in terms of normality. Applied to the exhibitionism described, the
form of the behavior in the particular individual is
likely abnormal because of its presumed low prevalence in the general population. (Its incidence may be
less abnormal in the population because of the frequency of the behaviors by those with exhibitionism.)
The functional attributions are in themselves normal

motivations, albeit perhaps toward the tails of the

normal curves for some, for example, aggression.
It is the blurring of normal motivations with abnormal behaviors that can result in an inappropriate
conclusion about the normality of sexual behaviors
when trying to employ the dimension perspective. An
understanding of the function, that is, motivations of
the sexual behaviors in the individual, (verstehen) as
Jaspers (1997) would describe it, is not the measurement of dimensional perspective. It is not sufficient
from the dimension perspective to hypothesize confidently why the sexual behavior was done by the individual. This is the work of the life story perspective; it
is not the task of the dimension perspective.
The dimension perspective takes the form of
the sexual behavior in question and measures its
frequency, duration, and intensity. How often does
the behavior occur? Is it episodic or is it a constant
component in the sexual repertoire of the individual? How long does the activity take to be completed? Is it measured in seconds, minutes, or hours?
How intensely is it experienced by the individual? Is
there a sense of being on automatic pilot once the
behavior has begun? Is there a compromise of social
judgment or awareness of consequences during the
behavior? Is there any dissociative element in the
experience for the individual? These measurements
of subjective intensity rely somewhat on observation;
but ultimately they depend upon the self-report of the
individual performing the sexual behaviors.
Once the form of the behaviors has been measured, the task of the dimension perspective is to
compare the measurements to some sample of other
individuals and their (non)experience of the behavior. While there are some population-based studies
that provide a range of normality for some sexual
behaviors, most of the sexual behaviors in these studies are limited to childhood experience of sex (including with an adult), adult noncriminal activities, and
sexual dysfunction (Laumann, Gagnon, Michael, &
Michaels, 1994). There is perhaps no reliable population measurement to establish statistical normality for
those behaviors which are categorized as paraphilia in
the DSM-TR-IV (American Psychiatric Association,
2000). The same condition exists for sexual offensives, both paraphilic and nonparaphilic.
The problem, then, for judging the normality
of sexual behaviors from a dimension perspective is
in the question, Normal as compared to what? In
judging the incidence or prevalence of a disease, the

PERSPECTIVES ON SEX AND NORMALITY

epidemiologists will take care to ensure that the population denominator over which the disease is placed as a
numerator is carefully determined (Gordis, 2000). The
denominator is the compared to what population.
For sexual behaviors, especially those that are illegal, socially censored, or culturally unaccepted, it is
extremely difficult to ascertain incidence or prevalence rates. While the numerator is arrested and/or
referred for clinical treatment, the denominator is
uncertain at best, guesstimated at worst. In general,
despite the numerous surveys and samplings of convenience, we do not know the prevalence or incidence
of sexual offenses or paraphilic sexual behaviors in
the general population.
The question, So what is normal, anyway?, is from
a dimension perspective largely unanswered when it
comes to what is currently labeled as sexual offenses
or paraphilic sexual behaviors. There are some indications of other sexual behaviors in the population
that have been given some preliminary responses, for
example, prevalence/incidence of same sex behaviors, the prevalence/prevalence of extramarital sexual
activity (Laumann et al., 1994). What is not normal
within the general population denominator may be
normal within a more stratified sample, for example,
the higher educated, urban. According to the sampling
frame, the boundaries of normality may shift.
In summary, the dimension perspective addresses
normality by measuring the frequency, duration, and
intensity of the form of the sexual behavior in question. It selects an arbitrary and hopefully acceptable
cutoff in the measurement for what will be considered
normal and abnormal on each side of the cutoff. The
dimension perspective is currently limited by the lack
of information about the incidence and prevalence of
sexual behaviors and so is limited in addressing the
question, Normal as compared to what? It should,
however, be a perspective that can be a meeting
ground for discussion about sexual behaviors because,
like science, its logic is measurement, not evaluation
of probity. The evaluation of probity is the work of the
behavior and life story perspectives in their approach
to the question of the normality of sexual behaviors.

SE X UA L NOR M A LIT Y A ND THE

BEH AV IOR PER SPECT I V E

Like the dimension perspective, the behavior perspective examines what the individual does. But

unlike the dimension perspective, it examines the

individuals human behavior as a series of unique
goal-directed, or teleological, activities that have
both antecedents that set the behavior in motion and
consequences that result from the commission of the
behavior. The terms for normality employed in the
behavior perspective are those such as disordered,
maladaptive, compulsive, addictive, and (self)
harmful. These, and similar terms are used to indicate that the behavior results in consequences that
are not positive either for the individual or for others.
Between the antecedents and the consequences,
the individual chooses to perform the behavior. If
there is no element of choice, the behavior is not a
human act (actus humanus) but simply an act of a (wo)
man (actus hominis). If choice is absent, as it certainly
may be compromised if not absent in bipolar disorder,
then the behavior perspective is not the appropriate
perspective to employ in discussing the normality of
the sexual behavior. The behavior perspective assumes
that the individual has some component of choice in
the sexual behavior he or she has engaged in.
Given the assumption of choice and with the
unique behavior as the object of observation, what does
the behavior perspective contribute to the discussion
of the normality of sexual behaviors? Put in simple
terms, the behavior perspective is the perspective of
a cultures normative institutions: religious, civil, and
social. The norms are taught, legislated, decreed, and
agreed upon by these institutions and consented to
in varying degrees by the individuals within the institution. When applied to sexual behaviors, the norms
are typically restrictive although occasionally may
be proscriptive, for example, the duty to have intercourse to bear progeny or fulfill spousal obligations.
The norms may be justified based on the behavior
itself, for example, ecclesial prohibitions against masturbation, or based on the consequences of the behavior, for example, the putative harm to a child whose
trust in adults/parents has been compromised by sexual abuse. The behavior perspective judges a sexual
behavior to be normal based on its observation of and
conformity to the prevailing norms.
There are two immediate problems. The first is
that the norms are prevailingsome for centuries,
some only for decades. Institutional norms, even
those of religious institutions, change. If the sexual
behavior is being judged normal in a period of institutional normative transition, it is difficult to reach consensus based on the prevailing norm under pressure

8 INTRODUCTION

to change. Certainly homosexual behaviors have

been subject, in the past century, to many changes
in the prevailing civil, ecclesial, and societal laws and
norms. Yet today there is no consensus about the
normality of homosexual behavior.
The second problem in judging sexual behaviors
as normal based on prevailing norms is that there
are discrepancies among the intersecting institutions
about the normative probity of specified sexual behaviors. The civil jurisdiction may say a behavior is not
normative, for example, the State of Georgias antisodomy law, while an ecclesial body, for example, the
Metropolitan Community Church, may teach that
it is normal and not against the church teachings. In
such situations of normative conflict, individuals may
have to determine their ultimate normative institution
and, of course, individuals will differ in their choices.
When the question of the normality of a behavior is discussed using the behavior perspective, the
first answer usually comes rather quickly, but then on
further examination (or rebuttal), comes up against
its inherent limitation: it is relative. Despite quests
of most institutions for absolute norms, the fact is
that the norms legislated are prevailing and relative.
Institutions, even autocratic ones, ultimately depend
upon the consent of their populations for their norms
to be normative. The Soviet Union has collapsed and
the antiusury and toleration of slavery norms of the
Roman Catholic Church have changed (Noonan,
2005). Consensus will shift and consent of the populations will always be tentativeeven if held constant
for centuries.
The behavior perspective is teleological, that
is, that behaviors are goal seeking and purposeful.
Beyond the concurrence with institutional norms,
the behavior perspective can address the normality
of sexual behavior by using the theoretical construct
of AntecedentsBehaviorsConsequences involved
in teleology. To the extent that the intensity, duration,
or frequency of certain sexual behaviors effect negative consequences for the individual or those whom
they may involve as objects or partners, terms such
as dysfunctional, maladaptive, fixated, compulsive, and disordered may apply. The logic of
the judgment is consequential: negative results mean
the action was negative. In ethical terms, if the bad
results are present, the action is considered bad
in itself. This is basic consequentialist ethics. The
strength of the consequentialist argument lies in
two further determinants: (1) the causal connection

between the behavior and the consequences; and (2)

the evaluation of the positive versus negative ratio of
the consequences.
Another limitation of the behavior perspective is
that while it examines the antecedents and consequences of the behavior, discourse about what the
individual does, his or her sexual behavior, is not on
the level of the values that are being supported by the
norm that is being applied. Thoughtful discussion of
norms and laws should drill into the institutional values that gave birth to the norm. This requires, however, another perspective, the fourth and final one,
the life story perspective.
In summary of the behavior perspective, the normality of sexual behavior is deceptively simple to
determine. Is the sexual behavior prohibited by prevailing institutional norms? If so, it is not normal to
choose to commit the behavior. Is the sexual behavior
prescribed by prevailing institutional norms? Then
the behavior is normal. To omit a prescribed sexual
behavior or to commit a prohibited sexual behavior is
to incur the judgment of abnormal, illicit, illegal, or
unacceptable sexual behavior.
In addition to its concurrence with institutional
norms, the behavior perspective can address the question of normality by using a consequentialist ethic.
Good results mean good behavior and the converse.
The behavior perspective is limited by the historical relativity of institutional norms and its dependence upon a supplemental perspective to examine
the institutional values that the norm protects. It is
also limited by the weaknesses of a consequentialist ethic. While the behavior perspective is a necessary component in the discussion of the normality
of sexual behavior, it requires the addition of the life
story perspective for advancing the question of sexual
normality.

SE X UA L NOR M A LIT Y A ND THE LIFE

STORY PER SPECT I V E

Enter, finally, the life story perspective. To address

the question of the normality of sexual behavior,
the life story perspective asks what meaning and values are attributed to sexual behaviors. What is the
purpose of sexual intercourse? Why is there sexual
pleasure? And ultimately, why is the human person
sexual? The questions and therefore the responses
are teleological, philosophical, psychological, and,

PERSPECTIVES ON SEX AND NORMALITY

for the religious communities, theological. The terms

for normal using the life story perspective are those
such as developmental, adaptive, natural, ethical, and good.
At this point in history, there are as many theoretical systems responding to these questions as there are
philosophical and theological traditions. But before
any tradition offering responses, we encounter the
current challenge to the assumption of philosophical or theological truth. Some deny its possibility;
others hold that truth is objective and absolute (even
if not knowable). That debate is epitomized by the
fundamental differences between those who have
been described as social constructionists and those
as essentialists. The debate between these two camps
has been especially rancorous when human sexuality
is the topic of discussion (DeLamater & Hyde, 1998).
Social constructionists assert that communities
construct meaning out of the social context of the
behavior. The central assertion of social constructionists is that reality is socially constructed by language
(Berger & Luckman, 1966). With the passage of time
and tempering in social attitude constructs that had
a pejorative connotation transmute into more socially
acceptable or neutral words. Prostitutes becomes
sex workers. Perversion becomes paraphilia,
which then becomes sexual variations. According
to this school of thought, even our understanding
of body and gender has been socially constructed
(Laquer, 1990). Sexual normality for a specific behavior can and will be constructed by the social communities because normality itself is a social construct
that is entirely plastic, entirely relative. Social constructionists freely employ the life story perspective,
albeit giving the social community more than the
individual, the salient role in constructing meaning.
Essentialists hold that there is a given order in
nature that can be discovered by reason and/or, in the
religious traditions, revealed by God. The normality
of any behavior is whether the behavior is consistent with the order or teleology for which the individual performing the behavior exists and for which
the behavior is intended. The essentialist position
relies on both philosophy (for the secular humanist
and intellectual theist) and theology (for the theists)
to address such profound questions as the nature of
the human person and the purpose that he or she has
in life. Sexual behaviors tend to be judged as having
a specific purpose in the history of the human race.
For example, the purpose of sexual intercourse has

been seen as intended for procreation and, in recent

centuries, also for the expression of love and intimacy. Essentialists posit natural laws or a Natural
Law that governs the purposes of all human behavior,
the normalityor the moralityof sexual behaviors
is not relative. Employing a confident Aristotelian
epistemology that says that reality is out there and
knowable, essentialists assert that normality may be
perceived differently by different cultures or in difference epochs, but the normality of all behaviors
including sexual behaviorscan be discovered (not
constructed) by the human community.
The debate between the social constructionists
and the essentialists has been seen by many as the
debate between moral relativists and moral absolutists. For our purposes, it is the debate between the
relativity of normality and the absolute fixedness of
normality. While this view of the two camps, social
constructionists and essentialists, may be stereotypical, it contains more than a grain of accuracy. Both
camps when speaking theoretically tend to confirm
the stereotype. When the discussion becomes applied
to a specific behavior in a specific situation, one witnesses a healthy stretching of the basic assumptions
of each school. Social constructionists would by and
large reject the forcing of sex upon an unconsenting
individual. Essentialists would, by and large, admit a
development (therefore a change) of what might be
judged as good sexual behavior. For example, in the
Roman Catholic tradition, engaging in marital intercourse for the purpose of experiencing the pleasure
of orgasm is no longer seen as sinful as it was by
St. Augustine in the fourth century.
The future of the social constructionist versus
essentialist debate about sexual normality may lie
therefore, in continued discussion about applied
sexuality behavior. At the present, there is, in general, a lack of mutual respect. Progress will be made
in reaching a fuller understanding from the life
story perspective when each school listens carefully
and thoughtfully to the positions of the other. There
may be, in the end, no agreement. The assumptions
of each school appear to preclude this. But societies
will be enlightened by the rationality of both social
contructionists and essentialists if each can be heard.
There is one other approach to understanding
sexual normality that is an examination of specific
behaviors using the life story perspective. The agenda
of the Communitarian movement is to elaborate
the rights and responsibilities of individuals within

10 INTRODUCTION

their communities. Based on the seminal writings of

sociologist Amitai Etzione (1993), Communitarian
thought is a reaction to rugged individualism with
its stress on the rights of the individual in western
culture, typified by the Libertarian movement. The
Communitarian mantra is rights and responsibilities. Individuals not only have rights; they also have
responsibilities to the communities in which they
exist and to the communities which will follow them.
The morality, or the normality, of behaviors will be
achieved in the successful and proper balancing of
individual rights and community responsibilities in
human behavior.
In the Communitarian agenda, the entire discussion of the nature and parameters of the rights
of individuals and the individuals communitarian
responsibilities is applied to specific situations. The
foundation of the rights of the individual are examined and the corresponding communitarian responsibilities are acknowledged and justified. There is
ground here for both social constructionists and
essentialist to contribute to the discussion of rights
and responsibilities. The discussion can obviously
be about sexual behaviors, about its normality, about
the rights of the individual to be sexual and behave
sexually. In the Communitarian framework the discussion will be about the responsibilities that the
individual has toward the community in which he or
she chooses to act sexually. For example, according to
Communitarian thought, sexual offenses are likely to
be abnormal behaviors not because they break societal laws or taboos, but because they fail to exercise
the responsibility that individuals have to honor and
respect the physical and psychological boundaries of
others. Obviously the philosophical basis of the individuals right to physical and psychological integrity
will need to be elaborated in establishing the corresponding responsibility.
In summary of the life story perspectives contribution to an understanding of sexual normality, there
is a basic disagreement between those who would
argue for the relativity of sexual normality and those
who would assert a foundational normality for human
sexuality. Between these two basic schools, often
referred to as social constructionist and essentialist,
there exists a wide chasm in the public debate. An
approach which may provide a common ground for
the application of sexual behaviors to specific situations is found in the Communitarian movement.
Employing Communitarian structure, the public

discussion of the normality of sexual behavior will be

had by examining both the individuals rights to be
sexual and the responsibility that the individual has to
the partner with whom and the community in which
his or her sexual behavior occurs.

THE QUEST ION OF NOR M A LIT Y

OF SE X UA L BEH AV IOR S

Is then the question of normality of sexual behaviors ever to remain a quest to which there will be no
satisfying answer? Returning to the confrontation of
Dr. Berlin and the man he was evaluating for a sexual
offense, will there ever be common ground for discussion? While complete unanimity may never be
achievedcertainly not in the case describedthere
are steps that can be taken to make the quest more satisfying and more informative for those who are asking
such questions.
The disease perspective calls for continued research into the neurological and physiological determinants of sexual behavior. The past two decades of the
biological bases of sexual behavior have been productive in animal research. We are beginning to see
reflections of this in human sexual research. We look
for more findings that are robust and replicated. The
dimension perspective requires more valid and reliable measures of sexual behaviors as they are practiced in varied cultures. Normality cannot be addressed
in the dimension perspective unless we have valid
measurement of the behavior in the population. The
behavior perspective challenges researchers in the psychology of human behavior to examine the multiple
causes of sexual behavior. What are the causal components, both of ordered sexual behavior and sexual
behavior that causes harm to self or other? A growing
identification of these factors is contributing to our use
of the term normality in sexual behaviors.
Lastly, those who would move the discussion of
normality into the life story perspective are doing
their societies a service if they engage in this discussion of meaning and values using both rational
arguments and respectful listening to conflicting
opinions. Not to include the disciplines of ethics,
philosophy, and theology into the discussion of sexual
normality is to reduce the question to skills of the scientific disciplines. Many will be content, even praise
that limitation. However, this author believes that the
fullest exploration of human sexuality requires not

PERSPECTIVES ON SEX AND NORMALITY

only science, but also wisdom. For this we must turn

to our wisdom traditions for assistance. The behavioral and basic sciences must continue their work to
help us explain sexual behavior; the wisdom traditions must continue their work to help us understand
sexual normality.

CONCLUSION

In summary, each of the four perspectives calls for

more disciplined research to respond to the question
of normality of sexual behaviors. Each of the four
perspectives will potentially deepen the discussion of
normality if employed consciously by the discussants.
The following chapters in this volume are examples
of researchers and clinicians who applied their disciplines to this question as pertaining to sexual offenders. They promise to deepen our understanding and
our discussion of sexual normality.
References
American Psychiatric Association. (2000). Diagnostic
and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision ed. Washington, D C.:
American Psychiatric Association.
Berger, P. & Luckman, T. (1966). The Social Construction
of Reality; A Treatise in the Sociology of Knowledge.
Garden City, NY: Doubleday.

11

Berlin, F. S. (2002). Medical Student Lecture. Lecture

by Berlin F. S. John Hopkins University School of
Medicine, Baltimore, Maryland. January 11.
DeLamater, J. D. & Hyde, J. S. (1998). Essentialism
Versus Social Constructionism in the Study of
Human Sexuality. Journal of Sex Research, 35(1),
1018.
Etzioni, A. (1993). The Spirit of Community: Rights,
Responsibilities and the Communitarian Agenda.
New York: Crown.
Fagan, P. J. (2003). Sexual Disorders: Perspectives on
Evaluation and Treatment Baltimore, MD: Johns
Hopkins University Press.
Goodman, A. (1992). Sexual Addiction: Designation
and Treatment, Journal of Sex and Marital
Therapy, 18(4), 303314.
Gordis, L. (2000). Epidemiology, 2nd Edition.
Philadelphia: W.B. Saunders.
Jaspers, K. (1997). General Psychopathology, Vol. 1.
Baltimore, Maryland: The Johns Hopkins University
Press.
Laquer, T. (1990). Making Sex: Body and Gender from
the Greeks to Freud. Cambridge, MA: Harvard
University Press, p. 313.
Laumann, E. O., Gagnon, J. H., Michael, R. T., &
Michaels, S. (1994). The Social Organization of
Sexuality: Sexual Practices in the United States.
Chicago, IL: The University of Chicago Press.
McHugh, P. R. & Slavney, P. R. (1998). The Perspectives
in Psychiatry, 2nd. Baltimore and London: The
Johns Hopkins University Press.
Noonan, J. T. (2005). The Church that Can and Cannot
Change: The Development of Catholic Moral
Teaching. Notre Dame, Ind: University of Notre
Dame Press.

Chapter 2

Phenomenology of Paraphilia:
Lovemap Theory
Gregory K. Lehne

Understanding the psychological experience of individuals who have unusual sexual interests and behavior
has fascinated professionals and the public since the
first publication, in the last quarter of the nineteenth
century, of the twelve editions of Psychopathia
Sexualis by Krafft-Ebing (19031965). Many of his
237 clinical and forensic cases describe individuals
with paraphilia. Until the last quarter of the twentieth
century, most sexuality that significantly differed from
potentially procreative behavior in a marital context
was considered sexually disordered. Contemporary
diagnostic standards, represented by DSM-IV-TR
(APA, 2000), offer a more ambiguous perspective
on what is a sexual disorder or paraphilia. The diagnostically specified paraphilias have been defined in
terms of their focus on behaviors which are frequently
illegal or cause distress, usually for others: exhibitionism and its complements voyeurism and frotteurism;
pedophilia, sexual sadism, and its complement sexual
masochism; and fetishism and its complement transvestic fetishism. The content of the sexually arousing

fantasies or sexual urges is what is considered to make

these conditions mental disorders, so they are clinically diagnosed from fantasy rather than behavior
(for a more clinical discussion, see Fagan, Lehne,
Strand, & Berlin, 2005; Plaut & Lehne, 2000).
DSM-IV-TR adds the proviso for diagnosis that the
individual is significantly distressed or there is associated impairment in functioning. Traditionally, however, the paraphilias have been conceptualized in
terms of their divergence from what was believed to
be normative heterosexual sexual interests, and popularly in terms of the bizarreness or kinkiness of their
sexual content.
Human sexual interests and practices, however,
are now known to be very diverse. Aspects of many
types of paraphilic imagery are found in individuals
who are not considered to have sexual psychopathology. Sexual looking and showing are commonplace.
Touching is the most typical invitatory sexual activity
of couples. A sexual interest in children is normative
among children. Sadomasochism is a widespread
12

PHENOMENOLOGY OF PAR APHILIA

sexually variant play activity among married couples.

A very large nonsexual commercial fashion market
thrives merchandizing clothing that is similar to
fetishistic items.
The Internet has exposed the fact that interest
in a variety of sexual content, previously thought of
as paraphilias not otherwise specified, may be more
widespread than ever imagined. The diversity of
paraphilic sexual interests almost defies categorization
or even enumeration (see, for example, Francoeur,
Cornog, Perper, & Scherzer, 1995; Love, 1992). Alphabetically, it starts with sexual interests in abduction,
abuse, accidents (automobile & others); acousticophilia (arousal by sounds); acrophilia (heights); acrotomophilia and apotemnophilia (amputee partner or
self); adolescents (ephebophilia); autonepiophilia or
infantalism (adult babies); agalmatophilia (statues);
age play, agoraphilia (sex in public place); aidoiomania (nymphomania, satyriasis); algolagnia (sadism &
masochism); anal fetishism, anasteemaphilia (difference in heights of sex partners); andromimetophilia
(attraction to a lady with a penis), animals (zoophilia);
anthromorphism (role play as an animal); apodysophilia (appearing naked in public); asphyxiophilia
(strangulation, self or other); augmentation (various
body parts, including penile vacuum pumps); autoerotic activities beyond enumeration, autofellatio,
autogynophilia (self as woman); autonephiophilia
(aischrolatreia, love of filth or obscenities); autogonistophilia (being observed in sexual activity); autoassassinatophilia (staging masochistic death of self,
complement of lust murder); autofetishism, and there
is no end in sight. Being abstinent may not yet be a
paraphilia, but asexualization, as for example, castration or becoming a eunuch, may be. Possibly new
paraphilias seem to arise frequently, based on the criteria of bizarre sexual content, while other paraphilias, such as a sexual interest in statues, seem to have
disappeared (although perhaps the modern equivalent is life-size sex dolls). Clearly we have reached,
if not exceeded, the limit in defining paraphilias in
terms of the bizarre content of sexual interests.
Defining paraphilias in terms of illegal behavior is
societally and temporally limiting. The definitions of
mental conditions should not change with national
boundaries and historical practices. Defining paraphilia in terms of bizarre sexual content is similarly
limiting, particularly when it is limited by professional knowledge about what people actually think
about and do sexually. Even the criteria of distress

13

or impairment are inadequate for characterizing

paraphilia, now that the Internet has reduced the guilt
and isolation of many individuals with paraphilia, so
that their sexualities are no longer ego-dystonic.
I propose that the phenomenology of paraphilia is
characterized by the specificity of the sexual content
combined with the intensity of the sexual arousal/
motivation. An analogy can be made to the phobias
(as McConaghy, 1993, has mentioned) or obsessivecompulsive disorders (see Bradford, 1999). Phobias
(like paraphilia) are all highly specific in content, previously enumerated by a long list of Greco-Latinate
names that specified the content. Their content may
be a type that arouses some fear or anxiety in many
people, but also could be individualistic or bizarre
(usually related to a childhood origin). Phobias (like
paraphilia) are all intensely arousing, which affected
individuals recognize as excessive or unreasonable.
Phobias are derived from the bodys underlying autonomic or vasovagal arousal process experienced as
anxiety and associated with a very strong avoidance
motivation. For paraphilias, the underlying autonomic arousal is experienced as sexual, and there
is a very strong approach motivation. Phobias (like
paraphilia) differ in factors that contribute to their
etiology, such as childhood experience, physiological,
and familial factors.
In the sections that follow, I first discuss normative sexual content in terms of lovemaps. Then I
apply the concept of lovemaps to the phenomenology of highly specific paraphilic content. Next I discuss sexual arousal/motivation related to paraphilia.
Then I look at the developmental manifestation
of paraphilia in terms of origin and expression,
followed by the phenomenology of some paraphilia
case histories. Finally I discuss the implications of
this approach. The approach that I take is developed
from my work over the last 25 years with Dr. John
Money of the Psychohormonal Research Unit and
Dr. Fred Berlin of the Sexual Disorders Clinic, both
at the Johns Hopkins University School of Medicine,
and the many hundreds of men with paraphilia who
shared their stories with me. Please note that I discuss
primarily males in this chapter.

LOV EM A PS

Human sexuality is characterized by diversity in

the content of sexual urges, fantasies, and behavior.

14 INTRODUCTION

Human sexuality is thus different from animal sexuality, which is not diverse in any specific species, but
instead focuses on an exclusive goal of reproduction.
Most animals are hormonal or physiological robots
in terms of sexuality, responding to highly specific
signals for reproductive breeding. The sexuality of
human beings functions for pleasure and bonding,
infinitely more frequently than just for reproduction.
People, unlike animals, vary greatly in the types of
partners they are aroused by and attracted to, and
the types of sexual and affectional activities they find
arousing and engage in. The diversity of sexuality
extends to issues of gender (Roughgarden, 2004).
Dr. John Money (1986, 1999) first proposed the
concept of lovemaps to describe the diversity of
human sexuality and the paraphilias. He defined
lovemap as the developmental representation or template in the mind and brain depicting the idealized
partner and program of sexuoerotic imagery or behavior (1986, p. 290). Every person has an individualized
lovemap which represents the variety of characteristics of partners and activities that are sexually arousing and erotically (in the sense of love) appealing.
Money published several lovemap autobiographies of
men with paraphilias (Keyes & Money, 1993; Money,
Wainwright, & Hingsburger, 1991). Human lovemaps
are diverse because people are diversethere is no
one ideal type of partner, sexual behavior is not a
standardized ritual, and sexual activity is not limited
to one type of act.
The diversity of lovemaps comes from many
sources. Some of it may result from genetic, hormonal,
or prenatal influences. But the specificity of the partners that are attractive or the many scenarios that are
sexually arousing, for example, has to come through
the sensesthere are no genes or hormones that could
determine whether an individual is attracted to people
of specific ethnic backgrounds or body types, or personality styles, for example. Thus aspects of lovemap
diversity have to come from input through the senses
related to experiences that occur during early development and later input or learning from life experiences. For reasons that are not yet understood, certain
aspects of sensory input are eroticized and encoded
in the lovemap, perhaps because of associations with
random or provoked changes in hormonal levels or
autonomic arousal. The lovemap cartographic system
may operate like a multisensory camera that episodically takes photos of the immediate environment and
stores them as depictions of the sexual terrain.

Lovemaps depict a variety of activities and partners that are potentially sexually and erotically
exciting for a specific individual. Lovemaps can be
thought of like a mental map composed of many
different terrains and political/social territories. Some
individuals lovemaps include vast areas, while others
are more limited in scopesome people have a world
of possibilities while others have a small village of
choices to explore.
But the geography of the lovemap is not automatically known to the individual. The individual may
not be aware when parts of the lovemap are encoded
through development and experience. Individuals
learn about their own lovemaps from reflection upon
their fantasies, actual experiences, and vicarious experiences (such as reading, looking at pictures, hearing
stories). They discover what attracts or arouses them
and what does not. Some individuals explore much of
the territory of their lovemap, while others are equally
content to live only in a small but satisfying part of
their lovemap realm. In the end, most people settle
down to a limited number of partners and sexual
activities. The challenge of relationships is to find a
partner and associated erotic and sexual activities that
correspond to a highly charged area of your lovemap,
while you correspond to reciprocal highly charged
parts of your partners lovemap.
Lovemaps allow for choices about which areas
to explore or not explore. Just because an area exists
in a lovemap does not mean that an individual must
explore it. Generally people explore those parts
of their lovemaps that are either more highly sexually/erotically charged or are more socially available
(which may also mean more socially acceptable).
These areas of an individuals lovemap may be similar or dissimilar, or may conflict. Areas of the lovemap
that an individual explores become more familiar,
and thus may be more likely to be revisited. In experiencing a familiar area, other associated aspects of the
terrain that were not initially important may become
more erotically charged with experience. Thus people tend to settle into delimited areas that correspond
to their lovemap.
The commonalities of lovemaps are related to the
commonalities of human experience. Typical developmental experiences in a shared social environment
tend to produce lovemaps with large areas in common. Atypical experiences may contribute to diversity
in lovemap content. And then there is a certain random factor. There are two aspects to experiencethe

PHENOMENOLOGY OF PAR APHILIA

experience in reality, and the representation of the

experience in the mind and brain. Like all maps,
the lovemap is only a depiction that represents or
corresponds to reality. Parts of experience that are
unfamiliar or not understood may not be accurately
represented in the minds lovemap, while experiences
that are associated with different types of arousal may
be encoded differently in the brains lovemap.
In a similar way, the content or territory of the
lovemap may have different valences. One is positive
or present while the other is negative or absent,
or there may be no valence specified. This is like a
figure/ground distinction. The figure may define the
outline of what is appealing or the ground may define
it. For example, a person may be attracted only to
people who share their ethnic background (positive),
or they may be attracted only to people who do not
share their ethnic background (negative), or ethnic
background may not matter (no valence). Similarly,
lovemap characteristics may apply to the self or to
the other, corresponding to a learning process of
identification or complementation. The self may be
represented in the lovemap with reference to the partner (other) both in terms of erotic attraction as well
as sexual activity. This is why many lovemaps and
paraphilias have complements.

LOV EM A PS A ND PA R A PHILI A

Paraphilic lovemaps can be considered vandalized

lovemaps (Money & Lamacz, 1989). Instead of the
individual developing an extensive lovemap with a
diversity of areas to explore, the lovemap territory is
very limited. Or the individual may have a more extensive lovemap, but is trapped in repetitively exploring
only a very limited and dysfunctional territory.
In their book, Vandalized Lovemaps, Money and
Lamacz (1989) describe seven cases of paraphilic
outcomes in children born with different congenital
sexological disorders. The cases include a male with a
history of hypothyroidism who developed pedophilia,
different types of sadomasochism in males with
micropenis or genital ambiguity, masochism in a 46,
XY female with the androgen-insensitivity syndrome,
and bondage and discipline paraphilias in females
with two different syndromes of birth defects of the
sex organs. In these cases, congenital factors contributed vulnerability for the development of paraphilia,
although the specific contribution varied in the

15

cases. More important were also socially induced vulnerabilities and experiences that contributed to the
specific content of the paraphilia. All these children
had problems with stigmatization, and limited participation or negative experiences in sexual rehearsal
play. It is not likely a coincidence that the sadomasochistic types of paraphilia were so prevalent in this
sample. Difficulties in coping with their anomalies
led to difficulties in social learning experiences and
identity development. However, there are also many
other children with similar sexological disorders who
did not develop vandalized lovemaps, although the
incidence would seem to be higher in this vulnerable
population.
Lovemaps may be vandalized by traumatic experiences. Sometimes these experiences may be sexual
victimization. For example, a boy who is sexually
abused may develop paraphilic fantasies involving
sexual activity with a boy (Dhawan & Marshall, 1996;
Hanson & Slater, 1988). Nonsexual punishments or
humiliations may have inadvertent sexual consequences for lovemap development. For example,
paraphilic arousal associated with spanking may
be more prevalent in boys who were spanked with
a paddle (and perhaps inadvertently became sexually aroused during the experience). Similarly, being
punished or embarrassed by being cross-dressed as
a young boy may lead to some boys eroticizing the
experience, which later is expressed as transvestism.
Medical procedures or administration of enemas may
lead to paraphilic eroticization of those procedures in
lovemap development. Punishing children unfairly
for sexual rehearsal play experiences may contribute to heightened eroticization of those activities in
lovemaps.
Several principles seem to be operating for the
creation of vandalized lovemaps. First, the individual
may have some vulnerability, which might not be
associated with dysfunction or hyperfunction in the
sexual system but could instead be developmental,
cognitive, or brain based. For example, individuals
with brain dysfunction including brain damage seem
more likely to manifest paraphilias (Lehne, 1986;
Mendez, Chow, Ringman, Twitchell, & Hinkin,
2000; Simpson, Blazcynski, & Hodgkinson, 1999).
Second, there may be experiences typically before
the age of 8 that involve potential sexual content associated with high autonomic or sexual arousal (Money,
1999, pp. 9499). The sexual arousal may be a result
of direct sexual stimulation, as in juvenile sexual

16 INTRODUCTION

experiences which might be consensual with peers or

associated with molestation, or force. Or the sexual
stimulation may occur as a result of physical or genital stimulation, for example during a physical activity
or medical procedure. Or the sexual stimulation may
occur spontaneously associated with other stimuli,
perhaps related to testosterone surges or just episodes
of erection which young boys experience. Nonsexual
autonomic arousal may also play a role, such as that
which occurs during some situations of punishment
or humiliation. Sometimes the experience may be
something which is not understood, and thus stored
in a literal way in memory, which somehow becomes
associated with other sexual imagery. Third, other
areas of the lovemap may not be as well elaborated.
This may be because the higher arousal associated
with the potentially paraphilic content diverts formative energy from the other areas, or distracts from
exploring them. Thus the elaborated paraphilic area
becomes expanded and explored, while other potential areas are never developed. The result can be an
area of atypical sexual imagery that is associated with
a large amount of sexual arousal.
Individuals can have areas of their lovemaps that
they never discover, explore, or express in fantasy or
behavior. Thus a vandalized lovemap also requires
other experiences which lead to its recognition and
possible expression. Little is known about these
releaser factors, but some individuals do report that
awareness of the paraphilic imagery emerged fullblown in fantasy (or in rarer cases behavior), or was
triggered by an actual experience or a vicarious experience through reading or viewing media including
pornography. In other cases, a paraphilic lovemap
may not emerge until late in life, perhaps associated
with the physical deterioration of the brain.

cases, but whether this is a cause of the high sexual

arousal or an effect has not been determined. But in
most cases, the levels of testosterone are not elevated.
In some cases, the acting-out of a paraphilia is also
associated with high levels of autonomic arousal, more
than what is typically associated with sexual activity. Some men report sweating profusely or stomach
upset. Fugue-like states are common, where extraneous stimuli are blocked by the extreme focus on the
paraphilic scenario, and behavior seems almost automatic (like a psychomotor fugue). Tunneling in vision
and selective hearing is often reported. Thus there
can be a dissociative aspect to paraphilic enactment.
While acting-out a paraphilia may include an
elaborate and well-practiced ritual, younger men
report highly specific fantasies but less commonly
report planning or practicing this behavior. Instead
they describe their behavior unfolding like a chain
of behaviors triggered by an external stimulus or an
internal drive state, rather than consciously motivated or determined. Men frequently talk about the
paraphilia controlling them rather than them controlling the paraphilia. Some talk about behavioral enactment or orgasm primarily as a way to get relief from
the sexual pressure or urge rather than as an achievement of a positive goal, as would be the case for more
typical sexual activity.
It is tempting to use a hydraulic model to explain
this high energy force of arousal or motivation. If a
typical lovemap includes a larger territory to explore
and act upon in sexual situations, like water flowing
over a broad plateau, the energy is spread out and
there are many options for run off. However, if the
territory is very limited, like water flowing through a
small valley, the force of the sexual energy is much
greater.

Sexual Arousal/Motivation of Paraphilia

Developmental Phenomenology
of Paraphilia

Paraphilias are typically associated with high levels

of sexual arousal or motivation. It is not unusual for
some men with a paraphilia to report long periods
of hypersexuality, to the extent that some of them
maintain erections for hours and may masturbate to
orgasm six or eight times a day or be constantly preoccupied with paraphilic fantasy and imagery. There
is an obsessional aspect to paraphilic imagery that is
even more obsessive than typical sexual and fallingin-love imagery, and less time limited. This may be
associated with high levels of testosterone in some

Individuals with paraphilias often report developmental vulnerabilities and early experiences that were
eroticized and seem to be closely related to the content of the paraphilic imagery or fantasy. Once established, the paraphilic lovemap may lay dormant until
it is energized by the hormones of puberty. In retrospect, some individuals with paraphilia report a special fascination with content related to the paraphilia
in childhood, although this was not recognized as
sexual. For example, men with a paraphilia involving

PHENOMENOLOGY OF PAR APHILIA

bondage might recall being particularly interested in

playing games such as cowboys and Indians as children, where they or another child might be tied to a
tree. In another case, the mother of a man with a shoe
fetish recalled that as a child he would hide under the
card table when her friends would come for bridge
games and seemed fascinated by their shoes. Of
course this led to an uproar, as the women assumed
he was looking up their skirts, and he was traumatically banished. A transvestite might recall some experiences cross-dressing as a child, and perhaps even
a special feeling associated with those activities. In
most cases, these experiences were not interpreted as
being sexual, or sometimes not even unusual or significant. However, many men with paraphilias recall
no such childhood experiences. Others can recall
one significant experience which may be related to
the origin of the paraphilia, but no other subsequent
experiences until adolescence.
After puberty, the paraphilic lovemap becomes
progressively characterized by obsessional thoughts
and fantasies. In many cases, these may present themselves uninvited and unwanted to the individual. The
individual may struggle to reduce or eliminate this
imagery, or there may be hypersexual masturbation
or associated sexual behavior. There is a questioning
and eventually realization that the individual may
not be like others in his private sexual thoughts or
interests.
Sexual thoughts and fantasies may soon lead to
compulsive acting-out of sexual behavior. Control
of sexual behavior becomes even more difficult if
the lovemap does not include many nonparaphilic
options. The paraphilic imagery and behavior by
its nature is very ritualistic and limited. It may be
expressed by obsessive collecting of items associated
with the paraphilia, including viewing and collecting
pornography.
The course of adolescent and young adult development may become altered depending upon the
nature of the paraphilic interests (see Lehne, 1990).
There may be reduced sexual motivation to pursue
more socially conventional paths of heterosexual or
homosexual relationships. Or there may be increased
pursuit of more conventional erotic and sexual activities in an attempt to overcome the paraphilic interests. The individual may find that he has to rely upon
the paraphilic imagery or practices for sexual arousal
or ejaculation, and may experience sexual dysfunction when he does not.

17

The paraphilic lovemap content has to be integrated into the self-concept. How this occurs depends
greatly on the specific paraphilia. Awareness of a primary sexual interest in boys, for example, may not be
apparent until the individual is out of adolescence.
Then as the individual develops a lifestyle that allows
more contact with boys, he is not involved in activities
with adults who might be potential sexual partners
or at least help broaden his interests in typical adult
activities. As he realizes the stigmatized nature of his
sexual interest, he may develop a negative self- concept
and a secretive style to avoid getting into trouble. He
begins to develop cognitive distortions and justifications of his behavior, which may further increase
his social alienation or feelings of being different.
A man with a lovemap involving cross-dressing might
experience confusion about gender identity or sexual
orientation, or unusual social beliefs about clothing
or the importance of men expressing their feminine
side. An exhibitionist with a history of frequent arrests
but otherwise no criminal interests may find himself a social outcast unable to pursue his otherwise
conventional social and work interests.
The paraphilia interferes with pair bonding, since
the process of sexual arousal may be focused on something other than an available partner. The paraphilic
sexual fantasy comes between the man and his partner. Sex with a partner is much less exciting than
paraphilic sexual activities. The man is likely to continue to explore paraphilic sexual outlets, which diverts
sexual energy away from a relationship. Aspects of his
life become secretive, and he becomes more emotionally walled off from a partner. A relationship is likely
to become more based on companionship rather than
erotically bonded. There may not even be sufficient
nonparaphilic territory in the lovemap to lead to
attempts to find a romantic or sexual partner.
In the end, depending upon the specific paraphilia, there may be characteristic distortions in the
path of typical psychosocial development. Instead
there is development of a lifestyle that centers around
the paraphilia. More typical patterns of heterosexual
or homosexual relationships and lifestyles may be
eschewed in favor of lifestyles that support the justification and expression of the paraphilia.
Multiplex Paraphilia
When paraphilias are defined according to a single
behavioral focus (such as DSM-IV-TR criteria), an

18 INTRODUCTION

individual may be diagnosed with several different

paraphilias. When paraphilias are conceptualized
in terms of lovemaps, all these multiple paraphilias
may be seen to be manifestations of one multiplex
paraphilia that is the embodiment of an earlier life
experience which was sexually imprinted in the lovemap. A man with a multiplex paraphilia who was followed for more than 40 years provides an illustrative
case example of the phenomenology of paraphilia
(Lehne & Money, 2000, 2003). The history is particularly interesting because much of it was recorded
prospectively instead of retrospectively.
Jack was punished for rowdy behavior in the first
grade by being made to wear a girls dress and stand in
the corner; he was humiliated by the other children.
At age 7, when he was still frequently wetting the bed,
his mother gave him a similar corrective punishment
of dressing him in a diaper and girls skirt and parading him around their housing project telling him, If
you are going to act like a sissy baby, you are going
to be treated like one. When Jack was 9, his mother
once used him as a dressmaker dummy, forcing him
to wear a skirt while she hemmed it. Although he
protested that he was embarrassed, he found that
he enjoyed this experience. He began secretly wearing his mothers skirts when he had a chance, and
although prepubescent, he reported that he had an
erection and a good sexual feeling at those times.
Jacks social presentation was very macho, and
he had extensive heterosexual experience. He crossdressed at times for masturbation (transvestic fetishism), and at other times for relaxation, except while he
was in the Army. He married soon after his discharge.
He had an active sexual relationship with his wife, but
often would also have from two to eight orgasms a day
through masturbation. Although he had not intended
to resume cross-dressing after his marriage, he had an
increasing urgency to wear womens clothing. Soon
Jack was involved secretly with transvestite groups and
writing TV erotic stories for publication. His wife was
upset by his cross-dressing, and said that she could
tell from his demeanor when he had done it while she
was gone. She also said that she could tell when he
had cross-dressing fantasies during sexual relations,
because intercourse was like he was masturbating in
her vagina.
When his son was 6 years old, Jack started playing
TV games with him. He cross-dressed his son in
girls clothes and at some of those times he sexually
aroused the boy (pedophilia). This led to his treatment

with Depo-Provera, and all sexual activity with his

son stopped and his cross-dressing stopped. Jack had
long periods of time without cross-dressing after he
stopped the Depo-Provera, and also had episodes of
relapses into cross-dressing. He never engaged in any
other sexual activities with children.
In his forties, Jack had stopped cross-dressing for
years, but appeared to have developed a new sexual
preoccupation with being an adult baby (infantilism).
Messy play with diapers, urination and defecation, was
part of his sexual scenario (urophilia & coprophilia),
which was not associated with erection or ejaculation.
However, he would recall his behavior and write stories about it, which was accompanied by masturbation. This remained his primary sexual interest for
the next 20 years, although he also continued to have
a regular sexual relationship with his wife.
Using traditional diagnostic criteria, Jack would be
diagnosed at different times in his life as having the
five paraphilias of transvestic fetishism, pedophilia,
infantilism, urophilia, and coprophilia. However, all
of these manifestations of paraphilias can be thought
of as one multiplex paraphilia related to his experience at age 6 of being dressed in a diaper and skirt as
a punishment for bedwetting. At different times in his
life he sexually enacted different parts of this multiplex paraphilic scenario that was most likely, sexually
imprinted at the time of his juvenile punishment.
There is a complementarity in Jacks multiplex
paraphilia. The core experience is being cross-dressed
(as a girl and a baby) when he was a 6-year-old boy.
Part of the paraphilic enactment involved crossdressing himself and also being a baby himself. But
the complementary enactment of this paraphilia
was cross-dressing his son when he was 6, about the
same age as Jacks critical experience. Thus multiple
perspectives of the same experience may be literally
imprinted as the paraphilia.
Complementary Paraphilias:
Sadomasochism
The story of Ron is reported in his lovemap autobiography called The Armed Robbery Orgasm (Keyes &
Money, 1993). His story became notorious when
he committed a series of 20 armed robberies over
a 6-week period, with no prior criminal history. He
used an insanity defense that he was a sexual masochist and his dominatrix girlfriend ordered him to
commit the robberies as part of their sexual activities.

PHENOMENOLOGY OF PAR APHILIA

This defense based on paraphilia (and bipolar disorder) was not successful.
Rons parents separated when he was 5 years old.
However, his father continued to return to the house
for visits until he was age 9. During those visits his
father would administer unjustified beatings with a
belt on the childrens bare buttocks, according to the
order of his mother who said the children had to be
punished for misbehavior. At about the age of 8 or 9,
Ron experienced an erection during a beating, which
shocked his father. His mother continued to spank
him into his teens, and he would have erections during many of those times from age 12 on. It is possible
that his father was a masochist and his mother was a
sadist.
When Ron began to masturbate, he would spank
himself to achieve erection and orgasm. His sexual
fantasies were of women dominating him in various
ways, and punishing him especially by spanking for
his misbehavior. He did not have fantasies of romantic
or affectionate relationships with women. His sexual
outlet in fantasy, and later usually in reality, was selfmasturbation rather than intercourse or other sexual
interactions. Ron did briefly marry, but could only
become aroused for intercourse by having fantasies of
being dominated and punished by women. He never
had a love affair, but has had obsessional relationships
with prostitutes, who would dominate him.
Ron always had a very high degree of sexual
arousal and obsession with masochistic fantasies.
When in a paraphilic state, he could continuously
masturbate for up to 10 to 12 hours with a constant
erection, ejaculating up to 12 separate times in a day.
Although he could be highly successful in his work as
a salesman, he was never able to accumulate money
or be consistently successful because of the time and
money he spent seeking out dominatrix prostitutes.
He met a stripper in a bar, on the Block in
Baltimore, and dominating men seemed to be her
sexual interest, not just her act. Physically she resembled his mother. He did not talk with her at their
initial meeting, but he sexually fantasized about her
continuously for about 8 hours afterwards. They commenced a weekly paid sexual relationship, where she
dominated him and punished him, but there was no
genital sexual contact for the first 6 months. He would
masturbate thinking about their encounters for 10 to
12 hours later. Then he persuaded her to move in with
him, and they were able to engage in intercourse for
about a month until they both needed to resume their

19

sadomasochistic relationship for sexual arousal. She

ordered him to do an armed robbery with her pistol,
then they would use the money to buy lingerie and
an expensive dinner. They would spend 12 or more
hours in a sexual episode, describing the robbery and
punishing him for his bad behavior. He would have a
constant erection from the time they set out to do the
robbery and frequent ejaculations, and she would also
be very sexually turned on and orgasmic. They did
this several times a week for more than a month.
Feeling totally out of control, Ron finally told her
that she had to move out. She then turned him in
to the police, and later she testified against him for
his final punishment of several concurrent 10-year
sentences of incarceration.
This is an example of two complementary paraphilias in sexual partners, a paraphilic folie a deaux.
Complementary matching of paraphilias between
two partners is more likely to occur for sadism and
masochism than any other paraphilia. It is also
more likely to occur for same-sex couples than for
opposite-sex couples. However, although Ron and
his dominatrix partner had an extremely strong bond
based on shared complementary sexual fantasies, the
couple was not erotically bondedthey were bonded
by sex activity, not sexual love. The intensity of the
paraphilic sexuality was too strong for either partner,
and their relationship exploded from the intensity.
A number of paraphilias are complements of each
other, and some may coexist within the same person.
Sadism and masochism occur together so frequently
that they are often lumped together as sadomasochism.
The roles of victim and perpetrator can be switched
in sexual fantasies and behaviors. Even Ron and his
partner in crime occasionally switched roles in their
later sexual play. Fetishism and transvestic fetishism
can be complimentary. In these cases, the fetishistic
items may be erotic on the self (transvestic) and also
erotic off the self (as objects) or on the other.

E X HIBIT IONISM A ND VOY EUR ISM

Exhibitionism (showing) and voyeurism (looking)

are complementary in the sense that they are different sides of the same coin related to the forbidden or
shock value of sexual nudity, but they do not usually
coexist within the same person. They do not flourish in situations where nudity is expected instead of
prohibited, like nudist camps or nude beaches. The

20 INTRODUCTION

acceptance of nudity among people of the same

sex generally means that exhibitionists typically are
heterosexual. Exhibitionism usually focuses on the
response of the viewer, be it surprise, or disgust, or
shock, or interest. Each exhibitionist is usually looking
for one particular type of reaction, and is not satisfied
with other types of reactions. In this sense exhibitionism shares a commonality with obscene telephone
calls, where the reaction of the caller is tantamount
for sexual excitement. In rare cases, exhibitionists
show photos of their penis to elicit a response from
a targeted female. Thus what is sexually arousing for
exhibitionists is the response of the target, not the act
of exposing. In this sense it is not the compliment of
voyeurism, where the turn on is seeing what you are
not supposed to see, without being seen so there is no
response from the target.
For voyeurism, the looking must be illicit, forbidden, for it to be exciting. In this sense looking
at pornography is not characteristic of voyeurism,
because pornography is a sexual media made to be
seen. But looking at webcams or secret photographs
(i.e., up-skirting, down-blousing, bathroom shots) of
unsuspecting women may be voyeuristic. Since this
is a prevalent heterosexual male interest, we can see
how conventional sexual lovemaps begin to shade
into paraphilic lovemaps in content. What is missing is the ritualistic, repetitive driving quality of the
motivation that is characteristic of paraphilia.

IN T ER NET, LOV EM A PS,

A ND PA R A PHILI A

The Internet offers a lovemap library that illustrates

both the diversity of human sexuality and the specificity of paraphilic sexuality. The Internet has quickly
become a primary source of sex education for individuals to learn about their lovemaps. Individuals can
check out stories, photographs and videos to learn
about what turns them on and what does not. The
range of content is staggering.
One commercial website that primarily sells mainstream adult DVDs offers more than 500 keyword
descriptor terms for heterosexual DVDs and more
than 250 for gay DVDs. The descriptors specify the
characteristics of the people, the sexual activities, and
the settings and themes. Potential buyers can search
for DVDs using any term(s) they choose. The site
will also suggest related DVDs purchased by other

customers who bought the DVD under consideration

for purchase. The range of choices reflects the diversity of normative human sexualitythis type of site,
selling mass market DVDs, is not catering to highly
specialized or potentially illegal sexual interests.
Individuals tend to explore a limited number of fantasy themes present in their own lovemaps. Customers
must purchase a DVD to see the content, so customers tend to buy what they know they like. This allows
the individuals to explore in depth a relatively delimitated area of their lovemaps. In the process of exploration, this area of the lovemap may become more
highly erotically charged. However, any specific item
of pornography tends to lose its highly arousing erotic
charge after repeated viewing. So the suggestion of
other DVDs, based not on keywords but on other
customers purchasing patterns, allows customers to
explore possibly related areas of their lovemaps which
they might not have explored before.
Individuals do not develop new sexual interests
simply as a result of being exposed to pornography
with a content that is new to them. They become interested and aroused primarily by sexual content that is
already represented in their lovemaps. However, in
some cases they may not be aware of all of the types
of content in their lovemaps. Exciting new content
has to be related to a territory previously delineated in
their lovemaps, but perhaps not explored. Exploration
creates the excitement of a first-time visit, and with
familiarity there may be some expansion of the sexual content which they find arousing. If something
is absolutely not present in the lovemap of an individual, it may be potentially interesting to look at but
will not be revisited. Or it may not be appealing, or
even be disgusting and avoided.
However, certain types of lovemap content commonly go together. For example, there are certain
characteristics of men or women that are more commonly associated with certain themes and certain
sexual activities. For example, sexual domination
is more often associated with an older partner, certain activities like spanking, and certain outfits like
leather, and perhaps specific settings. Other content
may not be included or excluded, and sometimes even
basic sex acts like intercourse or acts of affection like
kissing are not included. The practiced sex act of the
viewer is typically masturbation. So the types of lovemap content that are explored and which commonly
go together in conjunction with sexual arousal and
orgasm may become associated in the lovemap. Thus

PHENOMENOLOGY OF PAR APHILIA

a person may initially explore a lovemap area for the

mountain scenery and end up developing an associated love of the cuisine. In this sense exploration of a
lovemap may change the terrain of the lovemap, as a
person may come to eroticize sexual content which
could be associated with the lovemap territory but
was not initially eroticized. This eroticization can
become paraphilic.
Viewing sexual depictions of children is one dangerous example of developing somewhat paraphilic
interests. Since all adults were once children, they
may have represented in their brains affectionate and
erotic imagery of children. Many people still have
imagery in their lovemaps, infrequently reviewed, of
a boy or girl who was their first love when they were
age 8 to 12. Perhaps they were frustrated or limited in
their opportunities for adolescent exploration of sexuality or relationships. In coming across child pornography on the Internet, they may become interested in
seeing if the imagery is sexually arousing for them. Or
they may become interested in looking at what they
feel that they missed out on, or revisiting experiences
that they found highly erotic in childhood. Thus an
individual who may not be aware of pedophilic sexual
interests may become caught up in looking at child
pornography on the Internet. This exploration, while
initially not paraphilic, can lead to dangerous (and
illegal) developments in lovemap exploration.
The development of a long-term bonded sexual
relationship can illustrate this process of lovemap
elaboration in a positive sense. Erotically and sexually
bonded love relationships may indeed be a specific,
normative case of paraphilia. Individuals are initially
attracted to each other because of certain characteristics in their lovemaps. In the course of their relationship, other associated characteristics of the partner
and the activities they engage in together become
more eroticized. The partners themselves change over
time, and their new characteristics also may become
eroticized (or at least less de-eroticized than they
may have been). For example, with the aging of partners their more mature physical characteristics may
become more sexualized in their lovemaps. A tragic
situation is where the lovemap does not change, and
the sexual relationship stops at a certain point or the
partner is abandoned for a perhaps younger or different looking partner who better matches the characteristics specified in the lovemap. This is always the case
with paraphilic lovemaps, because they are highly
resistant to change.

21

But when lovemaps are explored not with a partner but on the Internet, the situation is potentially
different. While the Internet offers sexual diversity as a learning choice, it also offers specificity as
an alternative. Thus a person can explore hundreds
of variant scenarios, or hundreds of variants of one
sexual scenario. A lovemap becomes paraphilic when
the content that is explored as the primary source of
arousal is highly limited and specific and also highly
sexually charged or motivated. Because of the massive amount of highly specific sexual content available on the Internet, some individuals focus all of
their sexual energy on increasingly small amounts of
territory. It may be that this is the only territory available to them as a product of their physiological status and life history. Or it may be that this is the only
territory they choose to explore, and which therefore
becomes highly erotically charged for them. While
the Internet does make available access to partners for
sexual exploration, the primary sexual activity associated with pornography on the Internet is masturbation. On the Internet, the individual can always find
more of the same for masturbation. Some individuals
develop sexual arousal patterns that function only for
masturbation, and do not allow a role for a partner in
sexual activity, which could become characteristic of
a paraphilia.
The activity of looking at pornography or sexual
images and stories on the Internet itself can become
paraphilic for some individuals. They are able to tailor the sexual content they look at to their own highly
specific interests. In some cases these specific interests are themeslike the forbidden or the desire to
see something new. They go into trance-like states,
transfixed by the multitude of images and losing
track of time and their surroundings. They become
obsessed with their sexual looking. Their time on the
Internet becomes so compulsive that it crowds out
other activities from their lives, limiting their sleep,
interfering with work. They collect and catalogue
huge inventories of images. Masturbation to Internet
imagery diverts their sexual energy away from sexual
relations with a partner, or seeking to find a partner.
It interferes with pair-bonding and relationships.
Individuals with paraphilia are often drawn to the
Internet. Much truly paraphilic imagery cannot be
consistently expressed in reality. It is best represented
in fantasy, in the same way that pictures or movies
of beautiful vacation places are often more attractive than the reality. The Internet offers both breadth

22 INTRODUCTION

and depth of paraphilic depictions. It also offers

contact with other individuals who share aspects of
their paraphilic interests, regardless of how bizarre
or unusual or specific. Newsgroups, with paraphilic
focus, offer an opportunity to exchange information,
imagery, and perhaps even meet others with the same
interest. Usually when people share a paraphilic interest they are more like friends with an interest in common, rather than people who are interested in each
other as sexual or erotic partners. These Internet contacts encourage individuals to define their paraphilic
interests as being acceptable, to at least some social
group. Ego-dystonic paraphilias may thus become
ego-syntonic.
Many paraphilias are better expressed on the
Internet than in reality. For example, consider pedophilia. Pedophiles are typically interested in a highly
specific age, sex, and type of child. In reality it can be
difficult to develop a connection with such a child.
The child may be an object of sexual fantasizing. But
actual sexual activity with a child is both wrong and
illegal. Furthermore, the child is unlikely to have any
reciprocal sexual interest or engage in any type of
satisfying sexual behavior with the paraphilic adult.
Even if all these obstacles are overcome, the child will
soon age out of desirability. Many pedophiles do not
even have sexual fantasies of a mutual sexual activity
with a child that would bring the pedophile to orgasm.
Their fantasies are more akin to masturbating themselves to some recalled or viewed image of the child.
So child pornography is actually a more viable and
reliable sexual outlet than involvement with children.
It allows pedophiles to masturbate to a depiction preserved in time of their idealized imagery. Therefore,
many pedophiles become obsessive consumers and
collectors of child pornography, which is primarily
available through the Internet.

PEDOPHILI A

Pedophilia embodies the complexities of lovemaps

and paraphilia. To some extent, all individuals have
an erotic and sexual attraction to children previously
encoded in their lovemaps. Because of the developmental nature of human sexuality, when individuals
are young and in association with other youth, there
are sexual and romantic attractions. These attractions are preserved in the lovemap, although they
may not be often reviewed or rehearsed years later for

masturbation. Similarly, most youth do not have erotic

images of significantly older people in their lovemaps.
But as they get older, their progressive experiences
eroticize more aspects of people their age and older.
They may or may not find their attraction to younger
people waning. Also societies tend to eroticize certain
ages as an ideal, so there is additional input into the
lovemap that might, for example, make 25-year-olds
appear attractive to 50-year-old men, although they
would not find 15-year-olds attractive. At the same
time, they now find 50-year-old women attractive as a
result of progressive erotic experience, although they
might not have found them sexually appealing when
they were 15 or 25 years old (or perhaps they did). The
presence of residual imagery in the lovemap, even if
it remains in areas not explored since youth, is what
makes some men vulnerable to sexual involvement
with youth in certain situations even though they may
not have a paraphilia of pedophilia or ephebophilia.
For example, a man might have fallen in love with his
wife when she was 16 and he was 18. Many years later
he may experience a revitalization of that part of his
lovemap in a situation involving a daughter or granddaughter who bears a resemblance to what he found
attractive so many years ago in his young wife.
There are two general types of pedophilic lovemaps. One type is most frequently encountered as
boylovers, where the primary pedophilic lovemap
specifies the age range and types of boys that the
man finds erotically appealing, in the sense of falling in love with them. The pedophile loves the specific qualities of boys (often including their smell),
and sexual activities may not be so important. What
is important is spending time with boys, almost in
the role of another boy, and taking shared pleasure
in boy things. This lovemap may correspond to the
lovemap the man had at the time he was a boy, and
it never changed or was elaborated as he grew up. If
those activities include boy-types of sexuality such as
show-me play or masturbation, then sexual arousal
and ejaculation with boys may also be included in
the lovemap of their interactions with boys. These
lovemaps focus on developing a relationship with a
specific boy or group of boys. Boylovers often do not
have any other type of partner that they can fall in
love with, and thus do not have a romantic or sexual
interest in adults of either sex. For many of this type
of boylover, their only sexual outlet is masturbation in
private to child pornography or recall of their nonsexual experience. The depiction of boys in erotica may

PHENOMENOLOGY OF PAR APHILIA

emphasize their physical qualities, often with more

focus on the face and involvement in boyish activities rather than showing overt sexual activity with
another person. Their sex drive may be low although
their obsession in being with boys is high, so these
are paraphilias in consideration of the fact that their
lovemap is so highly specific in specifying the type of
partner for bonding.
Another type of pedophilic lovemap is more
specifically sexual, in terms of having a highly specific sexual content and a high intensity of sex drive.
This type of pedophilic lovemap may be related to
childhood traumatization. Sometimes the imagery
incorporates themes of punishment, humiliation, or
shame. Sexual activity rather than a relationship with
a boy is the focus, and thus the boy can be a stranger.
This type of pedophiles interest in child pornography
may include depictions of boys in sexual situations or
interpersonal sexual activity.
Men whose lovemaps primarily focus on teenagers
(ephebophilia) are similar, but some may also have
more potential sexual interest in adults. Men whose
lovemaps focus on girls are also more likely to have
potential sexual interest in adult women.

LOV EM A P PHENOMENOLOGY A ND
DI AGNOSIS OF SE X OFFENDER S

Lovemap phenomenology is a theoretical approach

to describe and explain diversity in the content of
human erotosexuality, not to diagnose pathology. Sex
offenders engage in illegal sexual activity for a variety
of reasons, some of which may be elucidated in the
process of differential diagnosis (see, for example,
Berlin et al., 1997). The diagnosis of paraphilia may
be related to sex offending behavior in many repeat
or incarcerated sex offenders, but perhaps not many
more than a simple majority depending upon the
sample and diagnostic criteria (see, for example,
McElroy et al., 1999). Many sex offenses are committed by men who have no sexual diagnosis, and do not
have a diagnosis of a major mental illness. Situational
factors, personality disorders, such as antisocial personality disorder, and alcohol and substance intoxication also play a large role in sex offending.
Although paraphilias are diagnosed in terms of the
content of sexual desire, the reason they contribute to
sex offenses is usually because of the intensity of the
sexual urges which the affected person cannot or does

23

not control. Individuals with paraphilias may have

the largest number of different victims or offenses,
but they may not commit the majority of many types
of sex offenses. For example, pedophiles are likely to
have more child victims per offender, but most sex
offenses involving children are not perpetrated by
pedophiles. Similarly, paraphilic rapists (who are
serial rapists) have the largest number of different victims per offender, but most rapes are not committed
by serial rapists. What a diagnosis of paraphilia influences is the likelihood of reoffending. For example,
a pedophile is more likely to engage in additional
offenses in the future than a nonpedophilic child sex
offender, such as an incest offender (Lehne, 1994).
In a similar vein, there are individuals who repeat
their inappropriate sexual behavior because they have
the high level of sex drive characteristic of paraphilias,
although they do not have the distinctively unusual
content of sexual interests which are often used to
define the paraphilias. Kafka and Hennen (1999)
refer to these as paraphilia-related disorders.
The phenomenology of lovemaps provides an
additional approach to understanding the sex offenses
of nonparaphilic sex offenders. People sometimes
engage in exploratory sexual behavior to learn about
their own lovemaps, which can particularly be a factor in adolescent sex offending. Otherwise, people
usually do not engage in sexual behavior that is not
somehow related to their lovemap. What an understanding of lovemaps contributes in the assessment of
offenders is what the related content of sexual behavior might be, and what other options there are for
sexual behavior.

CONCLUSION

Every person has a highly individualized lovemap

that represents the variety of characteristics of partners and activities that are sexually arousing and
erotically (in the sense of love) appealing. Lovemaps
are diverse because human sexuality is the diverse
product of physiological and life history events.
Individuals spend their lives learning about and
exploring their lovemaps, sometimes elaborating
their geography while at other times living in a small
territory. Lovemap theory provides a way for thinking
about the content and approach motivation of human
sexuality and paraphilic sexual disorders. This can
be analogous to the way anxiety theory relates to the

24 INTRODUCTION

content and process of human avoidance behavior

and phobias.
Sex offenses can be related to the exploration or
expression of part of the content of an individuals
lovemap. Paraphilias are specific types of vandalized
lovemaps characterized by very high specificity of
sexual content and high sexual drive or motivation.
Paraphilias can be mental disorders which may or
may not be related to sex offenses, although the historically named and popularized paraphilias tended
to be associated with sex offenses.

References
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and statistical manual of mental disorders, 4th (text
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Berlin, F. S., Lehne, G., Malin, H. M., Hunt, W. P.,
Thomas, K. & Furmaneck, J. (1997). The eroticized violent crime: A psychiatric perspective
with six clinical examples. Sexual Addiction &
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Bradford, J. M. (1999). The paraphilias, obsessive compulsive spectrum disorder and the treatment of
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Lehne, G. (1986). Brain damage and paraphilia: Treated

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McElroy, S., Soutullo, C., Taylor, P., Nelson, E.,
Beckman, D., Brusman, L., et al. (1999). Psychiatric
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Money, J., Wainwright, G., & Hingsburger, D. (1991).
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Part II

Neurobiology/Neuropsychology

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Chapter 3

Neuropsychological Findings
in Sex Offenders
Ron Langevin

broad categories: stimulus preferences and activity or

response preferences (see Langevin, 1983). Stimulus
preferences can be described as the properties of
persons or things that lead to sexual arousal. Typical
stimulus preferences involve the age and gender characteristics in the desired sex partner. Pedophiles who
erotically prefer children are among the most common stimulus preference group seen in forensic clinics at present. Response or activity preferences can
be described as the sexual behaviors an individual
wishes to carry out with their preferred person or
object. Sexual intercourse or oralgenital sex are the
most common conventional activities preferred, but
courtship disorders or combinations of voyeurism, exhibitionism, frottage, sexual aggression, rape, and/or
sadism, are common sexual disorders seen clinically.
Freund et al. (1983) theorized that these sexual behaviors represent abnormalities of normal courtship,
which they labelled searching, pretactile interaction,
tactile interaction, and genital union with a partner.

This chapter explores the brain structures and neuropsychological dysfunction associated with sexual
disorders. Evidence is reviewed that shows substantial numbers of sex offenders and men with sexual
disorders (paraphilias) have learning disabilities
and neuropsychological impairment, which manifest early as significant difficulties in school. For
instance, more than half have failed a grade in
school and more than a third were in special education classes for children with learning disabilities.
A theory that different sexual disorders are associated
with pathology in different brain structures is examined. Implications for education and therapy of sex
offenders are discussed.
Paraphilias appear to come in a variety of
types, from pedophiles, who erotically prefer children; to exhibitionists, who expose their genitals
to unsuspecting strangers; and fetishists, who are
drawn to inanimate objects for sexual gratification.
However, paraphilias can be classified into two

27

28 NEUROBIOLOGY/NEUROPSYCHOLOGY

Paraphilias make their initial appearance around the

time of puberty and, for the most part, persist a lifetime (see Langevin, 2004a). About half of the men
who are sexual offenders or who present at forensic
clinics have multiple paraphilias, making the study of
pure groups such as pedophiles more difficult (Paitich,
Langevin, Freeman, Mann, & Handy, 1977). Thus, it
is not uncommon to see a pedophile (stimulus preference) in combination with exhibitionism (an activity
preference). Why are these aberrant sexual behaviors
so strong and enduring and how do these different
paraphilias arise?
In case studies in the 1950s and 1960s, neurologists reported unusual sexual behavior associated with
brain injury or dysfunction (see Purins & Langevin,
1985 for review). The areas of the brain most associated with the sexually anomalous behavior were the
temporal lobes, believed to be a projection area in
the more developed brain from the primitive deep
limbic brain sites associated with sexual arousal and
release. A series of controlled computer tomography
(CT) studies by the author and his colleagues in the
1980s found support for these case studies and the
involvement of the temporal lobes especially, in that
there was significant dilitation of the temporal horns
of the brain among pedophiles and sexually aggressive men. It was interesting that the pedophiles more
often showed left hemispheric temporal horn dilitation, whereas the sexual aggressives (a generic term
for men who sexually assault and rape adult females)
showed right temporal horn dilitation. This led to the
hypothesis that the two different sexual behaviors
may be associated with brain pathology or dysfunction in different hemispheres, the stimulus preference
of pedophilia in the left language/classificatory side of
the brain and the activity preference of sexual aggression in the right or visual spatial/emotive side of the
brain. A study with Percy Wright, Jose Nobrega, and
Geroge Wortzmanin. (1990) found that the brain was
predominantly smaller on the left side of pedophiles
brains and smaller on the right side of sexual aggressives. Aigner et al. (2000) provided additional support
for these CT findings, using magnetic resonance
imaging (MRI) and they suggested that such abnormalities may be associated with violent behavior in
general.
Flor-Henry (1980) proposed a theory of normal
brain functioning related to sexual behavior. He
argued that sexual ideation develops in the dominant (typically left) brain hemisphere and normally

triggers an orgasmic response represented in the nondominant (usually right) brain hemisphere. He proposed that, in men with paraphilias, there is damage
or pathology in the dominant hemisphere and conventional (nonparaphilic) sexual behavior is not elicited. Flor-Henry et al. (1988) found some support for
the theory measuring electroencephalogram (EEG)
in exhibitionists.
This chapter reviews evidence that there are
functional differences in the brains of sexually disordered men, which are associated with their behavior
and may provide possible developmental and causal
explanations for the unusual sexual behaviors. School
difficulties in learning as children, intelligence, and
neuropsychological findings among sex offenders are
examined in order.

GR A DE FA ILUR ES A ND
SCHOOL DROPOU TS

When educational attainment is reported in studies

of sex offenders, it is usually incidental to some other
aspect of the study, such as treatment effectiveness.
Grade failures or repeats and placement in special
education are rarely mentioned and the mentally retarded are often excluded from studies. Men with
sexual disorders, in a variety of studies, typically present as high school dropouts. One may postulate many
reasons for individuals leaving school prematurely,
such as family problems or lower social class and poverty, rather than learning difficulties per se. Cohen
et al. (2002) examined 22 heterosexual nonexclusive
pedophiles and 24 controls and concluded that early
childhood sexual abuse led to neurodevelopmental
abnormalities in the temporal region mediating sexual
arousal and erotic discrimination and in the frontal
regions mediating the cognitive aspect of sexual desire
and behavioral inhibition. However, such conclusions
remain highly speculative. As Anderson et al. (2001)
indicated, when there is neurocognitive impairment
in a child, it may be difficult to determine whether
factors such as family problems exacerbate the impairment or result from it. It is beyond the scope of this
chapter to report on acknowledged family problems in
men with sexual disorders and the present focus is on
the neuropsychological findings.
A few studies indicate that not only do sex offenders and paraphilic men leave school prematurely, but
about half fail a grade before leaving school for good.

NEUROPSYCHOLOGICAL FINDINGS IN SEX OFFENDERS

In 1993 our research group (see Langevin & Pope,

1993) reported on 76 cases and found that 63% failed
and repeated at least one grade in public or high
school. It was interesting that, whereas 48% of the
25 pedophilic men repeated a grade, 85% of the 26
sexually aggressive men did so, suggesting greater
learning problems in the latter. It should be noted that
the last grade the offender attended was not included
in the failures, if the offender had left school before
completing his final year in school. A more recent
report (Langevin, 2004b) on 1339 cases found similar results and 51.7% of the total sample had failed
a grade before leaving public or high school. Results
were also similar for pedophilic groups with 51.5%
of the 404 cases failing a grade and 60.8% of the
171 sexually aggressive men failing at least one
grade. It seems the learning problems appeared at
an early age in many cases, with 38.3% of the failures occurring before grade three. The school system in Ontario, Canada, from which these data
are drawn, apparently does not keep data on grade
failures or repeats because officials, to whom I have
spoken, said that it is extremely rare. Children are
kept with their age peers and moved up a grade,
even if they have not mastered the material in their
current grade. However, in this same school system,
there are special education classes for children with
special needs and learning problems. When they
cannot function in the regular grade, they may be
moved to a special education class. Data from the
province indicate that between 2% and 3% of children in the school system generally were in special
education classes. Of the 1359 sex offenders we studied, 38.2% were in such classes. Thus, more than
12 times as many sex offenders, than expected by
chance in the Ontario population at large, were in
special education classes and were identified as having learning problems. Pattern of grade failures for
specific sex offender subgroups was repeated in the
findings on attending special education classes. A
total of 38.5% of pedophiles versus 52.7% of sexual
aggressives were in such classes. One reason for the
disparity in these two groups in our sample was the
higher incidence of attention-deficit/hyperactivity
disorder (ADHD) among sexual aggressives than
pedophiles. It is well known that about half of ADHD
children also have accompanying learning disabilities. Little attention has been paid by Forensic professionals in the past to ADHD diagnoses among sex
offenders, but 20% of the sexual aggressives studies

29

here did receive a childhood ADHD diagnosis, as

did 11.7% of pedophilic men. Vaih-koch et al. (2001)
examined 175 sex offenders using DSM diagnoses
and found a somewhat higher rate of 28% with an
ADHD diagnosis, indicating that ADHD should be
more thoroughly and carefully examined among
sex offenders. Daderman et al. (2004) reported on
10 rapists and found that 6 suffered from ADHD
and 7 were dyslexic. Ponseti et al. (2001) examined
44 violent and sex offenders and 81 nonsex offenders
in a German prison and found a similar but noteworthy incidence of ADHD in both groups, suggesting
that ADHD is not peculiar to sex offenders, but it
is a problem that merits attention in forensic cases
generally.
One also may ask if learning disabilities are as
common in the criminal population at large or in
nonsex offenders as they are in sex offenders, but there
is surprisingly little published on the question. Our
own findings suggest that grade failures and learning
problems are common in the general criminal population seen for psychological assessment, but they
are more common among sex offenders. Of the 127
nonsex offenders in the study, 43.5% failed a grade in
school, significantly less than the sex offenders, but
there were no significant differences in special education placements.
When sex offenders with predominantly stimulus
preferences versus activity preferences are examined
separately, it is the latter who fail grades significantly
more (59.0% vs. 51.2%) and are placed in special
education significantly more often (49.0% vs. 36.2%).
A possible reason for greater placement of response
preference cases is the higher incidence of ADHD in
that group. There was a trend (p < .10) for response
preference cases to be diagnosed more often with
ADHD than stimulus preference cases (18.6% vs.
11.3%). Results reported by Vaih-Koch et al. (2001)
showed a similar pattern, with 42% of sexual aggressives showing an ADHD diagnosis versus 29% of
pedophiles.
These results are not to imply that all learning disabled men or men who have been in special education classes are sex offenders or criminals, but only
that sex offenders are overrepresented among individuals with learning problems. It is unknown how many
learning disabled individuals end up in a life of crime
or with a paraphilia. However, it has been claimed
that the mentally retarded are more common among
sex offenders, the next topic.

30 NEUROBIOLOGY/NEUROPSYCHOLOGY
IN T ELLIGENCE

Griffiths and Marini (2000) have noted that the mentally retarded are often faced with court proceedings
and may not be properly represented. This may be
especially true in the case of sex offenses. Hawk et al.
(1993) examined 2536 cases of offenders seen in the
state of Virginia for DSM diagnosis of mental retardation and found that this diagnosis was overrepresented
among sex offenders, but not in other criminal groups.
Wormith and McKeague (1996), on the other hand,
examined Canadian criminal justice statistics on a
random sample of 2500 incarcerated offenders and
found that mental retardation occurred at an expected
chance level for the population at large, with 1.7% of
inmates in the federal correctional system being mentally retarded. However, no association of sex offenses
and mental retardation was reported. Hawke et als
report. suggests an association of mental retardation
with sexual disorders, but no actual intelligence test
results were reported and over 400 examiners provided
diagnoses with no indication of reliability of diagnosis or that an intelligence quotient (IQ) test had been
administered. Some jurisdictions may have a different
attitude to mentally retarded or brain injured offenders
and may mete out harsher sentences to protect the public. In other cases, the mentally retarded sex offender
may not go to trial at all, but is detained indefinitely in
institution nonetheless. Studies of intelligence scores
among sex offenders have provided different results.
When IQ scores have been reported on sex offenders, they tend to fall in the average or low average
range (see Cantor et al., 2005, for a review of these
studies). Mentally retarded individuals appear with a
chance frequency of about 2.3% when standard tests
are used. However, the few available studies indicate
that the distribution of IQ scores tends to be skewed
to the lower end of normal with an overrepresentation of sex offenders in the borderline retarded or low
average range. These results were first reported in a
series of studies on small samples of sex offenders,
completed with my colleagues in 1985 using a variety
of IQ measures. Blanchard et al. in 1999 examined
678 pedophilic and 313 sex offenders against adults
for mental retardation, using global estimates of intelligence based on available IQ test results, whether the
offender was living in a group home for the mentally
retarded, and whether they required accompaniment
to the interview. The pedophilic group was not more
often retarded than expected by chance.

Cantor et al. (2004) followed up on this study by

examining six scales (Information, Similarities, Digit
Span, Arithmetic, Picture Completion, and Block
Design) of the Wechsler Adult Intelligence ScaleRevised (WAIS-R) in 304 pedophilic and hebephilic
(preference for pubertal females) men. They found
estimated full IQs in the low average range (80 to 90)
to average range (90 to 110).
Recently, the author, Langevin (2004) examined 932 sex offenders from a variety of sex offender
groups, who were Canadian born and whose only language was English. Full WAIS-R IQ scores were average overall with an overrepresentation of scores in the
70 to 80 or borderline retarded range and an underrepresentation in the superior IQ range of 120 and
higher. Mental retardation occurred with a frequency
of 2.4%; close to chance expected at 2.6%. The borderline retarded group (IQ 70 to 80) were slightly, but
significantly overrepresented with 9.5% of cases in
that range versus 6.9% expected by chance. Mentally
retarded and borderline retarded individuals were not
overrepresented among any sex offender subgroup,
such as pedophiles, but appeared among them on a
chance basis. These results collectively indicate that
when standard IQ tests are used, sex offenders are not
mentally retarded, more than one would expect on
a chance basis, but their IQ scores tend to be in the
borderline or low average range, offering one reason
they may have some learning difficulties in school
and hence may experience similar difficulties in sex
offender therapy programs, which are typically carried out in groups. The borderline retarded IQ scores
are a composite of verbal and performance measures
that may reflect large disparities in the two and indicate a learning disability rather than mental retardation or global cognitive impairment.
Full IQ scores may be divided into verbal IQ
(VIQ) and performance IQ (PIQ). The former taps
language-based abilities, such as vocabulary and
language comprehension, whereas the latter taps
nonverbal and visualspatial abilities, represented
by block design and picture arrangement. In a gross
sense, language abilities tend to be associated more
with left brain hemispheric functioning and performance and nonverbal abilities are associated more
with the right hemisphere. Significant differences
between VIQ and PIQ are used as indices of minimal brain dysfunction or learning disabilities, associated with one brain hemisphere/locus or the other.
If VIQ is significantly different from PIQ it suggests

NEUROPSYCHOLOGICAL FINDINGS IN SEX OFFENDERS

that one hemisphere of the brain is not functioning as

well as the other. A lower VIQ than PIQ suggests left
hemispheric deficits, whereas a lower PIQ than VIQ
suggests right hemispheric deficits. The Wechsler
Adult Intelligence Scale (WAIS-R) (Wechsler, 1981)
is one of the most widely used IQ tests in the history
of Psychology. The WAIS-R manual indicates that a
VIQPIQ difference of 10 points is statistically significant and can be used as an index of a learning
disability or brain dysfunction, but, in practice it
recommends using 15 points as a clinically significant
difference.
Data from the 932 cases noted previously indicates
that 38% showed at least a 10-point difference in VIQ
and PIQ, when less than 5% would be expected by
chance, and 22.5% of the sex offenders showed at
least a 15 point VIQPIQ difference. A total of 13.1%
showed lower verbal than performance scores (using
the 15 point criterion), whereas 9.4% showed the opposite. The significant VIQPIQ differences were more
common in the average and higher IQ range. Thus,
both lower IQ and VIQPIQ differences appear to
contribute to the compromised cognitive functioning of sex offenders. These results were supported in
studies employing small mixed samples of sex offenders. Murray et al. (2001) suggested that the VIQPIQ
difference is significant in sex offenders, but not
nonsex offenders. Unique to their study, they examined 42 sex offenders with learning disabilities and
42 nonoffenders with learning disabilities, matched
on WAIS-R Full IQ score. The sex offenders, but not
the nonoffenders, had significantly lower VIQ than
PIQ. On WAIS-R subtests, sex offenders had significantly lower Vocabulary scores, but higher Object
Assembly scores. Supporting the latter findings,
Ponseti et al. (2001) found poorer spatial abilities in
sex offenders than in nonsex offender controls.
When examining the hypothesis that stimulus
preferences, such as pedophilia, would show deficits
in the left hemisphere, it is expected that more of
them would show a lower VIQ than a PIQ score.
On the other hand, activity or response preferences
seen in sexually aggressive men should show more
right hemispheric or nonlanguage based deficits
and a lower PIQ score compared to VIQ. Only a few
studies have examined this question and results are
complicated by incomplete information on sexual
history; primarily because of the lack of candor of the
offenders. The author (Langevin, 2004) found that,
when men are faced with criminal charges, only 69%

31

acknowledge committing the offense for which they

are mostly ultimately convicted and even fewer, 35.5%
acknowledge having a sexually deviant preference. Thus,
findings are tentative. In the sample of 932 sex offenders noted previously, expected differences in VIQ
PIQ among Stimulus and Response Preference groups
was contradicted and showed opposite to expected
results, but supported Flor-Henrys theory of left hemispheric deficits in sex offenders. However differences
were small and a range effect of means was noted.
Overall results of intelligence testing on sex offenders suggests that the majority of sex offenders IQs will
fall in the average range, but the distribution of scores
will be skewed to the lower end of normal. The mentally retarded are not overrepresented, but one can
expect to see somewhat more than expected IQs in
the borderline retarded range and fewer in the superior
range, when standard IQ tests are used. In addition,
one might expect to see more learning disabilities and
disparities in VIQ and PIQ. These results suggest that
other neuropsychological testing may be informative.

NEUROPSYCHOLOGICA L
T EST R ESULTS

Handedness
The majority of individuals in general are right hand
dominant with a 10% to 15% showing mixed hand or
left hand dominance. When an individual is nonrighthanded, it suggests that brain organization of functions may be the reverse of right handed individuals
or may be unusual or mixed. For example, the movement of the right hand side of the body is associated
with intact functioning in the left parietal/motor area
of the brain, that is, brain function is contralateral to
the side of the body it regulates. Some functions are
typically specialized in the left hemisphere, for example, Brocas Area is associated with language functioning and typically it is in the left hemisphere. This also
may be true of the left-handed person or it may be
on the right side of the brain. Thus overall, nonrighthandedness suggests a different brain organization
and if there are more nonright-handed individuals
among sex offenders, it suggests their brains may be
organized in a different way and be associated with
the development of their paraphilia. Left-handedness
is also more common among the learning disabled,
adding to their difficulties in learning.

32 NEUROBIOLOGY/NEUROPSYCHOLOGY

Very few studies have examined handedness

among sex offenders and paraphilic individuals. Work
by Hucker et al. (1988), Hucker et al. (1986), Langevin
et al. (1989), Langevin et al. (1989) on a variety of sex
offender cases did not find differences in handedness
from chance expectation. Bogaert and Blanchard
(1996) reviewed studies suggesting that homosexual men show more nonright-handedness, but they
failed to find a greater than chance rate of 10% to
12% nonright-handedness in 1004 homosexual and
4579 heterosexual men from the Kinsey Institute
sample. Cantor et al. (2004) examined handedness
in 473 pedophiles using the Edinburgh Handedness
Inventory and employing a complex scoring scheme
with analysis of covariance. They found a significantly higher incidence of nonright-handedness
among the pedophiles, but percentages with right
versus nonright-handedness were not reported.
The authors data using the Reitan scale for handedness on 766 sex offenders and controls, did not
find a statistically significant difference and 90.2% of
the sex offenders were found to be exclusively right
handed. There were no subgroup differences. These
results collectively suggest that if handedness is a
factor in the development of paraphilias, it plays a
very minor role.
Neuropsychological Test Batteries
There are very few studies of neuropsychological test
results for sex offenders. Studies by the author and his
colleagues in the 1980s found that pedophiles especially showed significantly more impairment on the
HalsteadReitan Neuropsychological Test Battery than
controls, with approximately one-in-four showing
an overall significant impairment index. Particular
deficits were noted in executive (frontal lobe) functioning and inflexibility in changing mental set,
that is, the Categories Subtest and Trails Making B
Subtest (see Hucker et al., 1986; Hucker et al., 1988;
Langevin et al., 1989; Langevin et al., 1989). Hucker
et al. (1986) also examined the Luria-Nebraska
Neuropsychological Test Battery, but did not find
the test to have satisfactory norms. This is a common
problem using neuropsychological tests, that is, test
validation is often lacking.
More recent work on 766 sex offenders, using
the better normed HalsteadReitan Battery showed
results in a number of sex offender groups, similar to
our earlier findings with 35.1% failing the Categories
Subtest and 29.3% the Trail Making B Subtest.

We also looked at hemispheric transfer more specifically on the Tactual Performance Subtest. In this
task, there are ten blocks to be placed in specifically
made holes on a board. The subject must place the
blocks correctly while blindfolded and initially using
only the dominant hand. Time to complete the task
is recorded. The task is repeated using the nondominant hand and again time is recorded. It is expected
that the subject will be 20% to 40% quicker on the
second trial as learning should have taken place
and information should have transferred to the nondominant side of the brain via the corpus callosum,
the connecting body between the two hemispheres
of the brain. A third trial allows the subject to use
both hands and again there should be a 20% to 40%
decrease in time to complete the task, assuming
functioning is intact in each hemisphere and in the
corpus callosum. Results showed that 27.0% of the
sex offenders took significantly longer using the nondominant hand on the second trial and 8.5% took
longer on the third trial using both hands, when
they would be expected to be quicker on both second and third trials than they were on the first trial.
There were no significant subgroup differences on
this task, but results support findings of intelligence
scores that there are disparities in brain hemispheric
functioning and transfer of information between
the brain hemispheres among sex offenders and
paraphilics.

BR A IN INJUR IES

If neuropsychological deficits are found in sex offenders,

the question arises whether the deficits are secondary
to a brain injury and/or coincidental to the sexual
behavior. Thus, one may ask if the sexual disorder
predated the brain injury or any neural insult the
brain may have endured (see Delbella et al., 1999;
Regenstein & Reich, 1978; Weinstein, 1974, for
example).
Simpson et al. (1999) studied 445 clients at a
brain injury rehabilitation center and found that
29 (6.5%) had committed sexual offenses after the
brain injury. The offenses involved mainly touching, followed by exhibiting and sexual aggression. In
the absence of a history of prior sexual offense and
alcohol abuse in the majority of cases, the authors
concluded that the traumatic brain injury may have
been a significant etiological factor underlying the
sexual offenses. Luiselli et al. (2000) examined 69

NEUROPSYCHOLOGICAL FINDINGS IN SEX OFFENDERS

children and adolescents with traumatic brain injuries and found that one third had criminal violations,
including sexual assaults, but there was no difference
in the pattern of injuries in those who offended and
those who did not.
Blanchard and his colleagues (2002 & 2003)
examined two samples of pedophiles. In 685 cases,
they found that pedophiles had more head injuries
before age 13 than controls, but did not differ in the
incidence after age 13. In another 413 pedophiles and
793 nonpedophilic forensic cases, they found that
childhood accidents before age 6, but not after age 6,
were associated with a higher incidence of pedophilia,
lower intelligence, and less education. These authors
concluded that early childhood head injuries may
either increase the risk for pedophilia and/or make
the individual more accident prone.
I also examined 513 sex offenders seen at a university psychiatric hospital and in private practice
for forensic assessment related to sex offense charges
or convictions (Langevin, 2004). A total of 49% had
sustained head injuries that led to unconsciousness
and 22.5% sustained significant neurological insults.
A major causative factor was motor vehicle accidents,
but lifestyle factors such as alcohol and drug abuse
contributed. The brain injured committed a wide
range of sexual offenses, but more often offended
against adults and showed somewhat more exhibiting
and polymorphous sexual behavior.
The possible origin of the learning disabilities and
cognitive deficits among sex offenders has recently
been examined (Langevin, 2004) and results suggest
that prenatal and perinatal factors may be linked to
the cognitive impairment seen in sex offenders. Both
maternal and paternal abuse of alcohol were associated
with at least two-thirds of the 1526 sex offenders examined and were seen on more than a chance basis. Older
maternal age at the birth of the sex offender and later
birth order were also significant factors. Noteworthy
was the association of alcohol abuse by the parents
especially with sex offenders having lower IQs, more
grade failures, more placement in special education,
and more ADHD diagnoses and symptoms. Results
suggest that brain abnormalities and cognitive impairment in sex offenders may have prenatal roots.

33

of sex offenders. Available results indicate that the

brain functioning of sex offenders is impaired from
an early age and they have problems learning at
school with many developing an attitude about
learning situations such as therapy (see Langevin,
Marentette, & Rosati, 1996). The learning disabled
sex offender may be considered uncooperative,
may not function in groups, for example, the silent
member, or cannot follow the group proceedings, and
little account is taken of his disability. The typical
sex offender is of average intelligence, but more cases
have low average or borderline retarded intelligence,
that predominantly reflects the presence of learning
disabilities. One can expect to see a small, but significant, minority of sex offenders who have overall
neuropsychological impairment. One can expect to
see one-in-three or more who show impairment in
executive functioning and associated poor judgment
and impulsiveness. Cognitive impairment also may
interact with other factors, such as abuse of alcohol
or drugs, and serve as important disinhibiting and
risk factors for acting out in sexually deviant ways.
Results of neuropsychological testing suggest that sex
offenders as a group have significant deficits that may
be related to the etiology of the sexual disorders they
suffer.
There was mixed support of the theory of hemispheric differentiation of dysfunction among subgroups of sex offenders and those with predominantly stimulus or response preferences. Candor of
sex offenders about their sexual history and limited
validation of neuropsychological tests played some
role in hampering conclusions in this respect. One
may expect to see more language and left hemispheric deficits overall in sex offenders, regardless of
group membership, supporting Flor-Henrys (1980)
theory although there have been few studies on cognitive functioning in sex offenders, available studies
have large samples and the findings are impelling,
with implications for treatment, indicating that
further work on the topic is warranted. The importance of brain damage and dysfunction cannot be
ignored if we are to make progress in understanding
and treating individuals with sexually anomalous
behavior.
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35

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Chapter 4

The Neurobiology of Sexual Behavior

and the Paraphilias
John M. Bradford and J. Paul Fedoroff

Recent advances in neurobiological research have

improved the understanding of how sexual behavior is influenced by neuroendocrine and neurobiochemical systems. It would be premature to make a
statement that the neurobiology of sexual behavior is
understood. Major advances have been made in neurobiochemical research particularly with serotonin
(5-HT) and specifically with research on serotonin
receptors. The role of neuropeptides, as well as other
cerebral monoamines has also enhanced this understanding. Much of the research examining the roles
of cerebral hormones, monoamines, and neuropeptides has been based on animal research. Research in
human sexual behavior has been primarily based on
research about the effects of pharmacological agents
as well as the effects of hormones The hormone
research has a pharmacological basis to it, but in
addition there has been research in the brain directly
on the actions of cerebral hormones as well as the
endocrine system in general. Many of the pharmacological agents used in general psychiatry influence

neurotransmitters, such as serotonin (5-HT) and

have contributed to the understanding of the role
of serotonin (5-HT) and other neurotransmitters
on human sexual behavior. Studies on hormones,
either influenced by pharmacological agents or studied in vitro have also provided valuable information
(Sjoerdsma & Palfreyman, 1990). This chapter is a
broad review of the neuroendocrine and neurobiochemical research. As the focus is on the paraphilias,
which are typically a male problem, the neuroendocrinology of male sexual behavior as well as the neurobiochemical influences on male sexual behavior
will be the principal focus of this chapter.
Fundamental to the understanding of human
sexual behavior is the sexual differentiation of the
brain and the influences on male and female sexual
behavior derived from genetic influences, hormonal
influences on the fetus, hormonal influences during
puberty, hormonal influences during adulthood, and
the influence of declining hormone levels with aging.
For many years, there has been an understanding of
36

NEUROBIOLOGY OF SEXUAL BEHAVIOR AND PAR APHILIAS

the role of sex hormones in human sexual behavior

(Bancroft, 1989). Hormonal effects on the brain can
be divided into organizing effects of hormones on the
sexual differentiation of the brain and the activating
effects of hormones affecting behavior, particularly
in the mature individual (Bancroft, 1984, 1989, 2002).
The organizing effects of hormones in the prenatal
period influence the sexual differentiation of the
fetus into male or female phenotypes as well as the
gender identity. Fetal androgenization is responsible
for the sexual differentiation of the brain. This will
not be covered in detail, as it is the activating component of sex hormones that is more closely related to
sexual behavior as is seen in the paraphilias. Sexual
drive, and sexual behavior in general, is dependent
on the levels of these sex hormones. In general terms,
androgens are important for the maintenance of sexual behavior in males. Many studies have shown that
from animals (including subprimates) to humans that
surgical castration has a significant impact on male
sexual behavior. Following surgical castration sexual behavior declines in a predictable manner with
ejaculation going first, followed by intromission and
then mounting behavior (Bancroft, 1989). The time
frame for the decline in male sexual behavior varies according to different species. Many studies have
shown that replacement androgen restores the sexual
behavior usually in the reverse order (Bancroft, 1989).
Studies on hormonal replacement in hypogonadal
men, 25 years ago, showed conclusively that androgen
withdrawal causing a decline in sexual interest over a
3- to 4-week timeframe that could be reversed with
androgen replacement in about 2 weeks (Bancroft,
1989). Erections, either nocturnal or in response to
erotic stimuli, although diminished, may not disappear completely (Bancroft, 1989). Research over the
past quarter of the last century has supported these
earlier findings.

HOR MONES, NEUROHOR MONES,

A ND NEUROT R A NSMIT T ER S

Behavioral endocrinology is the study of the influence of hormones on an animals behavior (Becker,
Breedlove, Crews, & McCarthy, 2002). The work in
this field has resulted in substantial progress in understanding the neuroanatomical, neuroendocrine,
and neurobiochemical aspects of sexual behavior
(Pfaus, 1999). All cells in an organism are engaged

37

in the synthesis of proteins. These proteins become

intercellular chemical messengers and are known as
hormones, neurohormones, and neurotransmitters.
Hormones are produced by endocrine cells and released into the general circulation; neurotransmitters are produced by neurons and released at the
synapses; and the neurohormones are produced by
specialized neurons known as neurosecretory cells
(Becker et al., 2002). There are distinct differences
in terms of where the chemical messengers are produced and where they are released and the effect on
various receptors. Cells produce proteins based on
their genetic code and generally they are secreted in
vesicles. Transmission across the synapses is through
neurotransmitters. Neurotransmitters are monoamines, amino acids, purines, and peptides. The neurotransmitters of most significance in sexual behavior
are the monoamines, serotonin, and dopamine. The
peptide hormone of most significance is gonadotropin releasing hormone (GnRH). Prolactin (PRL), a
peptide hormone, is also very significant in relation to
sexual behavior and is a common factor in the pharmacological action of many drugs that cause sexual
dysfunction. Steroid hormones, such as estradiol and
testosterone are very important in the maintenance of
sexual behavior.
A neurotransmitter is synthesized and packaged
in a synaptic vesicle in the presynaptic terminal.
When this package is released, it attaches on the post
synaptic receptor. When the neurotransmitter binds
to the postsynaptic receptor, changes in the electrical
potential of the membrane occurs proportional to
the amount of neurotransmitter released. The neurotransmitter can produce either inhibition or excitation depending on the effects on the membrane.
If the neurotransmitter does not bind to the postsynaptic receptor it is deactivated through enzymes in
the synaptic cleft or by reuptake into the presynaptic
terminal (Becker, 2002; Becker et al., 2002).
Peptide hormones and steroid hormones are
closely related to the hypothalamic pituitary axis.
Steroid hormones are produced in different parts
of the body but in addition, are stored partially in
the blood where they are bound to plasma proteins.
Testosterone is found in three different forms in the
plasma, bound to sex hormone binding globulin;
bound loosely to albumin; and also as free testosterone. The active portions are the testosterone
loosely bound to albumin and the free testosterone.
Steroid hormones act on distant receptors in the

38 NEUROBIOLOGY/NEUROPSYCHOLOGY

body and also in the brain. For example, there are

testosterone receptors in the testes; the spinal cord;
the skin, and the brain. Peptide hormones are stored
in the cells that produce them and then are released
in a pulsatile fashion. This means their blood levels
fluctuate considerably or they may only be present in
the plasma for brief periods of time after release. It
is these peptide hormones that play an intermediate
role as a neurotransmitter and a hormone. This has
been recognised by calling them releasing factors as
opposed to releasing hormones in some areas. As releasing factors or releasing hormones they are principally responsible for the release of other peptides
from their cells of origin. Gonadotropin releasing
factor for example, is responsible for the release of
lutenising hormone. The complex interaction of
neurotransmitters, peptide hormones, and steroid
hormones is centred in the hypothalamic pituitary
system. In terms of behavioral neuroendocrinology,
the hypothalamus is the most important part of the
brain. The hypothalamus is part of the diencephalon and has a profound influence on all hormones
in the body. The hypothalamus is the center of the
relationship between the brain and the endrocrine
system. It has specialized nuclei that are involved in
the regulation of the endocrine system. Within the
hypothalamus, the medial preoptic area (POA) and
the ventromedial hypothalamic nuclei are involved
in sexual behavior. These nuclei have special neuronal cells known as neurosecretory cells which release their chemical messages directly into the blood
vessels and are therefore known as neurohormones.
These are peptide hormones, luteinising hormone
releasing hormone (LHRH), and prolactin inhibiting factor (PIF). The hypothalamus is directly above
pituitary gland or hypophysis. The neurosecretory
cells of the hypothalamus release neurohormones
(LHRH and PIF) into blood vessels that supply the
anterior pituitary. These are known as releasing factors and stimulate or inhibit the release of hormones
(luteinising hormone [LH], follicle stimulating hormone [FSH] and PRL) from the anterior pituitary,
or adenohypophysis. The other neurosecretory cells
release neurohormones directly into the general
circulation by the posterior pituitary or neurohypophysis. The pituitary hormones act on peripheral
endocrine glands to stimulate or inhibit their release
of hormones. There is a feedback loop where the circulating levels of these hormones feedback on the
hypothalamus to exert feedback control on the levels

of releasing factors (LHRH and PIF) from the hypothalamus. Depending on the levels, there is either an
increase or decrease in the release of hypothalamic
releasing factors (LHRH and PIF). The levels of circulating steroid hormones (plasma testosterone, T)
control the release of hypothalamic releasing factors
(LHRH and PIF), which in turn affects the release
of LH and FSH from the pituitary gland (Becker
et al., 2002).
Other peptide hormones or releasing factors that
are important for understanding sexual behavior at
the hypothalamic pituitary level are oxytocin; PRL;
gonadotropin releasing hormone or LHRH, LH, and
FSH. Oxytocin is a neurohormone released from
the posterior pituitary or neurohypophysis. When
oxytocin is released into the bloodstream, it triggers
milk ejection as well as uterine contractions during
childbirth (Becker, et al., 2002). LH and FSH are peptide hormones known as gonadotropins. Other peptide hormones or neuropeptide transmitters are of less
direct significance to sexual behavior, corticotropin
releasing factor; endorphins; growth hormone releasing hormone; neurotensin; thyrotropin releasing
hormone; vasopressin, and a number of other neuropeptide hormones or neuropeptide transmitters.
The gonads release steroid hormones, in males
this is testosterone (T) and dihydrotestosterone (DHT).
In females these steroid hormones are estradiol and
progesterone. In males T and DHT are produced by
the testes, where 95% of the production of testosterone occurs, and by the adrenals where the remaining 5% is produced (Becker et al., 2002). Estradiol is
also produced by the testes and the adrenal glands
in males.
Hormones exert influences by the expression of
various genes. There are differences in the way this
manifests in steroid hormones versus peptide hormones (Becker et al., 2002) (see Chapter 2). There
are also different receptors for peptide hormones
and steroid hormones. The receptors for peptide
hormones are found on the surface of the cells.
Following this hormone receptor interaction there
are changes in intracellular molecules which may
result, in some cases, in second messengers (Becker
et al., 2002) (see Chapter 2). The most commonly
found receptors are G-protein coupled receptors.
When a peptide hormone binds to a receptor, a
G-protein complex is activated and this results in
the production of second messengers. The second
messengers are cyclic AMP (cAMP) and inositol

NEUROBIOLOGY OF SEXUAL BEHAVIOR AND PAR APHILIAS

phospholipids (ISP). This is the mechanism where

by many peptide hormones including oxytocin, LH,
FSH, and LHRH exert their influence (Becker et al.,
2002) (Chapter 2).
Steroid hormone receptors are known as transcription factors. They interact directly with DNA
and either increase or decrease the transcription of
particular genes (Becker et al., 2002) (Chapter 2).
These receptors are intracellular and are individual
proteins and when the steroid molecule enters the
cell it binds with the receptor protein. The activated
receptor interacts with DNA. Before this occurs the
steroid receptor may bind to other proteins. This interaction may involve the binding to other proteins
forming what is known as a transcriptional complex.
This makes the interaction with DNA highly specific, forming a hormone response element. These
hormone response elements are different for each steroid receptor (Becker et al., 2002) (Chapter 2). This
is known as a genomic action and is regarded as the
classic steroid action.
Sexual Differentiation
In the fetus the gonads are initially not differentiated
into male or female gonads. The sex chromosomes
and particularly the Y chromosome are responsible
for the differentiation. Once this has occurred further
sexual differentiation is driven by sex hormones. In the
presence of the Y chromosome the gonads form into
a primitive testis which secretes androgen hormones
and a male phenotype develops (Becker et al., 2002)
(Chapter 3). In the males there were two hormones
responsible for male development, testosterone and a
peptide hormone known as antimullerian hormone.
This hormone specifically acts to cause a regression of the mullerian ducts. The mullerian ducts in
females develop into the vagina, fallopian tubes, and
the uterus. The secretion of testosterone results in the
masculinization of the body and the brain. These
testicular steroids, at a very early point, masculinize
the brain as well as future behavior. This process has
been studied by Charles Phoenix and colleagues and
in 1959 this resulted in the organizational hypothesis.
This hypothesis is that the early androgen secretion
has a permanent effect on the brain, which leads to
masculine behavior during adolescence and in adulthood. This is therefore a permanent sexual differentiation of the central nervous system (Becker et al.,
2002) (Chapter 3). These organizational effects on

39

the central nervous system leading to permanent

changes in the developing central nervous system
can be seen in contrast to the activational effects
of steroid hormones occurring at other times of the
life of the organism, for example, puberty, which has
transient effects on the brain. It is also clear that steroid hormones particularly T and DHT have a masculinizing effect on the body early in development
including the first trimester of pregnancy, and then
as the organism grows older these steroid hormones
have little structural effect on the central nervous
system (Becker et al., 2002). It is not surprising that
these organizational affects of androgens would have
an effect on adult sexual behavior. The assumption
was clearly that early androgenization would have an
effect of masculinizing adult behavior and in contrast the absence of androgenization would lead to a
feminization effect on adult sexual behavior. Further,
the introduction of androgen at specific or sensitive
periods could have a specific effect depending on the
species. These behaviors were measured in animal
research using typical male behaviors such as aggressive play and mounting behavior. To summarize, the
organizational hypothesis means that the same hormonal influences that led to the sexual differentiation
of the genitalia also leads to the sexual differentiation
of the brain (Becker et al., 2002).
The sex differences in central nervous system
structures were discovered in the 1970s. Prior to that
there was general scientific agreement that steroid
hormone exposure early on caused structural changes
and had affects on subsequent behavior but this had
not been documented in a structural way. Darwin is
regarded as the originator of the term sexual dimorphism (Becker et al., 2002). This refers to most species having clearly defined differences in body shape
or size depending on sex. In some species the brain
differentiation can be observed by the naked eye
(Toran-Allerand, 1978). The full exploration of anatomical studies of the sex differences between males
and females in the brain is beyond the scope of this
chapter. Overall research from the late 1950s up until
today has clearly shown male-female differences in various parts of the brain. One of the first areas of malefemale differentiation identified was the preoptic area
(POA) of the hypothalamus in animal studies. Gorski
and colleagues found that there was an area within
the POA of the hypothalamus that was five times
larger in males compared to the females and they
called this the sexually dimorphic nucleus of the

40 NEUROBIOLOGY/NEUROPSYCHOLOGY

POA (Becker et al., 2002; Gorski, 1973, 1985). The

same area in human males has been found to be
larger than in human females (Swaab, 2003). In the
1970s, Maclean documented that the limbic system
is associated with sexuality (MacLean, 1974, 1978).
The mapping of the areas in the brain associated
with sexuality has resulted from stimulation studies
in animals including implanted electrodes, and then
lesion studies. Across a number of mammalian species lesions of the medial preoptic anterior (MPOA)
hypothalamic area has a very strong impact on sexual behavior to the point of eliminating it (Bancroft,
1989; 2002). Studies of implanted electrodes in anaesthetized mammals have identified sites that result in
ejaculation or an erection. Much of this work was done
in the 1960s and 1970s and showed that the areas that
have sexual effects when stimulated are, the POA; the
lateral hypothalamus; the tegmentum, and the anterior part of the cingulate gyrus (Bancroft, 1989; 2002).
There are also excitatory and inhibitory mechanisms
affecting the peripheral response to an erection.
There appears to be a normal level of inhibition from
the higher cerebral centres inhibiting erections by
setting an inhibitory cerebral tone. This is supported
in spinal injury where the threshold for local reflex
erections is decreased. This supports the removal of
inhibitory tone from the cerebral centers (Bancroft,
1989; 1999; 2002). In 1979, Perachio and colleagues
completed a study of implanted electrodes in
the brain of rhesus monkeys that were freely moving
and were awake. Stimulation of the lateral hypothalamus and dorsomedial nucleus of the hypothalamus
led to coital behavior and ejaculation, which exactly
simulated the typical mounting behavior of rhesus
monkeys. Stimulation of the POA also resulted in
mounting behavior but no ejaculation. They concluded that these areas were responsible for copulatory behavior with the POA being most specific
(Perachio & Alexander, 1979).
In humans, various pathological states with specific neuroanatomical lesions has helped understand
the cerebral representation of sexuality. This is complicated in the sense that some lesions cause disinhibited of behavior that may include hypersexuality. This
can be extrapolated to assume that lesions in various
brain areas are specifically related to different types of
sexual behavior.
Besides the neuroanatomical structure of the central nervous system, the autonomic nervous system
has two parts, the sympathetic and parasympathetic
nervous systems which are closely related to sexuality.

The sympathetic nervous system originates in the

upper part of the spinal cord from the cervical section to the L4 section of the lumbar spine. The parasympathetic nervous system emerges from the brain
through cranial nerves and especially the vagus
nerve and in a lower section which originates from
the sacral section of the spinal cord. The sympathetic and parasympathetic nervous systems balance each other out. Further, each has their own
neurotransmitters, noradrenaline in the sympathetic
nervous system, and acetylcholine in the parasympathetic nervous system. The sympathetic nervous
system is referred to as adrenergic transmission and
the parasympathetic nervous system as the cholinergic system. Adrenergic transmission has two types of
receptors, and . These are further subdivided into
1 and 2 and 1 and 2. receptors are generally
inhibitory and receptors are excitatory. 1 receptors are mainly in cardiac muscle with 2 in smooth
muscle in the intestine, the bronchi as well as vascular smooth muscle. 1 receptors constrict smooth
muscle and 2 receptors when stimulated inhibit
the release of noradrenaline at the synapses in presynaptic or a regulation role (Bancroft, 1989; 1999).
These receptors play an important role in the affects
of sexual arousal on the genitals of both males and
females. In terms of neurotransmitters in the central
nervous system a number of other neurochemical
agents are involved including gamma-aminobutyric
acid (GABA). They have excitatory and inhibitory
effects in the central nervous system which can have
an impact on sexuality. A full review is beyond the
scope of this chapter.
Sexual Arousal
The central nervous system response to external stimuli is also important in sexual arousal. In nonhuman mammals olfactory stimuli are very important,
particularly through pheromones. Vaginal secretions
when a female is in oestrus provide olfactory stimulation to males, which leads to sexual interest and
sexual arousal. Olfactory stimuli are most likely less
important in humans compared to visual stimuli,
although there is a current debate about the affects
of pheromones in humans. Tactile stimuli are clearly
important in the stimulation of the genital region
leading to tumescence of the penis and the clitoris. The human male and human female has been
shown to become sexually aroused to visual stimuli
in the laboratory.

NEUROBIOLOGY OF SEXUAL BEHAVIOR AND PAR APHILIAS

Sexual arousal is a concept that has both psychological and physiological components to it. Sexual
arousal can be measured in the laboratory through
tumescence in the genitals of both males and females.
Sexual arousal can be the result of a subjective sense
of sexual interest or sexual appetite, similar to hunger
or thirst as other basic biological drives. This sexual
appetite function causes the organism to seek out sexual relief by finding a sexual partner to interact with.
An intermediate step is clearly sexual arousal which
contributes to the motivating function to seek out the
sexual partner. As simple as this description of sexual arousal appears to be, it is an extremely complex
interacting system of stimulation of the central nervous system by external stimuli such as visual stimuli, internal stimuli such a sexual fantasy; leading to
sexually motivated behavior; and then a sexual interaction leading to orgasm. It is extremely complicated
in terms of concepts of sexual preference and sexual
orientation. This includes sexual orientation and can
also include age orientation when seeking out a suitable partner. The underlying neurobiological components of sexual arousal as already outlined involve a
complicated interaction between neurotransmitters,
neurohormones, and steroid hormones.
Sexual Dysfunction
Animal models of human sexual dysfunction have
been studied more recently. Specifically, fluoxetine
has been studied in sexually active male and female
rats from the standpoint of subchronic effects and
chronic effects of treatment. In male rats 6 weeks
of daily treatment produced a progressive decline in
the number of ejaculations which was both dose and
time dependent. There was also a decline in anticipatory sexual excitement. There were no effects on the
latency period to initiate copulation or the number
or rates of intromissions meaning that fluoxetine did
not actually cause specific sexual dysfunction such as
impotence or erectile dysfunction. A single dose of
oxytocin reduced the decline in ejaculation (Cantor,
Binik, & Pfaus, 1999; Pfaus, 1999). Studies on the
stimulation of sexual arousal in rats have also helped
to elicit underlying neurobiological mechanisms.
This research looked at noncontact erections in male
rats, which can be compared to erections secondary
to sexual fantasies in humans. In sexually experienced but castrated male rats noncontact erections
occurred when stimulated by implants of the testosterone and DHT but not estradiol. The noncontact

41

erections were impaired by infusions of an oxytocin

receptor antagonist or a competitive inhibitor of nitric
oxide (NO) administered to the lateral ventricle of the
brain.
Infusions of L-arginine or morphine to the paraventricular nucleus of the hypothalamus reduced
these types of erections, by reducing concentrations of nitrous oxide (N2O) in the nucleus. This
suggested a central mechanism for NO in noncontact erections. A competitive inhibitor of NO was
infused into the medial POA and this increased the
number of seminal emissions in a test of the reflex
emissions (Cantor et al., 1999; Moses & Hull, 1999;
Pfaus, 1999). Testosterone administered to castrated
male rats increases the number of NO labeled neurons in the medial POA indicating an increase in the
synthesis of NO (Du & Hull, 1999; Melis, Spano,
Succu, & Argiolas, 1999; Melis, Succu, Spano, &
Argiolas, 1999; Pfaus, 1999). Certain drugs and hormones have an effect on copulation and sexual stimulation. Ejaculation can be facilitated by an agonist of
the 5-HT1a receptor. Dopamine interaction with the
serotonin system, both in the POA and systematically,
has also been examined in terms of the stimulation of
sexual behavior (Matuszewich et al., 1999).

HUM A N SE X UA L BEH AV IOR

Much of the understanding of the neurobiology of

human sexual behavior has been based on pathological studies of endrocrine disorders; as well as
the observations of the effects of pharmacological
agents on sexual behavior. The neuropharmacology
of serotonin has been a very important component
of this understanding. By 1953 it was known that
serotonin was in three locations in the body, specifically platelets, the gastrointestinal system, and the
brain, based on research in animals (Sjoerdsma &
Palfreyman, 1990). Methods for the extraction and
assays of serotonin were developed and initially its
work in humans related to its possible involvement
in hypertension (Sjoerdsma & Palfreyman, 1990).
This work evolved with the study of carcinoid syndrome and eventually the role of serotonin in mental disorder in the 1950s and 1960s (Sjoerdsma &
Palfreyman, 1990). In the 1970s important observations occurred, specifically that serotonin precursors
L-tryptophan and 5-hydroxy tryptophan had antidepressant properties; the norepinephrine precursor
L-3, 4-dihydroxyphenylalanine (L-dopa) did not have

42 NEUROBIOLOGY/NEUROPSYCHOLOGY

antidepressant properties, coupled with other neurochemical work, led to the development of selective
inhibitors of serotonin uptake (SSRIs), which proved
to be antidepressants (Sjoerdsma & Palfreyman,
1990). This led to the development of the SSRIs as
pharmacological agents, following a classic paper
by Peroutka and Snyder in 1979 which defined multiple serotonin receptors. They provided the classification of 5-HT1 and 5-HT2 receptors. (Peroutka &
Snyder, 1979). Further work at the Merrell Dow
Research Institute in Strasbourg, France led to the
development of SSRIs for use in human pharmacological treatment. (Sjoerdsma & Palfreyman, 1990).
Further research of serotonin receptors has led to sub
receptors systems 5-HT1a; 5-HT1b; 5-HT1c; 5-HT1d;
5-HT1e; 5-HT1f; 5-HT2a; 5-HT2b; 5-HT-2c; 5-HT3;
5-HT4; 5-HT5; 5-HT6; 5-HT7 as well as other new
work some other receptors, based on research work
using receptor binding protocols; common second
messenger coupling, and research using various
ligands. All of the receptors for serotonin belong to
a family of G proteincoupled receptors (Kennett,
2000). Serotonin is a sophisticated neurotransmitter
involving different receptor classes. These classes of
receptors are not only differentiated by their neuropharmacological properties but also by their distribution in various brain systems. Therefore serotonin
acts on different brain systems through different
receptor subtypes. The serotonin receptors and subtypes of receptors are found principally in the limbic
system. The actual distribution and function of the
subtypes of receptors is beyond the scope of this
chapter. As the limbic system is mostly involved with
the modulation of emotion, it is not surprising that
drugs that potentiate the action of serotonin would
have an effect on mood, aggression, sex, as well as
other biological drives such as sleep and appetite.
When a SSRI is administered, serotonin concentrations in the synaptic cleft increases as it cannot be
removed by the reuptake carrier or serotonin transporter. There is also a decrease in serotonin turnover.
This is supported by animal model studies in behavioral pharmacology. There is also evidence that serotonin may be implicated in the regulation of anterior
pituitary hormones in particular PRL but also corticotropin and growth hormone (Cowen, Anderson, &
Gartside, 1990 a; Cowen & Sargent, 1997). Some
time ago it was clear that temperature and endocrine
responses could be used to study the functional
sensitivity of different serotonin receptor subtypes

(Cowen, Cohen, McCance, & Friston, 1990b). The

evidence is that PRL is mediated through 5-HT1
receptors and specifically the 5-HT1a receptor
(Cowen, 2000).
There is also an interesting finding that over time
the level of reported sexual dysfunction caused by
SSRIs has increased in different studies. Stark and
Hardison in 1985 reviewed multicenter studies of fluoxetine compared to placebo and imipramine, and
overall they reported the incidence of sexual dysfunction in fluoxetine treated patients as 2.7%. Herman
et al., (1990) studied 60 patients treated with fluoxetine and reported sexual dysfunction usually anorgasmia or delayed orgasm as 8.3%. This was followed
by Zajecka et al. (1991) in the study of 77 patients
where the reported incidence of sexual dysfunction
was 7.8%. Jacobsen (1992) looked at outpatients over
2 years treated with fluoxetine for major depression
and found that 34% of 160 outpatients reported the
onset of sexual dysfunction after the successful treatment of major depression. This was broken down into
10% of patients who reported decreased libido; 13%
reported decreased sexual responsiveness, and 11%
reported declines in both areas. Balon et al. (1993)
found that the incidence of sexual dysfunction was
43.3% during antidepressant treatment with fluoxetine. Paterson (1993) reported the incidence to be
75%. (See Table 4.1.) This clearly showed that over
time the incidence of sexual dysfunction after treatment with fluoxetine hydrochloride increased dramatically in self-reported surveys. Although it is not clear
why this trend occurred, the high levels of sexual dysfunction reported in the latter studies is in keeping
with what would be expected on the basis of what is
known from animal studies on serotonin. As serotonin levels increase, sexual drive and other aspects of
sexual behavior decreases. Further, it is quite clear
Table 4.1 Studies of Sexual Dysfunction Associated
with Fluoxetine Hydrochloride from 1985 to 1993
Study

Incidence of Sexual
Dysfunction (%)

Stark & Hardison, 1985

2.7

Herman et al., 1990

8.3

Zajecka et al., 1991

7.8

Jacobsen 1992

34.0

Balon et al., 1993

42.9

Patterson, 1993

75.0

NEUROBIOLOGY OF SEXUAL BEHAVIOR AND PAR APHILIAS

that different drugs such as fluoxetine and fluvoxamine most likely have different actions at different
receptors. Iatrogenically induced sexual dysfunction
has been seen in many pharmacological agents and
specifically the pharmacological agents used in psychiatry. Drug-induced sexual dysfunction has become
an important factor in understanding the neurobiological aspects of human sexuality.
The study of the neurobiology of hypersexuality
although limited can also help in understanding the
neurobiology of the paraphilias. Although extensive
animal research has been conducted in this area,
this is beyond the scope of this chapter and only the
research in relation to human sexuality will be briefly
reviewed. In general terms, research has shown that
various brain lesions can lead to disinhibited sexual
behavior. The neurological and neuropsychiatric
literature has considerable references with regard to
disinhibited behavior, including sexual behavior, as a
result of frontal lobe lesions. The main issues here are
that this is a general disinhibition of behavior and not
specific to sexual behavior. What has been described
as presenting clinically in dementia patients with
frontal lobe lesions is paraphilic behavior for the
first time in their history. This is clearly contrary to
the natural history of the paraphilias and therefore
secondary to the dementia and disinhibited behavior. A wide spectrum of disinhibited sexual behavior has been reported including exhibitionism-like,
pedophilic-like, and what can be described broadly
as hypersexuality. Further paraphilic-like behavior has been reported secondary to a wide variety of
neuropsychiatric disorders. These include temporal
lobe epilepsy; post encephalitic neuropsychiatric syndrome; septal lesions; frontal lobe lesions; bilateral
temporal lobe lesions; cerebral tumors in various
brain areas, and multiple sclerosis (Chow, 1999). Nonparaphilic hypersexuality and hyposexuality have been
reported in relation to various brain lesions. There
has also been some evidence of obsessive- compulsive
disorder (OCD)-type behavior reported in association with various brain lesions (Chow, 1999). There
are also interesting relationships that have been
described with OCD and Tourettes disorder. This
points toward the corticostriatal neurocircuits being
involved as well as there being various types of
behavior that overlap between the two conditions
(Comings, 1987; Comings & Comings, 1987a, 1987b;
Stein, 1996; Stein, Hugo, Oosthuizen, Hawkridge, &
van Heerden, 2000). The types of behavior that

43

have been described in Tourettes disorder includes

a spectrum of paraphilic-like and nonparaphilic-like
sexual behaviors and even the classic Tourettes disorder symptoms of coprolalia and copropraxia have
a sexual component to them (Kerbeshian & Burd
1991). There is also some evidence that in males, ticrelated disorders, including Tourettes disorder may
be involved with fetal androgenization (Alexander &
Peterson, 2004). There is also an hypothesis that
Tourettes disorder has an underlying dopamine
abnormality (Minzer, Lee, Hong, & Singer, 2004). In
neurobiological terms, Tourettes disorder, obsessivecompulsive disorder, and various manifestations of
paraphilic and nonparaphilic behavior are related to
dopamine abnormalities and possibly linked to fetal
androgenization. Again there is a significant volume
of literature that covers this area that supports these
connections but only a small fraction of the literature is referenced in this chapter. There is also the
literature on treatment that shows the symptoms of
OCD as well as Tourettes disorder respond to serotonin reuptake inhibitors as well as pharmacological
agents that affect dopamine levels such as conventional and atypical antipsychotic agents.
Hypersexuality is poorly defined in the sexual literature and is not defined in DSM-IV. An attempt
by Kinsey to define hypersexuality included the use
of the Total Sexual Outlet which was the number
of orgasm measured every 7 days. Kafka has also
attempted to better define hypersexuality, looking
at compulsive sexual behavior and paraphilias and
related disorders (Kafka, 1994a, 1994b; Kafka &
Hennen, 2003). Individuals with paraphilia-related
disorders in a small study were defined as having
greater than 5 orgasms per week as well as other measures of sexual behavior (Kafka, 2003). The problem,
however, is that large population prevalence studies are needed to clearly define hypersexuality. It is
clear, however, that hypersexuality may be paraphilic
or nonparaphilic although the absolute measures of
orgasm rates are not clearly defined. What is certain
is that some individuals report high levels of sexual
drive and exhibit compulsive sexual behaviors that
cause them significant personal distress and dysfunction. These behaviors may be paraphilic or if they are
nonparaphilic include compulsive use of masturbation compulsive use of pornography, and may lead
to high risk sexual behaviors such as of promiscuous
sexual behavior with prostitutes or anonymous sexual
partners.

44 NEUROBIOLOGY/NEUROPSYCHOLOGY

The actual incidence and prevalence of the paraphilias and paraphilia-related disorders is unknown
(Bradford, Boulet, & Pawlak, 1992). The most comprehensive information to assist with the understanding
of the neurobiology of the paraphilias comes from the
pharmacological treatment studies of sexual offenders
and sexually deviant men. The studies have their origins in those involving surgical castration, principally
coming out of Europe in the middle part of the last
century, followed by antiandrogen treatment studies
using cyproterone acetate medroxyprogesterone acetate and to a lesser extent oestrogen treatments. This
was followed by the use of SSRIs and LHRH agonists. These treatments now form a significant part of
the treatment of sex offenders worldwide. Bradford,
(2000), published an algorithm for the treatment of
the paraphilias. The first part of the algorithm is a classification of the severity of the paraphilias into four
categories:
1.
2.
3.
4.

Mild
Moderate
Severe
Catastrophic

These followed the scheme originally outlined in

DSM-III-R (American Psychiatric Association &
American Psychiatric Association Work Group
to Revise DSM-III, 1987). The last category of
Catastrophic was added to deal with individuals with
sexual sadism and the risk of severe sexual violence
or a sexually motivated homicide being the type of
sexual behavior they presented with. The actual algorithm consists of six levels of treatment for the four
categories of paraphilias:
Level 1: Regardless of the severity of the paraphilia,
all paraphilias are treated with some form of cognitive
behavioral treatment preferably a relapse prevention
program.
Level 2: Pharmacological treatment starts with the
use of SSRIs. The common pharmacological treatments are the use of sertraline and fluoxetine. These
are the most suitable as they reduce sexual drive and
sexual fantasies without causing sexual dysfunction
such as erectile difficulties or delayed ejaculation. The
usual dosage would be 150 mg to 250 mg of sertraline
per day or 40 mg to 60 mg of fluoxetine per day.
Level 3: If the SSRIs are not effective in 6 to 12
weeks of treatment, meaning no reduction in sexual

fantasy or significant reduction in sexual drive, using

adequate dosages, a small dose of an oral antiandrogen, either cyproterone acetate 50 mg per day or
medroxyprogesterone acetate 50 mg per day would
be added to the SSRI. This would be the treatment
approach most likely used in moderate cases of
paraphilias.
Level 4: If control was not adequate (as outlined
above in relation to sexual fantasies and sexual drive)
at level three men oral antiandrogen treatment would
commence. This would generally involve 50 mg to
300 mg of cyproterone acetate per day or 50 mg to
300 mg of medroxyprogesterone acetate per day. This
would be used in moderate and in some severe cases
of paraphilias.
Level 5: This would be full intramuscular antiandrogen treatment, either cyproterone acetate or
medroxyprogesterone acetate. Cyproterone acetate
would be given at dosage levels of 100 mg to 200 mg
usually biweekly. Medroxyprogesterone acetate would
be given starting at 400 mg per week and gradually
going to 400 mg every 4 weeks during a maintenance
phase.
Level 6: This would be the use of LHRH agonists
to create a state of pharmacological castration. The
usual medications with the leuprolide acetate, or
goserelin acetate given monthly at 7.5 mg per month.
With goserelin acetate an optional 3-monthly injection can be given.
The three main categories of pharmacological
treatment for the paraphilias are as follows:
specific serotonin reuptake inhibitors
antiandrogen and hormonal treatments
LHRH agonists
The various studies of pharmacological treatment
can be found covered in detail in another chapter in
this book and in other publications on the subject
(Bradford, 1999, 2000, 2001; Bradford & Pawlak,
1993a, 1993b).

CONCLUSION

There is considerable knowledge of the neurobiological underpinnings of the paraphilias and nonparaphilic hypersexuality. Considerable advances
have been made in understanding the monoamine

NEUROBIOLOGY OF SEXUAL BEHAVIOR AND PAR APHILIAS

neurotransmitters and how they affect sexual behavior. The effects of hormones on sexual behavior are
mainly seen in the pharmacological treatment studies.
The addition of LHRH agonists has provided a powerful pharmacological castration for the management
of difficult and high risk paraphilias. As drugs develop,
that have actions on serotonin receptors subtypes
this should considerably add to our understanding
of the contribution of monoamine neurotransmitters to the neurobiology of sexual behavior. Research
on sex hormone and specifically on various types of
hormonal receptors and hormone sensitive neurons
should also contribute significantly to our understanding of the neurobiology of the paraphilias.
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Part III

Assessment and Diagnosis

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Chapter 5

Violence Risk Assessment

Debra A. Pinals, Chad E. Tillbrook,
and Denise L. Mumley

Risk assessment is a broad concept with many meanings that vary depending on the context. Sex offender
and violence risk assessments have common features
but have emerged with some distinct approaches.
Clinical interviews may focus on different aspects of
a persons history, and actuarial tools have emerged
that are unique to these distinct types of assessments.
The involvement of psychiatric and other mental
health professionals in violence risk assessment most
appropriately encompasses those situations involving
questions related to diagnostic assessments, treatment
needs, and risk management. Mental health expertise
is often sought in clinical and medicolegal contexts,
as a means of assisting decision makers involved in
commitment and release contexts.
Overlap often exists between the need to assess risk
factors related to harmful sexual behaviors and the
need to assess risk of future violence. As the two lines
of research in sex offender risk assessment and violence risk assessment continue to expand, clinicians
in the position of assessing risk among sex offenders will also need to maintain an awareness of the

literature related to general violence risk assessment.

The purpose of this chapter is to review research and
current knowledge related to general violence risk
assessment and its overlap with mental illness, and
to delineate approaches to violence risk assessments
on the basis of current understanding of risk factors.
The impact of a clinician providing an assessment of
an individuals risk of violence, just like assessment
of risk of sexual reoffending, can be great, influencing determinations that may result in loss of liberty
and even death (e.g., Estelle vs. Smith, 1980). Thus,
it behooves professionals involved to have up to date
knowledge of assessment approaches and potential
consequences, both intended and unintended, in any
given context.

CON T E X T UA L BASIS FOR V IOLENCE

R ISK ASSESSMEN TS

Mental health professionals have long been aware

of the need to assess their patients for risk of suicide.
49

50 ASSESSMENT AND DIAGNOSIS

Historically, however, patients were not consistently

assessed for homicidal thoughts (Sanders, Milne,
Brown, & Bell, 2000). Several factors have converged
that have resulted in an increased awareness, on the
part of mental health professionals, of the importance
of incorporating evidence-based violence risk assessment into routine clinical management and clinical
assessment. Evolving laws related to civil commitment in nonsex offender contexts (Allbright, Levy, &
Wagle, 2002; Lessard vs. Schmidt, 1972; Pinals &
Hoge, 2003), release decisions for forensic and correctional populations (Baxstrom vs. Herold, 1966;
Foucha vs. Louisiana, 1992; R. vs. Demers, 2004;
Winko vs. British Columbia [Forensic Psychiatric
Institute], 1999), liability concerns related to public
safety (Smith vs. Jones, 1999; Tarasoff vs. Regents of
the University of California, 1976), and management
of violence risk among out-patients and persons moving to less restrictive settings (Douglas, Ogloff, &
Hart 2003; R. vs. Tulikorpi, 2004; Swartz et al., 1999),
for example, have influenced this trend. As clinicians
have found themselves increasingly in positions where
violence risk assessments are conducted, examples of
overzealous predictions of future violence, and trepidation about jeopardizing public safety have heightened
the need to better understand the potential impact of
and best approaches to violence risk analyses. Though
a detailed review of risk management strategies is beyond the scope of this chapter, Borum et al. (1996),
identified four important areas in understanding the
assessment and management of violence risk: The relationship between violence and various mental disorders, the rates of violence among clinical populations,
the ability of mental health professionals to predict
violence, and specific risk factors related to violence.
Aspects of these topic areas as they relate to violence
risk assessment are reviewed subsequently.

V IOLENCE A ND MEN TA L ILLNESS: A N

EVOLV ING LIT ER AT UR E

The assumption that persons with mental illness

are dangerous is not new, and the disadvantage that
has historically faced persons with mental disabilities as a result of that assumption has been acknowledged many times over in many contexts. For
example, the Supreme Court of Canada observed
that mental illness is one of the least understood
and least accepted of all illnesses. Further, the

Court said it creates fear and stereotypical responses

that may lead to discrimination and labeling
(Battlesfords and District Co-operatives Ltd. vs.
Gibbs 1995; R. vs. Swain, 1991). As well, images
of persons with mental illness engendering fear
because of their perceived great risk of violence
have been popularized in the modern media but
are longstanding perceptions (Monahan, 1992) that
continue to be investigated (Van Dorn, Swanson,
Elbogen, & Swartz, 2005). Early research of the
twentieth century, however, indicated that persons
with mental illness did not present a greater risk of
violence than persons in the general population.
Although this notion took hold and predominated
for many years, the relationship between mental disorders and violence continued to command research
attention. Over time, a new generation of scientific
thought regarding the relationship between mental
illness and violence evolved. Specifically, several
studies emerged leading to conclusions that there is
a significant association between mental illness and
the likelihood of engaging in violence, though the
relationship is felt to be small (Appelbaum, 1994;
Monahan, 1992; Mulvey, 1994).
Several studies from the late 1980s to early 1990s
demonstrated increased rates of violence among persons who were hospitalized (Hodgins, 1992; Steadman
et al., 1994). Further solidifying the research related
to violence and mental illness were several studies examining large community samples. The first of such
studies, often cited, is the report by Swanson and
colleagues (1990). In their study, they reviewed data
derived from the Epidemiological Catchment Area
(ECA) Surveys, one of the largest American studies of
the prevalence of psychiatric disorders in the community at the time. The ECA study involved structured
diagnostic interviews, and respondents were assessed
to see whether they met criteria for psychiatric disorders within the 12 months preceding the interviews.
Embedded in the diagnostic items were five questions related to violence (e.g., whether subjects had
ever hit or thrown things at their spouse or partner
and whether subjects had been in more than one
fight since age 18 that came to swapping blows, etc.).
Additionally, questions were asked regarding how
recently any reported violence occurred.
Out of approximately 10,000 respondents, Swanson and colleagues (1990) identified a base rate of
reported violence of 2% among persons
with no diagnosable disorder. A 5-fold increased risk

VIOLENCE RISK ASSESSMENT

(approximately 11%) of reported violence was observed

among persons with a diagnosable mental illness.
Interestingly, this pattern appeared similar for those
with schizophrenia, bipolar disorder, and major depressive disorders. Alcohol-related disorders accounted
for approximately a 12-fold increase (24.6%) in violence
risk, while other drug-related disorders accounted for
approximately a 15-fold increased risk (34.7%). Moreover, the combination of diagnoses increased violence
risk, especially when a substance use disorder was
one of the diagnoses involved.
Subsequent community studies supported and
expanded the findings of Swanson and colleagues.
Link et al. (1992) found that community patient
groups (where no diagnoses were reported) had significantly higher rates of arrest, hitting, weapon use,
and hurting someone in a fight, compared to the
community sample of nonpatient groups, even when
socioeconomic factors were considered. Furthermore,
they found that psychotic symptoms contributed to
the violence risk among all subjects.
A follow-up study by Link and Stueve (1994) examined whether specific types of psychotic symptoms
accounted for the increased rates of violence in the
earlier study by Link and colleagues. Violence examined, included hitting, fighting, and weapon
use. Symptoms of particular interest included those
referred to as threat/control-override, or TCO,
delusions, such as beliefs that subjects were being
threatened, that thoughts were being inserted into
subjects minds, or that their minds were controlled
by outside forces. Looking at 232 patients and approximately 521 community residents, these authors
found that the greater the degree of TCO symptoms, the greater the likelihood of violence. A subsequent reexamination of data by Swanson and
colleagues (1996) similarly found an association
between TCO symptoms and reports of violent
behavior, and an even greater risk of violence when
TCO symptoms were combined with substance
abuse. The association between TCO symptoms and
increased violence risk has since been called into
some doubt (Monahan et al., 2001). Still, robust
findings regarding the relationship between substance use and risk of violence among persons with
mental disorders continue to be replicated, with one
author suggesting that very early onset of substance
use followed by the emergence of mental illness
may be associated with the highest risk of violence
in the community (Fulwiler, Grossman, Forbes, &

51

Ruthazer, 1997). Additional studies examining other

symptoms of mental illness and their relationship to
violence risk are described in the following text.
As the number of studies related to the relationship of violence and mental illness grew, increasing
attention was paid to the methodology behind the
science. The MacArthur Violence Risk Assessment
Study sought to examine the issue of the prevalence
of violence among persons with mental illness using
methods that addressed many of the limitations of
prior studies. Several studies have emerged from their
data. The crux of the study design involved repeated
follow-up of 1136 patients who had been recently
discharged from civil psychiatric hospitals across
three sites. In a major publication of their findings,
Steadman and colleagues (1998) identified several
critical factors that bear on violence risk assessment
and the relationship to mental illness. First, they
noted that one data source alone will not provide all
the information related to a persons violence risk, and
that utilizing self-report (which still provides the most
robust information), in combination with records of
arrest and hospitalization, and a collateral contact
can each incrementally provide additional information. Second, their findings highlighted the importance of defining outcome; in their study violence
was divided into acts that resulted in physical injury
(which included sexual assault, use of a weapon, and
threat with a weapon in hand) and other aggressive acts
that did not result in injury. Third, they distinguished
between persons with more serious mental disorders
and those with other mental disorders, such as personality disorders and adjustment reactions.
In their study, Steadman and colleagues (1998)
reported a 1-year aggregate prevalence of violence
as being highest for those persons with other mental
disorders and substance use disorders (43%). Patients
with major mental disorders and substance use demonstrated a 1-year aggregate rate of violence of 31.1%, but
when no substance use was involved, patients 1-year
aggregate rate of violence was much lower (17.9%).
Furthermore, rates of violence among patients without
substance use appeared statistically indistinguishable
from rates of violence among the community sample that also did not engage in substance abuse. The
findings of the MacArthur study have been discussed
widely (Torrey, Stanley, Monahan, & Steadman,
2008) and have highlighted to role of substance use
in increasing violence risk and the importance of
ongoing research in this area.

52 ASSESSMENT AND DIAGNOSIS

In a separate study looking at violence and mental

disorders from a birth cohort of young adults in New
Zealand, Arsenault and colleagues (2000) reported
that individuals with alcohol dependence, marijuana
dependence, and disorders of the schizophrenia spectrum were more likely to be violent than controls. This
study specifically attempted to explore rates of violence
among individuals at an age that is correlated with
increased violence (i.e., young adulthood). Further,
the study examined substance use in the hours before
the violent offense in an effort to examine the effects
of acute intoxication on violence, along with issues
related to conduct disorder and threat perception.
Findings from the study highlighted that persons with
mental disorders accounted for significant violence
particularly when substance abuse was involved, but
that different mental disorders were linked to violence
in different ways. The findings suggested that that a
variety of contextual and historical variables should
also be explored in violence prevention strategies.
A more recent study looking at the prevalence
of violence and its correlates among persons with
schizophrenia who were residing in the community
found that certain symptoms, such as ideas of being
persecuted, labeled as positive psychotic symptoms,
increased the risk of both serious violence and more
minor violence (Swanson et al., 2006). In this study
looking at approximately 1400 persons with schizophrenia across numerous communities, social withdrawal and other negative symptoms seemed to
lower risk of serious violence. In general, more serious
violence was associated with a history of victimization
and childhood misconduct, as well as with psychotic
and depressive symptoms. The authors noted that
the risk of minor violence seemed to be increased
by nonclinical variables such as age, sex, housing
environment, and degree of vocational involvement,
among other factors. Substance abuse was found to
be related to minor violence, but its association with
serious violence disappeared once age, recent victimization, positive symptoms of schizophrenia, and
childhood conduct problems were controlled for.
Summarizing the findings of these types of studies, it appears that mental disorders (especially personality disorders and adjustment disorders) increase
the risk of violence to an extent that is important
to track, but that substance abuse specifically, as
well as contextual, demographic, and historical
variables contribute more significantly to overall violence risk.

PR EDICT ION OF V IOLENCE BY

MEN TA L HE A LTH PROFESS IONA LS

Given the prevailing view at the time that there

was little relationship between mental illness and
violence, Monahan (1981) reviewed five studies, as of
the late 1970s, on the accuracy of clinical prediction
of violent behavior. Monahan concluded in a nowoften-repeated reference that
Psychiatrists and psychologists are accurate in
no more than one out of three predictions of violent behavior over a several-year period among
institutionalized populations that had both committed violence in the past (and thus had higher
base rates of violence) and who were diagnosed as
mentally ill (Monahan, 1981, p. 47).
In making this statement at the time, Monahan had
been relying upon findings based on first-generation
prediction studies, which were cast in a sociopolitical
climate focused on controlling the lives of persons
with mental disorders (Melton, Petrila, Poythress, &
Slobogin, 1997). Melton and colleagues noted that
clinical decisions erred toward making erroneous
findings that these persons were dangerous (e.g., many
studies were discovering falsepositive percentage
rates exceeding 50%). These findings are not surprising given the numerous problems that plagued firstgeneration research, some of which could be fixed
and some of which have proven to be inherently
difficult to address when studying the prediction of
violent behavior (Otto, 1992).
Citing methodological and research design flaws,
Monahan called for the second-generation of studies described earlier. Given that much of the earlier
assessment research was characterized by restricted
predictors and simplistic outcome criteria, researchers began paying greater attention to the conceptualization and measurement of risk factors and of
violence. Coinciding with the appeal by Monahan,
the field began to move away from studying the
accuracy of categorical predictions of dangerous
or not dangerous, and instead promoting research
that focused on risk assessment. The aim has been
to begin providing more empirically supported information that is not only clinically meaningful
but, importantly, could also inform legal judgments
and risk management interventions (Melton et al.,
1997).

VIOLENCE RISK ASSESSMENT

Four methods to assessing violence risk

Both Douglas and Kropp (2002) and Melton et al.
(1997) reviewed the advantages and shortcomings of
several methods to assess risk of violence, including
clinical, actuarial, anamnestic, and structured professional judgment. Unstructured clinical assessment is
a method that relies on unsystematic and potentially
dissimilar approaches to case formulations (Melton
et al., 1997). The process involves no guidelines for
the evaluator, although presumably the clinician
would have some familiarity with literature related
to violence risk assessment. Decisions are made with
considerable clinical discretion and are usually justified according to the qualifications and experience of
the person making them (Douglas & Kropp, 2002).
An advantage of this unstructured clinical approach is
that it allows for an individualistic analysis of the
persons problematic behavior. Clinicians who employ
this method indicate that they are able to attend to
a large number of variables. However, because this
method maximizes professional discretion, it is vulnerable to evaluator bias and missing important factors (Douglas & Kropp), and the clinical accuracy
and utility of combining and weighing of relevant
factors by clinicians yielding findings of dangerous
or not dangerous is unknown (Dawes, Faust, &
Meehl, 1989; Melton et al., 1997). This clinical
method has been criticized for its lack of reliability,
validity, and accountability (Harris, Rice, & Cormier,
2002; Quinsey, Harris, Rice, & Cormier, 1998b).
Actuarial methods predict an individuals likelihood of future violence by mathematically comparing the person to a norm-based reference group
using a specific violence risk assessment tool. In contrast to unstructured clinical prediction, an actuarial
approach to risk assessment is designed to estimate,
in a relative sense, the risk posed by an individual
within a specific timeframe, according to the time
parameters identified by the research that formed the
basis of the actuarial instrument. Grove and Meehl
(1996, p. 294) described this approach as a formal
mechanical and algorithmic method. A mathematical combination of variables is used to generate a prediction that is very rigid; once the specific predictors
in an actuarial technique are set, all other information is irrelevant. The advantage lies in the ability to
offer predictions and risk assessments with minimal
bias, solely on the basis of an examination of empirically supported risk factors. However, its apparent

53

advantages can be viewed as disadvantageous in clinical and forensic settings. For example, an offender
who has unique violence-reducing characteristics
(e.g., quadriplegic) or situations (e.g., previously targeted victim immigrated to another country) that are
not recognized in the literature may still be classified
as dangerous by an actuarial procedure (Melton
et al., 1997). Additional shortcomings include difficulty in generalizing findings to persons outside of
the normative group and a tendency on the part of
decision makers, such as judges, to favor clinical data
and, at times, even ignore highly relevant actuarial
data (Melton et al., 1997). Douglas and Kropp (2002)
further suggest that actuarial assessments are limited
since they only inform us about ones overall level of
risk, without information related to risk management.
A third method is referred to as the anamnestic
approach to risk assessment (e.g., Melton et al.,
1997; Otto, 2000). In this approach, evaluators must
identify violence risk factors through a detailed examination of the individuals history of violent and
threatening behavior (Otto, 2000, p. 1241). Clinicians
attempt to identify violent patterns or themes as well
as any unique risk factors particular to the individual.
By reviewing historical information, clinicians
attempt to examine past episodes of violence to ascertain whether there are recurrent themes or patterns
related to victims or situations that lead to aggression or violence (Melton et al., 1997). Unlike methods previously discussed, this approach informs risk
management strategies and can be applied to violence prevention efforts. As such, the treatment literature supports identifying violence patterns so that
plans can be created to recognize an offenders early
signs of escalation to break that pattern (Douglas &
Kropp, 2002). This method, however, does not lend itself easily to procedural or empirical evaluation, given
that individual clinical judgment and data gathering
are utilized to form the assessment. Belfrage and
Douglas (2002) commented that this model assumes
a behavioral chain that will repeat itself and thus be
predictable. It does not recognize the complex nature
of violence and its multifaceted contributing factors
(Douglas & Kropp, 2002).
Finally, the fourth method of violence risk assessment, known as the guided clinical approach (Hanson,
1998) or structured clinical decision making (Hart,
1998), employs structured professional judgment.
Tools incorporating this approach offer guidelines
that reflect current theoretical, clinical, and empirical

54 ASSESSMENT AND DIAGNOSIS

knowledge about violence (Douglas & Kropp, 2002,

p. 626). Typically, relevant clinical data are gathered from multiple sources, reviewed and compared
against operationally defined criteria to determine
whether a specific risk factor is present. One measure
described subsequently that can be used to help with
this type of clinical risk assessment, the HCR-20
(Webster, Douglas, Eaves, & Hart, 1997), offers recommendations about how to implement risk management strategies, utilizing a guided clinical type of
approach. Additionally, this assessment approach systematically informs clinicians of those risk factors that
are most relevant for a given population and linked
empirically to violence. Methods using structured
professional judgment are more flexible than actuarial
techniques because they do not impose restrictions on
how to combine and weigh risk factors, and they are
more flexible than anamnestic approaches because
clinicians are not bound by the need to identify violent themes. The guided clinical approach relies on
professional judgment and discretion in the final step,
when combining and weighing the importance of risk
variables and making the overall judgment of relative
risk (Douglas & Kropp, 2002; Douglas et al., 2003).
Clinicians also may account for idiosyncratic variables
that may have critical importance to an individuals
violence risk (e.g., direct, specific homicidal threats).
Moreover, treatment providers can capitalize on this
systematic approach when creating interventions to
manage an offenders risk of violence. This method
not only assesses relative risk but also can link pertinent risk factors (e.g., dynamic) to theoretically and/or
empirically supported treatment strategies.
Clinician-Based Versus Actuarial Violence
Risk Prediction
We refer to clinician-based prediction as assessment
without the use of any structured aids. In comparison to instrument-aided prediction, only a few studies on clinicians predictions of violence have been
published since Monahans (1981) proclamation that
only one out of three predictions of violent behavior
is accurate. In a large study, Mossman (1994) examined clinicians predictive accuracy by reexamining
58 data sets from 44 published studies dating from
1972 to 1993. Although all focused on violence risk
prediction, the studies included a broad range of subjects, settings, population sizes, and clinical criteria
for assessing violence. On the basis of this review,

Mossman suggested that clinicians were able to distinguish violent from nonviolent patients with a modest, better than chance level of accuracy (Mossman,
1994, p. 790).
Lidz et al. (1993) studied a large sample of patients
examined in a psychiatric emergency room setting
and found that clinicians accuracy in predicting
male violence exceeded chance, regardless of whether the patient had a history of violence. However,
clinicians predictions of female violence did not differ
from chance, even though the actual rate of violent
incidents among discharged female patients (46%)
was higher than the rate among discharged male
patients (42%). Lidz et al. noted that this discrepancy
at predicting violence appeared to be a function of the
clinicians serious underestimation of the base rate of
violence among mentally disordered women. Moving
away from predicting violence in the community,
McNiel and Binder (1991) focused on clinical predictions of inpatient violence. They had nurses estimate
the probability (low: 0% to 33%, medium: 34% to 66%,
and high: 67% to 100%) that patients would become
violent within the first week of hospitalization. Of the
patients estimated to have a low and medium probability, 10% and 24%, respectively, committed a violent
act. Among those estimated to have a high likelihood
(i.e., 67% to 100%) of becoming violent, only 40%
were later found to have acted violently.
As seen earlier, a number of studies have indicated that clinical decisions can be made at abovechance levels in some contexts (e.g., Lidz et al., 1993)
and that they can be consistently accurate regarding
short-term risk of violent behavior (Binder, 1999).
Such findings are infrequently represented in the literature, however.
Many studies comparing actuarial and clinical decision making have concluded that actuarial
techniques typically outperform unstructured clinical approaches (Dawes et al., 1989; Faust & Ziskin,
1988; Lidz et al., 1993; Mossman, 1994) and that
this alone is an argument for the sole use of actuarial methods (Grove, Zald, Lebow, Snitz, & Nelson,
2000; Quinsey et al., 1998b). Proponents of the actuarial measures note that clinicians typically have too
much information, with hundreds if not thousands of
facts about each patient, to consider before reaching
a decision (Harris, Rice, & Quinsey, 1993), and that
actuarial methods offer the advantage of being transparent, systematic, and thorough in their approach
(Mossman, 2004).

VIOLENCE RISK ASSESSMENT

Although Monahan et al. (2001) asserted that the

demonstrated superiority of actuarial methods over
clinical approaches is a dead horse, there are those
who suggest the debate between the accuracy of
clinical and actuarial predictions will continue.
Buchanan (2008) commented that the accuracy of
actuarial predictions of violence among persons with
mental illness exceeds chance, but also noted that
with very low base rates of violence, predictions are
more error-prone, such that when making hospitalization decisions, to prevent a few acts of violence
one might end up hospitalizing many who would
not have become violent if relying on actuarial predictions. In a notable exchange with Harris and her
Violence Risk Appraisal Guide (VRAG; Harris et al.,
1993) colleagues over the years, Litwack (2001) argued
that actuarial versus clinical prediction methods have
never been tested head-to head. Others (see Campbell,
2000) also argue that the superiority of actuarial methods has not been established in real world (Dvoskin
& Heilbrun, 2001) forensic and clinical settings.
Critics of the purported superiority of actuarial
methods have argued that risk factors and outcomes
materialize in a complex interaction between human
behavior and environment (Sturidsson, HaggardGrann, Lotterberg, Dernevik, & Grann, 2004), and
that clinical risk assessments are often conducted by
multidisciplinary teams rather than individuals, as is
the case with actuarial approaches. This methodological distinction raises questions about the validity
of actuarial instruments, given that multiple clinical
assessments of violence have been shown to be much
more accurate than those generated by individual clinicians (Huss & Zeiss, 2004; McNiel, Lam, & Binder,
2000). Furthermore, risk assessment measures (even
with recent advances) have not consistently been able
to address the multifaceted nature of risk (Douglas &
Ogloff, 2003a). Huss and Zeiss (2004) note that violence risk assessment measures do not consider the
severity and imminence of violence and fail to capture
anything about the risk assessment process.
Comparison studies on the predictive validity
of clinical judgment narrowly focus on risk factors
rather than on protective factors (Rogers, 2000). Also,
the focus has been on individual risk factors (e.g.,
substance use, psychiatric symptoms) rather than
contextual (e.g., housing, employment, support) risk
management factors. Clinicians have the potential
to consider, on the other hand, protective and contextual factors as well as aggravating clinical and risk

55

factors known to be associated with increased violence potential. Given these facts, Monahan (2003)
also has since posited that clinically adjusted actuarial approaches are probably best.
That said, the literature in this area is growing
rapidly, and over time we will gain a more informed
perspective on actuarial instruments, clinical judgment, and mechanisms for maximizing our ability
to assess and manage violence risk.

SELECT V IOLENCE R ISK

ASSESSMEN T INST RUMEN TS

As noted earlier, over the years several more structured risk assessment instruments have been developed. Early risk assessment scales were nonempirically
based, idiosyncratic lists of items that varied from clinician to clinician on the basis of their training, background, and experience as to what they believed was
linked to increased risk of violence (Witt, 2000). These
unstructured professional opinions, or first-generation
assessments, had at best marginal predictive validity
for general and violent recidivism (Andrews, Bonta, &
Wormith, 2006). With the advent of tools and measures, empirically based item selection, improved
methodology (e.g., samples, and predictor and outcome variables), and more rigorous validation research,
researchers have continued to build momentum.
One of the early tools, the Violence Screening
Checklist (VSC; McNeil & Binder, 1991), was developed with the aim of predicting inpatient violence.
Other measures have focused on predicting risk
of more specific types of violent behavior, such as
domestic violence (Spousal Assault Risk Assessment
GuideSARA; Kropp, Hart, Webster, & Eaves, 1999),
fire setting (Rice & Harris, 1996), and male institutional violence (Rice, Harris, Varney, & Quinsey,
1989), but many of these tools are still early in their
development within research contexts and have produced only mixed results.
An alternative way of classifying risk assessment
tools is to sort them from an evolutionary point
of view. Following the unstructured professional
assessments came second-generation risk assessment instruments that employed historical or static
predictors such as criminological variables. The
VRAG (Quinsey, Harris, Rice, & Cormier, 1998a),
for example, has demonstrated good predictive validity and outperformed first-generation measures

56 ASSESSMENT AND DIAGNOSIS

(Andrews et al., 2006), but second-generation measures are limited as they cannot generally assess
changes in risk. Wong and Gordon (2006) argue that
such tools are not treatment-friendly as they provide
little information about the clients problem areas,
treatment potential, criminogenic needs, strengths,
current functioning, and so on (p. 280).
Measures such as the Level of Service Inventory
Revised (LSI-R; Andrews & Bonta, 1995) are representative of third-generation tools. They may be based in
theory (e.g., Andrews & Bonta, 1995) and account for
dynamic variables such as social, lifestyle, and attitudinal variables, mental illness and substance use, and
community supports. While dynamic variables have
been shown to predict risk as well as static variables,
the efforts of third-generation measures are still limited because, as Wong and Gordon (2006) state, predicting risk should not be the end product. Violence
reduction and prevention should be the ultimate
goal of risk assessment (Hart, 1998). In response to the
perceived need for tools that address these issues, two
fourth-generation measures have recently appeared
in the literature: Level of Service/Case Management
Inventory (LS/CMI; Andrews, Bonta, & Wormith,
2004) and Violence Risk Scale (VRS; Wong &
Gordon 19982003). These tools have been designed
to guide services that monitor and manage offenders
and provide treatment services.
The VRS (Wong & Gordon, 19982003) assists
treatment providers in integrating risk assessments
with treatment services among high-risk, high-need
nonsexual offenders (Wong & Gordon, 2006). The
VRS not only identifies who is at high-risk, but also
what variables are linked to violence and what therapeutic approaches may be effective in reducing this
risk. This tool is also designed to monitor changes in
a clients risk profile by allowing clinicians to periodically measure the effectiveness of treatment as it
is linked to a quantitative reduction in violence risk
(Wong & Gordon, 2006). The VRS, and its companions the VRSSex Offender Version and VRSYouth
Version, holds much promise as a psychometrically
sound risk assessment tool and has the advantage
of providing clinicians with information on how to
design and deliver risk reduction interventions. Future
research will likely shed more light on this instrument
and may place it among the more useful models for
tools to assess violence risk and management.
As noted in Chapter 6, there has also been a proliferation of tools designed to assess the risk of future

sexual offending behavior. With regard to general

violence risk assessment, prototypical empiricallyresearched measures include the HCR-20: Assessing Risk for Violence (HCR-20), the VRAG, and
the MacArthur Violence Risk Assessment Studys
Iterative Classification Tree (ICT), currently being
marketed as the Classification of Violence Risk
(COVR). The following sections will review each of
these in turn.
HCR-20: Assessing Risk for Violence
(Version 2)
The HCR-20 (version 2; Webster, Douglas, Eaves,
& Hart, 1997) comprises three domains (Historical,
Clinical, and Risk Management) and 20 risk items,
which are listed in Table 5.1. Technically not
Table 5.1 Variables on the Historical, Clinical,
and Risk Management-20 (HCR-20) Violence
Risk Scheme
Historical scale
Previous violence
Young age at first violent incident
Relationship instability
Employment problems
Substance use problems
Major mental illness
Psychopathy
Early maladjustment
Personality disorder
Previous supervision failure
Clinical scale
Lack of insight
Negative attitudes
Active symptoms of major mental illness
Impulsivity
Unresponsive to total treatment
Risk management scale
Plans lack feasibility
Exposure to destabilizers
Lack of personal support
Noncompliance with remediation attempts
Stress
Webster, C. D., Douglas, K. S., Eaves, D., & Hart, S. D. (1997).
HCR-20: Assessing Risk for Violence (version 2). Burnaby,
BC, Canada: Mental Health Law, and Policy Institute, Simon
Fraser University.

VIOLENCE RISK ASSESSMENT

considered an actuarial instrument, it is an example

of the structured professional judgment approach for
assessing risk of violence, and referred to as an aidemmoire. The 10 Historical items are primarily static
risk factors, as they reflect the temporal stability of
past conduct, mental illness and substance use, and
social adjustment (Webster et al., 1997, p. 27). The
five Clinical items measure changeable or dynamic
risk information, allowing risk levels to be modified or
adjusted on the basis of relevant clinical factors. The
last five items make up the Risk Management domain.
With dynamic content, they focus on how individuals will manage and adjust to future circumstances.
Temporally, the three scales emphasize past, present,
and future (Witt, 2000). The items were chosen following a review of the literature and selection of
those 20 factors that had consistent empirical support.
When designing the HCR-20 the authors also wanted
a measure that could be integrated easily into clinical
practice but, primarily, was empirically sound.
Clinicians rate the extent (0absent, 1partially
present, or 2definitely present) to which each risk
factor is present. A total score is not particularly
meaningful, as it is not compared to a normative reference group. Generally, higher scores on the HCR-20
relate to a greater incidence and frequency of violence than lower scores. This measure allows for the
possibility that just the presence of a small number of
risk factors may be substantial enough to determine
that a person is likely to behave violently. Rather
than relying on cut scores, clinicians are encouraged
to come to a clinical decision about a persons risk
for violence using terms outlined in the instrument
(low, moderate, or high) relative to other persons
in comparable settings. This risk level is associated
with the degree of intervention or management that
is required to prevent violence (Douglas & Kropp,
2002). Given the problems with rigid actuarial approaches, low, moderate, and high-risk levels are purposefully not associated with specific scores. Even
so, scholars (e.g., Heilbrun, Dvoskin, Hart, & McNiel,
1999; Monahan & Steadman, 1996; Otto, 2000) contend that these general categories are clinically meaningful and can yield reasonable reliability and validity
estimates (Douglas & Ogloff, 2003a, 2003b).
There have been many studies with diverse criminal and civil populations involving the HCR-20. In
a retrospective study with prisoners, Douglas and
Webster (1999) found that offenders with scores
above the median on the HCR-20 increased the odds

57

of past violence and antisocial behavior by an average

of four times. Within a civilly committed population,
Douglas et al. (1999) found that over a 2-year community follow-up, patients scoring above the median
were 6 to 13 times more likely to be violent than those
scoring below the median. In an unpublished study
cited by Belfrage and Douglas (2002), the measure
predicted incidents of onward aggression and postdischarge violence over a 6-month period among psychiatric patients on an acute care unit.
In some studies of the HCR-20, Clinical and
Risk Management factors contributed more to
the predictive accuracy than the Historical factors
(Strand, Belfrage, Fransson, & Levander, 1998). In
a study of inmates receiving mental health services
(Grann, Belfrage, & Tengstrom, 2000), the HCR20s historical variables demonstrated better predictive accuracy regarding future violence among
personality- disordered offenders and those diagnosed with schizophrenia, compared to variables on
an actuarial measure (i.e., VRAG [see subsequent
text]). However, the authors noted that clinical and
risk management factors, as compared to the historical items, may have greater predictive accuracy
for offenders with major mental illness. In a pseudo-prospective study of male forensic psychiatric
patients discharged from medium secure units, the
HCR-20 total score, and the historical and risk subscale scores but not the clinical subscale scores, were
good predictors of violent and other offenses after
discharge (Gray, Taylor, & Snowden, 2008). Given
its structured professional judgment approach, the
HCR-20 uniquely considers empirically-based clinical and risk management matters, thus permitting an
ongoing assessment of changes made in these areas.
Although historical variables have been shown to be
significantly correlated with risk of future violence,
the aforementioned studies have demonstrated that
the Clinical and Risk Management domains can also
be significantly related to violence (Belfrage, 1998).
Further, these scales, unlike the historical items, are
sensitive to changes related to individuals participation in psychiatric treatment and the development
and modification of release plans (e.g., Douglas,
Webster, Eaves, Hart, & Ogloff, 2001). This suggests
that psychiatric treatment, as well as situational variables and suitable risk planning can play a significant
role in postdischarge violence. For instance, some
authors report that scores on the Clinical and Risk
scales declined in the context of forensic and civil

58 ASSESSMENT AND DIAGNOSIS

psychiatric inpatient treatment (Belfrage & Douglas,

2002; Douglas & Belfrage, 2001; Webster, Douglas,
Belfrage, & Link, 2000).
Accompanying the HCR-20 is the Violence Risk
Management Companion Guide (Douglas et al.,
2001). Distinguishing itself from many other risk
assessment measures and embracing the goal of violence reduction and prevention, this guide provides
assistance to clinicians making recommendations to
care providers for managing a clients violence risk.
Ongoing research related to the HCR-20 and possible
future revisions of this measure will continue to shed
light on what appears to be the promising effectiveness of this tool for risk assessment and management.

Table 5.2 Violence Risk Appraisal Guide (VRAG)

Predictor Variables a
Psychopathy ChecklistRevised (PCL-R) Score
Elementary school maladjustment
DSM-III diagnosis of any personality disorder
Age at time of the index offense b
Separation from either natural parent (except death) under
age 16
Failure on prior conditional release
CormierLang scale score for extent and severity of
nonviolent criminal behavior
Never married
DSM-III diagnosis of schizophrenia b
Severity of physical injury suffered by the victim of the
index offense b

Violence Risk Appraisal Guide

The Violence Risk Appraisal Guide (VRAG; Harris
et al., 1993) was developed using a sample of over 600
men from a maximum-security forensic hospital in
Canada, all of whom were charged with a serious criminal offense. After assembling a wide variety of predictor
variables from institutional files, the authors defined
the criterion variable as any new criminal charge for
a violent offense or return to that institution for an act
that would have resulted in such a charge. A series
of regression models were computed, and the authors
identified 12 variables for inclusion in the final
actuarial instrument (see Table 5.2). As noted in the
table, the most heavily weighted risk factor is the individuals score on the Psychopathy ChecklistRevised
(PCL-R; Hare, 1991). Additionally, four variables
relate negatively to risk of violent behavior. According
to the foundational VRAG studies, male offenders
who were older, who chose a female victim, who injured a victim in the index offense, or who were diagnosed with schizophrenia were significantly less likely
to be violent recidivists than other male offenders in
the comparison sample (Banks et al., 2004). A complete description of the development of the VRAG
as well as scoring instructions has been published
(Quinsey et al., 1998a).
When Harris and colleagues (1993) dichotomized
the VRAG scores into high and low, the results indicated that 55% of the high scoring participants committed a new violent offense, compared with 19% of
those participants scoring low. Rice and Harris (1995)
found that the VRAG predicted violent recidivism
reasonably well in studies of 3.5, 6, and 10 years. Later
studies conducted by Rice and Harris (1997) found

Severity of alcohol abuse history

Female victim in the index offense b
a

Predictor variables are listed in descending order of weight or

relation to future violence.
b
These variables are inversely (negatively) related to future violence.
Harris, G. T., Rice, M. E., & Quinsey, V. L. (1993). Violent recidivism of mentally disordered offenders: the development of a statistical prediction instrument. criminal Justice and Behavior, 20,
315335.

that the VRAGs predictive performance was less successful when used to predict violence in sex offender
populations. Initially, Webster et al. (1994) held the
position that after the VRAG score was obtained,
there may be some instances where clinicians might
find it appropriate to vary the VRAG probability estimate using clinical judgment, but no more than 10%
in either direction. This clearly violates the assumptions postulated by the actuarial approach, and
4 years later, Quinsey et al. (1998a) changed their
position, stating that any clinical adjustment reduced
the VRAGs predictive accuracy.
As an actuarial risk assessment instrument, the
VRAG is an advancement from the first-generation
efforts, and it has been especially influential in the
prediction of violence among serious offenders who
are released into the community. However, similar
to other subsequent instruments, these actuarial
measures are only applicable to the specific groups
on which they have been normed. Therefore, populations of civil committees on acute psychiatric units,
women, and adolescents, for example, may not be appropriate for assessment with the VRAG or other actuarial instruments. There are two other critiques of
the VRAG. With so few items, it has been criticized

VIOLENCE RISK ASSESSMENT

for being overly simplistic (Grann et al., 2000) and

overly reliant on historical and static factors (Dolan
& Doyle, 2000). After first permitting clinical adjustment to VRAG estimates and then changing their
stance that the predictions should not be altered, the
authors subsequently recommended that the actuarial
predictions be supplemented by a checklist of clinical
factors to produce the Violence Prediction Scheme
(Dolan & Doyle, 2000; Webster et al., 1994).
MacArthur Violence Risk Assessment
Studys Classification of Violence Risk
Most recently, the MacArthur Risk Assessment Project
developed an actuarial risk assessment tool that is
founded in what the researchers refer to as an ICT
scheme. This approach to violence risk assessment is
based on interactive and contingency models, allowing clinicians to consider many different combinations
of risk factors in classifying a person as being at high
or low risk of engaging in violent behavior (Monahan
et al., 2000; Steadman et al., 2000). The classification
tree begins with a question asked of all persons being
evaluated. On the basis of the answer to that question,
one of two more questions is posed, the answer to which
determines the next question asked. This continues
until each person is classified into a category based on
violence risk (Banks et al., 2004; Steadman et al., 2000;
Monahan et al., 2006). This method contrasts with the
usual approach to actuarial risk assessment, in which
a common set of questions is asked of everyone being
assessed and every answer is weighted and summed to
produce a score that can be used for the purposes of
categorization (Monahan et al., 2001).
The principle results of the MacArthur Violence
Risk Assessment Study are reported in Steadman
et al. (2000) and in Monahan et al. (2000). The
ICT decision tree approach selects an optimal predictor of violence from a pool of over 100 risk factors. Monahan et al. (2001) sought to maximize the
ICTs utility for real-world clinical decision making by applying it to a set of violence risk factors
commonly available in clinical records or those capable of being routinely assessed in clinical practice.
Results showed that the prototype-ICT partitioned
three-quarters of a sample of psychiatric patients into
one of two categories with regard to their risk of violence toward others during the first 20 weeks after discharge. One category consisted of groups whose rates
of violence were no more than half the base rate of

59

the total patient sample (i.e., equal to or less than 9%

of violence). The other category consisted of groups
whose rates of violence were at least twice the base
rate of the total patient sample (i.e., equal to or greater
than 37% violent). The actual prevalence of violence
within individual risk groups varied from 3% to 53%
(Banks et al., 2004; Monahan et al., 2001).
After the initial development and evaluation of
the prototype-ICT model, the MacArthur group
opted to adopt an approach that integrates the predictions of many different risk assessment classification trees, each of which may capture a different
but important facet of the interactive relationship
between the measured risk factors and violence
(Banks et al., 2004). Table 5.3 illustrates the 10
ICT models they identified. Using a multiple ICT
approach, these researchers ultimately combined the
results of five decision trees, or prediction models,
generated by this methodology. Each of the five trees
features a different risk factor as the starting point for
the development of the tree. Using computer technology and taking only 10 minutes for a brief chart
review and instrument administration, the COVR, as
it became known, holds promise for those clinicians
conducting violence risk assessments on civilly committed psychiatric patients before discharge to the

Table 5.3 MacArthur Violence Risk Assessment

Studys Classification of Violence Risk (COVR) a
Model b

First Variable

Variables

ROC-AUC*

Seriousness of arrest

12

0.803

Drug abuse diagnosis

0.738

Alcohol abuse
diagnosis

13

0.764

Primary diagnosis

0.753

Anger reaction c

11

0.778

Schedule of imagined
violence

10

0.769

Child abuse c

14

0.791

Prior violence

10

0.766

Age c

16

0.784

10

Gender c

14

0.806

Adapted from Banks et al. (2004).

Characteristics of the multiple iterative classification tree models.
c
The five models retained for the multiple-model risk classification.
* ROC-AUC = Receiver Operating CharacteristicsArea Under
the Curvea measure of violence risk that allows for assessment
without confounds related to base rate. Numbers closest to 1.0 reflect
best predictive accuracy.
b

60 ASSESSMENT AND DIAGNOSIS

community. The COVR software can generate a report that contains an estimate of the patients violence
risk (ranging from 1% to 76% likelihood), though, as
the authors note, this estimate of violence risk should
not be the equivalent of a determination of whether
a patient should be discharged (Monahan et al., 2006).
However, it is recommended that clinicians could
utilize the information that the COVR provides to
aid in risk assessment and risk management planning (Monahan et al., 2006). Monahan and colleagues (2005, 2006) emphasized that the multiple
ICT model was constructed and validated, to date,
only on samples of psychiatric inpatients in acute facilities in the United States who would be discharged
into the community. Until additional research is conducted, the use of the COVR should be restricted to
circumstances that meet those parameters.

CLINICA L A PPROACH TO V IOLENCE

discernible patterns across violent episodes (regarding

factors such as motivation, targets, and the examinees
mental state at the time).
In conducting an interview aimed at violence risk
assessment, the complex interplay of appropriate probing, respect for the examinee, and attention to safety
is important to bear in mind. Clinicians less experienced with violence risk assessment interviews should
be mindful to avoid common pitfalls, including the
failure to probe because of a concern that it may be
best to let sleeping dogs lie or a fear that the person
will target the clinician when next violent. Clinicians
sometimes fail to elicit data because of an erroneous
assumption that treatment providers already know
that aspect of the patients history. Also, clinicians
conducting violence risk assessments should strike
a balance between asking structured questions that
may be based on known violence risk factors and
open-ended questions that allow for a more individualistic and anamnestic history.

R ISK ASSESSMEN T

Violence risk assessments typically involve gathering

data from a number of sources, including relevant
records (e.g., police reports, criminal record, victim/
witness statements, hospital records), third parties
(e.g., family members, police officers, mental health
treatment providers), and often most importantly, the
individual being evaluated. In addition to providing
useful data, collateral sources such as records, contact with third parties, and laboratory tests (e.g., toxicology screens) can offer information regarding the
reliability of the examinees self-report. The purpose
and time frame of the risk assessment, as well as the
type and amount of data available will vary depending
on the setting (Borum et al., 1996). Therefore, an important first step is to focus and shape the parameters
of the assessment process and question. Regardless of
the specific reason(s) for referral, however, any risk
assessment should ideally involve a clinical interview
addressing the examinees history and mental status.
Given its notable predictive power regarding violence
risk, an examinees history of violence must be thoroughly assessed in the clinical interview. Borum and
colleagues (1996) and Otto (2000), for example, recommend beginning with screening questions aimed
at determining the presence of potential risk, followed by conducting an anamnestic analysis of the
examinees violence history that addresses the nature
and precipitants of past aggressive behavior and any

R ISK FACTOR S FOR V IOLENCE

As noted earlier, guided clinical assessments involve

gathering data about factors shown to be empirically
related to violence risk and using clinical judgment
to integrate this and other relevant information in
formulating opinions about risk, possibly including
the use of a structured tool to help in the assessment,
such as the HCR-20 (Webster et al., 1997). As noted
by Monahan et al. (2001), research delineating particular risk factors for violence has focused on variables identified in both the criminological and clinical
literatures. These factors cluster into two primary
domains: static (i.e., variables that do not change or
are not readily changed) and dynamic (i.e., variables
that can change). Identification of both types of factors is important in terms of assessing an examinees
absolute level of risk and planning appropriate risk
management interventions (Otto, 2000). Table 5.4
presents a nonexhaustive list of variables identified
in the literature as most relevant to violence risk.
Following is a summary of the factors shown to be
associated with violence potential, as well as a brief
discussion of the relevant research. Although many
of the studies cited focus on samples of psychiatric
patients, some involve persons not diagnosed with
mental disorders. For detailed reviews of the research
in this area, the reader is referred to Borum et al.

VIOLENCE RISK ASSESSMENT

Table 5.4 Select Factors Associated with

Increased Violence Risk
Static Variables
Age
Sex
Intelligence/neurological impairment
History of violence/criminal behavior
History of childhood physical abuse/Domestic violence
Psychopathy
Dynamic Variables
Neighborhood context
Stress/Social support
Victim availability and specificity
Substance abuse/dependence
Comorbid mental disorder (with substance abuse)
Threat/control-override (TCO) symptoms a
Command hallucinations a
Violent thoughts
Anger
a

Although the available data regarding these factors are equivocal, some studies have found support for their association with
increased violence risk.

(1996), Melton et al. (1997), Monahan et al. (2001),

and Otto (2000).
Select Static Risk Factors
Studies in both the clinical and criminological arenas
have identified age as a risk factor for violence, with
late adolescence to early adulthood (i.e., ages 18 to 25)
representing the period of greatest risk for violent or
threatening behavior (Bonta, Law, & Hanson, 1998).
For the most part, research has noted the association
between age and violence among persons in the general population as well as those with mental illness. In
his examination of violent behavior among psychotic
patients, however, McNeil (1997) suggested that age
may have less predictive utility with respect to violence among more symptomatic persons because
clinical risk factors are likely to assume prominence
in the analysis of violence potential.
The criminological literature has long reported
sex as a risk factor for violence in the general population, with men exhibiting a much greater likelihood of engaging in violent behavior than women
(e.g., Reiss & Roth, 1993). Research on persons with

61

mental illness, however, suggests minimal or no

differences in rates of violence between men and
women (Estroff & Zimmer, 1994; Lidz et al., 1993;
McNiel & Binder, 1995; Monahan et al., 2001;
Tardiff, Marzuk, Leon, Portera, & Weiner, 1997).
Despite similar prevalence rates of violent behavior
among mentally disordered men and women, some
recent studies have noted gender differences in the
severity and/or context of the violence committed.
For example, Hiday et al. (1998) found similar rates
of self-reported, prehospitalization violence among
male and female patients but noted that men
engaged in more serious forms of violent behavior
(i.e., resulting in injuries or involving weapons) than
women. In an examination of posthospitalization
violence, the MacArthur Violence Risk Assessment
Study yielded similar data, as well as findings that
men were more likely than women to have been
using substances and failing to comply with psychiatric medications before committing violent
acts (Monahan et al., 2001). The MacArthur group
also found that women were more likely than men
to assault family members and to engage in violent
behavior in the home. Similar findings were reported
by Swanson et al. (1999), who noted that male psychiatric patients were more likely to engage in violent
behavior with acquaintances and strangers in public
places, while females were more likely to fight with
family members in the home.
Data from a number of studies have indicated
a relationship between low intelligence/neurological
impairment and violence (see review by Krakowski,
1997). Among clinical and nonclinical populations,
a history of violence or criminal behavior is a particularly robust predictor of future violence (Bonta et al.,
1998; Klassen & OConnor, 1994; McNiel, Binder, &
Greenfield, 1988; Mossman, 1994). A related relevant factor is the age at which the first serious offense
occurred and the versatility of prior criminal behavior (Borum, 1996; Patterson & Yoerger, 1993). In his
review of the variables relevant to violence risk assessment in outpatient settings, Otto (2000) noted that
persons with histories of serious illegal acts before
the age of 12 have been shown to be at increased
risk of engaging in violent and more serious criminal
behavior over the course of their lives.
A history of physical abuse or having witnessed domestic violence as a child is also predictive of later violence (Klassen & OConnor, 1994). The MacArthur
Study reported an association between childhood

62 ASSESSMENT AND DIAGNOSIS

physical abuse and posthospitalization violence but

not between childhood sexual abuse and violence
(Monahan et al., 2001). Data from the study also
indicate a relationship between excessive substance
use by a parent and increased rates of later patient violence, although the strength of this association varied
as a function of gender and race.
Over the past several years, there has been an increasing focus on the utility of the construct of psychopathy to predict violence. According to Hare (1998),
psychopathy may be understood as a fixed array of
affective, interpersonal, and behavioral characteristics, including egocentricity, deceitfulness, impulsivity, irresponsibility, superficiality, manipulativeness,
and a lack of remorse or empathy, as well as a history
of rule violations. Psychopathy is typically assessed
using the Hare Psychopathy ChecklistRevised
(PCL-R; Hare, 1991) or the Hare Psychopathy
ChecklistScreening Version (PCL-SV; Hart, Cox, &
Hare, 1995), each of which, contains items representing the aforementioned domains and allows for
ratings on each criterion. Chapter 10 in the text provides a more detailed description of this. Related to
violence risk, as reviewed by Hare (1998), research
has shown that persons scoring in the psychopathic
range on these measures are at increased risk of
engaging in violent and threatening behavior as
well as criminal acts in general. The three violence
risk assessment instruments discussed earlier in the
chapter incorporate the Psychopathy Checklists to
some extent. Not surprisingly, one of the most robust
risk factors on the HCR-20 and other measures is
the presence of psychopathy (Dolan & Doyle, 2000).
The MacArthur Study findings (Monahan et al.,
2001) indicated that scores on the PCL-SV among
civil psychiatric patients were strongly associated
with future violent behavior. Of note, Monahan and
colleagues (2001) found that most of the PCL-SVs
basic and unique predictive power was related to the
antisocial behavior factor, not the emotional detachment factor.
Select Dynamic Risk Factors
Data from the MacArthur Study (Monahan et al.,
2001) indicate that the contexts into which, hospitalized patients are discharged is relevant to predicting
their risk of subsequent violent behavior. In interpreting associations between individual-level predictors
(such as race) and violence, for example, it appears

especially important to consider contextual variables.

In the MacArthur Study sample, the significant relationship between race and violence disappeared when
neighborhood crime rate was statistically controlled.
Another key contextual variable is neighborhood
disadvantage, defined by the MacArthur group as
encompassing a number of factors, including neighborhood poverty, income, employment rates, and residential stability. They found no differences between
the violence rates of African Americans and whites
living in similarly disadvantaged neighborhoods,
despite the overall relationship between race and
violence. These data appear consistent with the findings of Swanson (1994) that higher rates of violence
among African Americans than whites may be attributable to differences in socioeconomic status (SES).
As noted by Otto (2000), there has long been theoretical support for the idea that perceived stress is a risk
factor for violence, and this notion has also received
some indirect empirical support. In addition to studies reporting an association between frustration/stress
and violent or threatening behavior (e.g., Berkowitz,
1998), the aforementioned findings of increased rates
of violence among populations with higher stress levels, such as low SES or a high-crime neighborhood,
seems to support this notion. Although it may be reasonable to assume that social support is associated with
decreased violence rates, the available data suggest that
the relationship between these two variables may be
mediated by level of functional impairment related to
severe mental illness (Swanson et al., 1998). According
to the findings of Swanson and colleagues, it may be
that persons with significant functional impairment
are more likely to be violent in the context of increased
contact with family and friends, while higher-functioning persons are less likely to engage in violent behavior
in the context of frequent social contact.
Important contextual variables to consider in any
violence risk assessment are victim specificity (e.g., is
the target one particular person or a broader group
of people?) and victim availability. A number of studies of aggression committed by persons with mental
disorders have found that family members are especially likely to be targets of patients violent behavior
(Steadman et al., 1998; Straznickas, McNiel, &
Binder, 1993). Estroff et al. (1998) found that mothers
residing with adult children diagnosed with schizophrenia and comorbid substance abuse were at significant risk of being assaulted by their children. This line
of research seems to suggest that for some persons with

VIOLENCE RISK ASSESSMENT

mental illness, contexts involving intensive contact

with family members may be a risk factor for violence.
A number of other variables may increase or mitigate
this risk, however, including the patients functional
level, as noted earlier (Swanson et al., 1998).
A diagnosis of substance abuse or dependence has
been shown to be a robust risk factor for violence,
and the presence of a coexisting major mental illness
or other psychiatric disorder appears to increase this
risk (Arsenault et al., 2000; Monahan et al., 2001;
Swanson et al., 1990; Swanson et al., 1996). Data
reported by Swartz and colleagues (1998) indicate
that subjects with severe mental illness who failed to
comply with their psychotropic medications and suffered from a comorbid substance abuse disorder were
at significantly increased risk for engaging in violent
behavior. As noted earlier in the chapter, however, a
diagnosis of a major mental disorder alone has been
shown to be a protective factor, that is, associated
with lower rates of violence than a diagnosis of other
types of psychiatric disorders, such as adjustment or
personality disorders (Lidz et al., 1993; Monahan
et al., 2001; Quinsey et al., 1998a). The MacArthur
group found that among major mental disorders, a
schizophrenia diagnosis was associated with lower
rates of violence than a diagnosis of depression or
bipolar disorder, which is consistent with data from
other studies (e.g., Gardner, Lidz, Mulvey, & Shaw,
1996; Quinsey et al., 1998a). Related findings suggest that persons experiencing a manic episode are
at increased risk for violent behavior (Beck & Bonnar,
1988; Binder & McNiel, 1988). That is not to say,
however, that a patient who is actively symptomatic
may not be at greater risk, and one would not want to
rely on diagnosis alone to make a risk determination.
One study, for example, demonstrated the association
of treatment noncompliance and substance use as a
predictor of violent behavior among persons with
serious mental illness (Swartz et al., 1998).
Studies examining the relationship between
schizophrenia and violence during the 1990s noted
the relevance of particular types of delusions involving perceptions of threat and beliefs that ones
thoughts and actions are being controlled by others.
As noted previously, Link and Steuve (1994) described
these TCO symptoms as a risk factor for violence, as
did others (Swanson et al., 1996). Similarly, McNeil
and Binder (1995) reported that acute hospital patients who exhibited suspiciousness were more likely to
engage in aggressive behavior than patients who

63

were not suspicious. In contrast to prior findings related to TCO and other delusional symptoms, the
MacArthur group reported no significant relationship
between delusions (regardless of content) and violence among recently discharged psychiatric patients
(Monahan et al., 2001). Of particular note is their finding that TCO delusions failed to predict higher rates
of violence. A related result may offer an explanation
for the discrepancy between these data and previous
research regarding TCO symptoms. However, nondelusional suspiciousness (i.e., possibly in the form of a
hostile attributional bias) was found to be associated
with subsequent violence in the MacArthur sample.
Monahan and colleagues (2001) caution that despite
the MacArthur Study findings regarding delusions,
these symptoms may be salient predictors of violence
in particular cases and thus should not be ignored as
potential risk factors. This is likely to be especially
true in cases of individuals who have a history of acting violently in response to delusions (Appelbaum,
Robbins, & Monahan, 2000).
Although conventional clinical wisdom suggests
a strong link between command hallucinations and
violent behavior, empirical findings have been more
equivocal. In a review of seven studies, Rudnick
(1999) reported that none found a positive association
between command hallucinations and violence.
Rudnick noted that when violent behavior did occur
in response to command hallucinations, it appeared
positively associated with the familiarity of the hallucinated voice and negatively related to the severity of
the violent behavior ordered. Subsequently, Braham
et al. (2004) posited that methodological limitations
of prior studies confounded the ability to draw conclusions from them. In their review of the literature,
they indicated that the weight of the evidence indicated that some individuals who hear commands
will act on them, but that there is a complex interplay of individualized factors that account for who
might act on such commands . In their review, Hersh
and Borum (1998) concluded that compliance with
command hallucinations was more likely if the voice
was familiar and if the nature of the command was
consistent with a coexisting delusion. Similarly,
others identified compliance with commands to
be associated with congruent delusions, a positive
view of the command hallucination, as well as increasing age and low maternal control in childhood
(Shawyer et al., 2008). The findings of the MacArthur
Study indicated no relationship between command

64 ASSESSMENT AND DIAGNOSIS

hallucinations in general and violence, but they did

suggest an association between command hallucinations with violent content and subsequent violence.
In particular, subjects who reported hearing voices
ordering them to commit acts of violence against
others were significantly more likely to engage in violence following hospital discharge than subjects who
did not experience violent command hallucinations.
Thus, as McNeil and colleagues (2000) noted, there
is clinical utility in asking about command hallucinations in conducting risk assessments in patients
with major mental illness, though command hallucinations should not be considered in isolation,
as the risk assessment formulation should examine
them in light of the total clinical picture.
Consistent with the clinical practice of inquiring
about homicidal ideation as a means of assessing
violence risk, the MacArthur data indicate a positive relationship between imagined violence during
hospitalization and violence following discharge
(Grisso, Davis, Vesselinov, Appelbaum, & Monahan,
2000; Monahan et al., 2001). This risk was increased
among subjects who continued to experience violent
thoughts after leaving the hospital. A much earlier
study by McNiel and Binder (1989) also reported an
association between verbal threats and subsequent violence among acute psychiatric patients. The authors
noted, however, that patients ultimate victims were
not necessarily the same persons they had threatened.
Common sense suggests that anger is a risk
factor for violence, and the results of empirical work
(much of it done by Raymond Novaco) support this
notion. For example, among samples of psychiatric
inpatients, anger has been shown to be positively
correlated with prior criminal convictions, use of
seclusion and restraint while hospitalized, and hospital assaults (Novaco, 1994). Anger was linked to a
risk of assaultiveness during forensic hospitalization
(Novaco & Taylor, 2004; Doyle & Dolan, 2006).
Similarly, data from the MacArthur Study indicate
that patients with elevated scores on the Novaco
Anger Scale (Novaco, 1994) during hospitalization
were twice as likely as those with low scores to commit violent acts following discharge. In a study involving
psychiatric inpatients who had reportedly engaged in
violent behavior before hospitalization, Swanson et al.
(1999) found that according to subjects reports, their
aggressive acts were most often accompanied by feelings of intense anger. Further, exposure to parental
anger and violence was associated with anger and

inpatient assaults for male forensic patients with developmental disabilities (Novaco & Taylor, 2008).

IN T EGR AT ING INFOR M AT ION FOR

CLINICA L R ISK ASSESSMEN TS

Once the relevant information is obtained from the

various sources, the clinician may begin to integrate
it to generate hypotheses about the examinees risk of
violent behavior. In some cases, the examinee may
not be willing or available to be interviewed, but
that may not necessarily preclude conducting a risk
assessment. Clinicians should generally indicate the
data sources utilized and any limitations in the information available. Opinions then should be qualified
accordingly. Approaches such as those utilizing the
VRAG, COVR and HCR-20 provide formulas and/
or algorithms that outline relevant variables and
produce a quantitative or qualitative risk estimates.
Clinicians utilizing the actuarial tools must remain
mindful of the debate in the literature regarding pure
and adjusted actuarial estimates and the populations with which, the actuarial measures have been
studied.
It has been suggested that risk assessment opinions
often require some mention of the type of violence
in question, the time frame for which risk is being
predicted, and an understanding of the base rate of
violence for the population from which, an examinee is drawn (Borum et al., 1996). Once these factors have been taken into account, precipitants and
circumstances of violent behavior and patterns across
incidents of aggression warrant consideration, as in
an anamnestic approach. Using all available data, the
clinician should then be able to specify the conditions under which the examinee may be more or less
likely to commit violence. It can be helpful to identify
known aggravating and mitigating factors for potential future violence.
After determining the salience of these conditions
during the time frame in question, the clinician in
some cases may wish to formulate an opinion about
the examinees level of risk for violent behavior during the specified time period in the identified context in which the examinee will be situated. However,
identifying levels of risk, especially if utilized in the
absence of a structured professional tool that offers
some mechanism for anchoring such classifications,
should be explained so that the reasoning behind the

VIOLENCE RISK ASSESSMENT

identified level of risk is clear. When indicated, it may

also be important to incorporate recommendations
in ones formulation that aim to reduce risk related
to risk factors that are amenable to intervention. It
should be understood that risk assessments and risk
management recommendations can inform clinical
decisionmaking, but that decisions regarding privileges, discharge, appropriate community placements
and the like involve a host of additional factors (e.g.,
available resources, a persons willingness to participate in recommended programming, legal requirements, etc.) that may come into play as such decisions
are being formulated.
For clinicians conducting risk assessments, the
challenge lies in linking the data available to what is
understood about the individuals violence risk potential. For other professionals who utilize clinical risk
assessments in arenas such as legal cases, it is important to recognize the importance and limitations of
undividualized assessments as they relate to prediction and management. With the ongoing evolution of
actuarial and clinical methodologies, understanding
empirically driven approaches to violence risk assessment and risk management and incorporating them
when indicated will continue to be important for optimizing the standard of practice in this complex clinical endeavor.
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Chapter 6

The Use of Actuarial Risk Assessment

Instruments in Sex Offenders
Gina M. Vincent, Shannon M. Maney,
and Stephen D. Hart

Sexual offending is increasingly seen as a major public health concern (Matson & Lieb, 1997). By virtue of this increased concern about sexual violence,
sexual offenders are more likely than any other type
of offenders to undergo psychological evaluations of
their risk for reoffending. Canada has legislated dangerous offender and long-term offender sentences in
the Criminal Code of Canada (1985) for the control of
the risks presented by sex offenders at the community
interface. Provinces may also resort to civil mental
health enactments (Starnaman vs. Penetanguishene
Mental Health Centre, 1995) to incapacitate the risk
to the public sex offenders present after the expiration of their criminal sentences. In the United States,
many states have enacted Sexually Violent Predator
(SVP) statutes to extend the confinement of sex
offenders under civil commitment laws (Janus &
Meehl, 1997). These preventive detention hearings
frequently call on psychological or psychiatric experts
to assess whether a person is at elevated risk for engaging in future sexual violence, the primary condition

for commitment. The initiation of SVP/DO laws

challenged the profession to increase the specificity
of general violence risk assessments to estimate the
likelihood of future sexually violent recidivism.
Risk assessment schemes traditionally have taken
one of two forms, clinical or actuarial decision making. Clinical decision making involves unstructured,
subjective predictions made by a decision-maker after
combining all the available data. Actuarial prediction
is more mechanical and involves a formal, algorithmic, objective procedure (e.g., equation) to reach the
decision (Grove & Meehl, 1996, p. 293). Because of
the consistency and predictive validity of actuarial
tools, several researchers have argued persuasively for
the superiority of actuarial decision making to estimate the likelihood of future violence.
In the past decade, many risk assessment tools
have been designed on the basis of the actuarial
approach to estimate the probability that a given
sex offender will commit an illegal sexual act in the
future. Researchers have demonstrated that many of
70

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

these tools have sound inter-rater reliability and predictive validity within restricted samples, and authors
of a few of these tools have made revisions to the
instruments to improve their predictive accuracy.
These actuarial tools increasingly are being used to
make decisions about whether a person should be
incapacitated to prevent future violence.
Though the accuracy of many of these tests has
been demonstrated under controlled conditions,
there is still insufficient justification for heavy reliance on these tests in legal and clinical decision
making (Grisso, 2000). Comprehensive reliability
studies of measures of risk for sexual recidivism are
nonexistent and have yet to be conducted systematically across various settings and populations. There
is some evidence that the accuracy of these tools
is variable across populations, the quantity of historical information, and the length of time at risk
(Harris, Rice, Quinsey, Lalumiare, Boer, & Lang,
2003b). The instruments do not provide any information relevant to a persons treatment or management needs and there is no evidence that the
risk for sexual recidivism tools have the ability to
detect improvement or deterioration in risk nor is
good management of risk reflected in the actuarial score. This undertaking is complicated because
little is known about actual base rates of sexually
violent recidivism after treatment and the validity of
methods for measuring change. Finally, the largest
concern is that many of these tools are interpreted
as prescribing estimates of the probability of future
sexual offending to individuals, which, as this chapter
will explain, cannot be done with known precision
(Hart, Michie, & Cooke, 2007).
This chapter will begin with a brief review of the
purpose of risk assessments for sexual reoffending
and will describe the nature of tools using the actuarial approach. The next section provides a detailed
summary of the characteristics and psychometric
properties of the most prominent actuarial tools
available for assessing risk for sexual recidivism.
We focused on information that would be essential
for making informed decisions about selecting and
evaluating these psychological tools for clinical use.
Finally, we provide a critique of these risk instruments for sexual offenders and actuarial approaches
in general and conclude with recommendations for
current practice, alternative approaches (i.e., structured professional judgment) and guidelines for
future research.

71

PUR POSE OF R ISK FOR SE X UA L

R ECIDI V ISM ASSESSMEN TS

Sexual violence can be defined as actual, attempted,

or threatened sexual contact with a person who is nonconsenting or unable to give consent (Boer, Hart,
Kropp, & Webster, 1998, p. 9). Sexual violence has
become a major public health concern because of
its high prevalence and perceptions of its resistance
to treatment. According to reported victimization
data, one in five American females above the age of
16 has been the victim of a completed rape (Furby,
Weinrott, & Blackshaw, 1989). According to a more
recent survey by the National Institute of Justice
(2000), 17.6% of all women surveyed had been victims
of a completed or attempted rape at some point in
their lives, 21.6% of which were under the age of 12 at
the time of the event. Mendel (1995) reviewed the
studies of prevalence of sexual abuse among males. In
general, the consensus was that between one in five
and one in eight males have been abused in childhood. Among sex offenders, according to the metaanalysis by Hanson and Morton-Bourgon (2005), the
observed sexual recidivism rate was 13.7% after an
average 76 month follow-up. Given reporting rates of
sex crimes, 13.7% is probably a gross underestimation
of actual recidivism rates over the long-term. Doren
(1998) estimated the actual long-term base rate to be
around 52% for child molesters and 39% for rapists.
Sexual offenders comprise a group of criminals
who have been singled out and subjected to special
statutes for commitment and detention to an extent
unparalleled by any other group of criminal offenders (Becker & Murphy, 1998). Between 1988 and
1990, the number of incarcerated sex offenders in the
United States increased by 48%, and by 1998, approximately one-third of the incarcerated population in
some states were sex offenders (Grubin & Wingate,
1996; Prentky, Lee, & Knight, 1997; Quinsey, Harris,
Rice, & Cormier, 1998). In addition to mandatory
chemical castration, sex offender registries, dangerous offender, and three strikes legislation enacted in
some states and Canada, SVP laws have been enacted
or are developing in at least 35 states since the constitutionality of SVP statutes was upheld by the U.S.
Supreme Court (Kansas v. Hendricks, 1997).
SVP laws permit continued preventative detention of sex offenders after completion of a criminal
sentence if there is a high likelihood of their engaging in future acts of sexual violence on account of

72 ASSESSMENT AND DIAGNOSIS

mental disorder. SVP statutes generally require four

conditions for commitment: (1) a history of sexual
violence, (2) a current mental abnormality, (3) an elevated risk for future sexual violence, and (4) a causal
link between the mental illness and the risk. There is
some evidence to suggest that many states with SVP
laws have been civilly committing sex offenders that
do not even reach, on average, a 50% probability of
reoffending (Janus & Meehl, 1997). As Janus and
Meehl argue, this is likely a result of the use of static
measures that have not been validated as being able
to accurately capture reoffense within an acceptable
level among civilly committed patients.
Often these civil hearings call for forensic evaluators opinions as to whether or not an offender is at
elevated risk for future acts of sexual violence (Hanson,
1998; Hart, 2003). After one is determined to be SVP,
the question for forensic evaluators becomes whether
the confined SVP has responded to treatment well
enough to warrant release. Forensic evaluators have
been assigned with the task of (1) making reliable and
valid decisions about an examinees level of risk and
the influence of a mental abnormality on that risk,
and (2) reassessing risk in a manner that will detect
improvement or deterioration.

Risk assessment tools applying actuarial decisionmaking schemes have demonstrated superior predictive validity, relative to unstructured clinical decision
making (Grove & Meehl, 1996). What defines actuarial decision making is applying a formal procedure,
generally an algorithm, to make a judgment, in this
case a judgment as to a sex offenders level of risk for
engaging in sexual offending in the future. Actuarial
instruments were designed to predict the future. The
majority of these instruments purport to calculate the
probability that a given examinee will sexually reoffend. Typically, the items of these tools are selected
empirically on the basis of their association with a
given outcome (reoccurrence of sexual violence) and
are scored and combined according to some algorithm to aid in producing a decision about the likelihood of recidivism. The Sex Offender Risk Appraisal
Guide (SORAG; Quinsey et al., 1998), for example,
contains items selected on the basis of the strength of
each variables prediction for sexual recidivism based
on retrospective studies of sexual recidivism in male
offenders from a single setting. The objectivity and
predictive accuracy of actuarial tools has led some
to advocate for their sole usage without contamination from clinical judgment (Grove & Meehl, 1996;
Quinsey et al., 1998).

Nature of Actuarial Decision Making

For the past 20 years, research into the risk factors and
recidivism rates for sex offenders has grown steadily in
the psychological literature. Previous to this, reviews
indicated that mental health professionals had no
special skills for determining risk and often were performing, at levels of accuracy that barely exceeded
chance (Borum, 1996; Grisso & Tomkins, 1996).
With the contributions of the second generation of
risk research in the past two decades, it has become
generally recognized that forensic evaluators have
some modest ability to predict violent behavior. This
improvement reflects not only a growing foundation
of knowledge about the factors related to violence and
violent reoffending, but also increasing knowledge of
the methods and analyses that are best suited to the
study of violence risk assessment (Mossman, 1994).
One problem in the past was reliance on unstructured
clinical decisions which do not necessarily make risk
variables explicit, may not be empirically validated,
and have demonstrated little value in the prediction
of recidivism (Grisso & Tomkins, 1996; Monahan,
1996; Quinsey et al., 1998).

R EV IEW OF ACT UA R I A L R ISK

ASSESSMEN T TOOLS FOR SE X UA L
R EOFFENDING

Over the past decade we have seen the advent of a

number of psychological actuarial tools designed
for assessing risk for sexual violence or recidivism.
This section reviews the most prominent actuarial
instruments and covers basic information that would
be essential for clinicians to evaluate the usefulness and applicability of the test to their needs. We
included nine tools in this chapter because each tool
fits two main criteria. First, we only included tools
designed for actuarial decision making or, in the
case of the Psychopathy Checklist-Revised, tools that
may not have been designed for actuarial use but
have been used actuarially with sex offender samples. Instruments like the Sexual Violence Risk-20
(SVR-20) are not included in this chapter because
these tools use structured professional judgment as
opposed to actuarial decision making. Second, we
only included tools that had been published or at least

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

were in widespread distribution for clinical use (as

opposed to research use) at the time of this review.
Each instrument summary that follows includes
information about the intended examinee population (e.g., adult male sex offenders), purpose of the
instrument (e.g., to predict sexual recidivism), design
(number of items and scales), administration procedures (e.g., requires an interview with the offender),
scoring procedures, how the instrument was developed, and a summary of research findings on the psychometric properties. Before reading these reviews,
readers should be familiar with a few issues. One issue
pertains to the nature of risk factorscircumstances
or life events that increase the likelihood of engaging in criminal activity. Risk factors (items in risk
assessment tools), can be either static (e.g., past sexual
abuse) or dynamic (e.g., negative mood, substance use,
attitudes that support rape). Dynamic factors are variable and can be used to guide rehabilitative efforts by
targeting influences on sexually offending behavior
and guiding interventions aimed at changing those
factors. Static factors on the other hand, are generally
historical and difficult if not impossible to change.
A second issue pertains to how one evaluates
whether a tool has demonstrated adequate predictive
validity. In other words, since these actuarial tools
were designed to predict sexual reoffending, the quality of the research used to demonstrate each tools
predictive validity is of utmost importance. Here it is
important to be familiar with some of the methods of
longitudinal research. The longitudinal studies can
vary in the length of follow-up periods, operational
definition of time at risk (the length of time one has
an opportunity to reoffend), method, and definition
of outcomes. The method can be prospective, studying trends by recording data at one point in time and
again during several points in time in the future (e.g.,
risk factors at Time 1 and recidivism at Time 2), or
retrospective, studying trends by recording data from
various time periods simultaneously.
Recidivism studies vary widely in the operationalization of outcomes. Most recidivism studies employ
a single method for measuring recidivism, generally
official criminal records, but a minority supplement
official records with self-report and/or collateral information. Added variability is found in the metric used
to quantify recidivism . This may include mere occurrence of a reoffense (any vs. no recidivism), frequency
(number of reoffenses during follow-up), or imminence (time to reoffending). Among the sex offender

73

studies, some made a clean distinction between generally violent and sexual recidivism, but more commonly, violent recidivism outcomes include both
sexual reoffenses and generally violent reoffenses.
This is important to note because, in these cases, the
violent recidivism category always will have higher
base rates than the sexual recidivism category, making it easier to predict for statistical reasons.
As summarized by Hart (1998) and Douglas et al.
(2006), in general, broader definitions of violence and
longer follow-up periods will lead to higher base rates
and more powerful statistical predictions. Further,
self-report measures of violence will generate significantly greater and ostensibly more accurate reports
of violent incidents. Unless the follow-up period is
fixed, it is particularly crucial that outcome measures
incorporate time at risk before reoffending, using survival or Cox proportional hazards regression analyses, because of the wide variability within samples.
Generally, statistics using dichotomous outcomes
will underestimate predictive accuracy because these
ignore the complexity of the data.
In the summaries that follow, when dichotomous
outcomes were used, we reported findings from the
recommended test of predictive accuracy, the receiver
operating characteristic (ROC) analysis (Mossman,
1994). ROC curves plot the association between sensitivity (the true positive rate) and 1specificity (the
false positive rate) for all possible cutoff scores on the
measure of interest. The area under the ROC curve
(AUC) is an index of the measures overall classification accuracy. The AUC can range from 0 to 1.0
where 0.5 indicates chance-level accuracy, greater
than 0.5 indicates above-chance accuracy, and
less than 0.5 indicates below-chance accuracy. For
example, an AUC of 0.68 would imply that there is
a 68% chance that a sex offender who was charged
with a sexual reoffense obtained a higher score on the
specific tool (e.g., SORAG) than a randomly chosen
individual who did not commit a sexual reoffense.
This figure does not tell us that an offender with a
certain test score has a 68% probability of recidivism
(Mossman, 2006), a common misinterpretation.
According to Swets (1988), AUCs for an acceptable
screening tool would be between 0.70 and 0.90.
Sex Offender Risk Appraisal Guide
The Sex Offender Risk Appraisal Guide (SORAG) is
a 14-item rating scale designed to predict violent and

74 ASSESSMENT AND DIAGNOSIS

sexually violent recidivism in men known to have

committed a sexual offense involving physical contact. The SORAG is a derivative of the VRAG developed to predict violent recidivism, including sexual
recidivism in sex offenders (Rice & Harris, 1997).
The SORAG includes all 10 items of the Violence
Risk Appraisal Guide (VRAG; Quinsey et al., 1998);
for example, the Psychopathy Checklist-Revised
(PCL-R; Hare, 2003) score, Elementary School
Maladjustment, CormierLang criminal history, and
alcohol abuse history; plus an additional four items
specifically related to sexual reoffending (e.g., phallometric deviance). Each item can be scored on the
sole basis of solely institutional file information,
with the exception of the PCL-R. Ostensibly, the
SORAG needs to be completed by a psychologist or
other qualified examiner since the PCL-R is one of
its items. Like the VRAG, the SORAG items have
varying low to high risk scale ranges (from negative
to positive integer weights), and these item scores
are summed into an overall risk score. Overall risk
scores are translated into one of nine categories
(bins) that give the individuals probability of recidivism using the risk score table. The probability of
recidivism ranges from 9% for Bin 1 (scores 11) to
>99% for Bin 9 (scores 32). It is important to note
that the bins are intended to estimate only the likelihood of another sex offense occurring. Like most
of the actuarial tools described in this chapter, the
risk categories of the SORAG say nothing about the
likely severity of the sex offenseostensibly, the reoffense could be an act like indecent exposure, which
involves no physical harm to a victim.
The items of the SORAG were selected using
stepwise multivariate methods with samples of sex
offenders institutionalized in a maximum security
psychiatric hospital (Quinsey et al., 1998). The interrater reliability of the SORAG appears to be quite
high, ranging from 0.90 (Bartosh et al., 2003) to 0.96
(Harris et al., 2003b), and has been calculated between research assistant raters and masters level clinicians (Barbaree et al., 2001). Several studies reported
the SORAGs concurrent validity with other tools
known to predict violent recidivism or sexual recidivism specifically. Correlations with measures known
to predict general violence, like the PCL-R (r = 0.72)
or VRAG (r = 0.90 to 0.93), are higher than those
with measures designed to predict sexual recidivism
specifically, such as the Rapid Risk Assessment for
Sexual Offense Recidivism (RRASOR) (r = 0.45 or

lower), Static-99 (around r = 0.65), and MnSOST-R

(r = 0.41) (Barbaree et al., 2001; Harris et al.,
2003b).
The predictive validity of the SORAG has been
tested on fairly heterogeneous samples by independent researchers with significant findings in the prediction of recidivism. The samples under study have
included incarcerated sex offenders, sex offenders
housed in a sex offender treatment program, and
nonincarcerated offenders referred to an outpatient
treatment program (Barbaree et al., 2001; Bartosh
et al., 2003; Harris et al., 2003b; Nunes, Firestone,
Bradford, Greenberg, & Broom, 2002). All of these
studies involved retrospective file-based scoring of
the SORAG and an average follow-up period ranging
from 3 years to more than 7 years. Most studies have
found the SORAG to be a significant predictor of
sexual recidivism, with the highest AUC only around
0.69 (Looman, 2006). The SORAG seems to be a better predictor of sexual recidivism for child molesters
than rapists (AUC = 0.70 vs. 0.62, respectively, Harris
et al., 2003b), and is better at predicting violent recidivism generally than sexual recidivism specifically
(Ducro & Pham, 2006).
Rapid Risk Assessment for Sexual
Offense Recidivism
The Rapid Risk Assessment for Sexual Offense
Recidivism (RRASOR; Hanson, 1997) is the shortest
tool available for predicting sexual reoffending. The
RRASOR is a 4-item rating scale designed specifically to predict sexual recidivism among men who
have been convicted of a sexual offense. The items
are based on ones age and details of their sex offense
history and are scored easily by using file information.
Total scores range from 0 to 6 with higher scores indicating higher risk. No other guidance is given about
how to use total scores. Presumably, little to no training is necessary for scoring the RRASOR but authors
have not formally addressed rater qualifications.
The items used for the RRASOR were derived
from a sample of seven risk predictors taken from the
meta-analysis of sexual offense recidivism by Hanson
and Bussiere (1996). Intercorrelations were computed
for the seven data sets and the correlations were averaged into a single correlation matrix (Hanson, 1997).
The best predictor variables were identified on the
basis of their high in a stepwise regression (Hanson &
Thornton, 1999). Thus, the RRASORs items were

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

selected on the basis of the best predictors of sexual

recidivism found across a wide range of samples and
studies. Inter-rater reliability of the RRASOR has
been reported to range between r = 0.90 (Bartosh,
Garby, Lewis, & Gray, 2003) to 0.95 (Harris et al.,
2003b) amongst research assistant raters and has been
reported at r = 0.94 (Barbaree, Seto, Langton, &
Peacock, 2001) between master level clinicians.
Several studies have reported the RRASORs concurrent validity with other tools known to predict
violent recidivism or sexual recidivism specifically.
Correlations with the Static-99 (r = 0.69 to 0.87) are
higher than those with the SORAG (r = 0.45 or lower)
and MnSOST-R (r = 0.32 or lower), and correlations
with the PCL-R have been reported as nonsignificant
(Barbaree et al., 2001; Harris et al., 2003b; Roberts,
Doren, & Thornton, 2002).
Studies have tested the RRASORs ability to predict recidivism primarily using some type of prison
sample comprising individuals convicted of a sex
offense (Lngstrm, 2004). Like the SORAG, studies of the RRASOR have used retrospective follow-up
designs and file-based ratings and have spanned an
average follow-up from 3 to 5.5 years. Studies have
identified the RRASOR to be a better predictor of
sexual recidivism than violent recidivism with fair
consistency, with the highest AUCs for sexual recidivism at 0.77 (Barbaree et al., 2001; Lngstrm, 2004).
In a study combining the samples from 10 studies,
there was little difference in the RRASORs predictive
accuracy for child molesters (AUC = 0.67) versus rapists (AUC = 0.69) (Hanson & Thornton, 2003), albeit
individual studies have found larger differences in the
tests predictive accuracy between these groups (see
Harris et al., 2003b; Sjostedt & Langstrom, 2001).
Static-99/Static-2002
According to a recent survey, the Static-99 is the
most widely used sex offender risk assessment instrument among forensic evaluators in North America
(Archer, Buffington-Vollum, Stredny, & Handel, 2006).
The Static-99 was designed to assess the long-term
potential of risk for recidivism of violent and sexual
offenses among adult males who have been convicted of at least one sexual offense against a child
or nonconsenting adult (Hanson & Thornton,
2003). The Static-99 is a 10-item tool that was created by combining items from the RRASOR and
Thorntons Structured Anchored Clinical Judgment

75

Scale (SACJ). Its revision, the Static-2002, is a 13-item

tool that added and refined items to the Static-99 to
improve the ease and consistency of scoring. The
authors selected and weighted items for the Static2002 from the meta-analysis by Hanson and Bussiere
(1998) on the basis of the strength of the prediction
for sexual recidivism, simplicity, and relevance. So,
like the RRASOR, the items for the Static-99 or
Static-2002 were selected on the basis of the strongest
predictors of sexual recidivism across a wide range of
samples and studies. Although this review discusses
both the Static-99 and Static-2002, it is important to
note that it is still the Static-99 that should be used
in practice until the Static-2002 has a comprehensive test manual and more extensive cross-validation
(Hanson, 2006; Langton, Barbaree, Hansen, Harkins, &
Peacock, 2007).
All items on these tools are static and scored on
the basis of file information. The coding is meant
to be straight-forward for an experienced evaluator,
which includes researchers, police, psychologists,
and parole and probation officers. There is a detailed
test manual that describes the scoring rules for each
item. The Static-99 provides estimates of risk on the
basis of the raw score. For example, a score of 0 to 1
indicates low risk, a score of 2 to 3 indicates low
to medium risk, and so forth. There is also a probability of recidivism table based on these categories
that is separated by 5, 10, and 15 year probabilities for
both violent and sexual recidivism (Harris, Phenix,
Hanson, & Thornton, 2003a). The 2003 manual for
the Static-2002 does not contain such categories so
the prescribed use of scores is unclear at this time.
Inter-rater reliability for the Static-99 has been
reported around r = .90 between researchers (e.g.,
Barbaree, Seto, Langton, & Peacock, 2001; Harris
et al., 2003b) and an intra-class correlation coefficient
(ICC) of 0.80. Interrater reliability for the Static-2002
ranges from 0.72 to 0.92 (Langton, Barbaree, Hansen,
Harkins, & Peacock, 2007a). The Static-99 is significantly, but only moderately correlated with other measures of risk for sexual and violent recidivism, having
the highest correlation reported with the SORAG.
The Static-2002 correlates with other tools reasonably well, starting with 0.71 with the SORAG, 0.69
with the RRASOR, and 0.58 with the MnSOST-R
(Langton et al., 2007a).
As far as its relation to recidivism, the Static-99
probably has been tested more than any other risk
assessment for sexual recidivism tool. Samples include

76 ASSESSMENT AND DIAGNOSIS

prisoners convicted of a sex offense, individuals evaluated at an outpatient sexual behavior clinic, and
forensic psychiatric patients in Swedish, Canadian,
and Dutch populations. These have been retrospective follow-up studies, of periods ranging from 3 to
more than 9 years that have used the Static-99 code
based on archival information. Hanson and Thornton
(2003) coded both the Static-99 and Static-2002 using
archival information from the combined sex offender
datasets of 10 recidivism studies, making a sample of
more than 4000 cases. Across studies, the Static-99
appeared to predict sexual recidivism and serious
and violent recidivism equally well with an average
AUC around 0.68. The Static-2002 showed a slight
improvement over the Static-99, resulting in an AUC
of 0.72 for sexual recidivism and 0.71 for violent recidivism. The Static-2002s predictive accuracy differed
between child molesters (AUC = 0.68) and rapists
(AUC = 0.73) by 5% points. A cross-validation study
of the Static-2002 recently reported similar findings
using an archival sample of 468 sex offenders that
were followed for an average of 5.9 years (Langton
et al., 2007b).
In a 9-year follow-up study, Stadtland et al. (2005)
compared the predictive validity of the Static-99 to
other risk assessment measures using three heterogeneous samples of sex offenders in Germany. The
Static-99 predicted contact sexual recidivism (AUC
= 0.66) with relatively the same accuracy as the other
instruments (e.g., PCL-R, HCR-20, SVR-20), which
was lower than its predictive accuracy for noncontact
sexual recidivism and violent recidivism. Survival
analyses indicated that the groups of sex offenders
falling into the higher risk categories on the Static-99
had significantly earlier relapses than the low risk
category groups.
Violence Risk ScaleSexual
Offender Version
The Violence Risk ScaleSex Offender Version
(VRS-SO) (Wong, Olver, Nicholaichuck, & Gordon,
2003) was designed to assess the risk for sexual
recidivism in forensic populations before and following treatment. The VRS-SO uses 24 items, seven
static and 17 dynamic, rated on a 4-point scale (03)
with 0 reflecting less risk and 3 reflecting higher
risk. These items were chosen based on empirical or conceptual links to sexual recidivism. The
Total PreTreatment Risk score (range from 0 to 72)

combines the static and dynamic risk items, and is

representative of current risk for sexual recidivism.
The VRS-SO also helps to identify treatment targets
(based on dynamic factors), readiness for treatment,
and can measure pre- and posttreatment risk to identify changes in risk. The Total Post-Treatment Risk
score combines the static and dynamic risk scores and
subtracts a change score based on the stage of change
of the individual before and following treatment
(e.g., precontemplation/contemplation stage, preparation stage, action stage, and maintenance stage).
Both Total Risk Scores can be divided into static or
dynamic risk scores. A clinical override is provided in
order to allow the rater to change the risk level based
on idiosyncratic factors. To score the VRS-SO, a file
review and semistructured interview are required,
and if available, other collateral information can be
used to assist in scoring. The scoring of the VRS-SO
requires only a couple days of training and the tool
can be used by front-line criminal justice staff; no
professional qualifications are required.
The VRS-SO is one of the newer risk assessment
tools, so there has only been one psychometric study
reported to date (Olver, Wong, Nicholaichuck, &
Gordon, 2007). The study used a sample of 321 male
federal offenders who participated in a sex offender
treatment program in a maximum-security Canadian
mental health facility. In this study, four risk categories were created: low risk (020), moderate-low
(2130), moderate high (3140), and high (4172).
Three factors were identified within the dynamic risk
items (sexual deviance, criminality, and treatment
responsivity). The VRS-SO demonstrated acceptable internal consistency and interrater reliability
(pretreatment dynamic risk score ICC = 0.74 and
posttreatment dynamic risk score ICC = 0.79). The
VRS-SO total scores positively correlated with the
Static-99 (pretreatment risk score, r = 0.55 and posttreatment risk score, r =0.54). The predictive accuracy of the VRS-SO over an average period of 10 years
was better for the static score (AUC = 0.74) than for
the dynamic pretreatment (AUC = 0.66) or dynamic
posttreatment (AUC = 0.67) scores.
Minnesota Sex Offender
Screening Tool-Revised
The Minnesota Sex Offender Screening Tool-Revised
(MnSOST-R) (Epperson, Kaul, Huot, Hesselton,
Alexander, & Goldman, 2000) is a 16-item rating

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

scale designed to predict sexual recidivism among

rapists and extrafamilial child molesters. The authors
excluded intrafamilial sex offenders because they
were thought to be different than other offenders.
Twelve items of the MnSOST-R are Historical/Static
and four items are Institutional/Dynamic in nature.
The total score is then used to assign an overall risk
level of low, moderate, or high risk for sexual recidivism. Items are scored by trained examiners on the
basis of institutional file information and well-defined
scoring criteria. An advantage of the MnSOST-R is
its ability to produce different cut scores for different
decisions to reduce the likelihood of false positives
and negatives.
The original version of the MnSOST was created around 1995 (Epperson, Kaul, Huot, Hesselton,
Alexander, & Goldman, 1995). Based on a review
of the literature, 14 items were identified, and the
authors assigned weights to these items based on
clinical judgment. Preliminary studies found fair reliability and validity but the MnSOST was still criticized for its clinical versus statistical formulation of
the relative weights within the items (Doren, 1999).
The revision of the MnSOST began in 1996 to apply
an empirical approach to the clinically based item
selection and scoring. Its revision, the MnSOST-R,
was published in 2000 with risk prediction and scoring based on a 6-year follow-up of the development
sample (Epperson et al., 2000). In 2003, the authors
extended the follow-up of the development sample,
updated the validity data, and suggested risk level cut
scores (Epperson, Kaul, Huot, Goldman, & Alexander,
2003).
The MnSOST-Rs inter-rater reliability based
on the development sample was reported in the test
manual to be ICC2 = 0.76. The authors also reported
an ICC = 0.86 from a reliability study conducted in
the field, which better reflects the conditions where
the MnSOST-R is usually scored. A few studies
have reported the concurrent validity between the
MnSOST-R and other measures of risk for violent
or sexual recidivism. Although the MnSOST-R has
been significantly correlated with other measures,
the strength of these correlations has been quite inconsistent. For example, Roberts et al. (2002) found
the correlation between the PCL-R and MnSOST-R
to be 0.61, whereas Barbaree et al. (2001) reported
the correlation at only 0.30. Only a couple published
studies have examined the predictive validity of the
MnSOST-R on independent samples. Earlier studies

77

found that the MnSOST-R did not significantly predict violent or sexual recidivism (Barbaree et al., 2001;
Bartosh et al., 2003). However, a more recent study
found that it performed about as well as other risk
instruments in predicting risk for sexual (AUC =
0.70) and serious (AUC = 0.64) recidivism (Langton
et al., 2007b) in a 5.9 year follow-up study of an archival sample of sex offenders.
Sex Offender Need Assessment Rating
The Sex Offender Need Assessment Rating (SONAR;
Hanson & Harris, 2000) is a 9-item tool designed to
assess change in risk for sexual recidivism among sex
offenders, and to aid in developing responsive interventions and management plans. Currently, this is the
only actuarial instrument among those in widespread
distribution which was designed to be dynamic and
capable of measuring actual changes in risk. As the
authors of this tool noted, most items on the extant
scales are historical in nature and consequently, are of
little use when it comes to evaluating long-term risk.
The items of the SONAR were identified as relevant to recidivism among sex offenders as informed
by theory, previous research, and observation. To
identify dynamic predictors of recidivism, the authors
compared a group of sexual offenders who recidivated
(n = 208) sexually or violently while on community
supervision to a matched group of sexual offenders
who did not recidivate (n = 201; Hanson & Harris,
2001). The authors recorded variables based on the
offenders background, scores on the Static-99 and
VRAG, and structured interviews with probation
and parole officers who supervised the offenders in
the community. The officers were asked whether certain problems were of a concern during the time they
supervised the offenders and whether each problem
was worse 6 months before recidivism (for the recidivist group only) or 1 month before recidivism (the past
month of supervision for the nonrecidivist group).
The dynamic risk factors that differed between the
groups were included in the SONAR.
The SONAR contains five relatively stable factors
(intimacy deficits, negative social influences, attitudes
tolerant of sex offending, sexual self-regulation, and
general self-regulation) scored on a three-point scale
(0 to 2) with scores corresponding to the 12-month
time period preceding the assessment. It also contains
four acute factors (substance abuse, negative mood,
anger, and victim access) that were designed to help

78 ASSESSMENT AND DIAGNOSIS

identify when sex offenders are most likely to reoffend, rather than identify long-term recidivism potential. These items are scored on a scale ranging from
1 to +1, which were designed to capture whether an
examinees specific behavior improved, stayed the
same, or worsened over the previous month or since
the last assessment. The sum of the stable and acute
factors results in a total score of 4 to 14. Total scores
are summed and translated into one of five risk categories (low, low moderate, moderate, high moderate,
and moderate).
The examiner qualifications and necessary assessment procedures for the SONAR are not entirely
clear but it appears that the test can be administered
by probation officers and requires a combination of a
structured interview and review of case information.
To date, the psychometric properties for the SONAR
are based on only the development sample. Hanson
and Harris (2001) calculated the inter-rater reliability of the SONAR from a sample of sex offenders on
community supervision. Inter-rater agreement on the
scale was high for file codings (95% average agreement) and interview codings (97%) and internal consistency was fairly low ( = 0.43). Concurrent validity
appears low in terms of its relation to the Static-99
(r = 0.14) and moderate in its relation to the VRAG
(r = 0.39). Based on the development sample the
SONAR seems to have adequate predictive accuracy
(AUC = 0.74) with regards to sexual recidivism, and
incremental predictive validity over the VRAG and
Static-99; however, its ability to predict recidivism has
yet to be validated on other samples.
Sexually Violent Predator Assessment
Screening Instrument
The Sexually Violent Predator Assessment Screening
Instrument (SVPASI) was designed by the Colorado
Division of Criminal Justice (DCJ) and the Colorado
Sex Offender Management Board (SOMB) in 1999
for use with convicted adult sex offenders or juveniles tried as adults in the Colorado criminal justice
system. The SVPASI is separated into 4 parts plus the
SOMB checklist. Part 1 consists of demographic and
index offense information, Part 2 regards the relationship to the victim, Part 3 consists of 10 yes/no items
known as the DCJ Sex Offender Risk Scales (SORS),
and Part 4Mental Abnormality, contains results
from the PCL-R or the Millon Clinical Multiaxial
InventoryIII (MCMI-III). The SOMB checklist

contains seven categories (motivation, denial, readiness to change, social skills, positive social support,
deviant sexual practices, and taking care of business)
with 56 items rated on a scale from 0 Not at All to
5 Very Much. Some Parts of the SVPASI are completed by probation officers and some require SOMB
evaluators.
The development sample consisted of 494 adult
male sex offenders involved in probation corrections,
or parole in Colorado during the time spanning
December 1, 1996 to November 30, 1997. The study
investigated the relation between both static and
dynamic variables to recidivism during a 12-month
and a 30-month follow-up period. The SORS was
developed using a stepwise regression model. Ten
risk factors were identified, including, for example,
juvenile felony adjudications, prior adult felony convictions, drug or alcohol use at the time of offense,
and employment. Internal consistency for the SOMB
checklist scale range from 0.74 to 0.94. Odds ratios
demonstrate that individuals scoring 4 or more on the
SORS are at increased risk of failure at 12-months and
at 30-months after release.
Each Part of the SVPASI has a specified procedure
to determine whether criteria have been met. For
example, criteria is met for Part 4 when an offender
scores 18 or higher on the Psychopathy Checklist:
Screening Version (PCL:SV), 30 or higher on the
PCL-R, or scores 85 or more on the narcissistic, antisocial, and paranoid scales of the MCMI-III. If an
offender meets criteria for Parts 1 and 2 plus criteria
for Part 3 or Part 4, then the offender will be referred
to the court as a SVP (however, the court makes the
final determination for designation as a SVP). There
is a detailed manual for the SVPASI but this tool has
yet to be validated on independent samples outside of
the development sample.
Registrant Risk Assessment Scale
The Registrant Risk Assessment Scale (RRAS;
Whitman & Farmer, 2000) was created for use with
convicted sex offenders in New Jersey to provide prosecutors with a method for making community sex
offender notification decisions mandated by statute.
The intent of the RRAS was to allow prosecutors
to apply the notification law uniformly throughout
the state. The RRAS has 13-items organized into
four general areas: (1) seriousness of the offense, (2)
offense history, (3) characteristics of the offender, and

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

(4) community support (e.g., therapeutic support, residential support, employment/educational stability).
Each item is scored on a 3-point scale and each of the
four areas is weighted on the basis of the relevance of
their relation to recidivism. Total scores are translated
into categories of low, moderate, or high risk, which
are used to place offenders into tiers for levels of notification. Prosecutors can only override these tiers in
specific situations.
Development of the RRAS began in 1995 when
New Jerseys attorney general commissioned a panel
of forensic experts to design an objective measure for
making notification decisions for sex offenders. Items
were selected on the basis of empirical support but
they were weighted on the basis of the judgment of
this expert panel. The RRAS can be completed by
trained personnel on the basis of file information
alone using detailed scoring criteria in the manual
(Ferguson, Eidelson, & Witt, 1998). The RRAS has
been published and is available for widespread use.
The RRAS factor structure and ability to classify
groups of offenders was cross-validated on half of the
development sample, but the structure and predictive validity has yet to be replicated in independent
samples. To date its inter-rater reliability has not been
reported.
Vermont Assessment of Sex Offender Risk
The Vermont Assessment of Sex Offender Risk
(VASOR; McGrath & Hoke, 2001) is a 19-item scale
designed for use with adult male sex offenders to
assist probation and parole officers in making placement and supervision decisions. The VASOR was
designed to be scored by probation officers and correctional caseworkers who have completed some
practice scoring and have some familiarity with risk
factors and psychological assessment. The items are
coded on the basis of scoring criteria in the test manual using information from case files and offender
interviews. The authors claim it is best used as a
decision-making aid along with professional judgment and other tools until more research has been
conducted.
The VASOR items were chosen on the basis of an
exhaustive literature review, clinical experience, and
ease of scoring. Items were weighted on the basis of
empirically guided clinical judgment (McGrath &
Hoke, 2001). Most items are historical and static in
nature, but a few pertain to more dynamic factors

79

such as amenability to treatment and lifestyle stability. The VASOR contains two scales, a 13-item
scale that assesses reoffense risk and a 6-item scale
that assesses violence. Scores on the two scales are
plotted on a scoring grid that places the offender into
a category of low, moderate, or high risk. Low risk
suggests one can be considered for community supervision and treatment, moderate risk suggests one may
or may not be appropriate for community placement,
and high risk suggests the offender is not appropriate
for community supervision and treatment. The tool
correctly classified 92.6% of offenders in the development sample as being in one of these three levels of
supervision.
The VASOR has undergone rigorous tests of its
inter-rater reliability, finding good agreement with
an ICC = 0.83 for the reoffense risk scale, ICC
= 0.89 for violence, and an ICC = 0.87 for total
scores (Langton, Barbaree, Harkins, Seto, & Peacock,
2002; McGrath, Hoke, Livingston, & Cumming,
2001). The VASOR scales and total scores are significantly related to other measures of sexual violence
and general violence risk, including the MnSOST-R,
RRASOR, and PCL-R (Packard & Gordon, 1999).
Finally, the VASORs predictive validity has been
tested with independent samples. In terms of its 3-year
prediction of sexual recidivism it performs as well as,
or better than other instruments listed in this chapter
(Langton et al., 2002) with an AUC = 0.75. To date,
no studies on the VASORs reliability or validity have
been published.

LIMITAT IONS W ITH ACT UA R I A L R ISK

ASSESSMEN T TOOLS FOR SE X UA L
R EOFFENDING

Several critics have pointed out the limitations of actuarial assessments and the dangers of reliance on actuarial decision making (Berlin, Galbreath, Geary, &
McGlone, 2003; Dvoskin & Heilbrun, 2001; Grisso,
2000; Hart, 2003; Hart, Kropp, Laws, Klaver, Logan, &
Watt, 2003). We will discuss several of these issues in
light of the tools and their research findings covered in
this chapter.
Questionable Inter-rater Reliability
Few studies of the actuarial risk tools for sexual recidivism have reported indices of inter-rater reliability.

80 ASSESSMENT AND DIAGNOSIS

Grisso (2000) stated, I see a field that does not know

much about the inter-examiner reliability of its measures. Grisso went on to note that, despite the ostensible objectivity, evidence that the actuarial risk
assessments for sexual offending are impervious to
rater error and variability is lacking. One should expect some rater variability because many instruments
do not have detailed technical manuals that would
prevent examiner error when coding difficulties
arise.
The precision of ratings across raters is particularly
important with these actuarial risk tools given even
very small differences (+/1 point) can lead to very
different estimates of risk. Though inter-rater reliability estimates that have been reported are promising,
the majority of these estimates were based on the ratings of two research assistants and small subsets (10 to
30 cases) of fairly homogeneous samples of male sex
offenders from prison settings. The generalizability
of these parameters across populations, raters, and
in real world settings remains uncertain. Most studies have been retrospective file reviews conducted by
research assistants despite the fact that some of these
tools were intended to be administered in an interview setting by probation/parole officers, correctional
case managers, or mental health professionals.

decisions, examinees will be doomed to perpetual

commitment because they will always achieve the
same score. The measurement of change in risk for
sexual reoffending is a crucial issue because once civilly committed as a SVP, or criminally as a dangerous
offender, an offenders risk level has to decrease sufficiently before they will be released. The problem is
that the majority of these sex offender risk assessment
tools were based almost entirely on static risk factors
that, by definition, do not change.
Although we may infer that change in risk can be
measured during the course of treatment or institutionalization by focusing on dynamic variables supported in the literature, no risk assessment measure
has been tested rigorously for its ability to measure change. The validation study for the SONAR
(Hanson & Harris, 2000) provides some limited support for its ability to measure changes in risk, reporting that a one point increase in SONAR scores
corresponded to a 38% increase in the likelihood of
sexual recidivism. However, this was only one study
and the decrease in an individuals risk for future sexual offending, which is difficult to operationalize, was
measured by only official reports of reoffending. The
VRS-SO appears promising for the purpose of measuring change, but we will need to see future research
with this tool.

LIMIT ED CLINICA L U T ILIT Y

LIMIT ED LEGA L R ELEVA NCE

Actuarial tools have limited clinical utility. A product

of empirical test construction methods is that, many
risk factors in these tests make little sense theoretically or clinically. Consequently, assessment procedures are not tied to intervention strategies in a
prescriptive manner. Actuarial measures are also of
little value when it comes to understanding the etiology of sexual offending because of the undue focus
on the effect of a variable, rather than its meaning
(Grubin & Wingate, 1996). Most of the factors included in actuarial schemes are static variables that
are difficult if not impossible to change, and thus
provide little guidance with respect to risk management (Grisso, 2000; Hanson, 1998; Hart et al., 2003).
For example, Hanson and Thornton (1999) stated in
the Static-99s test manual that this tool was not to be
used to measure changes in risk.
Grisso (2000) referred to this problem as the tyranny of static variables, arguing that if actuarial
instruments are the sole clinical criterion for release

Another issue worth noting is the limited legal relevance of actuarial risk assessment tools designed for
sexual violence or sexual recidivism. Note that in
SVP cases evaluators must determine whether the
individuals elevated risk for sexual violence is due to
a mental abnormality. If the risk is not due to disorder,
then civil commitment is not possible. But the actuarial tools do not allow one to determine the quantum
of risk attributable to mental abnormality. In fact,
most of them ignore mental disorder as a risk factor
altogether. So, they do not address the fundamental
legal questions. The existence of a mental disorder
or personality disorder can be established easily using
other clinical assessment tools (e.g., PCL-R, SCID);
but this depends on how the court has defined mental
abnormality, which is not clear in the legislation.
Some would argue that psychopathy and other personality disorders should not qualify (Prentky, Janus,
Barbaree, Schwartz, & Kafka, 2006). Nonetheless,

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

as it stands, actuarial tools do nothing to provide direction for forensic evaluators as to how to establish
a causal link between the disorder and the criminal
activity.

A BILIT Y TO PR EDICT R ECIDI V ISM H AS

UNK NOW N GENER A LIZ A BILIT Y

Studies have demonstrated the reasonable predictive

validity of actuarial tools for sexual and nonsexual
violence both within single samples from various
settings (i.e., male prisoners and male forensic psychiatric patients) in different countries (i.e., Sweden,
Germany, United States, Canada, and Wales), and
across multiple samples (Hanson & Thornton, 2000;
Roberts et al., 2002). Nonetheless, the research on
which this evidence has been based has substantial
limitations that threaten the generalizability and validity of these results.
First, validity in the laboratory does not necessarily translate to validity in the field. Evidence of the
accuracy of these tools in the field is limited because
all of the research has been based on small construction samples, use of archival information to code the
measures, and retrospective designs, all of which
increase the chance of making false positives in the
real world (e.g., Berlin, 2003; Dvoskin & Heilbrun,
2001; Hart et al., 2003). None of the studies reviewed
in this chapter used outcome measures other than
official records of reoffending and few if any studies
used statistics that accounted for within-sample variability in the actual time at risk.
Another issue that limits the generalizability of actuarial tools is the representativeness of the samples
on which they were created. The more representative the development sample is of the population on
which the test will be used, the more generalizable
the tests predictive power. As Gottfredson and Moriarty
(2006) explained, the problem is that there is no way
to tell in the development sample how much of the observed relation between the variables and recidivism
is due to underlying associations that will be shared in
new samples and how much is due to unique characteristics of the development sample. We see one consequence of the lack of representative development
samples in the evidence that parameter estimates of
several of the actuarial SVR tools vary on the basis
of the setting of participants and some participantcharacteristics. For example, the Harris et al. study

81

indicated that the predictive accuracy of actuarial

tools (i.e., SORAG, RRASOR, and Static-99) varied
as a function of setting, availability of file information, and length of follow-up period.
Further, sex offenders are an extremely heterogeneous group. The most obvious area of variability
is in the type of sex crime. There is some evidence
that tests are better at predicting recidivism among
child molesters and incest offenders than rapists (see
Bartosh et al., 2003). Aside from the obvious variance
in crimes, there are several other factors that separate
groups of sex offenders. Some actually suffer from a
paraphilia (e.g., pedophilia, sadism) while others do
not. Some will have a major mental illness while others will not. Say a given tool is developed on the basis
of the most powerful predictors of sexual recidivism
within a prisoner sample, which consisted primarily
of child molesters and rapists. Can we assume this
tool would have the same predictive accuracy for a
forensic psychiatric patient who may be more likely
to have a paraphilia with a comorbid major mental
illness? More importantly, can we assume that the
cutoff scores for any of these tools generalize to
the case of deciding whether to release a SVP into
the community? To date, no violent recidivism studies have been published using a sample of SVPs
released from civil confinement. Finally, the relevance of any of these tools to the case of a civil psychiatric patient demonstrating inappropriate sexual
behavior, yet who may never have been convicted of
a sex offense, is unknown.
Another issue is that many of these tools have been
cross-validated using independent samples in other
studieshowever, these studies have cross-validated
actuarial tools as measures of relative risk for sexual
violence, not absolute risk. In other words, assigning
a probability of recidivism for particular test scores
on the basis of the percentage of individuals from
the development sample who recidivated and had the
same score is not a valid practice. Doren (2004) indicated that this was a valid practice in a recent study.
In a persuasive secondary analysis, Doren demonstrated that the 5-year recidivism percentages for the
RRASOR remained stable for every risk percentage
category using multiple datasets from other studies
resulting in a sample of more than 4000 sex offenders.
He also concluded that the 5-year risk percentages for
the Static-99 were stable across multiple datasets of
real cases for every risk category except category 4
(moderate risk). In the development study, 25.8%

82 ASSESSMENT AND DIAGNOSIS

of the sample fell into the moderate risk category;

whereas 12.9% of the aggregate sample from seven
studies fell into this category.
However, Dorens (2004) work is overly optimistic. Mossman (2006) provided an excellent critique
of Dorens work indicating that he erred in his analyses of the problem. Basically, most categories did not
cross-validate within individual samples, but some
appeared to after collapsing across samples. So, it
wasnt evidence of good cross-validation. Mossman
(2006, p. 59) demonstrated that the recidivism rate
associated with each category of the RRASOR or
Static-99 is a function of the scales sorting properties and the base rate of reoffending in the population being evaluated. He went on to conclude that
the discriminative properties of an actuarial tool
(e.g., predictive accuracy) can stay constant across
samples if the development sample was representative but the probability of recidivating associated
with a particular score definitely does not. However,
a score on one of these tools can only tell us where
an evaluee ranks within his population (Mossman,
2006, p. 60). It cannot tell us the evaluees probability
of recidivating.
Another issue that limits the generalizability of
the predictive validity and accuracy of these tools is
that, since only a few factors can be included in any
one actuarial measure, factors that are idiosyncratic to
an examinee do not enter assessments of risk regardless of their relevance to a specific case (Campbell,
2003; Gottfredson & Moriarty, 2006). To give an
extreme example, say a high risk sex offender was in
an accident that left him quadriplegic. This offender
would continue to be identified as high risk for sexual
recidivism on the basis of these actuarial tools despite
the substantial decrease in risk resulting from severe
physical disability. Thus, the emphasis on empiricism
that went into the creation of each of these tools, can
lead to the exclusion of factors that are undeniably
related to risk but have unknown validity (e.g., homicidal ideation, physical ability). As summarized by
Campbell, this limitation of actuarial tools has led
some to suggest use of adjusted actuarial estimates.
The adjusted actuarial approach involves modification of an instrument-derived actuarial estimate
of risk based on other factors that may be related to
recidivism risk. However, this has been criticized
because it is an unstandardized method that lacks
research evidence as to its accuracy (Campbell, 2003;
DeClue, 2005). In the words of Prentky et al. (2006),

this approach provides little more than empirical

window dressing for clinical judgment (p. 380).

PROBA BILIT Y EST IM AT ES H AV E

SUBSTA N T I A L M A RGINS OF ER ROR

Possibly the most important limitation in the use

of actuarial risk assessment tools are the substantial
margins of error in the risk estimates made using
test scores, particularly when it comes to individual
predictions (Hart et al 2007). According to actuarial tools, violence risk is defined as the probability of committing future violence. As Hart et al.
explained, actuarial tools apply the following logic
to estimate the probability that an individual will
reoffend. For a given test, the first line of reasoning is that in the sample used to construct the test,
68% of people with scores in the high risk category
were known to have committed violence during the
follow-up period. Say a particular examinee scores
in this high risk category. The conclusion then is
that the risk of this examinee committing violence
in the future is similar to the risk of people in the
construction sample68%. This is how actuarial
tools generally operate.
As Hart et al. (2007) explains, the problem is that
moving the focus of analysis from groups to individuals changes the way in which risk is conceptualized
(see Hajek & Hall, 2002). Say we have a bag of 100
marbles, 75% of which are black and 25% are white.
Each time we draw a marble, we return the marble
to the basket and then draw a marble again. I say an
individual does this 1000 times. The person should
expect to draw a black marble 750 times (or 75% of
the time), but the 95% confidence interval is 720 to
780 times. In other words, the person can be 95% certain that they will draw a black marble between 720
and 780 times (or 72% to 78% of the time). Decrease
the number of draws to 100 and the confidence interval gets widernow the 95% CI is 66 to 82 (or 66% to
82%). So, although the estimated probability that the
individual will draw a black marble is still 75 times
out of 100the margin of error in this estimate is
larger.
Now, take this down to the individual levelif a
person draws a marble only one timealthough the
best guess is that it will be black, because this is what
it should be 75 times out of 100we cannot say this
with any degree of precision. We do not have 95%

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

confidence intervals for individual cases at this point

in our science.
When we bring this issue to violence risk
assessmentany probability estimates are also hindered by the fact that the individual we are assessing
would need to be like the individuals in the tests
validation sample for the probability estimates to
generalize at all. It is often unclear what it means to
be like the people in the development sample. One
issue is that the average probability for the validation
sample does not necessarily reflect any individual
case in that sample. A second issue is that examinees
do not come to us with characteristics that are random. In the case of sex offenderseven the type of sex
offender could impact our confidence in the probability estimates of a given test. Studies have shown that
the predictive accuracy of many of these tests differ by
2% to 5% points between child molesters and rapists.
A rapist comes to us with a characteristic that is not
randomthey are already at decreased probability of
recidivating sexually (at least according to studies using
official records for recidivism) and, in many cases,
obtain test scores with a decreased predictive accuracy.
To give a different example, say we know that 60% of
majors in psychology are female. Should we predict
that J. Smith has a 60% chance of being female?
Aside from the problems with the individual case,
Hart et al. (2007) demonstrated that, because of the
nature of the scale construction of even those tools
with the most rigorous developmental and validation studies, the margin of error in the probability
estimates even at the group level are substantial. The
authors used probability theory and a method for
estimating the precision of group estimates using the
Static-99 as an example. Group estimates for the 6
risk categories of the Static-99 showed that the confidence intervals for these groups of recidivists overlapped substantially, indicating that the Static-99
actually has only two distinct group estimates of risk:
Low (Categories 03) and High (Categories 46+).
The latter issue; namely, the group estimate problem,
could be rectified by using a significantly larger development sample (see Hart et al., 2007, for a discussion
of this). The problem with individual estimates and
generalizing from group data to the individual, however, is not unique to violence risk assessment. This is
a limitation with any aspect of medical or social science and although it can be improvedby improving
our prediction models so they explain more of the
variance in violence risk assessment, by increasing

83

and diversifying our samples, and by conducting

more tests of individual differences within these samplesit will not go away.

CONCLUSIONS A ND
R ECOMMENDAT IONS

Though some support this use of risk measures in

commitment hearings unequivocally, Grisso (2000)
warned forensic evaluators that the practice of solely
relying on these tools for such high-stake decisions is
ethically questionable until more research has been
conducted. In 2001, Litwack pronounced that the
complete replacement of clinical decisions with actuarial instruments would be premature.
It must be underscored that preventative detention legislation targets the reasonable possibility of
controlling an offenders risk in the community.
It is not the same as segregating the offender from
society until s/he gets control of his or her lawlessness thereby entirely eradicating risk. Rather, the
court must be satisfied that the risk can be controlled
in the community. Can we as a society justify the
indeterminate internment of citizens on the basis
of actuarial predictions that involve a fair amount of
errorespecially when the prisoner has behaved perfectly while incarcerated and when the detainee has
been permitted to cascade to low security facilities
without getting into trouble?

R ECOMMENDAT IONS FOR R ESE A RCH

The actuarial tools and, thus, actuarial decision

making can be improved with more research. The
problems described in this chapter may be seen as an
outline for a much needed research agenda. Most notably, these tools should be tested systematically for
inter-rater reliability, particularly for examiners working in the field (Grisso, 2000; Hart et al., 2003). Many
of the tools lack test manuals that are comprehensive
enough to meet the requirements of psychological
tests. For example, few specify rater qualifications
or the essential rater training and few if any include
comparative norms aside from those obtained in the
development samples.
We need more validation studies, on more diverse
samples (SVPs being released from confinement),
with large enough sample sizes to examine systematic

84 ASSESSMENT AND DIAGNOSIS

differences in the accuracy of these tools on the

basis of demographic differences. This would at
least allow the field to provide known estimates of
the generalizability of these tools. Another big issue
here is the definition of cross-validation. Actuarial
SVR assessment tools have been cross-validated as
measures of relative riskhigh scores are associated
with more recidivism, as revealed by ROC analyses.
However, they have not been validated as measures
of absolute riskthat is, their ability to make specific
probability predictions is unknown. There is also the
problem of probability estimates based on group data.
Hart et al. (2007) suggested that, when designing actuarial tools, test developers need samples in the several thousands to derive accurate estimates and they
should identify score categories with extreme estimates of violence risk.
Further, enhancing both the clinical and legal relevance of actuarial SVR assessment tools would be
a worthwhile endeavor. First, the prediction models
themselves can be improved. The problem is very
few of these tools take dynamic or contextual variables into account. The few tools that were designed
to detect changes in risk should be seen as a step in
the right direction but these have yet to be properly
validated. Second and particularly in SVP cases, we
also need legally relevant instrumentsthose that
attempt to estimate the degree of risk attributable to
mental disorder, such as sexual deviation or personality disorder.

R ECOMMENDAT IONS FOR

CUR R EN T PR ACT ICE

The restrictions of actuarial tools cannot be discounted and are great enough that sole reliance on these
tools for making detention decisions are unwarranted.
Indeed, it could be argued that any reliance on
actuarial tools is unwarranted. Currently, a given sexual recidivism risk actuarial tool, like the Static-99,
may be one of the best single predictors that our
science has to offer in the area of sex offender risk
assessment. It is evident from recidivism studies that
this tool does not account for much of the variance
in recidivism and, even at the group level, performs
at only 70% accuracy. Thus, it would be careless to
expect this tool to do the forensic evaluators jobs
for them. It is impossible for one of these actuarialderived tools to cover the universe of relevant risk factors to an individual case. Not to mention the Static-99/

Static-2002, like most all of the tools described in this

chapter, does little to assist us in decreasing a persons
risk. In this sense, a well-trained forensic examiner
should consider the prominent and clinically-useful
risk factors identified from meta-analyses in addition
to the Static-99 score (Hanson, 2006). The training of
the clinician in this sense is crucial given the notion
that when left to clinicians to adjust actuarial scores
upwards or downwards, they generally decrease the
validity of the actuarial tool.
There are some serious cautions to the use of this
approach. Given the high stakes of SVR assessment,
particularly in the context of an SVP or dangerous
offender hearing, forensic mental health professionals have an ethical responsibility to familiarize themselves with the limitations of actuarial risk assessment
instruments (Heilbrun, 1992). Examiners should be
extremely cautious when using actuarial instruments.
As is the case with all areas of assessment, the examiners must educate the consumers of test information
(i.e., the courts) about the limits of the data. They
should understand that it is impossible to make accurate estimates about the probability of an individual
reoffending using these tests (Hart et al., 2007). This
is particularly important in high stakes cases where
prediction errors at the individual level have a high
cost. It also is important to remember that actuarial
tools should only be one part of a comprehensive clinical assessment of an individuals risk. This needs to
be supplemented with contextual information (e.g.,
risks present in the environment in which an offender
would likely be released) and clinical information
(e.g., amenability to treatment).
An alternative to the use of actuarial tools is risk
assessment tools developed on the basis of the SPJ
framework. SPJ risk assessment tools were developed
in response to the limited clinical utility and the
rigidity that may limit the generalizability of actuarial tools. These tools are informed by the state of the
discipline in clinical theory and empirical research
to provide guidance for clinical decision making and
treatment planning (Borum, 1996). The intent of this
model was to improve clinical judgment by adding
structure, and improve actuarial decision making
by adding clinical discretion. These instruments
are not designed to provide absolute determinations
of risk. They emphasize prevention as opposed to
prediction. Thus, these tools contain both static
and dynamic risk factors because they assume that
risk is not entirely stable and can change as a result
of various factors, such as, treatment quality and

USE OF ACTUARIAL INSTRUMENTS IN SEX OFFENDERS

quantity, treatment adherence, protective factors, and

context. Structured professional judgment risk assessment tools are designed to guide forensic evaluators to
determine what level of risk management is needed,
in which contexts and at what points in time.
The Risk for Sexual Violence Protocol (RSVP;
Hart et al., 2003), previously known as the SVR-20, is
a SPJ risk assessment for sexual violence instrument
that allows evaluators to characterize the risks in terms
of the nature, imminence, severity, and frequency
while determining what steps should be taken to minimize the risk. Although RSVP items can be summed
into a total test score for research purposes, the RSVP
does not use an algorithm to make determinations
about an examinees risk level. Instead, it guides the
examiner to make a judgment as to an examinees risk
level (high, medium, or low) for engaging in future
sexual violence. Framing decisions in terms of relative risk may be preferable to giving probability estimates; unfortunately, research of clinicians indicates
that there is limited agreement as to how to categorize
low, medium, or high risk (Hilton, Carter, Harris, &
Sharpe, 2008).
Though few studies have been conducted in this
area, there is evidence that these structured clinical
summary risk ratings have incremental predictive
validity over actuarial risk ratings (Dempster, 1998;
Kropp & Hart, 2000). In fact, de Vogel et al. (2004)
recently reported that the SVR-20 outperformed
the Static-99 at predicting sexual recidivism in their
Dutch sample of sex offenders followed over an average of 11.6 years. The AUCs for the SVR-20 and
Static-99 were 0.80 and 0.66 respectively. This is not
to say that tools like the RSVP do not suffer some
of the same limitations as the actuarial instruments
covered in this chapter, at least in terms of the need
to demonstrate inter-rater reliability and the ability
to assess changes in risk. As critics have noted, the
limitation with any SPJ approach is that the sensitivity, specificity, and error rates are unknown. However,
these factors are largely unknown for the actuarial
tools as well when faced with the problem of the individual case.
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88 ASSESSMENT AND DIAGNOSIS

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Chapter 7

Laboratory Measurement of Penile

Response in the Assessment of
Sexual Interests
J. Paul Fedoroff, Michael Kuban,
and John M. Bradford

If the pathognomonic feature of all paraphilic sexual

disorders is deviant sexual arousal, and if increased
blood in the penis is associated with sexual arousal
in men, then the objective measurement of changes
in penile blood volume would appear to be an essential tool for clinicians and researchers in the field of
pathologic sexual behaviors. Surprisingly, the merits
and use of laboratory measurement of penile tumescence in the lab versus other methods of sexual preference measurement have proven to be somewhat
complicated (Hanson, 2002; Johnson & Listiak, 1999;
Konopasky & Konopsaky, 2000; Laws, 1989, 2003;
Seto, 2001).
One reason for the confusion is the fact that
measurement of changes in penile blood volume
in response to external stimuli has gone by many
names. These include phallometry (Freund &
Watson, 1991); penile tumescence testing (PTT);
and penile plethysmography (PPG).

While techniques vary concerning types of

stimuli and methods of presenting them, instructions
given, and ways of estimating changes in penile blood
volume, all terms refer to the process of attempting
to measure penile tumescence during presentation
of sexual stimuli. For the purposes of this chapter,
unless otherwise noted, the abbreviation PPG
will be used. Several comprehensive reviews of PPG
have been published (e.g., Barbaree, 1990; Barker &
Howell, 1992; Fernandez & Marshall, 2003; Marshall
& Fernandez, 2000a, 2000b; Murphy et al., 1984;
Simon & Schouten, 1991).

HISTOR ICA L OV ERV IEW

Kurt Freund (1957), a Czechoslovakian sexologist,

pioneered phallometric testing in the 1950s, after
being asked by government officials to help identify

Sections of this chapter are paraphrased from a grant application on which Susan Curry was a coauthor.

89

90 ASSESSMENT AND DIAGNOSIS

heterosexual men who were avoiding military service

by claiming to be homosexualan exclusionary condition at that time. Dissatisfied with other psychological
or projective testing methods, Freund investigated
differentiation of sexual orientation on the basis of
physiological measures of penile responses to heterosexual and homosexual stimuli. He invented a technique in which he could reliably measure changes in
penis volume by placing the penis in a sealed glass
cylinder and monitoring the resulting air pressure
changes (air displacement) within the cylinder as men
viewed potentially erotic stimuli (nude male or female
photographs). By correlating change in penis volume with the stimuli being presented, Freund (1963)
showed that he could reliably assess sexual orientation.
The success of this technique and stability of responses
convinced Freund that sexual arousal patterns were
physiologically determined and he subsequently (and
successfully) fought to repeal laws criminalizing
homosexuality in Czechoslovakia in 1961. This early
success led Freund to extend this methods use in the
1960s toward measurement of sexual partner age preference on the basis of the hypothesis that offenders
against children had pedophilic preferences, despite
their understandable reluctance to admit having them
(Freund, 1965, 1967, 1991).
Freunds work with volumetric plethysmography
was soon followed by the development of circumferential plethysmography (Bancroft, Jones, & Pullan,
1966), in which a small tube filled with an electrical
conductance liquid (mercury or indium/gallium) is
placed around the penile shaft. Electrical resistance
changes proportionally as the gauge is expanded
allowing dynamic measurement of circumferential
changes in penis size.
Soon after, the Barlow metal gauge was designed
(Barlow, Becker, Leitenberg, & Agras, 1970). In this
method, a metal U shaped device, calibrated to
detect pressure changes, is placed over the penile
shaft. Pressure changes on the device have been
shown to correlate with change in penis size.
These three techniques have been used since the
1960s and continue to be used today, though now, by
far the most widely used measurement is some variant
of the circumferential method.

ME ASUR EMEN T T ECHNIQUES

Some debate has remained over the relative accuracy

of volumetric versus circumferential measurements,

with initial impressions being that the volumetric

method was more accurate, largely due to its ability to
detect penile elongation that precedes circumferential enlargement during early stages of arousal. Kuban
et al. (1999) examined the issue in detail, concluding that both volumetric and circumferential measurement apparati produced identical test outcomes
provided there was at least a 10% (2.5 mm) increase
in penis size. However, the volumetric apparatus was
found to be more accurate in detecting changes in
penis diameter less than 2.5 mm.
As noted earlier, circumferential measurements
are now used much more widely. The reasons include
the fact that volumetric testing is technically more
difficult to conduct, and is considered by most to be a
more invasive intervention due to the elaborate setup
procedures. The Kurt Freund Phallometric lab in
Toronto, Canada, annually assesses 250 to 300 new
patients using the volumetric method, but is now one
of the very few functioning labs in the world relying
on volumetric testing.
In contrast, the comparative ease of use of circumferential strain gauges has led them to become
the industry standard, circumferential test apparatus
are commercially available, fairly inexpensive, and of
equal reliability to volumetric measurements except
at the lowest levels of penile tumescence.
Measurement, scoring, and interpretation of PPG
data remains an issue since they were first reviewed.
Howes (1995) reported results from a mailed questionnaire survey of 48 PPG labs. The study found
considerable inconsistency across labs. In addition
few labs had published (or even measured) standardization values such as sensitivity and specificity and
there was noted inconsistency on basic parameters
such as the minimum response requirements (ranging often from a low of 0% to 30% of erection).
Scoring methods also differed (Earls, Quinsey,
Castonguay, 1987). Labs were found to vary in terms
of the weight placed on absolute versus relative
penile responses. In general, absolute response refers
to simple measured change in penile circumference
or volume. Since penile responsivity has a great deal
of interindividual variance, most labs use relative
measurements in which measured changes in penis
circumference or volume in response to the test
stimulus are compared with the changes in response
to neutral or normal (nondeviant) stimuli. They
also varied in terms of how the data were analyzed
(e.g., area under response curves, use of z-scores, use
of differential scores vs. quotient scores, diagnostic

PENILE RESPONSE IN THE ASSESSMENT OF SEXUAL INTERESTS

cutoff criteria). Labs also differed in terms of the

interpretation of response values. In part this may be
due to an inherent conflict between interpretation of
results on the basis of group data and the interpretation of results based on individual data. For example, does an 80% response to child stimuli compared
with adults represent a pathologic response pattern?
Would equal responses to child and adult stimuli
be of concern? What about two men, one of whom
responds 50% to child stimuli and 100% to adult
stimuli while the second man responds 20% to child
stimuli but only 10% to adult stimuli? Which is more
pedophilic? More important, which is more dangerous? As Launay (1999) commented about PPG testing, No sooner is a review published to recommend
its use, than another more critical publication urges
caution . . . (pp. 254).

91

In spite of these findings, there are some validated

PPG stimulus sets indicating that age and gender
preferences are best assessed with pictures depicting
males and females at different stages of development
(Freund & Blanchard, 1989; Harris, Rice, Quinsey,
Chaplin, & Earls, 1992). Notable validated sets
include the Farrall stimuli, the Oak Ridges stimuli
(Penetanguishine, Ontario), and the Freund audiovisual stimuli set. Attempts to standardize the use of the
same stimuli across correctional services in Canada
have been undertaken, as have attempts to standardize recording equipment and stimulus materials in
a set of over a dozen sites in the United Kingdom.
The final outcome of these larger studies involving
identical stimulus sets is still pending. However,
past attempts at large-scale multisite comparisons
have been fraught with problems (Laws, Gulayets, &
Frenzel, 1995).

Stimulus Sets
Laboratories vary widely in their stimulus sets, many
having developed idiosyncratic assessment batteries (Howes 1995; Launay, 1999). Stimuli may involve
visual slides/images (Freund, 1967), audiotapes (Abel,
Becker, Murphy, & Flanagan, 1981), or movies/
videotapes (Abel, Becker, Blanchard, & Djenderedjian,
1978). Opinions vary about the efficacy of each stimulus modality. Concerns have also been raised about
the content of stimulus sets (Maletsky, 1995) to the
extent that work is also now underway to develop
stimuli based on multisensory virtual reality stimulus
sets (Renaud et al., 2005).
Clearly, since different presentation modalities
elicit different degrees of response and different levels
of discriminative efficiency, the choice of modality
of presentation is important. Movie depictions are
reported to generate the greatest response both in
men with paraphilic sexual interests and in men with
nonparaphilic interests (Abel, Blanchard, & Barlow,
1981). Paradoxically, of possible stimulus modalities,
while videotape stimuli are generally the most arousing, they also present the most specific information.
For this reason, it has been hypothesized that they
may not be most suitable for testing sadism or coercive sexual preferences, due to the potentially idiosyncratic nature arousal characteristics (e.g., body
type of victim, or victim reaction). Of three violence
tests conducted on hundreds of patients in Freunds
laboratory in the early 1990s, only the audio version of
one rape test produced sufficiently reliable documentation for publication (Seto & Kuban, 1996).

Testing Sexual Arousal to Coercion

As noted earlier, rape proneness may be most accurately assessed using audio stimuli, with the most valid
stimuli including graphic depictions of violent coercive sex (Lalumire & Harris, 1998; Rice, Chaplin,
Harris, and Coutts, 1994). Lalumire et al. (2005) discuss problems in detecting sadism as opposed to rape
proneness, arguing that the difficulty in clinically
identifying sadism on PPG is the potentially idiosyncratic nature of sadistic fantasies.
The issue is further complicated by the differences
between individuals who are aroused by consensual
sadistic scenes and those who are aroused by nonconsensual sadistic activities since most studies to date
have assessed primarily criminal men. Even within
the criminal subsection of the population, rapists
commit their offenses for a variety of reasons. Prentky
and Knight (1991) attempted to taxonomize rapists
into several mutually exclusive subtypes based on a
variety of factors. Since then, the possible etiologies
of rape have been further explored (Lalumire et al.,
2005). If a preferential rape pattern exists within
some males then it may be expected that such men
will show greater relative phallometric responses to
coercive nonconsenting interactions than to consenting sexual scenarios.
PPG studies with stimuli depicting consenting sex,
rape, nonsexual violence, and neutral scenarios have
varied widely over the past 30 years (e.g., Abel, Barlow,
Blanchard, & Guild, 1977; Barbaree, Marshall, &
Lanthier, 1979; Quinsey & Chaplin, 1982, 1984).

92 ASSESSMENT AND DIAGNOSIS

Lalumire et al. (2003) reviewed the earlier literature and reported on two large-scale meta-analyses
involving published studies of PPG testing for sexual
coerciveness in which the dependent variable was the
rape index, a ratio of responses to stimuli depicting
rape and responses to stimuli depicting consensual
sexual scenarios. The overall effect sizes were 0.71
(Hall, Schondrick, & Hirshman, 19939 studies) and
0.82 (Lalumire & Quinsey, 199416 studies). These
results are generally considered to represent moderate to large effects (Cohen, 1992). The different
effect sizes were related to individual study differences, such as whether rapists were compared with
other sex offenders or to nonsex offenders (Hall et al.,
1993), or to the particular stimuli set (Lalumire &
Quinsey, 1994).
Not surprisingly, there have often been mixed
and controversial results with regard to rape testing.
As reviewed by Lalumire et al. (2005), rapists as a
group have been shown, relative to control subjects,
to respond more to coercive stimuli than cwonsenting
stimuli (Abel et al., 1977; Eccles, Marshall, & Barbaree,
1994; Freund, Scher, Racansky, Campbell, & Heasman,
1986; Quinsey & Chaplin, 1984; Quinsey, Chaplin, &
Varney 1981; Rice et al., 1994).
However, other studies have found no difference
(Baxter, Marshall, Barbaree, Davidson, & Malcolm,
1984; Murphy et al., 1984; Seto & Barbaree, 1993).
These contradictory findings have brought into question the validity and utility of rape testing. In fact, following years of testing with video assessment stimuli
for sadism and coerciveness, Freund discontinued development of a stimulus set that could distinguish between men with criminal sadism and those without.
He concluded that too many normals respond
highly to sexually coercive stimuli (personal communication, 1994).
Nevertheless, research on the identification of
rape proneness via PPG testing has continued with
some success. Current research indicates that the
best discrimination between rapists and controls is
obtained when the stimuli involve more extreme violence that emphasizes the victims suffering (Harris,
Rice, Chaplin, & Quinsey, 1999). Lalumire et al.
(2003) concluded that since all studies reviewed
in his study produced positive effect sizesrapists
always had a higher rape index than the comparison
groupit is incontestable that rapists differ from
nonrapists in their responses to sexually coercive
stimuli. This study also examined the most recent

PPG rape literature, and found three of the five new

studies showed greater responding to rape scenarios,
while one showed no difference, and a fifth showed
greater responses to coercive interactions among the
nonsex offending controls. On the basis of this literature review it was concluded that, even though some
studies show small differences, the general conclusion
remains that rapists tend to be much more aroused to
scenarios depicting coercive sex than do controls.
Questions also remain about the relationship
between response to sadistic stimuli and actual
(enacted) criminal activity. Two studies examined
men who self-reported interest in rape (Malamuth &
Check, 1983) or who said they had sadistic sexual fantasies but had not acted on their interests
(Seto & Kuban, 1996). Both studies found these men
responded more to coercive stories than to consensual stories. In fact, the latter study found the sexually sadistic admitters to have greater responses to
coercive stimuli than did rapists who had committed
assaults but who denied sexually sadistic or coercive
fantasies.
In a separate study, Lalumire et al. (2003), compared 24 sexual assaulters to 11 nonsexual offenders
and 19 community volunteers. Using graphic sexual
stimuli from the Rice et al. (1994) stimulus set, it
was found that the two comparison groups scored
similarlyin that they responded more to consenting
sexual scenarios than rape scenarios.
However, men in the rapist group responded
similarly to rape categories and consenting categories
when the events were described from the female (victim) point of view, slightly more to rape scenarios than
consensual scenarios. The Cohens effect size was
d = 1.50. Effect size is technically defined as a
measure of the magnitude of a treatment that is
independent of sample size. By usual criteria, 1.50
indicates a large effect size. Further, the tests sensitivity was determined to be 0.63, while the specificity was 0.84 and 0.91, based on the control group of
community men and the known assaulters, respectively. Thus, 63% of rapists compared to 13% of nonrapists had a rape index larger than zero. Consistent
with findings from the other sets of meta-analytic
studies reviewed, these authors concluded that as a
group, relative to controls, rapists, could be shown to
respond more on PPG testing to forced, nonconsenting sexual behavior, particularly when the test stimuli are of a very graphic and violent nature, and are
described from the womans point of view.

PENILE RESPONSE IN THE ASSESSMENT OF SEXUAL INTERESTS

Faking and Dissimulation

The intentional manipulation of testing, mentally
or physically, certainly contributes to the acknowledged poor sensitivity of PPG in the assessment of
sex offenders. This is important since the sensitivity
(correct identification of true positives) of PPG testing
has consistently been found to be much lower than its
specificity (correct identification of true negatives). It
is generally accepted that only 50% of child molesters
who do not admit pedophilic interests may be correctly identified, while more than 95% of men with no
known child victims are found on PPG testing to be
nonpedophilic. One reason for such a low sensitivity
is that penile tumescence is partially subject to voluntary control (Adams, Motsinger, McAnulty, & Moore,
1992; Freund, 1961; Freund; 1963; Freund, 1967,
Lalumire & Earls; 1992; Mahoney & Strassberg,
1991 McAnulty & Adams, 1991; Quinsey & Chaplin,
1988). In fact, voluntary suppression could be why
so many subjects display very low penile responses,
(roughly one-third in most laboratories are found to
be low responders, also referred to in the field as
flat liners) (Kuban et al., 1997).
Other methods of manipulating PPG results
include stimulus avoidance (looking away from the
visual images), fantasy manipulation (thinking of
arousing themes to increase penile response or thinking about sexually aversive themes to suppress penile
response), pumping (contracting perineal musculature in an attempt to voluntarily produce penile
erection (Freund, Watson, & Rienzo, 1988), or direct
manual gauge manipulation (such as pulling on the
circumferential gauge).
Management of PPG response (faking) manipulation by clinicians and researchers has taken a variety
of forms. The earliest method was through the use of
low-light cameras to consensually observe and ensure
subjects to ensure that they were actually looking at
the presented visual stimuli and that they were not
manipulating the test apparatus. It should be noted
that, standard testing excludes visual monitoring
of the penis. Typically the subjects genital region
remains covered during the entire test. Subjects often
comment that the lack of visual feedback about their
erectile response is disconcerting. Moreover, modern
strain gauges and highly sensitive data acquisition
equipment (such as 16-bit sensors) make physical
manipulation of the equipment readily detectable
by the examiner. Visual monitoring of the subject by

93

the PPG technician has become standard, and even

when subjects are listening to audio narratives, observational cameras can show if headphone or other
equipment manipulation occurs.
The use of more potent stimuli is another way
to potentially decrease dissimulation, as videotapes
with audio normally produce higher levels of arousal
than audiotapes alone (Abel, Barlow, Blanchard, &
Mavissakalian, 1975; Card & Farrall, 1990). According
to this theory, the more potent the stimuli, the more
penile response elicited, the less likely the incidence
of low responses, and the better discrimination that
can be observed (Freund & Blanchard, 1989; Harris
et al., 1999). However, use of explicit sexual stimuli,
particularly those depicting illegal themes, is limited
by moral, legal, and ethical considerations.
In addition to obvious physical attempts at test
manipulation, attempts have been made to detect
dissimulation or manipulation by identification of
unusual test outcomes. Freund et al. (1988) described
several signs that he associated with faking. The
most obvious is evidence from the printed test curves
that intentional perineal contractions were occurring
during the test. These muscular contractions appear
as small spikes during the section of the test in
which the man is hoping to show arousal (usually the
adult female category). These have been identified
as attempts to voluntarily produce or enhance erections by men who do not find adult females sexually
arousing. Of course, men with erectile dysfunction
may also be tempted to use similar methods even if
their primary arousal is toward adult females. This
motivation would be particularly important in cases
in which there are legal implications from the test
results.
Other signs identified by Freund included results
in which the highest response score is to visually
neutral stimuli (such as landscapes). This has been
interpreted to be the result of voluntary suppression
to any of the sexual stimuli. It is hypothesized that
subsequent relaxation of efforts to suppress erection
during neutral scenes may then result in higher relative responses to the neutral stimuli. Cases in which
the highest responses occur during presentation of
neutral stimuli may be considered grounds for test invalidation (Freund et al., 1988; Lalumire & Harris,
1998). Again, while a rebound effect is one possible
interpretation of this phenomenon, it does not exclude
other explanations such as the possibility that neutral
stimuli unmask fantasies. Evidence to support this

94 ASSESSMENT AND DIAGNOSIS

alternative explanation comes from studies of women

who were shown to demonstrate greater arousal on
female vaginal plethysmography when given distracting tasks (Laan, 1994).
While more controversial, Freund also reported
that faking might be suspected in cases where the
highest responses (during PPG testing) are to an adult,
and in which the second highest response is to stimuli
depicting an adult of the opposite gender. Among
control subjects, Freund and others, (see Lalumire
et al., 2005) observed that in nonpedophilic men,
pubescent age minors of the most preferred gender
produced much higher penile responses on PPG
than opposite gender stimuli. As a result, Freund
concluded that a test profile in which the two highest
responses were to adults (both male and female) sex
should be considered evidence of response suppression to minors. Again, this interpretation is based on
the now somewhat controversial assumption that true
bisexuality never occurs in males.
Prior experience with PPG by men being tested
also factors into PPG test validity. Subjects with prior
experience in being assessed by PPG testing are believed to be better able to manipulate their responses
(Freund et al., 1988; Golde, Strassberg, & Turner,
2000). A further uninvestigated question concerns
whether the increased availability of pornographic
materials (e.g., through the Internet) has had the
effect of reducing the salience of the test stimuli used
in most PPG labs.
Assessment of Pedophiles
Research on the assessment of pedophiles has undoubtedly been complicated by the fact that not all
pedophiles molest children and not all child molesters are pedophiles. Early studies reporting accurate
classification of offenders (Abel et al., 1977; Abel et al.,
1978; Abel, Becker, & Skinner, 1980; Barbaree et al.,
1979) failed to show the same degree of accuracy in
replication studies (e.g., Avery-Clark & Laws, 1984;
Baxter et al., 1984; Murphy et al., 1984) Some studies
have been criticized on the basis of small, select samples. Others failed to replicate their findings in other
studies, such as Quinsey et al. (1984), and Letourneau
(2002), the focus was on particularly dangerous and
violent offenders incarcerated in maximum security
institutions. These data suggested that the validity of
PPG testing in the assessment and treatment of sexual
offenders required further empirical support and none

of these studies supported the application of PPG

technology for the assessment of suspected offenders.
Mussack et al. (1987) attempted to determine
the validity of the penile tumescence testing using
a sample of 24 comparison subjects with no known
paraphilic interests, recruited from the general population, and 34 heterosexual child molesters. The
assessment procedure consisted of gathering interview and psychometric data, along with measures of
sexual responses to visual and auditory stimuli using
PPG. They conducted a discriminant function analysis on the sexual arousal measures using group as
the dependant variable. The analysis correctly classified 73% of the subjects (p <.004) (67% of the comparison subjects and 77% of the child molesters). In
a small cross validation sample, six out of six of the
comparison subjects and seven out of eight of the
child molesters were correctly classified.
In a later study, Laws et al. (2000) assessed the
extent to which the use of multiple measures of pedophilic interest, including penile tumescence testing, improved on the diagnostic accuracy of any one
measure alone. The authors found that PPG testing
with slides yielded a sensitivity of 86.1%, and the use
of PPG testing with audio resulted in a sensitivity of
81%. Overall classification accuracy was increased to
91.7% when PPG testing with both slides and audio
stimulus sets were analyzed together with a card sort
assessment procedure. Similarity in efficacy between
audio and slide stimuli was replicated in a study by
Looman and Marshall (2001), which found that both
stimulus sets were equally effective in discriminating
child molesters from a group of rapists.
Firestone and associates (2000) examined the ability of PPG to discriminate between 216 child molesters and a comparison group of 47 nonoffenders from
the community. They found that child molesters
(both homicidal and nonhomicidal) had significantly
higher pedophile index scores than the comparison
group (p <.05).
Blanchard et al. (2001) conducted a similar study
using 82 male sex offenders against women, 172
offenders against unrelated children, and 70 offenders
against their own biological children or stepchildren.
Using PPG assessments, they obtained a specificity of
96% for offenders against adult women, with a calculated minimum sensitivity of 61% for positive diagnoses of pedophiles.
In another study, two groups, child molesters and
normal control subjects, were compared using visual

PENILE RESPONSE IN THE ASSESSMENT OF SEXUAL INTERESTS

stimuli (Grossman, Cavanaugh, & Haywood, 1992).

Although the pedophilic group was significantly
discriminated from the control group, a significant
interaction effect also showed that nonincestuous
pedophiles responded more to child stimuli than
either the control group or the incestuous fathers
(both of which scored similarly). Furthermore, the
nonincestuous pedophiles scored higher than the
incestuous fathers on sexual interests toward adults,
although they scored lower than the control group
of men with no known paraphilias or criminal history. These results support the potential importance
of PPG in the assessment of non incestuous child
molesters. A similar effect was found by Letourneau
(2002), in which PPG using audio stimuli resulted in
significantly lower arousal to female child stimuli for
men with female child victims than that of men with
other victim types (boys or both boys and girls).
Regrettably, many studies involving PPG do not
include sufficient data to calculate the sensitivity and
specificity of the test. The results of several studies in
which sensitivity and specificity data were presented

95

are summarized in Table 7.1. Inspection of the studies in Table 7.1, reveal that the majority exclude cases
in which the results are faked or insufficient to interpret. Arguably, this artificially inflates the reported
sensitivity of the test.

FOR ENSIC ISSUES

Most labs conduct the majority of their PPG assessments on men accused or convicted of sex crimes.
Therefore, any assessment of PPG testing should consider the potential forensic implications. For more on
this topic see Simon and Schouten (1992).
The Association for the Treatment of Sexual
Abusers (ATSA) discusses PPG testing in its Practice
Standards and Guidelines for Members of the
Association for the Treatment of Sexual Abusers
(2004) (www.atsa.com). Concerning PPG testing,
Section 22 of the document indicates that informed
consent to undergo PPG testing must be obtained
before proceeding and that the results should not

Table 7.1 Sensitivity and Specificity of PPG Tests for Pedophilia

Study

Groups (N)

Sensitivity (%)

Seto et al.,
1999

Mixed incest and

extrafamilial (64)

56.3

80

Other groups had lower

sensitivity Excluded technical
problems, faking, psychosis,
and MR

Seto et al,
2000

Adolescent offenders against

children (75)
Young adult offenders
against children(39)
Comparison controls (39)

42

92

Control includes 23 rapists

Rates higher for admitters
Adolescent offenders with only
female victims similar to
control group
Excluded technical problems

Blanchard et al.,
2001

Rapists (82)
Sex Offenders against children (172)
Incest offenders (70)

61

96

Excluded technical problems,

uncooperativeness,
Nonresponsiveness. Invalid
profiles

Barsetti et al.,
1998

Child molesters (39)

Nonoffenders (18)

66.7

95

Excluded nonresponders

Chaplin et al.,
1995

Child molesters (15)

Unemployed men (15)

Freund &
Watson, 1991

Sex Offenders against

2 + girls (27)
Sex offenders against
2 + male minors (22)
Sex Offenders against
women ( 41)
Paid Volunteers (50)

100

78.2
88.6

Specificity (%)

100

97
80.6

Comments

No exclusions
Discrimination on the basis of
violent stimuli
Exhibitionists excluded
Psychosis, MR excluded
Pedophiles were
nonadmitters
Faking or low output
excluded

96 ASSESSMENT AND DIAGNOSIS

be used as the sole criterion for estimating client

risk . . . , making recommendations to release (or not
release) clients to the community, or deciding that clients have completed a treatment program.
The question of whether PPG testing constitutes degrading treatment under Article 3 of the
Convention of Human Rights, has been considered
by the Court of the Council of Europe (1999) (http://
hudoc.echr.coe.int). The case involved a prisoner
with sexual identity problems who alleged that he
was coerced into submitting to PPG testing which
he found humiliating and degrading. Part of the prisoners argument was that refusal to undergo PPG
would have slowed acceptance into a sex offender
treatment program. The Court did not find in favor
of the prisoner, though it did comment that it would
have been more reasonable for the test to have been
conducted by a male technician (Gazan, 2002).
Concerns have also been raised about the use of
stimulus materials that involve children and other
sexually prohibited themes (see ATSA (2005) for discussion and comments). One of the most widely used
stimulus sets used primarily in the United States and
published by Farrall Instruments has been banned
because it included nude pictures of children.
Prohibition against the possession and dissemination
of child pornography has impeded the standardization of PPG stimulus sets. Remarkably, studies investigating PPG with stimuli that do not include nudity
have never been published.
Notwithstanding the issues raised in the preceding paragraphs, the primary forensic concerns about
PPG, have involved its admissibility in court. In
North Carolina, the Court of Appeals considered a
lower courts decision to exclude the evidence of
a doctor who had argued that an accused was not
a pedophile on the basis of negative PPG results:
In view of the lack of general acceptance of the
plethysmographs reliability and utility and therefore,
its reliability for forensic purposes in the scientific
community in which it is employed, we hold that
the trial court did not abuse its discretion in finding
the defendants plethysmograph testing data insufficiently reliable to provide a basis for the opinion
testimony which defendant sought to elicit from
(the doctor) (State of North Carolina vs. Robert Earl
Spencer, 1995).
Since then many, but not all courts in the U.S.
have rejected the admissibility of PPG evidence (see
Smith, 1998 for review of cases).

CONCLUSION

Aside from substance abuse disorders, sleep disorders, and a handful of psychiatric disorders resulting
from medical illnesses, sexual disorders are the only
group of psychiatric disorders with verified physiologic markers: abnormalities on PPG testing. In
spite of this, abnormalities on PPG testing are not
part of the DSM of ICD diagnostic criteria for any
of the paraphilias and many, if not most, treatment
programs for sex offenders do not use PPG testing.
Similarly, the trend in judicial decisions appears
to be to exclude evidence based solely on PPG test
results.
The reason is that in spite of a concerted research
effort over the past half century, the sensitivity of
PPG testing is insufficient and the specificity while
certainly higher, is not known for certain. This state
of affairs should come as no surprise since PPG testing has never been intended to determine guilt or
innocence in criminal matters. Nor has the potential
sensitivity and specificity of PPG testing ever been
established in the way most other psychological or
medical tests are standardized. What would happen
if the validity of blood glucose testing were based on
studies of men, some with diabetes and some without, at various stages of treatment, in which blood
glucose levels were compared to the self-report of the
men about whether they had diabetes? What if the
same men also had varying motivations to attempt
to trick or mislead the lab? The problem for validation of PPG testing is further compounded by the fact
that the relationship between penile tumescence and
sexual arousal is far from direct, even in healthy men
on no medications.
Will PPG testing go the way of dexamethasone
suppression testing for mood disorders? Probably.
Future research needs to focus on physiologic
changes associated with sexual arousal that occur
before penile tumescence results. One important
candidate is nitric oxide, a gaseous neurotransmitter
involved in the cascade of physiologic events that
culminate in penile tumescence. In addition, work
needs to be done to establish standard stimulus sets
with equivalent versions. This is important since the
salience of stimulus sets decrease with repeat administration, making reliability testing problematic and
decreasing the utility of PPG testing as a means to
measure response to treatment. Further research on
the effect of alcohol on PPG testing would also make

PENILE RESPONSE IN THE ASSESSMENT OF SEXUAL INTERESTS

sense since many sex offenders are intoxicated at the

time of their crimes (Wormith, Bradford, Pawlak,
Borzecki, & Zohar 1988). Further work on the refinement of stimulus sets, especially ones that do not
involve illegal images, will likely be necessary if PPG
testing is to become more widely employed (Renaud
et al., 2005).
In the meantime, clinicians should be vigilant to
guard against overinterpreting results. In its current
form, PPG testing remains an investigational tool.
Results of PPG testing in isolation will never be sufficient to prove the guilt or innocence of a suspect.
As with any tool, the utility of PPG testing depends
on the skill of the ones who use it. In combination
with clinical judgment and other investigational
procedures (e.g., psychological testing, eye-tracking,
polygraphy, etc.), PPG may be invaluable.
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with incarcerated rapists: Further validity issues.
Archives of Sexual Behavior, 13(6), 545554.
Mussack, S. E., Bays, L., & Hindman, J. (1987) An
investigation of the criterion validity of the penile
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Conference of the A.B.T.S.A., May, Newport,
Oregon.

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Prentky, R. A. & Knight, R. A. (1991). Identifying critical dimensions for discriminating among rapists.
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127135.
Quinsey, V. L. & Chaplin, T. C. (1982). Penile responses
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Quinsey, V. L. & Chaplin, T. C. (1984). Stimulus control
of rapists and non-sex offenders sexual arousal.
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Quinsey, V. L., Chaplin, T. C., & Upfold, D. (1984).
Sexual arousal to nonsexual violence and sadomasochistic themes among rapists and non-sexoffenders. Journal of Consulting and Clinical
Psychology, 52, 651657.
Quinsey, V. L. & Chaplin, T. C. (1988). Penile responses
of child molesters and normals to descriptions of
encounters with children involving sex and violence. Journal of Interpersonal Violence, 3, 259274.
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Madrigrano, G., Bradford, J., et al. (2005). The
recording of observational behaviors in virtual
immersion: A new clinical tool to address the
problem of sexual preferences with paraphiliacs.
Annual Review of Cybertherapy and Telemedecine,
3, 8592.
Rice, M. E., Chaplin, T. C., Harris, G. T., & Coutts, J.
(1994). Empathy for the victim and sexual arousal
among rapists and nonrapists. Journal of Interpersonal Violence, 9, 435449.
Seto, M. C. (2001). The value of phallometry in the
assessment of male sex offenders. Journal of Forensic
Psychology Practice, 1(2), 6575.
Seto, M. C. & Barbaree, H. E. (1993). Victim blame and
sexual arousal to rape cues in rapists and nonoffenders. Annals of Sex Research, 6, 167183.
Seto, M. C. & Kuban, M. (1996). Criterion-related
validity of a phallometric test for paraphilic rape
and sadism. Behaviour Research and Therapy,
34, 175183. Seto, M. C., Lalumire, M. L., &
Kuban, M. (1999). The sexual preferences of
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Seto, M. C., Lalumire, M. L., & Blanchard, R. (2000).
The discriminative validity of a phallometric test for
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sexual deviance: An overview. Archives of Sexual
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100 ASSESSMENT AND DIAGNOSIS

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M., & Zohar, A. (1988). The assessment of deviant sexual arousal as a function of intelligence,
instructional set and alcohol ingestion. Canadian
journal of psychiatry. Revue canadienne de psychiatrie, 33(9), 800808.

Chapter 8

Visual Reaction Time: Development,

Theory, Empirical Evidence,
and Beyond
Gene G. Abel and Markus Wiegel

This chapter discusses the theoretical foundations for,

development of, empirical evidence for, and the continued development of visual reaction time (VRT)
as a measure of sexual interest. The evaluation of
paraphilic sexual interests must adapt to scientific
and technical advances, as well as to the cultural
and societal attitudes, sociopolitical context, and the
legal environment in which these advances occur.
The thorough evaluation of individuals with possible
paraphilias must include assessment of their sexual
interest patterns, especially evaluation of any sexual
interest in children. Some sexual abusers are highly
motivated to conceal their sexual interest and, therefore, objective instruments that are difficult to fake
are essential. In 1987, the assessment of possible sexual abusers was dominated by circumferential penile
plethysmography (PPG) measures of adult males in
the United States and circumferential and volumetric PPG measures of adult males in Canada. Neither
standardized PPG stimuli, nor standard questionnaires, existed for evaluating the broad spectrum of

paraphilias. In addition, standardized systems for

assessing adult females, adolescent males, and adolescent females were lacking. That year, The Behavioral
Medicine Institute of Atlanta was formed to research
VRT as a potential psychological test to assist clinicians in determining the sexual interests of individuals with potential paraphilias. The most critical
objective of our research was to determine if a brief,
valid screening instrument could be developed to
identify those with sexual interests in children who
were applying to organizations that work with youth,
such as the Boy Scouts of America, Big Brothers and
Big Sisters, the Catholic Church, the Civil Air Patrol,
and so on.
Our scientific research had to adapt to a variety
of nonscientific factors while developing this system.
Since a number of clergy were being evaluated following accusations of sex offenses against children,
their superiors (especially in the case of the Catholic
Church) were reluctant to have their priests, who
were to remain celibate, view nude images. The FBI

101

102 ASSESSMENT AND DIAGNOSIS

and the State agencies began threatening arrests at

those laboratories using slides of nude children to
assess potential sexual abusers. Very importantly,
those working with survivors of child sexual abuse
were outraged by images of nude children being
used in assessment and were concerned that the use
of such images was a revictimization of the children
depicted (beyond the original taking of the pictures).
These and other factors culminated in the Governor
of Nebraska demanding that the Farrell Instruments
Company of Grand Island, Nebraska, who supplied
most of the slides used in PPG laboratories in North
America, terminate selling such depictions.

T HEOR ET ICA L FOU NDAT IONS

While the criminal justice system is essentially concerned with determining whether an individual is
guilty of a sex crime, for example, whether someone
has sexually touched a child, the clinical evaluation
of alleged child sexual abusers is concerned with
whether the individual has sexual interest in children.
Sexual behavior is influenced by a multitude of factors, both internal and external to the person. To understand these factors, there are a number of concepts
that need to be defined and distinguished from one
another. These include sexual desire, sexual arousal,
sexual interest, and sexual attraction. Sexual desire
can be conceptualized as a motivation to experience
sexual sensations, sexual arousal, and potentially orgasm. Thus, sexual desire can be seen as one motivation to engage in sexual behavior. Singer and Toates
(1987) conceptualize sexual motivation as following
the rules of general incentive-based (as opposed to
drive-based) models of motivation, but allowing for
sexual desire to be determined by multiple factors,
for example, hormones, satiation, and deprivation, as
well as personality and social factors. Sexual arousal is
probably the most complex to define. It has been conceptualized among the emotions, in that it involves
preconscious processing of stimuli, cognitive appraisal of stimuli, autonomic arousal (genital as well
as other peripheral autonomic arousal), and a subjective feeling state (Everaerd, 1988; Everaerd, Laan, &
Spiering, 2000; Singer, 1984). Sexual arousal, like
other emotional reactions, depends on appraisal of
stimuli, which includes memory and attentional processes interacting with each other. As such, any stimuli
is not intrinsically sexual, but must be appraised or

interpreted as such, occurring at preconscious and

conscious levels of awareness (Everaerd et al., 2000).
It is this appraisal or interpretation of specific stimuli
as sexual that is the essence of sexual interest. It is
unknown whether sexual interests are already determined at birth; however, it is clear that we are
born with a sensitivity for sexual stimuli, (e.g.,
genital touch). This sensitivity strengthens during
development, becoming prominent at puberty and
continuing, although attenuated, through old age. A
persons interactions with the environment, as well
as internal rehearsal (fantasy), build up experience
and potentiation of sexual stimuli (Everaerd et al.,
2000). We prefer the term sexual interest to the terms
sexual orientation and sexual preference, because
orientation connotes more of a biological etiology,
while preference connotes a more learned and even
voluntary nature. Sexual interest refers to the result of
biopsychosocial processes (hormonal, genetic, conditioned, and socially learned) that guide the appraisal
of stimuli as sexual stimuli.
The etiology of specific sexual interests may vary
depending on the nature of the stimuli. For example,
a shoe fetish or preference for sexual partners with
a particular hair color are more determined by conditioning and learning, while sexual attraction to a
specific gender (i.e., heterosexual vs. homosexual), especially in men, seems to be more biologically determined. A persons sexual interests determine what
they find sexually attractive. Singer (1984) conceptualized three stages of sexual attraction: (1) increased
visual attention to the stimulus, (2) movement toward
the stimulus, and (3) resulting genital response.
Conceptually, PPG assesses the third of Singers
stages of attraction and is based on the assumption
that sexual arousal, as measured by penile circumference or volume change, to a stimulus (e.g., image,
film, or audiotaped scenario) is evidence of sexual
attraction to the type of person or activity represented
by the stimulus. In contrast, attentional measures of
sexual interest are concerned with the first of Singers
three stages of attraction and are based on the assumption that the greater a persons attraction to a stimulus, the more attentional resources will be devoted
to attending to that stimulus. Attentional measures of
sexual interest can be divided into three categories:
(1) direct measures of attending, for example, stimulus viewing time (Abel, Rouleau, Lawry, Barrett, &
Camp, 1990; Abel, Lawry, Karlstrom, Osborn, &
Gillespie, 1994; Abel, Huffman, Warberg, & Holland,

VISUAL REACTION TIME

1998; Abel, Phipps, Hand, & Jordan, 1999; Quinsey,

Ketsetzis, Earls, & Karamanoukian, 1996), (2) measures of stimulus interference (distraction) while performing another task, for example, choice reaction
time (CRT; Wright & Adams, 1994, 1999), and (3)
measures of preconscious processing of stimuli (rapid
serial stimulus presentation and stimulus priming)
(Kalmus, 2003; Spiering & Everaerd, 2007).
The measurement of stimulus viewing time, also
called VRT, involves the respondent viewing images
of different aged and gendered individuals presented
via a slide projector or computer monitor. The images
are advanced by the respondent via a laptop computer. Thus, respondents determine the length of
time that each stimulus is presented (and presumably
viewed) while the computer measures the amount of
time that each stimulus is presented. Respondents
are not informed about the measurement of VRT. It
is assumed that the longer a person views an image,
the greater his or her sexual interest in the type of
individual represented in the image. In addition to
viewing the images, respondents may be asked to rate
their sexual attraction to each image for comparison
with the VRT measure of sexual interest. On the Abel
Assessment for sexual interest (AASI), after viewing a set of images once, respondents are asked to go
through the set a second time to rate each image on
a 7-point Likert scale (1 = very sexually disgusting to
7 = very sexually attractive). Acquiring the subjective
ratings also helps to ensure that the respondent is processing the stimuli with a sexual mindset. Creating
such a mindset through the instructional set before
the VRT assessment and through the use of subjective ratings is particularly important when the stimuli
include non-nude images of individuals.
Early Development and Validity of VRT
The AASI refers to a specific assessment instrument
developed to evaluate sexual interest in children that
utilizes information from both a detailed and standardized questionnaire and from a VRT measure.
However, in the early stages of its development, the
focus was on developing and validating a brief screen
for sexual interest in children based on VRT. The
ascent of the microcomputer, the availability of nude
and non-nude slides from Farrell Instrument Company, an extensive pool of patients with paraphilias
undergoing assessment or treatment, and staff privileges at a community hospital with an Institutional

103

Review Board, allowed us to investigate whether an

individuals attention to visual stimuli depicting males
and females of various ages suggested the individuals sexual interest. These initial studies did not stem
from an extensive review of the scientific literature,
but instead, from the researchers simple observation
that humans spend more time looking at individuals
to whom they are more attracted. At first, this screening tool, named the Abel Screen, was developed using
slides of nude individuals. However, as the political
climate changed and Farrell Instruments ceased business, we explored the possibility of using non-nude
stimuli. We developed our first set of non-nude stimuli depicting males and females from ages 8 to 10 and
upwards, and depicting the major ethnicities in the
United States (Caucasian and African-American),
through a modeling agency.
An additional compound was that the cultural
makeup of the United States was changing with an
increasing number of Hispanic and Latino Americans,
and we feared that the AASI may not be sensitive
to this growing ethnic group. We, therefore, conducted a number of studies where new images of
Latino adults and children were compared with the
images of Caucasians already in use. To our surprise,
Latino individuals were more responsive to images
of Caucasians than they were to images of Latinos
and we, therefore, did not alter our basic set of 160
images. By the mid 1990s, we were concerned that
preschool-aged children were not depicted in our
standard set of 160 images. Initially, we had included
three categories of couples that could be used to determine adult sexual preference (two non-nude males
hugging, two females hugging, a heterosexual couple
hugging); all other slides depicted non-nude, single
individual characters showing no sexual behavior).
Believing that determining adult sexual preference in
this manner, beyond an individuals awareness, was
unethical, these three couple categories and a neutral category (depicting landscapes) were replaced by
depictions of male and female children of preschool
age, which completed our current set of stimuli.
The stimuli currently used in the VRT assessment
of the AASI include 160 images, which depict a frontal view of the individual in a bathing suit without
depictions of sexual activity or arousal. The images
portray males and females of Caucasian and AfricanAmerican ethnicity and include individuals who are
preschool aged, grade school aged, adolescents, and
adults. The stimulus set includes seven images of

104 ASSESSMENT AND DIAGNOSIS

each category (e.g., seven images of Caucasian preschool girls, seven images of Caucasian grade school
girls, etc.). In addition, the AASI includes images
depicting six types of nonchild related paraphilic sexual behavior (exhibitionism, voyeurism, fetishism,
frotteurism, sadomasochism targeting females, and
sadomasochism targeting males).
On the basis of our work as well as others, there is
ample evidence that VRT using images of non-nude
individuals has construct validity, as well as discriminant validity for identifying individuals with a sexual
interest in children. Early studies found that, as the
erotic content of heterosexual images increases, so
does VRT by both men and women (Brown, 1979;
Brown, Amoroso, Ware, Pruesse, & Pilkey, 1973).
Landolt et al. (1995) found viewing time to increase
linearly with attractiveness ratings of images depicting only the head and shoulders of male and female
adults. On the basis of samples of heterosexual men,
VRT correlated significantly with ratings of image attractiveness, sexual arousal, and sexual stimulation
(Lang, Searles, Lauerman, & Adesso, 1980; Quinsey,
Rice, Harris, & Reid, 1993; Quinsey et al., 1996). On
the basis of the results of four independent samples,
Quinsey and colleagues (1996) also calculated the
mean Pearson correlation (r) between image sexual
attractiveness ratings and viewing time to be r = 0.72,
range = 0.54 to 0.91. Additional support for the validity of VRT as a measure of sexual interest comes
from convergent validity analyses between VRT and
PPG assessments. On the basis of a sample of heterosexual, university-aged men (N = 24), the correlations
between VRT and PPG ranged from r = 0.05 to
r = 0.84, with a mean correlation of r = 0.42 0.27
(Quinsey et al., 1996).
The ability of VRT to discriminate between
individuals with different sexual interest is of particular importance in regard to the practical application of VRT as a measure of sexual interest.
Studies comparing individuals with opposite-sex and
same-sex sexual orientation/preferences found that
each group viewed stimuli depicting their preferred
gender longer than stimuli depicting their nonpreferred gender (Abel et al., 1990; Wright & Adams,
1994, 1999). Using a CRT paradigm (another type of
attentional assessment of sexual interest), Wright and
Adams (1994) demonstrated that various groups (e.g.,
gay men, heterosexual men, lesbian women, and heterosexual women) had significantly longer reaction
times to nude slides of their preferred gender. They

replicated these findings using slides of clothed individuals in addition to images of nudes (Wright &
Adams, 1999). The pattern of results was the same
for both images of nude and clothed individuals, but
the effect was stronger for nude images. The CRT
had an 87.5% accuracy in differentiating between
individuals with same and opposite gender sexual
orientation/preference using nude slides and a 75%
accuracy using clothed slides.
Most importantly, VRT measures are sensitive to
age preferences (Abel et al., 1990; Abel et al., 1998;
Harris, Rice, Quinsey, & Chaplin, 1996; Quinsey
et al., 1996). VRT has been shown to discriminate
between male child sexual abusers and community men (Abel et al., 1994; Harris et al., 1996) and
between male child sexual abusers and nonchild
related sex offenders (Abel et al., 1998). Harris and
colleagues (1996) examined VRT and PPG (penile
circumference) discriminant validity between child
sexual abusers and nonsexual abuser, community
male adults. The sample included 26 child sexual
abusers and 25 nonsexual abuser heterosexual men.
The VRT stimuli included nude images of males
and females, aged 5 to 8 years, pubescent aged
(partial sexual development), and adult aged, with
10 slides in each category. The authors calculated
a deviance index for VRT by subtracting the longest mean VRT for a child category from the longest mean VRT for an adult category. Child sexual
abusers had a significantly smaller deviance index
score (M = 0.14 0.97) than community volunteers
(M = 1.26 1.47), indicating that relative to adult
stimuli, child sexual abusers viewed child stimuli
significantly longer, p < .01. The magnitude of this
statistical difference (effect size) was large (Cohens
d = 1.0) and corresponded to 55.4% of the scores
obtained by child sexual abusers and community volunteers not overlapping. Similarly, a deviance index
was calculated for PPG by subtracting the greatest
erectile response (in z-scores) to child stimuli from
the greatest erectile response to adult stimuli (also
in z-scores). Again, child sexual abusers (M = 0.47
1.12) differed significantly from the community
volunteers (M = 1.88 1.14) on the PPG deviance
index, p < .001. The effect size was also considered
large (Cohens d = 2.1) and corresponded to 81.1%
of the scores for child sexual abusers not overlapping
with those of community volunteers. It is unclear
why the authors transformed penile tumescence into
z-scores before calculating the deviance index, but

VISUAL REACTION TIME

used the raw mean visual reaction times for each category to calculate the VRT deviance index.
It is not only important to demonstrate significant differences in VRT to adult and child stimuli
between child sexual abusers and nonchild sexual
abusers, but of greater interest is the ability to correctly classify individuals with and without sexual interest in children based on VRT. Letourneau (2002)
compared the ability to classify sex offenders on the
basis of the VRT portion of the AASI and the results
from PPG (penile circumference) assessments for 57
men incarcerated for sexual offenses in a maximum
security military prison. The AASI was administered
using the standardized procedures and stimuli. The
AASI includes images of Caucasian and AfricanAmerican males and females in preschool, grade
school, adolescent, and adult age categories. Internal
reliability (measured by Cronbachs alpha) is a measure of the degree of association of the images within
a category. Typically, alphas above 0.80 are considered acceptable. The alphas for the VRT as assessed
by the AASI were as follows: Caucasian preschool
female = 0.87, African-American preschool female
= 0.72, Caucasian grade school female = 0.86,
African-American grade school female = 0.87,
Caucasian adolescent female = 0.85, AfricanAmerican adolescent female = 0.83, Caucasian
adult female = 0.80, African-American adult
female = 0.79, Caucasian preschool male = 0.60,
African-American preschool male = 0.72, Caucasian grade school male = 0.75, African-American
grade school male = 0.87, Caucasian adolescent
male = 0.90, African-American adolescent male
= 0.87, Caucasian adult male = 0.90, AfricanAmerican adult male = 0.87.
The PPG assessments were conducted in accordance with the standards of The Association for the
Treatment of Sexual Abusers (ATSA, 1997, pp. 4452)
and utilized commercially available ATSA audiotapes. The ATSA audiotapes consist of 16 threeminute vignettes that describe a male engaging in
masturbation or sexual activity with another individual in four categories: (1) Adult female consenting,
(2) adult male consenting, (3) minor female (compliant and coercive), and (4) minor male (compliant
and coercive). The tapes do not explicitly mention
the age of the target person, but instead the examiner instructs the respondent to think of a child just
the age he likes. The internal consistency of tumescence response (PPG) for each of the stimulus

105

categories for the ATSA tapes was as follows: Adult

female consenting = 0.85, adult male consenting
= 0.91, minor female = 0.82, and minor male
= 0.91.
To assess the validity of the AASI and PPG, each
participant was assigned to one of four classifications
based on the characteristics of the person against
whom they offended: abusers of girls (n = 34), abusers of boys (n = 10), abusers of adolescent females
(n = 9), and abusers of adult females (n = 8). Three
participants were included in more than one classification because two participants abused individuals
in two different categories and one participant abused
individuals in three categories. Letourneau (2002)
calculated the correlations between PPG (penile
tumescence change score from baseline) and the
AASI (VRT raw scores, in milliseconds). The PPG
change scores and AASI VRTs were significantly correlated for female child stimuli (r = 0.28, p < .05),
male child stimuli (r = 0.61, p < .01), and the adult
female rape stimuli (r = 0.38, p < .01), but not for the
female adolescent stimuli (r = 0.18, p = ns). In addition, Letourneau (2002) compared the offender classification on the basis of victim characteristics with
the predicted classification based on the results of
the PPG assessment and the VRT portion of the
AASI. Kappa is a measure of agreement that takes
into account agreement due to chance. The kappa
coefficients comparing classification based on victim and classification based on VRT were nonsignificant for abusers of girls (kappa = 0.19), abusers of
adolescent females (kappa = 0.01), and abusers of
adult females (kappa = 0.08). In contrast, there was
a significant degree of agreement between the two
means of classification for abusers of boys (kappa =
0.65, p < .001), indicating a degree of agreement
above and beyond that expected by chance. Similarly,
the coefficients of agreement between classification
based on PPG and classification based on the victims age and gender were significant for abusers of
boys (kappa = 0.61, p < .001), but nonsignificant or
in the wrong direction for abusers of girls (kappa =
0.37, p < .01), abusers of adolescent females (kappa
= 0.19), and abusers of adult females (kappa = 0.21).
The extremely low degree of agreement between
classification based on VRT and based on choice of
victim was due to the finding that, based on VRT,
all but one of the participants were classified as having sexual interest in adolescent females. This is
not altogether surprising since men without sexual

106 ASSESSMENT AND DIAGNOSIS

interest in children (i.e., normative controls) tend to

look at the adolescent images as long or longer than
adult images (Feierman, 1990; Freund, McKnight,
Langevin, & Cibiri, 1972). It is also interesting that
the kappa coefficient for abusers of girls based on
PPG compared to victim choice was significant, but
in the opposite direction. One would have expected
that PPG should be positively correlated with victim
choice.
The methods and findings from this study raise
some important and interesting issues regarding the
two objective measures of sexual interest. Letourneau
(2002) converted the raw tumescence data into
change from baseline scores and considered a 10% or
more mean increase above baseline for a stimulus category as evidence of sexual arousal to that category.
Some PPG evaluation centers consider a response of
less than 10% to all the stimulus categories as signifying nonresponders. How to operationally define
sufficient erectile response is to some degree dependent on the type of stimuli used. Erotic films tend to
elicit the greatest erectile response in studies of nonsex offender men, with images and audiotapes typically eliciting a weaker response. As a result, for
stimuli predicted to elicit strong erectile responses, a
change score of 10% or less might indicate a lack of
arousal, and for stimuli predicted to elicit a weaker
response, a change score of 10% or greater might
be considered a substantial response. Harris and
colleagues (1992) found that while nonchild sexual
abusers evidenced their greatest erectile tumescence
to appropriate adult stimuli, they obtained greater
tumescence to the deviant stimuli than did the sex
offenders, based on a comparison of raw penile circumference change scores (in millimeters). This is one
of the reasons why the use of z-scores and deviation
indexes, rather than responses to individual stimulus
categories has been recommended for obtaining the
maximum discriminant validity of PPG (Harris,
Rice, Quinsey, Chaplin, & Earls, 1992).
To determine whether a respondent had sexual
interest in a particular stimulus category on the basis
of VRT, Letourneau (2002) employed the method
of thirds (Abel, 1997), which involves the interpretation of z-score converted visual reaction times relative to the categories with the highest and lowest
z-scores. The method of thirds states that any child
stimulus z-score that exceeds one-third the difference
between the highest adult/adolescent VRT z-score
and the lowest VRT z-score among all categories is

indicative of possible sexual interest in that child category. This method has been criticized because it
attempts to interpret ordinal scores (i.e., ranks, which
should not be used to compare the magnitude of
responses) as if they were scale scores (i.e., with an
absolute zero point and defined distances between
points) (Fischer & Smith, 1999, p. 196). The use of
empirically derived logistic regression models that
include the raw visual reaction times (in milliseconds) or ratios of the raw VRT, rather than z-scores, is
one of the ways this criticism has been addressed by
Abel Screening, Inc. (Abel, Jordan, Hand, Holland, &
Phipps, 2001; Abel, Wiegel, & Jordan, 2004). These
regression models also integrate the AASI questionnaire data with the VRT data to assess pedophilic
sexual interests. Thus, the discriminant validity of
the AASI as reported in Letourneau (2002) does not
reflect the methods used by the AASI as it is currently
marketed, but instead describes the convergent and
discriminant validity of only VRT using the AASI
images.
Abel and colleagues (1998) administered a measure of VRT to a sample of 157 admitted sexual abusers, 56.7% of whom had admitted to having sexual
contact with children and/or adolescents. The slide
categories included male and female grade school,
adolescent, and adult individuals, with seven slides
per category. All images were of individuals in bathing suits, standing in front of a blue background.
The internal consistency for the stimulus categories
ranged from = 0.84 for adolescent female stimuli
to = 0.90 for child female stimuli ( > 0.80 are
considered acceptable). On the basis of regression
analyses, the measure of VRT resulted in the highest overall percentage correctly categorized (child
sexual abuser vs. nonchild sex offender) for child
sexual abusers of male adolescents (91.2% correctly
classified). The rate of true-positives (i.e., correctly
categorized as child sexual abusers) was 60%, with
6.5% incorrectly classified as child sexual abusers.
Similarly, the percentage of the sample correctly classified for child sexual abusers of boys was also high at
90.6%. However, the rate of true-positives (sensitivity)
was only 38% for abusers of boys, but because the
rate of false-positives was very low, with only 4.4%
false-positives, the overall percentage correctly classified remained high. For child sexual abusers of
female children and female adolescents, the percentages correctly classified were 65.6% and 76.7%,
respectively. The rate of true-positives was adequate

VISUAL REACTION TIME

(female child 67.4% and female adolescent 60%);

however, based on VRT, a fairly high percentage of
nonchild related sex offenders were incorrectly classified as child sexual abusers of girls (35.2%) and as
child sexual abusers of female adolescents (20.8%).
The higher rate of false-positives in the female adolescent category is not that surprising because nonsex
offender, heterosexual men show sexual interest in
and arousal to adolescent female stimuli (Feierman,
1990; Freund, McKnight, Langevin, & Cibiri, 1972).
Of greater concern is the unacceptably high rate of
classifying nonchild related sex offenders as child
sexual abusers of female children. Demonstrating
a low rate of false-positives is critical for any measure used in the assessment of child sexual abusers
because the consequences of being falsely categorized as a child sexual abuser are very serious. One
of the limitations of this study and what may have
contributed to the higher rates of false-positives was
that the comparison group was composed of admitted sexual abusers who were accused of nonchild
related sexual offenses (e.g., exhibitionism, voyeurism, etc.) rather than nonsexual abusing men. Abel
and colleagues (1998) also administered PPG assessments to 56 of the participants and found comparable
results between VRT and PPG.
In contrast to Abel and colleagues (1998), who
found good discriminant validity for the female
child stimuli, Letourneau (2002) found poor agreement between the classification based on VRT and
the criterion classification based on choice of victim. The difference in findings may be due to the
different comparison groups used in the two studies. Letourneau (2002) used all sex offenders who
were not in the category of interest as the comparison group. Therefore, her results are reflective of the
ability of VRT to discriminate between child sexual
abusers of female children and child sexual abusers
of male children, female adolescents, and female
adults. In contrast, Abel et al. (1998) used a sample
of nonchild related sex offenders as the comparison
group. Thus, the findings by Abel et al. (1998) are
reflective of VRTs ability to discriminate between sex
offenders against children and offenders against adults.
Johnson and Listiak (1999) conducted a further
study comparing the AASI and PPG (penile circumference) procedures based on a sample of 24
incarcerated male sex offenders. They used similar
procedures as Letourneau (2002), but evaluated two
commercially available PPG stimulus sets that utilize

107

videotaped images of non-nude models. Johnson

and Listiak (1999), like Letourneau (2002), used the
rule of thirds as the criteria for determining significant response based on the VRT portion of the AASI.
Johnson and Listiak (1999) defined an erectile circumference change of 5 mm or greater as indicating
a significant response on the PPG assessments. The
authors reported that, based on the VRT portion of
the AASI, 94% of the child molester category were
correctly identified on the basis of the age and gender
of the abuse victim for which they were convicted.
The two sets of PPG stimuli each categorized 62%
correctly in terms of age and gender of their victim.
Caution in interpreting these results is warranted
because of the small sample size, nonuse of z-scores
or deviation indices for the PPG data, and the particular criteria used to determine significant response
on the AASI and PPG assessments.
When taken together, the reviewed studies indicate that VRT shows acceptable levels of being able to
discriminate between child sexual abusers and non
child related abusers. The accuracy of VRT alone
is similar to that of PPG, but avoids problems of so
called flat-liners (a failure to show erection responses to any category of stimulus) and is less intrusive.

FROM SCR EEN TO ASSESSMEN T

INST RUMEN T: THE A DDIT ION
OF QUEST IONNA IR ES

In the early 1990s when we presented the initial Abel

Screen at the annual conference of the ATSA, the
largest organization of individuals working with sexual
abusers, we were startled to find minimal interest in
developing a screening methodology (Abel et al.,
1990). This lack of interest probably emanated from
ATSA members focusing predominantly on evaluating potential sexual abusers (including child sexual
abusers), but within the clinical setting of evaluating
and treating such individuals, not screening large
numbers for potential risk in working with children.
The Catholic Church scandal relating to child sexual
abuse by Catholic priests had not broken to the media
and most therapists working in the area focused on
sexual abusers after they had committed sex crimes
and were not focused on identifying predilections
for sex with children among individuals who had not
been accused of child molestation. A further problem
was that funding for our initial research studies came

108 ASSESSMENT AND DIAGNOSIS

from profits from private psychiatric care and, as the

financial costs for our research mounted and the lack
of interest in screening continued, we temporarily
refocused our research efforts to adapting the Abel
Screen so that it could be used by clinicians evaluating and working with alleged sexual abusers.
At the time, there were no commercially available
systematic questionnaires that evaluated the broad
range of paraphilias, the cognitive distortions held
by sexual abusers (especially child sexual abusers),
and those being examined were attempting to give
socially desirable responses. On the basis of clinical
experience since the late 1960s, a detailed questionnaire for adult males was added to the VRT assessment to create the Abel assessment for sexual interest
(AASI). Including a standardized and detailed selfreport questionnaire in any assessment of suspected
sexual abusers is important because individuals may
be more forthcoming on a questionnaire completed
in private, as compared to a face-to-face clinical
interview. In addition, such a questionnaire allows
for the efficient assessment of a wide range of problematic sexual behaviors, which is important since
many individuals engaging in one paraphilia tend
to also be involved with other paraphilic behaviors
(Abel, Becker, Cunningham-Rathner, Mittelman, &
Rouleau, 1988).
The questionnaire is divided into four sections.
Section I contains items that inquire about the respondents demographics, social relationships as a
teenager, past sexual abuse and sexual coercive behavior of the respondent, child sexual abuse related
cognitive distortions, their sexual attraction, sexual
fantasies, and masturbation activity. Section II contains five items that assess the respondents subjective
appraisal of his social skills and of the role of alcohol
and pornography in his sexual behavior. Section III
gathers information about the following 21 sexual
behaviors: exhibitionism, public masturbation, fetishism, frotteurism, voyeurism, zoophilia, telephone
scatologia (obscene phone calls and letters), necrophilia, sexual masochism, coprophilia, adultchild
sexual contact (the respondent as the perpetrator),
coercive sexual behavior (rape), sexual sadism, transvestic fetishism, professional sexual misconduct, sex
with prostitutes, sexual affairs, sex with strangers, use
of pornography, calling telephone sex lines, and gender identity dysphoria (transsexualism). Section IV
includes items that ask respondents to rate each of the
21 sexual behaviors described in Section III regarding

how sexually arousing each is and amount of sexual

fantasy to each type of behavior, as well as legal history (i.e., convictions, arrests, or accusations). Section
IV also includes 20 items that assess social desirability, the individuals willingness to admit to minor
violations of common social mores.
Including a questionnaire that assessed a variety
of paraphilic and problematic sexual behaviors in a
standard manner, including age of onset, number of
times engaged in the behavior, number of victims,
and the relationship between the respondent and
the victim, has resulted in the systematic collection
of data on a large sample of alleged sexual abusers
presenting for evaluation. Analyses of this continually
growing database resulted in the Abel and Harlow
Stop Child Molestation Prevention Study (Abel &
Harlow, 2001, 2002), which summarized the findings based on a sample of 3952 admitted male sexual
abusers of children. Currently, the database contains
information on almost 50,000 individuals evaluated
throughout North America using the AASI who
admitted to a variety of paraphilic and sexually problematic sexual behaviors (see Table 8.1). The results
indicate that individuals seeking evaluation are more
likely to have been involved in child sexual abuse
relative to any other paraphilia.
In 1995, the research and development arm for
VRT, called Abel Screening, Inc., was established
as a separate entity from the Behavioral Medicine
Institute of Atlanta. After 8 years of preliminary
research, the company sold its first product for objectively measuring a variety of sexual interests, using
VRT and gathering information on a number of sexually problematic behaviors, cognitive distortions, and
social desirability. Having a separate research company that operated as a free-standing company rather
than as a research center in a clinical setting has
resulted in two advantages. First, it allowed the availability of specific staff who were able to exclusively
focus on providing technical assistance and customer
service to clinicians who had purchased and were
using the AASI in their practice. Second, it allowed
for ongoing research regarding how to best improve
the AASI, which was funded by the revenue generated through sales of the evaluation technology. Over
the years, funneling all the profits back into research
and development has led to a number of advances in
using the AASI in the evaluation of potential sexual
abusers. These include developing a standardized
assessment system for adult women, as well as male

VISUAL REACTION TIME

109

Table 8.1 Problematic Sexual Behaviors Assessed by the AASI and their
Associated Prevalence in Sexual Abusers Presenting for Evaluation
Problematic Sexual Behavior

Males (N = 47,265)

Females (N = 1,684)

Count

Percent (%)

Count

Exhibitionism

4762

10.1

105

6.2

Public masturbation

3904

8.3

44

2.6

Fetishism

4069

8.6

56

3.3

Frotteurism

2966

6.3

28

1.7

Voyeurism

6525

13.8

43

2.6

Sex with animals

2706

5.7

82

4.9

Obscene phone calls/letters

2670

5.6

88

5.2

92

0.2

0.1

Sexual masochism

815

1.7

63

3.7

Sex involving urine/excrement

649

1.4

17

1.0

13901

29.4

268

15.9

1354

2.9

17

1.0

971

2.1

28

1.7

2036

4.3

17

1.0

Sex with dead bodies

Child sexual abuse

Rape
Sexual sadism
Transvestism
Professional sexual misconduct
Use of prostitutes

Percent (%)

738

1.6

32

1.9

12,285

26.0

45

2.7

Sexual affairs

17,038

36.0

496

29.5

Affairs with strangers

12,806

27.1

305

18.1

Phone sex
Use of pornography
Transsexualism

2,448

5.2

25

1.5

12,519

26.5

166

9.9

882

1.9

49

2.9

and female adolescents; the development of probability values for comparison of a clients pattern of
responses to those of known child sexual abusers;
and the development of an assessment system specifically designed for the evaluation of individuals with
intellectual disabilities.

THE A ASI A ND THE COURTS

Since 1993, the Daubert standard (Daubert vs. Merrell

Dow Pharmaceuticals) is used in many state and federal cases as the criteria for evaluating whether expert
testimony is admissible in a particular court case. The
Daubert standard is a two-pronged approach that states
that the science on which the testimony is based must
be reliable and valid, and that the testimony must be
relevant to the issues of the case. Thus, expert testimony in a case can be excluded on the basis of lack
of scientific merit or lack of relevance. The Daubert

standard establishes some guidelines in evaluating

scientific merit. These include (1) whether the underlying theory or technique is empirically testable and
has been tested, (2) whether the theory or technique
has been subjected to peer review, (3) whether the
theory or technique has a known or potential error rate
and associated safeguards and standards controlling its
operation, and (4) whether the theory or technique is
generally accepted in the scientific community.
The results of Daubert motions for the AASI
have been mixed. The AASI has passed the Daubert
standard in some federal and state court cases, and
has been excluded in others. In U.S. versus Robinson,
2000, the court decided that AASI met all four of
the suggested guidelines to judge scientific merit and
that the testimony and the AASI results were relevant
to the case. However, in U.S. versus White Horse,
2001, and U.S. versus Birdsbill, 2003, the AASI was
judged not to pass the Daubert standard. This was due
in part to the lack of evidence that the AASI, and in

110 ASSESSMENT AND DIAGNOSIS

particular VRT, were valid among Native American

test-takers, since among some Native American cultures it is impolite to make prolonged eye contact,
which could affect the validity of the VRT. The
latter case, excluded expert testimony based on the
AASI, both for lack of relevance and lack of scientific merit, citing the Ready versus Commonwealth of
Massachusetts ruling. In Ready versus Commonwealth of Massachusetts, 2002, the AASI was found
not to meet the Daubert standard for scientific validity because the original research study that developed the rule of thirds used to score the VRT, was
never published. However, the rule of thirds was
also used by Letourneau (2002), which was published
in a peer review journal. In addition, the court found
that because the defendant had abused boys aged
6 to 12, and that this age range is not represented
in the AASI VRT images, that the test was neither
valid nor relevant for this defendant. Furthermore,
the court felt that the method used to remove outliers
in the VRT data had not been adequately tested by
researchers who were not connected with Dr. Abel.
Lastly, the court found that the defendants AASI
results were not relevant to the issues of the case which
pertained to sexually dangerous persons (SDP), future
dangerousness, and risk to reoffend. Interestingly, in
Ohio the AASI is a standard part of the states sexual predator evaluation, and the results are routinely
accepted as one aspect of the evidence used to judge
as to whether a person qualifies as a sexual predator.
Since Ready versus Commonwealth of Massachusetts,
the AASI has been admitted as evidence in at least
one Massachusetts case, Commonwealth of Massachusetts versus Lyons aka Swimm, 2002. In addition,
testimony regarding the AASI results were admissible in several federal cases, for example, U.S. versus
Graves, 2005 and U.S. versus Stoterau, 2008.

EVA LUATING FEM A LE

SE X UA L A BUSER S

While the vast majority of sexual abusers appear to

be males, there have been increasing reports by both
male and female abuse survivors that their abuser
was female, and more attention is being paid to the
clinical assessment and treatment of female sexual
abusers (Grayston & De Luca, 1999). Finkelhor and
Russell (1984) reviewed 17 studies regarding the prevalence of women who sexually abuse children. After

reviewing possible sources of bias, they concluded

that, by best estimates, 14% to 27% of cases involving male survivors and 0% to 10% of cases involving
female survivors could be attributed to female perpetrators. Laumann et al. (1994), in a nationally representative survey, found that 3% of the total sample
had been sexually touched as a child by an adolescent female and 1% by an adult female. The survey
also asked respondents whether they had ever forced
someone to do something sexual that the other person did not want to do. Only 0.1% of the female
respondents reported forcing sexual contact with a
female and 1.5% reported having forced a male into
sexual contact, as compared to 2.8% and 0.2% of male
respondents, respectively.
In contrast to the clinical and empirical work
done with male sexual abuses, sexual interest in or
attraction to children is rarely examined and has not
been well studied in female child sexual abusers.
Even when sexual attraction to children by women
is acknowledged, it is frequently discounted. For
example, Mathews et al. (1989) reported that 11 of 16
women in their study acknowledged either arousal
to or sexual fantasies about the children they sexually abused; however, according to the authors, the
majority of these women reported that sexual arousal
was not a main motivating factor. Similarly, based on
interviews with 67 incarcerated female child sexual
abusers, Davin (1999) concluded that, even though
over 25% of the women who sexually abused children
without a cooffender (n = 30) experienced orgasms
while offending, sexual gratification was not a motivating factor in the offenses. While there are a number of social, cultural, and political factors that make
it more difficult to acknowledge that women, and
mothers in particular, are sexually attracted to children, another factor contributing to the dearth of
empirical work focusing on sexual attraction and sexual interest in female child sexual abusers stems from
the lack of empirically validated and reliable objective measures of female genital sexual arousal.
As mentioned, the PPG (circumferential or volumetric) is a common method of measuring genital
sexual arousal in men. Vaginal photoplethysmography
is the corresponding method of measuring female
genital arousal (Janssen, 2002; Laan, Everaerd, & Evers,
1995; Sintchak & Geer, 1975). The vaginal pulse amplitude (VPA) signal is a measure of the moment-tomoment blood flow to the genitals (Janssen, 2002;
Laan et al., 1995). Measures of genital sexual arousal

VISUAL REACTION TIME

are based on the assumption that sexual arousal in

response to a specific stimulus is indicative of sexual
interest in the type of person or activity depicted in
the stimulus. This assumption is probably valid in
men; that is, male sexual arousal is category specific.
However, recent research findings suggest that genital
sexual arousal in women may not be category specific. Chivers and colleagues (2004) measured genital
sexual arousal in heterosexual and gay/lesbian men
and women, as well as male-to-female transsexuals in response to malemale, femalefemale, and
malefemale sexual stimuli. The results indicated
that heterosexual and gay men evidenced their greatest erectile tumescence to stimuli depicting their
preferred gender. In contrast, VPA did not differ significantly between the three types of stimuli in heterosexual women. Additionally, heterosexual and
lesbian women evidenced significantly lower correlations between self-reported sexual preference and genital arousal. To rule out that these findings were due to
differences in the method of measuring genital sexual
arousal (i.e., PPG vs. vaginal photoplethysmography),
Chivers and colleagues (2004) included a group of
male-to-female transsexuals, since these individuals
were biologic males but with female genitalia and,
thus, their genital arousal would be measured using
photoplethysmography. The results indicated that
male-to-female transsexuals showed a similar category
specific pattern of arousal, as did the heterosexual and
gay men. The authors concluded that women have a
nonspecific pattern of sexual arousal that is quite different from mens category specific pattern (p. 741).
On the basis of these findings, one would predict that
using photoplethysmography to assess genital sexual
arousal in adult female child sexual abusers would
result in sexual arousal responses to most stimulus
categories, and thus be insufficiently specific to discriminate a womans sexual interest pattern.
To date, only one published study has utilized
vaginal photoplethysmography in the assessment of a
female sexual abuser. Cooper et al. (1990) presented
a case report of a 20-year-old female pedophile with
multiple comorbid paraphilias. The results of the
physiologic assessment using VPA revealed high
physiologic sexual arousal to all categories of stimuli
presented (e.g., adults as well as children, and males
as well as females). The authors concluded that the
womans responses indicated polymorphous eroticism, with sadistic, masochistic, and pedophilic elements (p. 336). Alternatively, the VPA data could be

111

interpreted as supporting the findings by Chivers and

colleagues (2004) that female vaginal response is not
category specific.
The validity of using vaginal photoplethysmography for female sexual abuser evaluations is ultimately
an empirical question that requires well controlled
studies. However, if female genital arousal lacks category specificity as suggested by Chivers and colleagues (2004), then VPA would not be well suited for
assessing female sexual interest patterns. A method
of measuring sexual interest that is not dependent on
vaginal sexual arousal, yet still not easily dissimulated
or misrepresented, is needed for female sexual abuser
evaluations. Attentional measures of sexual interest
provide that alternative.
VRT measures of sexual interest have also been
shown to have some validity in women. Brown
(1979) showed slides of varying erotic content to
male and female college students. The slides ranged
from images of dressed couples to explicit images of
group sex, and also included images of same sex sexual activity. The female participants viewed all but
the male same sex images for less time than their
male counterparts and evidenced greater variability
in their VRT. However, there was an overall trend
for VRT of the female participants to increase with
increased erotic explicitness of the images. Quinsey
and colleagues (1996) measured VRT and subjective
ratings of attractiveness of images depicting nude
adult, pubescent, and child males and females in a
sample of heterosexual male and female college students. The results indicated that female participants
evidenced their longest VRT to adult images of their
preferred gender, with decreasing VRTs as age of the
depicted male decreased, and they viewed nonpreferred gender images of all age groups for a similar
amount of time. While male participants had longer
VRTs than female participants for adult images of
their preferred gender, this difference was not statistically significant. However, male participants viewed
pubescent images of their preferred gender significantly longer than female participants. The average
correlation between VRT and image attractiveness
ratings was significantly higher among male participants (Pearson r = 0.80) than among female participants (Pearson r = 0.60).
The earlier studies are evidence that, in women,
VRT is a valid measure of sexual interest when
using images of nude individuals or images with
sexual content. There is also some evidence for the

112 ASSESSMENT AND DIAGNOSIS

validity of attentional measures of sexual interest

when using non-nude images of individuals. Using
images showing just the head and shoulders of individuals that had previously been rated as unattractive,
moderately attractive, and attractive, female college
students evidenced a linear relationship between
z-transformed VRT and image attractiveness rating,
with more attractive images viewed for longer time
periods (Landolt et al., 1995). Additionally, Wright
and Adams (1994) assessed a measure related to VRT,
and found that CRT discriminated opposite sex from
same-sex sexual orientation in both men and women.
Attentional measures of sexual interest, including
VRT, require further validation and study in samples
of female sexual abusers, specifically female child
sexual abusers.
Amassing an adequate sample of admitted adult
female child sexual abusers to validate VRT takes
a lot longer because of their lower prevalence.
However, to date, we have collected a sample of 81
adult women who admit to having sexually abused at
least one child, and the results look promising. On
the basis of an overall sample of 411 women who were
evaluated for problematic sexual behaviors, the internal reliability (Cronbachs alpha) of the visual reaction times for the different age and gender categories
were all above = 0.85. The adolescent male category had the least internal reliability with an = 0.85,
while the 14 images in the preschool boys category
(seven Caucasian and seven African-American boys)
had the greatest degree of internal reliability with an
= 0.93, and the remaining categories having
Cronbachs alphas around = 0.90 (see Table 8.2).
The sample of 411 adult female sexual abusers
included 81 women who admitted to sexually abusing at least one child (younger than 14 years), 94
women who admitted to sexually abusing at least one
adolescent (age 14 to 17), and 236 women who were
evaluated for nonchild related problematic sexual
behaviors (e.g., exhibitionism, sadomasochism, multiple sexual affairs, etc.). These three groups of sexual
abusers were compared on VRT to child and adult
stimuli by using the natural log transformed VRT.
When examining objective measures of sexual interest, whether PPG or VRT, it is clinically most useful
to analyze the relative sexual interest in inappropriate stimuli to the sexual interest in appropriate sexual
stimuli by either using a sexual deviance difference
score (e.g., child minus adult) or a sexual deviance
ratio (child divided by adult). As a result, the three

Table 8.2 Cronbachs Alphas for VRT Categories

in Adult Female Sexual Abuser Sample (N = 411)
VRT Category

Cronbachs Alpha

No. of Images

Preschool males

0.925

14

Grade school
males

0.914

14

Adolescent males

0.851

14

Adult males

0.902

14

Preschool females

0.896

14

Grade school
females

0.908

14

Adolescent females

0.877

14

Adult females

0.913

14

groups were compared on the ratio of child VRT to

adult VRT. A between-groups analysis of variance
(ANOVA) indicated that the three groups significantly differed on the child/adult VRT ratio, F(2,408)
= 22.38, p > .001. Bonferroni-adjusted follow-up tests
revealed that the adult female sexual abusers of children evidenced significantly greater child/adult VRT
ratios (i.e., greater relative sexual interest in children) than the nonchild related sexual abusers and
the sexual abusers of adolescents. However, adult
female child sexual abusers of adolescents did not differ significantly from either of the other two groups.
To get a better understanding of these differences,
the three groups were compared on their natural
log transformed VRTs to adult males, adult females,
child males, and child females. The between-groups
ANOVA indicated significant differences on the VRT
to adult females, F(2,408) = 5.34, p > .01, as well
as, on the VRT to child females, F(2,408) = 15.74,
p > .001, and child males, F(2,408) = 19.16, p > .001.
Bonferroni-adjusted follow-up t-tests found that none
of the groups differed on their natural log transformed VRT to adult males. However, adult female
sexual abusers of children evidenced significantly
longer VRTs to adult females, female children and
male children. Again the group of admitted sexual
abusers of adolescents evidenced VRTs in between
those of the child sexual abusers and the nonchild
related sexual abusers, which did not differ significantly from either of the other two groups.
These data, while preliminary, indicate two important findings. First, VRT seems to be a promising measure for evaluating the sexual interest of adult women
who have sexually abused children (younger than
14 years) since these women had significantly higher

VISUAL REACTION TIME

child/adult VRT ratios from nonchild related sexual abusers. Second, sexual interest in children by
female child sexual abusers may play a more important role in the factors influencing sexually abusive
behavior by adult women towards children than
has previously been reported in the scientific literature. Certainly, further rigorous empirical studies of
female sexual abusers are needed to confidently draw
these conclusions.

THE A DDIT ION OF

PROBA BILIT Y VA LUES

Our next scientific advancement occurred with the

development of probability values. Probability values
are calculated using logistic regression equations
that are developed on the basis of samples of known
groups of child sexual abusers and nonchild related
sexual abusers or nonsexual abusers (i.e., community
volunteers without a history of sexual behavior with
minors). The logistic regression models include information from both VRT and the questionnaire. The
integration of different types of information results in
several advantages. First, it makes it more difficult to
fake good, since respondents would not only need
to keep track of the relative VRTs to 160 images, but
also would need to know how to specifically answer
questionnaire items, many of which are not apparent
as being related to sexual interest in children. Second,
the use of more information results in a higher accuracy of classification. In one preliminary study, including questionnaire data in addition to VRT data
in logistic regression modeling, on average, increased
the area under the receiver operator characteristic
(ROC) curve from 0.778 to 0.843 (Abel et al., 1999).
ROC curves plot the true-positive rate (sensitivity)
against the false-positive rate (one minus the specificity). The area under the ROC curve is a measure of
the instruments ability to differentiate between the
two groups. Last, the integration of VRT and questionnaire data by the AASI allows for the construction
of empirically derived regression equation models for
different types of child sexual abusers and an associated probability value for each respondent. Thus, a
probability value represents a method for integrating
self-reported information with objective measures of
sexual interest and using the resulting score to help
answer the question, What is the likelihood that this
person has sexually touched a child in the past?

113

The development of probability values began with

a sample of admitted child sexual abusers and a comparison group of nonchild related sexual abusers (e.g.,
exhibitionists, voyeurs, etc.). These admitter probability values were of minimal clinical utility from an
assessment standpoint, since they only substantiated
the self-reported sexual behavior of the individual.
However, developing the first probability values on
the basis of a sample of admitted child sexual abusers
allowed us to test the construct validity of the probability value. Much more clinically relevant is a probability value developed to discriminate between child
sexual abusers who appear to have sexually abused a
child but deny their alleged offenses and those who
have not sexually touched a child. We empirically derived one regression model for differentiating between
nonchild related sexual abusers and admitted child
sexual abusers of girls, and a second model for differentiating between nonchild related sexual abusers
and admitted child sexual abusers of boys (Abel et al.,
2001). On the basis of those two admitter logistic regression models, the first denier- dissimulator model
was derived for differentiating between nonchild related sexual abusers and suspected child sexual abusers who deny committing their offenses, but were
thought to have sexually touched a child. Information
was gathered from those individuals who had been
accused of child sexual abuse and denied culpability,
but whose interview or explanation of the allegations
appeared preposterous, they had been found guilty
of child sexual abuse, or at least two different families had accused them of child sexual abuse. These
individuals were called denier-dissimulators, because
their clinician, based upon the sum total of information, concluded that they had indeed committed
child sexual abuse, but were attempting to deny the
same. This group was different than individuals who
denied culpability but no determination could be
made regarding whether they had indeed been involved in child sexual abuse; these latter individuals
were simply labeled as deniers, and excluded from the
denier-dissimulator group.
The three logistic regression models were based
on a sample of 747 men undergoing sex offender
evaluation for a variety of offenses. Forty-one percent
(n = 308) were being evaluated for nonchild related
sexual offenses or problematic sexual behaviors
(e.g., exhibitionism, voyeurism, or excessive affairs),
30.79% of the sample (n = 230) admitted to sexually abusing girls (below age 14), 6.16% of the sample

114 ASSESSMENT AND DIAGNOSIS

(n = 46) admitted to sexually abusing boys (below

age 14), 4.15% of the sample (n = 31) admitted to
abusing both boys and girls, and 17.4% were denierdissimulator child sexual abusers (n = 130). Incest
child sexual abusers were excluded from the samples
used to develop the models for admitted child sexual
abusers of girls and admitted child sexual abusers of
boys, thus none of the admitted child sexual abusers
had offended exclusively against family members.
However, genders, ages, or relationship type (incest or
nonfamilial) of the children abused were not known
for the denier-dissimulator child sexual abusers.
Thus, individuals in the denier-dissimulator sample
probably included both extrafamilial and incest child
sexual abusers, as well as abusers of adolescents and/
or children. Half the total sample was randomly
assigned to a model building sample, while the other
half was assigned to a holdout sample.
The first logistic regression equation was based
on men who admitted sexually abusing girls below
14 years of age (Abel et al., 2001). The model included the following predictors: VRT for images depicting grade school girls (coefficient = 0.29), cognitive
distortion score (coefficient = 1.34), self-reported
attraction to grade school girls (coefficient = 0.31),
self-reported attraction to adult males (coefficient =
0.20), number of times married (coefficient = 0.39),
and the response to the item I feel that I am someone children look up to (coefficient = 0.68). The
second logistic regression equation was developed
using men who admitted sexually abusing boys
under the age of 14 years (Abel et al., 2001). In this
model, VRT of grade school boys (coefficient = 0.53),
cognitive distortion score (coefficient = 1.30), being
the survivor of child abuse (coefficient = 2.43), and
a measure of hobbies and interests (coefficient =
0.31) were included as predictors for classifying sex
offenders.
The last regression model was developed for
the denier-dissimulator group (Abel et al., 2001).
Predictors for this first denier-dissimulator model included a measure of hobbies and interests (coefficient
= 0.27), the higher of the predicted values from the
previous two models (coefficient = 3.97), a behavior
denier scale score (coefficient = 0.14), and a variable representing the combination (interaction term)
of the behavior denier scale and the higher of the
predicted value from the previous two models (coefficient = 1.22).
The holdout sample was used to determine the
specificity and sensitivity of each of the models. The

use of higher or lower cut points with each logistic

regression model results in different sensitivity and
specificity values. A cut point for the logistic regression score of 0.48 applied to the child sexual abuser
of girls model resulted in a sensitivity of 74% and a
specificity of 73%. Using a higher cut point of 0.88
increased the specificity to 99%, indicating that 99%
of nonchild sexual abusers were correctly classified
as nonchild sexual abusers in the holdout sample.
The higher specificity unfortunately comes at a cost
of the sensitivity, which was reduced to 25%, on the
basis of a cut point of 0.88. Similarly, for the child
sexual abuser of boys model, a cut point of 0.21 had a
sensitivity of 86% and specificity of 86%. Obtaining
a specificity of 99% required a cut point of 0.83,
which resulted in a sensitivity of 28%, indicating that
only 28% of sexual abusers of boys would be correctly identified. A cut point of 0.32 with the denierdissimulator model resulted in a sensitivity of 75%
and a specificity of 76%, while a cut point of 0.83
resulted in a specificity of 99%, indicating that 99%
of nonchild sexual abusers would correctly be classified as nonchild sexual abusers; however a cut point
of 0.83 results in a sensitivity of 22%, meaning that
only 22% of denier-dissimulators would be classified
as such. The first two models, for child sexual abusers
who admit sexually touching children, are important
primarily as demonstrating criterion validity for the
AASI, while the model for denier-dissimulator child
sexual abusers has practical applications for identifying nonadmitting child sexual abusers.
The first set of three logistic regression models demonstrated that the AASI probability values
could discriminate between child sexual abusers and
sex offenders being evaluated for nonchild related
offenses; however, it was unclear how well the AASI
discriminates between child sexual abusers and nonsex offender controls (community volunteers).
A further study was subsequently designed to develop a logistic regression equation based on a sample
of 2356 men suspected of sexually abusing minors
and 170 nonsex offender men recruited from the community (Abel et al., 2004). All of the suspected child
sexual abusers denied having sexually abused minors
or having sexual interests in children and they met
the criteria for being denier-dissimulator child sexual
abusers. This second denier-dissimulator model was
developed in such a way that it would be free of race
bias and respondent age bias. The resulting maximum
likelihood logistic regression equation included nine
predictor variables. The overall model likelihood

VISUAL REACTION TIME

ratio chi-square was significant, 2 (9, N = 2526) =

236.61, p< .0001. The model was found to have an
acceptable goodness of fit. The nine model predictor
variables included the ratio of child stimuli VRT to
frotteurism stimuli VRT (coefficient = 3.04); VRT for
frotteurism (coefficient = 0.43); marital status (coefficient = 1.49); cognitive distortion score (coefficient =
0.86); hobbies and interest score (coefficient = 0.78);
respondent having been sexually abused as a child
(coefficient = 0.98); and the responses to the single
items, I talk to children on their level (coefficient
= 0.36), I enjoy being around children (coefficient
= 0.23), and I would rather spend my time with children (coefficient = 0.23). The area under the ROC
curve for this denier-dissimulator learning model
was 0.83. Rather than using half of the sample as a
holdout sample, a ten-fold cross-validation method
was used to determine the sensitivity and specificity
of the model. The mean area under the ROC curves
based on the ten-fold cross-validation was 0.81, indicating good cross validation. Using a cut point of 0.3
for the model, the sensitivity was 87%, with a specificity of 45%. A predicted value cut point of 0.6 resulted
in a sensitivity of 61% and specificity of 86%. Thus, on
the basis of a child sexual abuser prevalence of 50%
(i.e., 50% of the population of men referred for sex
offender evaluation are child sexual abusers), a person whose model score was 0.3 would have a 22.4%
probability of being a denier-dissimulator child sexual
abuser, whereas an individual whose model score was
0.6 would have a 81.3% probability of being a denierdissimulator child sexual abuser.
The use of a probability score dramatically increases the clinical applicability of the AASI results
because it avoids having to choose one cut point and
making an either/or determination. The newer AASI
denier-dissimulator probability value can then be
integrated into a clients overall assessment results,
adding another tool to help clinicians discriminate
those who have actually sexually touched a child
in the past from those who have not (an important
issue to the average evaluator). As described earlier,
every test and measure has false-positives, and must
be interpreted in the context of all of the information gathered during an assessment from a variety of
sources. Unfortunately, some clinicians have taken
the denier-dissimulator scores into the courtroom,
where it was inappropriately being used to argue guilt
or innocence of a charge of child sexual abuse. This
of course, is not a valid use of the denier-dissimulator
probability values, since they can only indicate the

115

likelihood that a person has sexually touched a child

in the past, but not whether the individual has sexually touched any one particular child. Guilt or innocence of an alleged child sexual abuser is always an
issue for the judge or jury to determine, never by a
clinician or a psychological test.

THOSE W ITH A LE A R NING DISA BILIT Y

A ND THOSE W HO A R E ILLIT ER AT E

Individuals with intellectual disabilities or who are

illiterate represent a major challenge for testing and
evaluation. These underserved populations are often
prone to carry out inappropriate sexual behaviors, often
because of a lack of understanding of cultural norms.
In addition, only limited evaluative instruments have
been available for them (Blasingame, 2005).
In collaboration with Gerry D. Blasingame, who
is an expert in the field of assessing and treating
individuals with intellectual disabilities, the Abel
Blasingame Assessment System for individuals with
intellectual disabilities (ABID) was developed.
Blasingame was especially experienced with the
language and the common problems experienced
by individuals with intellectual disabilities, as well
as the unique challenges inherent in their evaluation. In developing an assessment system for this
population, it was important that the assessment
went beyond identifying the self-reported inappropriate sexual behaviors, and also assessed education
and training, living arrangements, sexual education and experience, cognitive beliefs about sexual
behavior, alcohol and substance abuse, and very
importantly, the respondents own history of being
sexually abused. Additionally, the assessment system needed to be flexible enough to be comprehensible to individuals with a wide range of intellectual
disabilities and functional levels, not only by using
easy language but also by giving the evaluator the
opportunity to get direct feedback about the clients
understanding of the items and provide clarification
when needed.
The ABID is intended to assist in the assessment
of individuals with intellectual disabilities who are
being evaluated for problematic sexual behaviors.
The ABID represents a system of evaluation tools or
components that include the following:
Demographic information and presenting problem
Psychosexual history (self-report)

116 ASSESSMENT AND DIAGNOSIS

Assessment of the clients history of being sexually abused (self-report)

Objective assessment of sexual interest (visual
reaction time)
Items inquiring in detail about 16 problematic
sexual behaviors (self-report)
Sexual fantasy ratings (self-report)
CognitiveDistortion Scale (related to sexually
abusing children)
Social Desirability Scale
Substance use history (self-report)
Assessment of the clients ability to distinguish
between different ages and genders (using
images)
Assessment of conduct disorder/antisocial behaviors
The ABID is administered on a laptop computer
and includes three parts: (1) an evaluator section, (2)
a self-report questionnaire (which is read aloud to
the client), and (3) an objective assessment of sexual
interest that is measured beyond the clients awareness (VRT assessment).
The ABIDs development took over 2 years and,
based on the field testing, it seems to be an effective
tool for evaluating individuals with individuals whose
full scale IQ (FSIQ) is as low as 60. The ABID may
also be appropriate for individuals with FSIQ lower
than 60, but further research and clinical experience
using this new assessment are needed. Since the evaluator reads the questions to the client, the client does
not need to be able to read or write. The ABID can be
used with both adults and adolescents. No lower age
limit has been set because in individuals with intellectual disabilities, chronological age is not always a
good indicator of functioning ability. For example,
many adults with mild intellectual disabilities function cognitively at the developmental levels of early
adolescence (Blasingame, 2005). The comprehension
level for the ABID is measured at approximately the
second or third grade reading level.

COMPLET ING A SCR EEN FOR THOSE

W HO WOULD BE WOR K ING
W ITH CHILDR EN

The recent scandal associated with the Catholic

Church has continued to dominate the media for the
past 5 years, emphasizing the importance of having
a screening system for determining individuals who

are at risk of sexually abusing children. Almost two

decades after beginning to work on a brief screen for
sexual interest in children, we have now come full
circle and are proceeding with developing such a
screen, called The Diana Screen. However, at
this point we can build on our database of denierdissimulator child sexual abusers and community
volunteers (those not referred because of some type of
sexual problem) as well as the benefit of years of experience researching and using VRT. The screening
system was field tested for 3 years. The screen is based
on the assumption that anyone attempting to gain
access to children out of sexual interest in children
or a desire to sexually touch children will be highly
motivated to hide such sexual interest from potential
employers, as well as conceal it during any sort of
testing. As a result, The Diana Screen, similar to the
denier-dissimulator probability value on the AASI,
uses logistic regression models to integrate information from approximately 100 specific self-report items
and results from a VRT assessment. The screen itself
takes only about 60 minutes to complete and is easy
to administer.
Due to the complexity of and variability in employment laws across the United States, we decided to
test the efficacy of The Diana Screen exclusively in
situations involving churches (where most aspects of
employment law do not apply) and only in situations
in which the individual has already been incorporated into the church system (postulates, permanent
deaconates, and deacons). The successful outcome of
this 3-year test indicates that the screen could expand
into use by secular organizations. However, The
Diana Screen is not designed to function as a standalone assessment, but as a screen to determine which
individuals may need further assessment before an
organization makes any final decision regarding their
hiring.
CONCLUSION

We have tried to accomplish two objectives in this

chapter. First, we have outlined the development of
these assessment systems within the climate of the
scientific, political, legal, and cultural attitudinal
environments at the time. We have tried to show how
scientific developments, especially dealing with sex
research, must adapt, modify, and change as a result
of a multitude of factors, beyond pure science. As our

VISUAL REACTION TIME

culture adapts, these factors will change themselves

further, requiring the developers of assessment systems to remain responsive. Second, we have shown
the scientific support that now exists for the development of the various VRT-related instruments that
currently assess not only adult males but also adult
females, adolescent males and females; probability values that help the clinician predict the likelihood that
a patient has actually molested a child; assessment of
the intellectually disabled patient; and now, full circle, we are clarifying the development of a screening
instrument to evaluate the risk that individuals might
pose to children in their workplace. We have focused
on the AASI since it is broadly used throughout the
United States and we obviously have been intimately
aware of the problems in developing such a system,
given the current climate in the United States.
Given our own experience, it is almost impossible
to predict what scientific advancements will occur
in this area. We have already noticed presentations
dealing with CRT (Wright & Adams, 1994, 1999)
and rapid serial stimulus presentation and stimulus priming (Kalmus, 2003; Spiering & Everaerd,
2007). It is highly probable that scientific focus on
all these areas will be productive in the assessment
of paraphiliacs.
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Chapter 9

Mental Illness and Sex Offending

Fred S. Berlin, Fabian M. Saleh,
and H. Martin Malin

The terms sex offending and mental illness are

sometimes inextricably linked, often in improper
ways. For example, the legal term Mentally Disordered Sex Offender, or some variant, known in the
popular parlance as a sexual predator, is now widely
used to justify civil commitment for some sex offenders who have completed their sentences in penal
institutions.
The basis for the civil commitment of sex offenders is that some offenders are deemed at high risk
to reoffend if released into the community because
many have not had adequate treatment while incarcerated. Some of these civilly committed offenders
have identifiable paraphilic disorders or other Axis
I diagnoses (such as impulse control disorders) that
could predispose them to commit sex offenses.
Others do not carry Axis I diagnoses and are civilly
committed because it is believed that their underlying personality structure (Axis II traits or disorders)
places them at risk to offend again. Additionally, other
sex offenders who have a variety of other diagnoses

that are deemed dangerous to society are civilly

committed.
The utility, as well as aspects of the legality, of civil
commitment as a modality for managing sex offenders and reducing recidivism continues to be a topic of
considerable debate. (For a general discussion of the
civil commitment of sex offenders in see Falk, 1999;
for a cross-cultural discussion comparing civil commitment practices in the United States and Rumania,
see Loue, 2002).
Strictly speaking, personality disorders are considered to be mental disorders, coded on Axis II,
(American Psychiatric Association, 2000). However,
in practice many use the term mental disorder to
refer only to Axis I conditions, as opposed to personality disorders or mental retardation. This chapter will
largely focus on sex offending by patients with an Axis
I diagnosis who do not have an Axis II personality disorder, but will also include some discussion of patients
who engage in sex offending behaviors related to an
Axis III medical condition.
119

120 ASSESSMENT AND DIAGNOSIS

There is general agreement among treatment professionals that sex offense recidivism can be reduced
with appropriate psychological and psychopharmacological treatments, at least for some kinds of offenders.
Although it is not always possible to accurately predict
in advance the precise recidivism risk for any specific
individual it is often possible to reduce whatever risk
may have been present by means of proper treatment, monitoring and supervision (Berlin, Galbreath,
Geary, & McGlone, 2003).

SE X OFFENSES IN THE CON T E X T

OF M AJOR MEN TA L ILLNESS

It is sometimes overlooked that some sex offenders

commit their acts in the context of an Axis I major
mental illness, rather than in the context of an Axis I
paraphilic disorder or an Axis II personality disorder
(which can sometimes be more refractory to treatment). That is not necessarily to say that the major
mental illness itself directly causes the sex offense,
but just as postpartum depression can sometimes predispose to irrational and even illegal acts, major mental illness can sometimes also predispose to sexual
misconduct. Treatments and social interventions over
time have sometimes been organized on the assumption that the targeted class of individuals are sociallysick (Sutherland, 1950).
The flip side of the coin is that sex offenders
come in many varieties. Many sex offenders have
co-occurring conditions, whether or not directly
related to their instant sexual offenses. There is the
risk that these disorders could go untreated in conventional cognitive-behavioral, or relapse prevention
sex offender treatment programs which are designed
specifically to identify cyclical patterns of behavior
resulting in reoffense. Co-occurring conditions (e.g.,
depression or alcoholism) left untreated may increase
the chances of sex offense recidivism. We will discuss
this aspect of mental illness in sex offenders later in
this chapter.
Among the commonly seen Axis I major mental
disorders are those which significantly disrupt cognitive processes such as schizophrenia (Glaser, 1985;
Henderson & Kalichman, 1990) or bipolar disorder,
and other conditions such as traumatic brain injury
(DelBello et al., 1999). Such cognitive disruptions
can be of significant importance in the commission of sex offenses and ex offenses committed in

the context of a major mental illness have been well

documented. Less common Axis I diagnoses, some
still a source of controversy, may also contribute to sex
offending. One example includes sex offenses committed by individuals while sleeping (sexsomnias)
a phenomenon that has been reported in the literature on parasomnias (Ebrahim, 2006; Fenwick, 1996;
Rosenfeld & Elhajjar, 1998; Schenck & Mahowald,
1992).
Berlin (1986) has documented the case of one
bipolar rapist whose delusional system and command
hallucinations while in a manic phase had resulted in
a series of rapes. That case can serve as an instructive
example of patients who commit sex offenses as the
result of nonparaphilic major mental illnesses.
The patient, who had no prior history of any criminal activity, began to experience altered states of
consciousness as a young man during what he had
termed a nervous breakdown. In between episodes
of increasingly severe mania, he led a normal, if sometimes confused life. He considered himself to be a
moral person who participated actively in his church,
and had committed no prior crimes.
In the grips of his illness, however, he had delusions of being special, and he had come to believe
that he was a biblical hero, a role he believed other
people intuitively understood even if they did not
react to him differently. He had spent time under the
night sky convinced that he had had special Godgiven powers and that he could move meteorites via
his mental abilities.
As his illness had progressed, he began to hear
clear voices of a darker sort telling him that he was
somebody else. The voices, which by now he had
believed were perhaps Satanic, told him to shave off
his moustache and beard, which he did. The voices
insisted that he become the other me. He described
racing thoughts, increasing in intensity, like sirens
going off in your head. The voices insisted that he
was their agent and told him youre going to do this
for me. He struggled to make sense out of the voices,
at one time concluding that he was part of a struggle
between the forces of God and Satan, and at other
times believing that he was being controlled by the
Russians.
During a 4-week period in which he raped several
women, he had come to believe that the women were
actually seeking him out, or for some reason were
being sent to him. He believed that he had to find
victims. He reported It was like I was in a picture

MENTAL ILLNESS AND SEX OFFENDING

show, and I was going through the movements but it

wasnt me. There was something telling me what to
do and doing it in me.
He described himself as a lion and his victims as
lambs. He said When I was a lion I was being a part
of the lamb. I could smell the lambs flesh and want
its blood . . . like a ritual . . . the sexual contact was part
of the battle or the conquest, between the forces of
good and evil. During a prior manic episode, while
in the military in Turkey, he had been seen running
about the canteen totally naked.

121

them build close family, community, and peer-support

systems, and working through the emotional trauma
of realizing that they are not OK, not normal, and
not like other people can be crucial as well.
When such patients can be taught how to treat
their illnesses by means of both psychotherapy and
medication, they, or their families, may then be able to
recognize the signs of impending abnormal psychotic
episodes. That can enable them to seek out additional
treatment, perhaps even brief hospitalizations, should
they be slipping toward a period in which they could
become a danger to themselves or others.

Treatment Considerations
Clearly, conventional sex offender treatment regimens will not be much help with patients who offend
in the context of a nonparaphilic Axis I major mental
illness. In such cases, directly addressing the Axis I
disorder is the treatment of choice. Subsequent counseling, however, either individually or in groups can
also be helpful.
Sex offenses in the context of Axis I disorders
appear to occur most frequently in those cases in
which there is an altered state of mind with respect
to the perception of reality. Sex offenses have been
reported in the context of substance abuse, mania,
depression, delusional states, hallucinations, obsessions, and compulsions.
Treatment depends on the primary diagnosis. For
mood disorders, antidepressants and mood stabilizers are the pharmacotherapy of choice. Most individuals with mood disorders will also benefit from
psychotherapy.
For psychotic disorders such as schizophrenia or
drug-induced psychoses, antipsychotics can be the
cornerstone of initial treatment. Many individuals
with psychotic disorders will benefit from psychotherapy once their hallucinations or delusions have
been medically controlled. Patients with substanceinduced psychoses will also need substance abuse
treatment, and possibly, management during drug
withdrawal.
A good social support system can also be useful in
the treatment of individuals with these Axis I disorders. Individual and group psychotherapy, designed
to break through patients denial about suffering from
a significantly impairing major mental illness, while
emphasizing the importance of continuing to take
medications even if they do not feel that they need
them at the moment, can also be important. Helping

SE X OFFENSES IN THE CON T E X T OF

A PA R A PHILIC MEN TA L DISOR DER

Paraphilias are Axis I mental disorders that are qualitatively quite different from the other Axis I mental
illnesses that we have discussed earlier. The major difference is that sex offenses arising from the paraphilias are motivated behaviors linked to sex hormones.
In that sense, to some extent, they may be conceptualized as disorders of appetite.
Paraphilias are sexual disorders characterized by
uncommon or unusual erotic appetites involving a
wide range of behaviors with animate or inanimate
partners. Approximately 50 paraphilias have been
described in the literature.
The term, paraphilia, (from the Greek para
[beside] philos [love]) is an English translation of
a word first used by the physician Wilhelm Stekel
around 1925 to describe what he saw as sexual
aberrations. Stekel had not wanted to resort to the
already pejorative term perversion that had been
in use among the Freudians of his dayterminology
that nevertheless continued to be used in psychiatric
circles until the 1950s.
The fourth revision of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR) specifies
that a paraphilia must include recurrent, intense sexual urges, fantasies or behaviors that involve unusual
objects, activities or situations. Paraphilias can also
cause clinically significant distress or impairment
in social, occupational or other important areas of
functioning (Association, 2000). Thus, paraphilic
behavior may be the manifestation of a mental disorder both because (1) cravings for the preferred partner are highly unusual (e.g., corpses or shoes) and
because (2) the presence of those cravings can lead to

122 ASSESSMENT AND DIAGNOSIS

impaired sexual functioning with a socially defined

suitable partner. Paraphilias are often associated with
volitional impairment (e.g., in exhibitionism, impairment of the ability to consistenly resist cravings to
expose). They can also be associated with cognitive
impairment (e.g., in pedophilia, impairment in the
ability to objectively appreciate the immature developmental level of a young child). Although there are
exceptions, paraphilias primarily afflict men (Berlin
& Malin, 1991).
The intrusive thoughts, fantasies, and behaviors
that are so often sexually exciting to a person with
a paraphilia may either be not sexually arousing at
all or be repugnant to most individuals. Although the
average individual might be capable of exposing
publicly, he is not driven by recurrent, intense sexual
urges to do so. Similarly, while most people would
find just the idea of having sex with a corpse repugnant, the paraphilic necrophile experiences recurrent
cravings to do just that (Rosman & Resnick, 1989).
Like the term perversion before it, the term
paraphilia is becoming increasingly more pejorative. While pedophilia has a precise psychiatric definition, even mental health professionals can confuse
the terms paraphile or paraphiliac with the term
pedophile. It is not uncommon for mental health
professionals, as well as the lay public and others, such
as lawyers and journalists, to conflate the terms pedophile, child molester, paraphiliac, sex offender,
and sexual predator.
The phenomenology of paraphilic arousal dictates
that a satisfactory sexual response cycle, ending in
orgasm, may either invariably, or at least sometimes,
be dependent upon fantasizing about, or acting on,
paraphilic imagery. Borrowing from legal vocabulary,
paraphilic imagery in masturbatory fantasies is more
or less a condition precedent to making a diagnosis
of a paraphilia.
Failure to appreciate this phenomenological (mental state) aspect of paraphilias can lead to significant
diagnostic errors. It can also lead to treatment errors
as well (Saleh, Malin, Berlin, & Thomas, 2007).
Much of the misunderstanding stems from a lack
of appreciation that phenomenology is paramount
in the diagnosis of the paraphilias. While behaviors
emphasized by DSM-IV-TR are the symptoms
of the psychiatric affliction that will typically bring
a person with a paraphilia to the attention of clinicians or civil authorities, the internal phenomenological experience is the defining factor of a paraphilic

disorder. Paraphilic behavior has traditionally been

considered by the criminal justice system to be
entirely volitional, and will usually elicit little sympathy during a judicial sentencing proceeding. That is
the case even though, paradoxically, the justification
for civilly committing some persons with paraphilias
for treatment at the conclusion of a prison term has
been based, in no small part, upon the concept of
volitional impairment.
It is certainly possible to describe a behaviorfor
example, genital exposureand to prescribe social
consequences for it, without resorting to phenomenology. But to qualify as a paraphilia, the phenomenology underlying the behavior must have some
erotosexual valence for the individual experiencing it
(Saleh, Malin, Berlin, & Thomas, 2007).
For example, there are many instances in which a
person could choose to expose his genitalssome as
commonplace as a physical examination. Others, like
mooning, are not strictly legal but are socially tolerated to some degree. Yet others, such as masturbating
in public, are considered to be sexually offensive and
are illegal.
Civil authorities will generally deal differently with
different manifestations of genital exposure. However,
they may not appreciate the phenomenological difference between paraphilic and nonparaphilic exposing.
Unfortunately, when a clinician fails to make such a
distinction, treatment errors can occur.
If the paraphilic behavior is not illegal, such as
enacting a shoe fetish, it is often viewed as nuisance
behavior. Nevertheless, the individual in question
may face significant social ostracism, including dissolution of a marriage, loss of employment, and loss
of other community support, should his condition
come to light. In addition, many members of the general public, as well as some professionals, may unjustifiably fear an inevitable escalation of relatively
harmless paraphilic behaviors to more serious ones.
If the behavior is illegal, a person with a paraphilia
can often expect to experience the full weight of the
criminal justice system (Berlin, 1994). On the other
hand, depending upon the severity of the illegal
behaviors, some patients may be ordered into treatment by the Court with criminal justice oversight.
Sometimes even the nature of the treatment itself is
not so subtly influenced by civil authorities. Paraphilic
patients who commit more serious offenses can expect to be incarcerated, often without the benefit of
treatment, or in some cases executed.

MENTAL ILLNESS AND SEX OFFENDING

Treatment Considerations
Conventionally the treatment of paraphilic patients
includes some form of behaviorally based group treatment (e.g., cognitive behavioral therapy or relapse
prevention therapy), sometimes combined with medication intended to suppress sexual appetite. Some
treatment models do not make use of testosteronelowering medications, but instead rely entirely on
behavior-based interventions. However, failure to
provide informed consent to a patient about the possible benefits of sex drivelowering medications should
not be considered a form of best practice. No current treatment models rely solely upon pharmacological interventions. Treatment methods intended to
recondition erotic arousal patterns, though previously in wide use, have not proved themselves to be
generally effective.
The treatment of sexually disordered (paraphilic)
sexual offenders can be a challenging task. The main
consideration should be community safety. The goal
is to reduce sexual recidivism by increasing the persons ability to exert better behavioral control.
Most psychologically based therapies are designed
both to support patients who are typically undergoing significant emotional distress and to confront
patterns of denial that may impede the patients
ability to adopt more appropriate behavioral patterns.
Therapies designed to challenge and change patients
distorted thoughts, belief patterns, and behaviors fall
into several broad categories. These include cognitive
behavioral therapy (to confront thinking errors that
can lead to abusive behaviors), relapse prevention (to
identify triggers and to intervene early in the cycle
that can lead to abusive behaviors), and behavioral
therapy (to condition or decondition fantasies, urges,
and behaviors).
Psychodynamic and psychoanalytic treatment
modalities have produced disappointing results with
paraphilic patients. Therefore, they have largely been
abandoned in favor of therapies that have been able to
demonstrate concrete, prosocial behavioral change.
Behavioral therapy, an outgrowth of social learning theory, primarily concerns itself with deviant
acts without respect to what the underlying cause of
that behavior might be. With dangerous paraphilic
patients the rationale for behavioral therapy is that,
although a patient might thoroughly understand the
antecedents of his behavior, such understanding by
itself will not necessarily facilitate change.

123

Among the techniques of behavioral therapy are

desensitization, aversion therapy, biofeedback, masturbatory satiation, and covert sensitization. Each
involves a somewhat different method.
Covert sensitization, for example, pairs paraphilic
sexual fantasies with mental images of their potential
negative consequences (e.g., jail, social ostracism).
The hope is that this will give the patient sufficient
incentive to use other techniques (e.g., thought
blocking) to block the paraphilic fantasy, and to not
permit himself/herself to be aroused by it. Covert
sensitization is a form of aversion therapy in which
imagining what will happen if the paraphilia comes
to light is aversive, in and of, itself. Other tools, such
as olfactory conditioning, might be used adjunctively
to help make it easier to give up the paraphilic
fantasy.
Masturbatory satiation is a two-part process that
begins with instructing a patient to masturbate to
orgasm (if possible) only in response to appropriate
sexual fantasies. Following orgasm, the patient is
instructed to continue masturbating, switching to his
paraphilic fantasy.
Since the patient is typically in the refractory
phase of his sexual cycle following orgasm, reaching
orgasm again will likely be difficult, if not impossible.
Masturbation during the refractory period is usually not pleasant and may even be painful. Orgasm
is assumed to be a powerful reinforcer of fantasies
(possibly a false assumption) so that the expectation
is that the nonparaphilic fantasies will be enhanced,
whereas the paraphilic fantasies will be extinguished.
However, is it really the case that sexual interest is
only present because of the reinforcing aspects of
arousal and orgasm? When a heterosexual man masturbates while looking at a centerfold picture of a
woman, does his doing so reinforce his interest in
women, or is that simply indicative of the fact that he
has had such an interest in the first place? Certainly,
he would not be expected to lose that interest, were he
to simply refrain from masturbating.
Virtually all of the methods that have been used
to try to recondition a persons erotic make-up have
been based on Pavlovs model of classical conditioning. Indeed, Pavlov did demonstrate that certain
conditioned physiological responses (e.g., salivation
to the sound of a bell) could be deconditioned.
However, some physiological responses are, in effect,
stamped in, via a learning process known as
imprinting. Such physiological responses, even if

124 ASSESSMENT AND DIAGNOSIS

learned, cannot ordinarily be unlearned. That may

be true as well with respect to ones sexual make-up.
How many heterosexual men could be successfully
deconditioned so as to lose their interest in women
(assuming that such an interest was even learned in
the first place)?
In the past, efforts to recondition homosexuality were a clear failure. The same would appear to be
true of methods intended to recondition paraphilic
conditions such as pedophilia. Instead, other methods may often be more helpful.
Cognitive Behavior Therapy
and Relapse Prevention
Cognitive therapy posits that distorted cognitions help
to maintain paraphilic behaviors. Cognitive therapy
attempts to change thinking errors and beliefs, and
to disrupt unacceptable thought processes, through
techniques such as cognitive restructuring and
thought stopping. Thought stopping is a technique
intended to interrupt paraphilic thoughts and to
encourage their replacement with appropriate thoughts.
Relapse prevention is premised on the assumption that without treatment, paraphilic sex offending
behaviors will almost certainly recur after a period
of absence, much like falling off the wagon for an
alcoholic who was previously able to stop drinking.
According to that theoretical model, relapses will
likely occur unless they are actively prevented from
doing so. That can be accomplished by teaching a
patient about the cyclical nature of relapses, and the
antecedents to them. The goal of relapse prevention is
to make the patient aware of this cycle and to provide
tools for containing paraphilic thoughts and behaviors early in the cycle at a time during which they are
presumably easier to control.
In addition to the therapies mentioned earlier, victim empathy, assertiveness training, and social skills
training are often integrated into treatment programs
for paraphilic patients. However, not all patients with
a paraphilic disorder lack either victim empathy or
social skills. Beyond that, teaching either assertiveness or better social skills to a patient with pedophilia
could backfire, should that enable him to more assertively approach a child in a skillful fashion. All of the
psychological therapies can be provided in either an
individual or a group setting, although group treatment is generally preferred because it provides an
environment in which patients can be both supported

in their struggles as well as challenged by their peers.

It is believed that peer confrontation and support,
with adjunctive professional guidance from trained
therapists, carry additional weight and may not be so
actively opposed by some, since the authority figure
is not the therapist but a peer group member.

BIOLOGICA L T R E AT MEN TS

Biologically based sex drivelowering treatments are

a powerful intervention many paraphilic patients.
They should be offered to those patients whose cravings are so strong that they experience difficulties
in successfully resisting them. They should also be
offered to persons who have no acceptable form of
sexual release (e.g., those whose erotic attractions
are directed exclusively toward children, especially
in cases in which masturbation serves only to whet
sexual appetite). Many patients will need to be maintained on sexual appetite suppressants indefinitely,
while in other instances, especially as the individual
grows older, it may be appropriate to consider whether
the patient can be safely weaned off.
In the past, the only effective biological treatment
methods available to physicians had been orchiectomy (surgical castration, which is removal of the
testes), and in rare instances, stereotaxic hypothalamotomy (brain surgery). It is clear, from past studies, that orchiectomy can dramatically decrease sex
offender recidivism. Orchiectomy has become somewhat more widespread in recent years as offenders
have sometimes requested it, possibly in some cases at
least, hoping that a judge may lessen a sentence.
However, the use of orchiectomy alone, particularly in nonparaphilic patients, may not ensure
that an individual will not recidivate sexually.
Surreptitious testosterone replacement in orchiectomized patients is often a simple matter of ordering it
over the Internet, from a country where supplies of
exogenous testosterone may be obtained without a
prescription. Testosterone replacement therapy may
even be obtained legally in this country from physicians who may be misled concerning all of the facts
involved with an orchiectomized patient. Although
some testosterone is normally manufactured in the
adrenal glands, that amount is ordinarily insufficient
to support much intensity of sexual drive.
Finally, it should be pointed out that on rare
occasions it has been possible for an orchiectomized

MENTAL ILLNESS AND SEX OFFENDING

patient with no detectable free testosterone in his

blood to commit a sexual offense. While studies have
shown that orchiectomy substantially decreases a sex
offenders risk for sexual recidivism, with rates ranging between 50% to 60% for nonorchiectomized and
1% to 3% for orchiectomized sex offenders, the recidivism rate is still not zero.
Orchiectomy is not the only intervention for
reducing testosterone. Equally efficacious results
can be obtained using testosterone-lowering medications including progesterone derivatives, such as
Depo-Provera, and gonadotropin releasing hormone
analogues, such as leuprolide (Depo-Lupron). DepoLupron would appear to be a more powerful agent
with fewer side effects. Some clinicians have suggested that serotonergic agents, many of which have
the side effects of both lowering libido and of being
anti-obsessional, may also be helpful in treating
paraphilias. However, evidence about the efficacy of
testosterone-lowering medications as a means of suppressing sexual drive is far more compelling.
Serotonergic agents may play a role in managing
some patients, however, including those who may
be suffering from depression or other conditions
co-occuring with their paraphilia. Furthermore, it is
important to keep in mind that the obsessional ruminations that are so often part of a paraphilic disorder
are eroticized obsessions and as such may be responsive to treatment with serotonergic agents.

125

Nowhere, perhaps, have the boundaries between

traditional values of psychiatric intervention, as
opposed to community-driven social control strategies, become more blurred than in the treatment of
certain paraphilic sexual offenders. For example, in
those states that civilly commit individuals for treatment rather than releasing them to the community
at the conclusion of their criminal sentences, is the
desire to treat or to further confine? If the intent is
to treat, then why have so many incarcerated offenders not been offered treatment while still serving their
sentences?
For these reasons, the concept of stand-alone
treatment as applied to paraphilic sex offenders seems to be declining, even among individuals
trained as psychiatric professionals, in favor of the
more inclusive sociological term offender management. Individuals, who were traditionally considered
to be patients, are now more likely to be labeled
clients, or perpetrators, even by mental health
professionals. (For a general discussion of the ramification of some of these linguistic changes, see Slavney
& McHugh, 1987.) In our judgment, conditions such
as pedophilia are legitimate psychiatric disorders, and
afflicted patients in treatment are deserving of the
status of patient. In general, we do not believe that
treatment that supports a we versus they attitude
has been shown to be helpful. For those patients who
are on either parole or probation, however, we do support a close working relationship between therapists
and parole/probation agents.

LI A ISONING W ITH THE CR IMINA L

JUST ICE SYST EM
COMOR BID PSYCHI AT R IC ILLNESS

Many treatment models also include a variety of monitoring strategies by law enforcement, particularly
parole and probation officials. These may include
random drug-screening when appropriate, electronic
surveillance, polygraphs, and periodic unannounced
searches of premises and equipment, such as computers for contraband, including pornography or
evidence of inappropriate chat room participation.
From a psychological perspective, however, it is undemonstrated that limiting exposure to, or possession of,
adult pornography, is, in itself, a therapeutically useful intervention (Linz, Malamuth, & Beckett 2002).
In some instances, it has become increasingly
more difficult to define boundaries between legal
interventions as an aid to therapy, as opposed to mandated therapy as a component of legal proscription.

A MONG NONPA R A PHILIC A ND

PA R A PHILIC SE X OFFENDER S

Comorbid psychiatric illness is prevalent among sex

offenders in psychiatric treatment, including among
those who do not have a paraphilia. Such comorbidity, if untreated, might reasonably be expected to negatively impact subsequent treatment success, and to
increase recidivism rates. However, there has been
little research to date concerning this aspect of sex
offender treatment.
The available research focuses largely upon discerning the prevalence of specific comorbid psychiatric conditions such as depression or alcoholism in
sex offenders, particularly in prison settings. In many
instances, treating these comorbid conditions has

126 ASSESSMENT AND DIAGNOSIS

not, as yet, been integrated into mainstream models

of sex offender treatment. To the contrary, practitioners sometimes select out seriously psychotic
patients or provide adjunctive treatment for severely
depressed patients. The literature concerning these
patients is sometimes difficult to interpret, for a variety of reasons.
Research into the area of psychiatric comorbidity
has been limited, and methodological problems, such
as small size and sample heterogeneity, have confounded studies. One problem in research designed
to assess for comorbidity is that much of it has been
carried out with large heterogeneous populations of
sex offenders, child molesters, or sexual predators, without providing any sort of diagnostic clarity.
To date, there have been no large-scale studies on the
Axis I and Axis II base rates within clinically relevant
subgroups of nonparaphilic sexual offenders.
McElroy and his colleagues (1999) looked for
comorbidity in a small heterogeneous group (n = 36)
of convicted sex offenders in a residential treatment
center. Of the sample, 97% met criteria for a nonparaphilic Axis I diagnosis, and 94% qualified for an
Axis II diagnosis. In a smaller subset of paraphilic sex
offenders (n = 21), they found a high rate of comorbidity with mood, anxiety, and eating disorders.
In a larger heterogeneous sample Dunseith evaluated 113 consecutive male patients convicted of
sexual offenses (Dunseith et al., 2004). Patients had
been referred from prison, jail, or probation to a residential treatment facility. There, they had undergone
structured interviews designed to assess for Axis I and
II disorders, including sexual disorders. Of the total
sample, 84 (74%) had a paraphilia.
That study compared offenders with and without
paraphilias. The overall sample displayed a high incidence of lifetime Axis I and II disorders, including
substance use disorder (85%), mood disorder (58%),
bipolar disorder (35%), and depressive disorder (24%).
In addition, 38% had an impulse control disorder,
23% an anxiety disorder, 9% an eating disorder, and
56% a personality disorder. In this study, the presence of a paraphilia correlated positively with mood
disorder, major depression, bipolar I disorder, anxiety disorder, impulse control disorder, and avoidant
personality disorder. It did not correlate with either
antisocial personality disorder or with narcissistic personality disorder.
When considering comorbidity, it is helpful to
recall the nosology delineated in the Diagnostic

and Statistical Manual of Mental Disorders of

the American Psychiatric Association, (Association,
2000). Not all comorbid psychiatric conditions are
limited to Axis I. As some of the studies cited here
have shown, Axis II personality disorders can also be
present in sex offenders. While impaired intellectual
functioning is typically not considered a mental illness, mental retardation is defined as an Axis II mental disorder. Lindsay and colleagues (2004) looked
at a group of 184 men who were either mentally
retarded or learning disabled. They found a subgroup
of 106 who had committed a sexual offense. The 78
others had committed a nonsexual offense. Of those
intellectually compromised men who had committed
a sexual offense, one-third had at least one comorbid
nonparaphilic Axis I disorder.

COMOR BID PSYCHI AT R IC ILLNESS

A MONG PA R A PHILIC SE X OFFENDER S

Raymond et al. (1999) examined the rate of comorbid

Axis I and Axis II disorders in a small, homogeneous
(n = 42) sample of men with a diagnosis of pedophilia
from several outpatient, and one inpatient, residential treatment programs. They found that 93% of men
with pedophilia met the diagnostic criteria for an
additional Axis I diagnosis over their lifetime, with
55% exhibiting symptoms that met criteria for five or
more comorbid psychiatric disorders. Mood and anxiety disorders were the most common diagnoses in this
sample. They also determined that 33% of the sample met criteria for one or more of the paraphilias in
addition to pedophilia. Sixty-seven percent had only
pedophilia. Over half of the sample (60%) met criteria
for an Axis II disorder as well. However, of note, only
a small percentage met the criteria for either narcissistic personality disorder or antisocial personality
disorder.
In another study of a dichotomous sample (n =
120) of outpatients with paraphilic (PA) or paraphilicrelated disorders (PRD) such as sexual addiction
Kafka and his colleagues found that the PA patients
experienced significantly higher rates of inpatient
hospitalizations for either substance abuse or other
psychiatric illnessess (Kafka & Hennen, 2002). When
the overall study sample was further subdivided
into those who had been criminally charged with a
sexual offense, and those who had not, the sex offender group (n = 66) had a significantly higher rate

MENTAL ILLNESS AND SEX OFFENDING

of inpatient psychiatric hospitalization. A smaller

study (n = 60) found high rates of both mood and
anxiety disorders, as well as a high prevalence of
both attention-deficit/hyperactivity disorder (ADHD)
and dysthymia, among paraphilic patients (Kafka &
Prentky, 1998). Not all of those paraphilic patients
were sexual offenders.

THE R EL AT IONSHIP BET W EEN

A X IS III (MEDICA L DISOR DER S)
A ND THE PA R A PHILI AS

Axis III pathology can also be a contributor to sex

offending behavior in some instances. A few documented cases of traumatic brain injuries and diffuse
central nervous system lesions (e.g., multiple sclerosis)
have been linked to changes in sexual drive and associated behaviors.
Burns and Swerdlow (2003) reported the case of a
patient with an orbitofrontal tumor who presented de
novo with pedophilic behaviors. His pedophilic interests and behaviors had ceased after his tumor had been
removed. Huws et al. (1991) reported on a patient with
multiple sclerosis who had developed a foot fetish and
hypersexuality in the context of that illness. An MRI
revealed lesions in both his temporal and frontal lobes.
In a 5-year retrospective study Simpson et al.
(1999) reviewed the case files of 445 patients who
had sustained a traumatic brain injury (TBI). Of
those patients, 29 (6.5%) engaged in sex offending
behaviors following their TBI (Miller, Cummings,
McIntyre, Ebers, & Grode, 1986). Similarly, Miller
reported on patients presenting with aberrant sexual
behaviors after suffering from a TBI (...). In one such
case, a 39-year-old man began to engage in public
masturbation following rapture of an anterior communicating arterial aneurysm. Another male patient
had become hypersexual following surgical resection
of a frontal meningioma, as had a woman who had
suffered a right-sided stroke.
Temporal lobe pathology, including epilepsy, is
sometimes associated with paraphilia-like behavior
(e.g., fetishism, and exhibitionism). In one study, a
patient with temporal lobe epilepsy presented with
cross-dressing and fetishistic behaviors. Symptoms
decreased following temporal lobectomy (Mitchell,
Falconer, & Hill, 1954).
Mendez and colleagues (2000) reported two cases of
men with both frontotemporal dementia and bilateral

127

hippocampal sclerosis who had developed late-onset

homosexual pedophilia. Positron emission tomography
(PET) scan using the ligand 18-fluorodeoxyglucose
subsequently confirmed hypometabolic activity in the
right temporal lobe.
These cases manifesting Axis III pathology offer
tantalizing clues to the underlying biology. Similarly,
the few, small-scale studies of otherwise healthy
patients who have exhibited sexual misconduct in the
context of an episode of major mental illness reminds
us of how much more there is to be learned. In spite
of the significant implications for treatment, and a
better understanding of etiology, risk assessment and
patient management, there have been very few studies to shed light on some of these areas.

CONCLUSION

Treatment of sex offenders is an evolving process, and

recently, thoughtful critiques have begun to emerge
about treatment practices that have assumed the level of
Standards of Care over the past two decades. VivianByrne (2004), for example, has strongly challenged
the core tenets of behavioral treatment for sexual
offenders as initially conceptualized by McGuire and
Priestly (1985). Instead, he invites us to examine our
assumptions about psychological treatment in therapy
in general. However, we should not throw out the
baby with the bathwater. In the 1960s Szasz (1960) suggested that conditions such as schizophrenia should,
perhaps, not be thought of as mental disorders, speaking instead, about the myth of mental illness. He was
wrong. Schizophrenia is a serious mental disorder and
so are many of the paraphilias. In addition, though not
curable, many can be successfully treated.
There is some consensus that state-of-the-art treatment can be effective in reducing sexual recidivism.
Clearly, that is the case with respect to sex-drive-lowering interventions. Group therapy has also produced
promising results. Berlin and colleagues (1991) published a study that included more than 400 men with
pedophilia, (only some of whom had had sex-drivelowering treatments). Most had been in group therapy,
and that study documented low rates of sexual recidivism. Other investigators (e.g., Hanson et al., 2002;
Maletzky & Steinhauser, 2002; Saleh & Berlin 2003)
have also documented good outcomes. At the same
time, results assessing the efficacy of essentially psychological treatments must be interpreted cautiously,

128 ASSESSMENT AND DIAGNOSIS

in part, because of the low base-rate of sexual offending in the population at large. That is so, despite seemingly high numbers of sex offenses reported by criminal
justice agencies and the large numbers of incarcerated
sex offenders who make up about 20% to 25% of the
more than 2 million males incarcerated in the United
States. However, the fact that sexual offenses of varying degrees of severity may be quite prevalent does not
constitute evidence that those who have entered into
treatment are continuing to reoffend.
Studies in prison populations have consistently
demonstrated that a significant number of sex offenders have major mental health problems. Beyond
that, according to Human Rights Watch, one in six
prisonersbetween 200,000 and 300,000 men and
women in U.S. prisonssuffer from serious mental
disorders, including such illnesses as schizophrenia,
bipolar disorder, and major depression. An estimated
70,000 are psychotic on any given day (Abramsky,
2003; Lamb & Weinberger, 1998; Pinta, 2000). These
figures do not appear to include the specifically sexual
mental disorders (i.e., the paraphilias). Many of those
individuals have been additionally confined via the
process of civil commitment.
Additional studies on large, properly diagnosed
and assessed samples are needed to further clarify
the relationships between major mental illness, the
paraphilias, and sex offending behaviors, and to
design future treatment regimens that will continue
to be increasingly more effective.

References
Abramsky, S. & Fellner, F. (2003). Ill Equipped: U.S.
Prisons and Offenders with Mental Illness.
New York: Human Rights Watch.
American Psychiatric Association. (2000). Diagnostic
and Statistical Manual of Mental Disorders, 4th
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Chapter 10

The Assessment of Psychopathy and

Response Styles in Sex Offenders
Michael J. Vitacco and Richard Rogers

Studies have demonstrated a robust relationship

between high scores on the Psychopathy ChecklistRevised (PCL-R) (Hare, 2003) and violent recidivism (Salekin, Rogers, & Sewell, 1996). However,
these predictions are complex and multidetermined.
As described by Hart (1998, p. 133), psychopathy is a
necessary but not sufficient factor in the assessment
of violence risk. In some cases of sexual violence,
the violence may be related more to disturbances
of normal attachment processes rather than the
pathological lack of attachment associated with psychopathy (Hemphill & Hart, 2003). In summary,
psychopathy plays a critical role in sexual violence
for a minority of sex offenders. Objectives for assessing psychopathy among sex offenders are threefold in
evaluating (a) the risk of recidivism, (b) institutional
adjustment, and (c) treatment needs and outcome.

OV ERV IEW OF PSYCHOPATH Y

Psychopathy is defined by a constellation of affective, interpersonal, and behavioral characteristics,

including egocentricity; impulsivity; irresponsibility;
shallow emotions; lack of empathy, guilt, or remorse;
lying; manipulativeness; and the persistent violation
of social norms and expectations (Hare, 1996, p.25)
and is the longest standing recognized personality
syndrome. The diagnosis of psychopathy originated
in the eighteenth century (Pinel, 1801) with the first
systematic criteria authored by Cleckley (1941). Hare
(1985, 2003), based on the work by Cleckley, developed the Psychopathy Checklist (PCL and PCL-R), a
semistructured interview that is widely considered the
gold standard in psychopathy measurement (Rogers,
2001a).

130

PSYCHOPATHY AND RESPONSE STYLES IN SEX OFFENDERS

As a group, psychopaths are characterized by

moderate levels of violence (Salekin et al., 1996) with
longstanding problems evidenced from adolescence
to adulthood (Gretton, Hare, & Catchpole, 2004;
Vitacco, Neumann, & Jackson, 2005). However,
many psychopaths have virtually no history of violent
behavior. In the next section, we discuss how psychopathy relates to sex offending.

131

often demonstrate a pattern of escalation beginning

with noncontact sex offenses culminating in contact
offenses (MacPherson, 2003). Moreover, Porter et al.
(2002) posited that the psychopathic offending behavior is motivated by thrill seeking rather than paraphilias. Combining across investigators, the prototypical
cases of psychopathic sex offender are typified by control, opportunism, and thrill seeking. Recognizing the
heterogeneity of psychopathy, other sexual psychopaths
are likely to exhibit very different patterns.

THE A PPLICAT ION OF PSYCHOPATH Y

TO SE X OFFENDER S

Subtyping Sex Offenders

The classic study by Abel et al. (1986) categorized
sex offenders by their primary motivation into three
groups: psychotic, antisocial, and paraphilic. Of special interest to this chapter, nearly one-third (29%)
were motivated predominantly by their antisocial personalities. Extrapolating from Abel et al. we surmise
that facets of their psychopathy motivate a substantial
minority of sex offenders.
Theoretically, psychopathy is likely to be particularly
relevant to a subset of sex offenders who are generalists.
Generalists engage in a broad range of criminal activities and have poor work histories and unstable relationships. Psychopathy is least likely to be relevant for sex
offenders who specialize in child offenses (see Miller,
Geddings, Levenston, & Patrick, 1994) but are otherwise unremarkable with respect to criminal lifestyles.
Several formulations have been proposed to understand the motivation of dynamics for psychopathic
rapists. Meloy (2002) posited multiple determinants
including callousness, lack of bonding, sense of entitlement, and sensation seeking. From a very different
perspective, Prentky and Knight (1991) conceptualized the psychopathic rapist as guided by impulsivity
in many areas of criminal behavior, including sexual
offenses. Psychopathic sex offenders are viewed as
both predatory and impulsive. Offering a third perspective, Brown and Forth (1997) found psychopathic
rapists to be opportunistic in their offending and predominantly angry.
Psychopathic rapists can also be described by their
offense behavior. For example, Langevin (2003) found
sex offenders who used violence to control victims, were
substantially higher on psychopathy when compared
to general sex offenders. Psychopathic sex offenders

Psychopathy and Recidivism

in Sex Offenders
In general, most offenders, but specifically sex offenders, including recidivists, are not psychopaths. Hare
(2003) provides a useful summary of sex offenders
and recidivism.1 On average, sexual recidivists scored
substantially lower than the threshold (PCL-R>
30) for psychopathy: (a) 21.4 (Langevin et al., 2001),
(b) 23.4 (Hanson & Harris, 2000), (c) 21.5 (Dempster,
1998), 23.2 (Simourd & Malcolm, 1998), and
(d) 21.7 (Firestone, Bradford, & McCoy, 1999).
The unweighted average is 22.0, far short of the
minimum level for the classification of psychopathy. As expected, nonrecidivating sex offenders substantially lower PCL-R scores than recidivists. For
the four studies cited previously, nonrecidivists had
average PCL-R scores of 15.7, 16.7, 13.3, and 16.3.
With an unweighted average of 15.5 and reported
SDs from 5.9 to 8.7, very few of these sex offenders
likely qualified as psychopaths.
Walters (2003) conducted the most recent metaanalysis of the PCL-R factor scores and sexual recidivism. With five studies, the effect sizes were quite
modest for both Factor 1 (weighted M r = 0.05) and
Factor 2 (weighted M r = 0.08). These correlations
account for less than 10% of the variance. Overall,
these studies suggest that PCL-R factor scores are
generally not helpful in identifying sexual recidivism
but that PCL-R total scores may be moderately helpful in differentiating groups.
Can the PCL-R be used to predict the risk of
sexual violence in an individual case? Forensic practitioners are likely to be divided on this issue. It is
instructive to examine closely the conclusions of two
prominent investigators who are closely associated
with Hare. Hemphill and Hart (2003, p. 96) offered
the following conclusions.

132 ASSESSMENT AND DIAGNOSIS

It is important to note that there is no good scientific evidence (contrary to some claims; e.g., Harris,
Rice, & Quinsey, 1993) that diagnoses or traits of
psychopathy, including scores on the PCL-R, can
be used either on their own or in combination with
other variables to estimate the absolute likelihood of
future violence for a given individual with any reasonable degree of scientific or professional certainty.
This is particularly important given the practice of
some professionals to use diagnoses of psychopathy or
antisocial personality disorder to support the conclusion that an individual is more likely than not (i.e.,
more than 50% likely) to commit acts of future violence or sexual violence. In some jurisdictions, such
a conclusion is used to justify indeterminate civil
commitment of a sexual predator (e.g., Janus, 2000)
or even capital punishment (Cunningham & Reidy,
1998, 1999). Such a practice is simply unfounded and
unethical at the present time.
Hemphill and Hart (2003) appear concerned
about the overall accuracies of risk assessments and
the substantial danger of false-positives. Their conclusions apply to both the PCL-R alone and attempts
to combine the PCL-R scores with other actuarial
measures, specifically the Violence Risk Appraisal
Guide (VRAG) and the Sex Offender Risk Appraisal
Guide (SORAG) (see also Quinsey, Rice, & Harris,
1995).
Character pathology rather than psychopathy per
se may contribute to sexual recidivism. In a metaanalysis of 87 studies of sex offender recidivism,
Hanson and Bussiere (1998) found antisocial personality disorder (r = 0.14), total number of prior
offenses (r = 0.13), and sexual interest in children
(r = 0.33) predicted sexual offense recidivism. This
meta- analysis offers a competing hypothesis to
psychopathy.
In summary, sex offenders often have multiple
motivations for their deviant behavior. In a subset of
sex offenders, psychopathic traits appear to play an
important contributory role. At present, we do not
know which psychopathic traits or facets are most
responsible for predicting continued sex offending.

ASSESSING PSYCHOPATH Y
IN SE X OFFENDER S

This section provides a selective review that focuses

on the three primary measures of psychopathy in

adult populations. These measures are comprised

of the PCL-R (Hare, 2003), Psychopathy Personality
Inventory (PPI; Lilienfeld & Andrews, 1996), and
the Self-Report of Psychopathy-2nd Edition (SRP-II;
Hare, 1991). In addition, we summarize research on
two popular multiscale inventories, specifically the
Minnesota Multiphasic Personality Inventory-Second
Edition (MMPI-2; Butcher, Dahlstrom, Graham,
Tellegen, & Kaemmer, 1989) and the Personality
Assessment Inventory (PAI; Morey, 1996).
The Psychopathy Checklist-Revised
The PCL-R is a 20-item semistructured interview
measuring four inter-related facets (i.e., affective,
interpersonal, lifestyle, and antisocial behavior)
of psychopathy. In addition to the PCL-R, two
other versions include the PCL: Screening Version
(PCL:SV; Hart, Cox, & Hare, 1995) and the PCLYouth Version (PCL-YV; Forth, Kosson, & Hare,
2003). The PCL-R is the most frequent measure
used to assess psychopathy. Strengths of the PCL-R
include extensive data on its reliability, validity, and
generalizability. Regarding its reliability, Rogers
(2001a) reviewed 21 investigations of the PCL-R.
Overall, the studies found excellent inter-rater reliability for the total scores ranging from 0.77 to 0.98.
PCL-R factor scores were substantially lower (0.55
to 0.86) but still good. In examining PCL-R criteria, the results for inter-rater reliability are decidedly mixed with two studies in the 0.3 range and
three studies in the 0.5 range. Relatively little data
are available on testretest reliability; for PCL-R
total scores, three studies range from moderate (0.63
for a 2-year interval) to excellent (0.80 and 0.94 for
1-month intervals).
The PCL-R has generally demonstrated similar
factor structures and item response theory (IRT)
analyses across gender and racial cultural groups (e.g.,
Cooke & Michie, 1999; Cooke, Kosson, & Michie,
2001; Jackson, Rogers, Neumann, & Lambert, 2002;
Kosson, Smith, & Newman, 1990). The critical question is whether gender and racial cultural groups are
similar in their expression of psychopathy and attendant risks. Clearly, women and Europeans have
much lower rates than North American men with
less associated violence in those classified as psychopaths (Cooke, 1998; Salekin et al., 1996). Racial differences require more research; Rogers (2001a) found
variable results mostly limited to African Americans

PSYCHOPATHY AND RESPONSE STYLES IN SEX OFFENDERS

and European Americans. On this point, Hare (2003)

cited unpublished research finding differences in
Factor 2 scores.
Clinicians must be aware of potential limitations
when drawing conclusions from PCL-R data. Some
psychologists simply neglect the standard error of
measurement (SEM) for the PCL-R in their offender
evaluations. The official test standards require that
SEM be considered (see American Psychological
Association 1999). The SEM for the total PCL-R score
is approximately 3 (Hare, 2003) or 3.25 (Hare, 1991).
Hart (1998), a close associate of Hare and the coauthor of PCL:SV, recommended that predictions of
violent recidivism take into account 1 SEM. Based on
this recommendation, only offenders with PCL-R
total scores >33 would be considered psychopathic
and potentially at higher risk than nonpsychopaths.
As observed by Rogers and Shuman (2005), even
this recommendation leads to a false positive rate of
approximately 16%.
The PCL-R should be only used in forensic consultations when its semistructured interview is compared with corroborative records. Use of the PCL-R
interview alone is unacceptable (Hare, 2003). Use of
the records alone is vulnerable to insufficient or biased information. The recommended format is helpful in addressing the minimization and denial often
used by sex offenders attempting to portray themselves
as less sexually deviant (see Wasyliw, Grossman, &
Haywood, 1994; Marshall, 1994). The effects of defensiveness on PCL-R scores of sex offenders have
not been adequately evaluated. The only study to formally address defensiveness found that delinquents
were able to lower their scores significantly (M =
5.03 points) on the PCL:YV with minimal coaching
(Rogers et al., 2002).
The Psychopathic Personality Inventory
The Psychopathic Personality Inventory (PPI) is a
relatively recent multiscale instrument consisting
of 187 items designed to measure psychopathy. The
primary focus of the PPI is the measurement of psychopathic personality traits (Lilienfeld & Andrews,
1996). The PPI consists of eight psychopathy scales:
Machiavellian Egocentricity (ME), Social Potency
(SP), Coldheartedness (CH), Carefree Nonplanfulness
(CN), Fearlessness (FE), Blame Externalization (BE),
Impulsive Nonconformity (IN), and Stress Immunity
(SP). These scales were intended to assess two broad

133

psychopathic facets (a) social dominance and levelheadedness and (b) aggression and unconventional
attitudes (Benning, Patrick, Hicks, Blonigen, &
Krueger, 2003).
The PPI concurrent validity with the PCL-R
yielded disappointing results. Of its eight scales, only
the ME evidences a moderate relationship (0.56),
with three modest correlations (i.e., SP = 0.37,
CH = 0.37, and IN = 0.31) and four nonsignificant
ones (Poythress, Edens, & Lilienfeld, 1998). These
results indicate that the PPI cannot be used to measure psychopathy, as measured by the PCL-R.
Construct validity, investigated by Sandoval et al.
(2000) with 100 inmates yielded mixed results. Most
promising was the significant correlations between
several scales of the PPI (i.e., total [0.60], ME
[0.64], FE [0.37], BE [0.63], and IN [0.51]) and the
Aggression Questionnaire. Focusing on correctional
populations, Edens et al. (2001) found the total score
of the PPI to modestly predict institutional infractions
(rs from 0.26 to 0.37). Despite small to moderate correlations with the PCL-R, the only study documenting inter-rater reliability was in the initial sample of
1,104 undergraduates. The lack of reliability studies
severely constrains the applicability of the PPI with
sex offenders.
A potential strength of the PPI is the presence of
validity scales measuring both fake-good and fakebad indices. Two validity indices, Unlikely Virtues
and Deviant Responding, measure defensiveness
and malingering, respectively. However, studies analyzing the validity scales on the PPI have consisted
of analogue studies and have lacked clinical comparisons (Baldwin & Roys, 1998; Edens, Buffington,
Tomicic, & Riley, 2001).
Pending further investigations, the PPI is not currently recommended for clinical use in evaluating sex
offenders. Its limitations include (a) lack of concurrent data with the PCL-R and (b) absence of research
on sex offenders. Its potential usefulness for evaluating defensiveness among sex offenders should be
explored.
The Self-Report of Psychopathy-2nd
Edition (SRP-II)
The SRP-II (Hare, 1991) is a 60-item self-report scale
of psychopathy. It is administered in a paper and pencil format with a very low reading level (3.70). The
SRP-II was designed to parallel the original factor

134 ASSESSMENT AND DIAGNOSIS

structure of the PCL-R (Zagon & Jackson, 1994).

Efforts to apply the SRP-II to correctional samples
have proved unsuccessful. While initial results produced moderate correlations with the PCL-R total
and factor scores, subsequent studies have found
only modest to low moderate relationships and limited information addressing reliability (Hare, 2003).
In applying the SRP-II to mentally disordered offenders, Vitacco (2003) found low internal consistencies
and poor convergence with the PCL-R. The SRP-II is
currently undergoing substantial revisions (Paulhus,
Hemphill, & Hare, in press) which may improve
its reliability and validity. Presently, it should not
be employed as either a measure or a screen for
psychopathy.
Multiscale Inventories
Clinicians are often tempted to use multiscale inventories in forensic assessments because they conveniently evaluate different aspects of psychopathology
and impairment. The two commonly used multiscale
inventories are the MMPI-2 (Butcher et al., 1989) and
the PAI (Morey, 1991). When using measures designed
to address a spectrum of clinical correlates, the key
issue is bandwidth fidelity (Widiger & Frances, 1987);
as the breadth of a measure increases, its accuracy for
specific clinical construct decreases.
The MMPI-2 is a 567-item multiscale inventory
that is widely employed to assess patterns of psychopathology, clinical correlates, and response styles. One
clinical scale, Psychopathic Deviance (Pd), may be
mistakenly used as a measure of psychopathy. Despite
its name, the Pd scale was not developed or validated
to assess psychopathy as it is currently conceptualized. Instead, the Pd scale was intended as a measure
of chronic but relatively minor delinquency. Not surprisingly, the MMPI-2 Pd scale has a low correlation
(r = 0.26) with the PCL-R total score (Hare, 2003).
The PAI is a 344-item multiscale inventory
designed to assess for psychopathology, treatment
needs, and response styles. Its advantages over the
MMPI-2 include its easy reading level (fourth grade),
use of multiple gradations, and the homogeneity of its
scales and subscales (i.e., high alphas and low interitem correlations). Extensive research (Morey, 1996,
2003) provides strong evidence of its reliability and
validity.
The PAI has an Antisocial Features (ANT) scale
that was designed to measure two core elements of
psychopathy (Egocentricity and Stimulus Seeking)

and evidence of social deviance (Antisocial Behaviors).

Conceptually, these subscales correspond roughly to
Hares two-factor model of psychopathy. Edens et al.
(2000) examined the usefulness of the ANT scale
in evaluating sex offenders. They found that only
the Antisocial Behaviors subscale was significantly
correlated with the PCL:SV (r = 0.54) and PCL-R
(r = 0.40) total score. Contrary to expectations, two
psychopathically based scales were not significantly
related to psychopathic personality measured by the
PCL-R.
In summary, multiscale inventories are not recommended for the assessment of psychopathic sex offenders or other forensic populations. However, many
practitioners will use these measures to assess to evaluate psychopathology and response styles. Importantly,
validity scales of the MMPI-2 and PAI offer no information about the denial or minimization of sexual
deviance. In particular, normal validity indicators
do not suggest that sex offenders are forthcoming
about their sexual practices. Likewise, defensive
validity indicators do not suggest sex offenders are hiding information about their sexual practices.

PSYCHOPATH Y A ND SE X UA L
PR EDATOR L AWS

In the United States the treatment and indefinite containment of sex offenders has had two distinct movements. Beginning in the 1930s, many states passed
laws focused on sexual psychopaths. The purpose of
this legislation was to offer treatment to sex offenders.
Although they were labeled psychopaths, this term
should not be confused with modern conceptualizations of psychopathy.
The second movement began with the Washington
statute (Washington Revised Code 7 1.09.020(1)) and
emphasized indefinite containment in locked hospitals rather than treatment. The Supreme Court
in Kansas versus Hendricks (1997) upheld the right
of states to civilly commit convicted sex offenders
deemed likely to reoffend. In clarifying volitional
impairment, the Supreme Court ruled in Kansas versus Crane (2001) that the inability to control sexual
behavior need not be absolute. Since these landmark
decisions, 17 states have developed statutes authorizing the civil commitment of sex offenders (Doren,
2002; Schopp & Slain, 2000).
These sexual violent predator (SVP) laws vary by
jurisdiction but typically include three prongs, (a) the

PSYCHOPATHY AND RESPONSE STYLES IN SEX OFFENDERS

presence of a mental condition (e.g., a mental disorder or mental abnormality) and (b) a concomitant loss
of volitional abilities, which leads to (c) a substantial
likelihood of engaging in a sexual offense. Despite
the SVP designation, states vary whether the sexual
offense must be violent. Rogers and Shuman (2005)
discuss two major concerns regarding SVP laws: the
unknown error rate associated with specific SVP
commitments and the absence of research congruent
with the SVP standards.
SVP statutes have largely discarded psychopathy,
although it may still play a role in these commitment proceedings. Levenson (2003) concluded that
psychopathy was a strong determinant of which sex
offenders were committed under Floridas sexual
predator law. Analogue research by Guy and Edens
(2003) suggested that any designation as high-risk
psychopath may increase the perceived risk of sexual
recidivism offenses, irrespective of the actual risk.
The assessment of psychopathy, via the PCL-R or
other measures, does not take into account the requirements of SVP statutes for three reasons. First, these
measures do not evaluate the broad range of clinical
conditions as set forth in the SVP criteria. Second, the
loss of volitional impairment resulting from psychopathy remains unknown. Third, the individualized risk of
sexual recidivism posed by a particular SVP candidate
is largely speculative. Beyond these pivotal issues, a low
psychopathy score does not rule out recidvism (Edens,
2001; Porter, Fairweather, Hughes, Angela, & Birt,
2000). If psychopathy is assessed as part of SVP evaluations, forensic clinicians have a professional responsibility to clarify its marginal role in these determinations.
Rogers (2001b) observed that comprehensive risk
assessments must include both risk (e.g., variables that
increased the likelihood of recidivism) and protective
(e.g., variables that reduced the likelihood of recidivism) factors. Unfortunately, research on sex offenders has virtually ignored protective factors. As a result,
risk assessments of sexual recidivism are skewed by
their unbalanced design.
Psychopathy can play a useful role in determining
general risk of recidivism. Clinicians must be alert to
practitioners who improperly attempt to extrapolate
from this general risk to sex offender recidivism. In
the evaluation of sex offenders, we present the following clinical recommendations:
1. Clinicians should only consider psychopathy
as a peripheral issue in SVP determinations.
They have an ethical responsibility to ensure

135

that their assessment results are not misused or

misinterpreted by others.
2. Beyond SVP determinations, psychopathy
should be evaluated selectively. It may be very
helpful in decisions regarding institutional
placement and in development of specific treatment intervention aimed at the most malleable
traits.
3. Psychologists involved in program development
must consider the complex interplay of paraphilias, psychopathology, and facets of psychopathy. The offenders readiness for change should
also be incorporated into any intervention.
4. The measurement of psychopathy is not precise, as documented by the SEM. Training and
supervision are required for both PCL-R and
PCL:SV; otherwise, problems with imprecision
are magnified.

PSYCHOPATH Y A ND ITS ROLE IN THE

M A NAGEMEN T A ND T R E AT MEN T
OF SE X OFFENDER S

Recent research by Hill et al. (2004) demonstrated

that patients in a maximum-security forensic hospital
with Axis I disorders and comorbid psychopathy committed more institutional infractions including verbal
abuse, verbal threats, and fighting (see also Caperton,
Edens, & Johnson, 2004; Edens, Buffington-Vollum,
Colwell, Johnson, & Johnson, 2002; Hildebrand,
Ruiter, & Nijman, 2004; Walters, 2003). In applying these result to sex offenders, Buffington-Vollum
et al. (2002) discovered modest biserial correlations
between psychopathy ratings and nonaggressive
(r = 0.37), verbally aggressive (r = 0.40), and physically aggressive institutional infractions (r = 0.23).
Institutional programs that deliberately ignore these
data may put staff and other offenders at undue risk.
Psychopathic sex offenders are problematic to treat
in generic programs that do not take into account their
psychopathy (Gacono, Nieberding, Owen, Rubel, &
Bodhodlt, 1997). Historically, psychopaths have been
faulted for not responding to intervention programs
that are not designed to treat their psychopathy. Rather
than criticizing the naivet of the interventions, psychopaths are often labeled untreatable. However, two
recent reviews underscore the potential treatability of
psychopaths. Using 44 independent samples, Salekin
(2002) discovered many examples of psychopaths
improving with treatment. Most notably, improvements occurred through implementation of a variety

136 ASSESSMENT AND DIAGNOSIS

of psychotherapeutic interventions. Independent of

treatment modality, Salekin (2002) found that successful programs included intensive individual therapy lasting at least 1-year and augmented with group
interventions. In fact, those studies suggesting the
intractability of psychopaths lack sound methodology
and do not implement specific treatment for psychopathy (DSilva, Duggan, & McCarthy, 2004).
Seto and Barbaree (1999) offered the same cognitive-behavioral interventions to both psychopaths
and nonpsychopaths. Without modifying their interventions to address psychopathy, their findings were
predictable. In particular, the explicit nature of some
cognitive-behavioral programs makes them easily
vulnerable to manipulation. Many psychopaths were
able to graduate from the program without any real
improvement. Not surprisingly, their recidivism rate
did not substantially decrease.
Care must be taken not to blame treatment oversights on sex offenders. Scholars (Lsel & Schmucker,
2005) have provided programmatic guidelines including using cognitive-behavioral techniques that
encourage patient accountability and focus on maladaptive behaviors. On the basis of their recommendations we provide the following guidelines for
developing treatment programs for psychopathic sex
offenders.
Treatment should target cognitive distortions
(Beck, Freeman, & Davis, 2004) that are frequently employed to minimize responsibility.
Treatment should target the affective deficits
that impair the psychopaths ability to experience the emotions of others, including their
victims.
Treatment must be long-term with specific
components aimed at improving psychopathic
personality traits.
Treatment should also target issues related
general recidivism, perhaps within the paradigm of the transtheoretical model of change
(Prochaska, DeClemente, & Norcross, 2003).

PSYCHOPATH Y A ND R ESPONSE ST Y LES

Some evidence exists suggesting that individuals high

on psychopathy are more likely than other offenders
to engage in significant distortions and fake psychopathology (see Gacono, Meloy, Sheppard, & Speth,
1995). Unfortunately, many clinicians simply assume

that the presence of psychopathy indicates response

distortion. Engaging in this type of ad hominem fallacy (Rogers & Vitacco, 2002) compromises the clinicians ability to conduct an objective and thorough
evaluation. In addition, forensic clinicians may be
vulnerable to countertransference. Therefore, we
recommend that clinicians be aware of their own
emotional responses and rely only on empirically
validated methods when assessing psychopathy and
response styles.
Kropp and Rogers (1993) found that most psychopaths are no more effective at malingering (i.e.,
faking bad) or engaging in defensiveness (i.e., faking good). To illustrate this, Poythress et al. (2001)
discovered low correlations between malingering on
standardized tests and scores on the PPI in a sample
of prison inmates. Likewise, Kropp (1994) found that
psychopaths were not more likely to malinger than
nonpsychopaths; however, he also found a trend indicating successful feigners were more likely to be from
the psychopathic group. In explaining Kropps findings on psychopathy, Rogers and Cruise (2000) suggested that the capacity to deceive is well represented
in certain variants of this classification (p. 271). In
other words, specific symptoms of psychopathy may
be associated with malingering, but the classification
as a whole is not.
To assist clinicians in assessments of malingering with psychopathic offenders, Rogers and Cruise
(2000) provided two overarching recommendations.
First, clinicians should differentiate between general deceptions, designed to enhance self-image or
to deny criminal activity, and specific malingering.
Second, clinicians should not discount genuine Axis
I symptoms in psychopaths; psychopathy and psychopathology are not mutually exclusive. Clinicians
following these recommendations can (1) conduct
comprehensive evaluations of risk and mental health,
(2) tease out symptoms of criminal thinking and
behavior from malingering, and (3) avoid unethical
practice by prematurely discontinuing the evaluation
of comorbid Axis I disorders.
Overview of Response Styles
and Sex Offenders
Sex offenders often engage in gross misrepresentations of their offending behavior. Specific strategies
include outright denial of sexual deviation or minimization of the offending behavior on their victims

PSYCHOPATHY AND RESPONSE STYLES IN SEX OFFENDERS

(Happel & Auffrey, 1995; Lanyon, 2001). Kennedy

and Grubin (1992) performed a cluster analysis of
102 sex offenders engaged in denial and four primary
groups emerged. The largest group completely denied
committing a sex offense. Other groups included
(a) those who admitted the offense but denied any
harm to the victim, (b) offenders who admitted the
offense but blamed others, and (c) those who offered
excuses for their offending (e.g., diminished mental
state). Although rarely utilized by sex offenders, malingering of extreme psychopathology may be employed
to excuse the offense or mitigate sentencing.
Owing to the prevalence of defensiveness and
denial among sex offenders, Sewell and Salekin (1997)
recommended that response styles should be evaluated in conjunction with physiological indices, such
as deviant arousal. Offenders who deny sexual deviance may also minimize other personality difficulties
(Haywood, Grossman, & Hardy, 1993). Therefore,
assessments of defensiveness should include both
general as well as specific indicators. This section of
the chapter focuses on assessing response distortion
in sex offenders. It includes the following:
Definitions of response styles frequently observed
in sex offenders
Explanatory models for understanding dissimulation in sex offenders
General measures and instruments employed
in evaluating defensiveness in sex offenders
Information on specific psychophysiological
measures used in sex offender evaluations

137

Hybrid Responding (Rogers & Vitacco, 2002)

refers to employing a variety of response styles.
For instance, a sex offender may exaggerate their
own histories of sexual and physical abuse, be
forthright about their depression, but completely
deny their offending behavior. Hybrid responding is common among sex offenders and complicates their evaluation and treatment.
Malingering (American Psychiatric Association,
1999) refers to the deliberate production of
false symptoms or exaggeration of symptoms
to obtain an external goal. Although rare, sex
offenders may fabricate psychotic symptoms in
attempting to deny responsibility for their illegal behavior. Clinicians are urged to consult
the text by Rogers (2008) for comprehensive
chapters on assessing malingering.

E X PL A NATORY MODELS OF R ESPONSE

ST Y LES IN SE X OFFENDER S

Rogers and Dickey (1991) described three explanatory

models that seek to understand the motivations of sex
offenders when they attempt to deny and discount
sexually deviant behavior. These models are criminological, pathogenic, and adaptational models. Sewell
and Salekin (1997) proposed a fourth motivation, specifically the socioevaluative model. Understanding
these underlying motivations may assist in treating
sex offender distortions.
The Criminological Model

Definition of Response Styles

Utilized by Sex Offenders
Sex offenders will frequently engage in distortions
to minimize or externalize responsibility for their
criminal behavior. Three response styles that may be
encountered when evaluating sex offenders: defensiveness, hybrid responding, and malingering.
Defensiveness is defined by purposeful denial
or severely minimizing symptoms to achieve an
external goal. Both outright denial and minimization of sexual deviance are frequently encountered in sex offender evaluations and treatment
(Tierney & McCabe, 2001). For instance, an
offender may deny having a sexual attraction to
children or minimize the impact of their behavior on their victims.

The criminological model posits that antisocial persons engage in a broad range of deceptions. The
denial and defensiveness of sex offenders is simply a
subset of these deceptions. For some clinicians, the
criminological model has intrinsic appeal that is possibly exacerbated by feelings of countertransference.
Despite its intrinsic appeal, we believe this model
only explains a small minority of distortions found
in sex offenders. One danger of the criminological
model is a fostering of cynicism (Vitacco & Rogers,
2005), which can hinder clinical assessment and subsequent interventions.
The Pathogenic Model
Rogers and Dickey (1991) proposed that a small
number of sex offenders may engage in denial and

138 ASSESSMENT AND DIAGNOSIS

minimization to protect themselves from the enormity of their actions. For instance, a male intrafamilial child molester may find it difficult to acknowledge
or cope with the psychological damage he caused his
young daughters. As such, denial becomes a defense
mechanism to protect the offender against his unforgivable and reprehensible actions. It may also explain
why some sex offenders continue to hold adamantly
onto cognitive distortions, even after their convictions (Sewell & Salekin, 1997).
The pathogenic model may serve to protect sex
offenders from devastatingly negative self-images.
Ward and colleagues (Ward, Hudson, Marshall, &
Siegert, 1995; Ward, Louden, Hudson, & Marshall,
1995) explained how denial wards off negative selfevaluative thoughts and thereby contributes to further
offending. It may also have some utility in explaining
the pervasive denial found in some pedophiles.

scrutinized for any additional evidence of maladaptive behavior. Aligned with this model, Marshall
(1994) found sex offenders used less denial when they
believe they would not be rejected for their admissions. This finding has treatment implications in
explaining how sex offenders may respond to perceived rejection by clinicians.

The Adaptational Model

The MMPI-2 is the one widely used to assess general

defensiveness. The MMPI-2 contains 12 indices of
underreporting. These indices include standard validity scales (i.e., Lie [L] and Correction [K] scales), their
derivatives (i.e., L K, F K, and L + K) and several
specialized scales of defensiveness. Baer and Miller
(2002) conducted an extensive review of underreporting and defensiveness on the MMPI-2. Two specialized scales were more effective than the standard
validity indices: the Wiggins Social Desirability Scale
(d = 1.56) and the Positive Malingering (d = 1.36).
Archer et al. (2004) found the Superlative (S) scale
to add incremental validity in assessing underreporting among psychiatric inpatients. Importantly, the
MMPI-2 scales evaluate general defensiveness as
specific denials of sexual deviance.

The adaptational model assumes that the sex offender is caught in a highly adversarial set of circumstances and is seeking a favorable outcome. In pretrial
evaluations, a full admission of sexual deviance may
lead to further criminal sanctions. A complete denial
of sex deviance may lead to negative characterizations (e.g., callous and remorseless) with no access to
treatment. Some sex offenders struggle with what to
admit and what to deny in an attempt to secure the
least negative outcome. After conviction, pedophiles
are particularly vulnerable to prison abuse. They face
another set of challenges in their denials or admission of sexual deviance. Those sex offenders, forthcoming in treatment of the extensiveness of their
deviant thinking and practices, may find their selfdisclosures are subsequently used against them in
SVP commitments.
The Socioevaluative Model
Sewell and Salekin (1997) proposed the socioevaluative model and described its application to sex
offenders. Closely aligned to the adaptational model,
the socioevaluative model posits that dissimulation
is a learned response to any evaluative stimulus
(Sewell & Salekin, 1997, p. 332). This model goes
beyond the adaptational model by not requiring an
adverse situation, only the presence of the offenders
judgment. Once detected, sex offenders are routinely

ASSESSING DEFENSI V ENESS A ND

DENIED SE X UA L DEV I AT IONS

This section reviews measures and instruments used

to assess sex offenders response styles. We focus predominantly on defensiveness, given its prevalence
among sex offenders.
General Tests of Defensiveness

The PAI (Morey, 1993) contains two scales

designed to assess general defensiveness, the
Positive Impression Management (PIM) scale
and the Defensiveness Index (DEF). Peebles
and More (1998) found good classification rates
for each scale. However, PIM requires a lower
cut score (see also Cashel, Rogers, Sewell, &
Martin-Cannici, 1995). Like the MMPI, the
PAI is only designed to evaluate general defensiveness.
The Paulhus Deception Scale (PDS; Paulhus,
1998) consists of two scales measuring defensiveness. First, Impression Management (IM) assesses
attempts to conform to social norms. Second, SelfDeceptive Enhancement Scale (SDE) attempts to

PSYCHOPATHY AND RESPONSE STYLES IN SEX OFFENDERS

measure unconscious biases leading to positive

self portrayals. Its usefulness with correctional
(Richards & Pai, 2003) and clinical (Salekin,
2000) populations requires further testing.
Sex Offender Specific Tests
of Defensiveness
Multiphasic Sex Inventory-II (MSI-II, Nichols &
Molinder, 2000) contains 12 validity scales that
measure aspects of response distortion. ) demonstrated that the MSI-II possess some effectiveness at assessing denial in sex offenders. While
the original MSI was designed to assess offenders who acknowledge culpability (Nichols and
Molinder, 1984) the MSI-II is not hindered by
such limitations (Molinder, personal communication, October 2004). However, the MSI-II is
hindered by a lack of studies demonstrating its
accuracy.
The Penile Plethysmograph (PPG) records differential penile responses of normal and deviant sexual stimuli. PPG stimuli can be presented
either audibly or visually. Different assessment
laboratories may use PPG different stimuli and
equipment thereby constraining the generalization of research findings. Among the strongest
evidence, Laws et al. (2000) found a 91.7% correct classification rate for child molesters when
the PPG was combined with a card-sorting
self-report technique assessing sexual interests.
Clearly, the PPG can play an important role
monitoring deviance in sex offenders undergoing treatment.
Polygraph Testing is often used in sex offender
treatment programs to assess forthrightness of
sex offenders in making full and complete disclosures of their sexual deviances. Blasingame
(1998) found that disclosures were increased
during interview before the polygraph. Thus the
polygraph may motivate more self-disclosures,
despite weaknesses in its reliability and validity
(see also Ahlmeyer, Heil, McKee, & English,
2000). Use of the polygraph in treatment may
assist in controlling deviant behaviors (Grubin,
Madsen, Parsons, Sosnowski, & Warberg 2004).
Without the polygraph, Hindman and Peters
(2001) concluded, adults minimize their participation in juvenile and adult offense and exaggerate their history of childhood victimization.
The polygraph should be used in treatment but
not court evaluations, given problems with its
validity and admissibility (Iacono & Lykken,
1997; Saxe & Ben-Shakhar, 1999).

139

Final Caution on Measuring Defensiveness

Research on defensiveness has consistently indicated that assessment methods are imprecise and
less accurate than malingering (Baer & Miller,
2002; Nicholson et al., 1997). To address its imprecision, Nicholson et al. (1997) recommended multiple
sources be used for any determination of defensiveness. In a sex offender evaluation, these sources could
include standardized tests with validity scales, psychophysiological measures, and structured interviews
with the alleged perpetrator.

CONCLUSION

Psychopathy and response styles are important albeit

distinct clinical constructs that are critical to the
evaluation and treatment of offender populations.
Among sex offenders in particular, antisocial and psychopathic motivations can play an important role in
a minority of cases. In contrast, issues of denial and
defensiveness are very common among sex offenders
irrespective of their motivations or type of paraphilias. The motivations of paraphilias and the separate
motivations for deception must be considered in any
comprehensive assessment of sex offenders.
In closing, forensic clinicians should be aware that
many practitioners are guided by intuitively appealing ideas that are not supported by the empirical
literature. Given its far-reaching implications, the
assessment and treatment of sex offenders requires
both specialized knowledge and methods. Clinicians
should insure their instruments and methodologies
have been properly validated on sex offenders and
apply them appropriately.
Notes
1. We did not consider the Canadian studies at the
Oak Ridge Division where many insane acquittees were
forced to participate in extremely coercive interventions
that included elements of involuntary treatment, deprivation, and restraint.
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Chapter 11

The Role of Personality Disorder

in Sexual Offending
Roy J. OShaughnessy

Persons who commit sexual offenses are a heterogeneous group of individuals who may demonstrate
various underlying psychiatric illnesses or personality disturbances described in other chapters of this
book. Sexual assaults are complicated behaviors
that result from the interaction of various factors,
including sexual thoughts and interests, social and
cultural values, psychological needs and desires as
well as possible underlying psychiatric illness or disturbances in personality. While many individuals
commit sexual assault simply because they do not
conform their conduct to the requirements of law
and social values, many offenders also demonstrate
significant psychopathology that may or may not be
related to their sexual offending behavior. In many
individuals there is a complex relationship between
their underlying personality traits and/or personality
disorders and psychiatric illnesses such as paraphilia.
The focus of this chapter will be to demonstrate
the role of personality traits and disorders in sexual
offending behavior.

DEFINING PER SONA LIT Y DISOR DER

Personality disorder is defined by the DSM-IV (American Psychiatric Association, 2000) as an enduring
pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset
in adolescence or early adulthood, is stable over time,
and leads to distress or impairment. DSM defines
personality traits as
enduring patterns of perceiving, relating to, and
thinking about the environment and oneself that
are exhibited in a wide range of social and personal contexts. Only when personality traits are
inflexible and maladaptive and cause significant
functional impairment or subjective distress do
they constitute Personality Disorders (American
Psychiatric Association, 2000).
The decision in DSM-III (American Psychiatric
Press) to code personality disorders on a separate axis

144

THE ROLE OF PERSONALITY DISORDER IN SEXUAL OFFENDING

from other psychiatric illness led to greater research

interest in personality disorders, which resulted in
substantive changes in the research literature for
DSM-IV. Further research is now influencing the
formulation of personality disorders for DSM-V
(Livesley, 2003).
Categorical Models of Assessment
The initial DSM-III concept of personality disorder
was challenged by subsequent research that illustrates a number of deficits in the early diagnostic
model. In particular, research data led to questions
regarding the reliability and validity of the different
DSM-III personality disorders (Livesley, 1991). The
categorical diagnostic approach used in DSM-III was
not supported by data that suggested a dimensional
view of personality was more accurate (Schroeder,
Wormworth, & Livesley, 1992; Zimmerman, &
Coryell, 1990).
Comprehensive review by Zimmerman (1994)
outlined the research pertaining to the reliability
and stability of DSM-III-R personality disorder diagnoses. While studies suggested that joint interviews
using standardized interview formats showed good to
excellent inter-rater reliability, other research demonstrated that clinicians not using standardized instruments only achieved poor to fair inter-rater reliability.
Studies examining self-report measures of personality
and those examining informant descriptions of personality showed marked differences in the descriptions of usual personality functioning. Information
available was insufficient to justify which perception,
self-report, or informant, would be more accurate.
Zimmerman also noted marked variability between
the DSM-III-R disorders and instruments available at
that time to measure Personality Disorder. Further,
different Personality instruments lacked concordance
with each other and with DSM criteria and coverage
of the disorders. Concern was also noted regarding
state versus trait bias in individuals responses to various self-report personality measures and inventories.
Despite concerns about the lack of empirical support
for the DSM-III-R approach to Personality Disorder,
few changes were made in DSM-IV.
Further criticisms of the DSM-III-R model was
noted pertaining to the diagnosis of Antisocial Personality Disorder (APD ) (Duggan, 1993, Widiger &
Corbitt, 1994). Specifically, DSM-III-R chose to
focus primarily on antisocial behavior as opposed to

145

underlying personality traits such as described previously by Cleckley (1976). Paradoxically, the focus on
actual behaviors led to improved inter-rater reliability in the diagnosis of APD compared to other DSM
Personality Disorders. As a consequence of focusing
only on behavior, the APD description was somewhat bereft of the richness in personality traits one
would hope to achieve in order to adequately understand and describe the complexity of APD.
DSM-IV TR acknowledged some of the criticisms
of earlier research (American Psychiatric Association,
2000). In the preamble, DSM-IV TR noted that the
clustering of Personality Disorders into different
groupings had not been consistently validated and
individuals frequently presented with co-occurring
Personality Disorders from different clusters. It
was acknowledged that the diagnosis of Personality
Disorder often required multiple interviews focusing on the persons enduring pattern of traits over
the course of time. The complication of diagnosing
a Personality Disorder when the individual does not
perceive their traits to be problematic was also identified It was recognized that features of Personality
Disorder usually can be seen in adolescence but
caution was voiced in making such a diagnosis given
that many such traits do not persist into adult life.
DSM-IV also documented the difficulties in external validity in which many of the traits of Personality
Disorder are in fact found in other Axis I mental disorders and are not exclusive to Personality Disorders.
Accordingly, DSM-IV advised caution in diagnosing
Personality Disorders during episodes of Mood or
Anxiety Disorders.
DSM-IV TR also recognized the research demonstrating that dimensional models of Personality
Disorders seem to be more appropriate than categorical
models, and suggested that the DSM-IV Personality
Disorder clusters may also be viewed as dimensions
representing spectra of personality dysfunction on a
continuum with Axis I mental disorders. DSM-IV
proposed that the integration and utility of dimensional models need further investigation.
Livesley (2001) has done an extensive review of
the literature on personality disorders and offers
cogent criticisms of the DSM-IV diagnostic process.
Multivariate studies of individuals do not offer empirical support for the categories defined by DSM-IV.
Further, psychometric properties and in particular
inter-rater reliability is relatively poor, unless individuals apply structured interviews that are rarely used in

146 ASSESSMENT AND DIAGNOSIS

clinical settings. He also noted the lack of validity of

most personality disorder categories. Internal validity,
or the extent to which the diagnostic criteria identify
a homogenous group, is relatively poor. DSM-IV personality disorders are diagnosed by affirming a certain
number of diagnostic criteria within a list of traits.
Two individuals who meet the minimum threshold
to diagnose a Personality Disorder may in fact demonstrate very different traits of personality. The external validity, or the extent to which a diagnosis of one
personality disorder differs from other diagnoses, is
also very questionable. There is a substantial overlap
between the traits in certain personality disorders and
other Axis I disorders. Likewise, there is substantial
overlap in traits between different personality disorders. Further, individuals meeting the minimum
threshold of traits to diagnose a personality disorder
are not substantially different from those individuals
who fail to meet the threshold by one or two criteria.
These issues have critical import in forensic settings
where a diagnostic category such as personality disorder may play a substantial role in social and legal
proceedings.
Dimensional Models of Assessment
Dimensional models of personality argue that personality traits are on a continuous distribution depending on the extent of the presence or absence of
certain traits. Much of the research is derived from
normal populations as opposed to clinical populations in attempts to understand personality generally. Dimensional models of normal personality
are derived from multivariate analysis of personality traits that are grouped to form clusters or factors.
Different researchers have placed varying emphasis
on the factors that have emerged from multivariate
analyses.
The three factor approach (Eysenck, 1987) identified a number of specific traits that Eysenk organized into three higher order factors: extraversion,
neuroticism, and psychoticism. These three higher
order factors then interacted in a manner to define
personality and behavior. The five factor approach
(Costa & McCrae, 1992; Widiger, 2000) identified
five higher order factors including neuroticism, extraversion, openness to experience, agreeableness, and
conscientiousness. Each of these specific factors was
in turn subdivided into six facets. While clearly multivariate analysis affirmed the traits and the specific

factors, there has never been a model that allows

these factors to be adequately assessed in clinical
populations or to be clinically useful.
Multivariate studies have also been conducted on
clinical populations to evolve a dimensional model of
Personality Disorder. Item analysis of DSM-IV items
(Livesley, Jang, & Vernon, 1998; Mulder & Joyce,
1997) identified a four factor model of Personality
Disorder. These included asthenia or emotional disregulation, antisocial or dissocial factor, asocial or
inhibited factor, and an anakastic or compulsivity
factor.
Another method of examining dimensional models has been the use of prototype descriptions of personality. Prototypes based on the five factor model
(Widiger & Lyna, 1998) have been tested in clinical
samples. Prototypes generated by clinicians showed
good agreement with profiles generated by self-report
and showed convergent validity with a semistructured interview. Patients with Borderline Personality
Disorder according to DSM-IV criteria were compared with other patients with Personality Disorder
and a general control group (Pukrop, Herpertz,
Sass, & Steinmeyer, 1998). Patients with Borderline
Personality Disorder showed specific profiles compared to other groups and gave support to the view
that a dimensional approach had sufficient sensitivity
and specificity.
Dimensional models remain very difficult to
implement. Livesley (2003) argues for alternative categories, for example, the establishment of prototypes
that would have more favor within clinical settings.
Prototypes would be those disorders in which clinicians would have high agreement on specific features. Patients would then be graded as to their fit
within the prototype. Recent methodology utilizing
Q sort (Schedler & Westn, 2004; Westn & Schedler,
2003) offers a potential methodology for prototype
classification that seems more congruent with views
of what is clinically important. Clinicians were asked
to rate 200 descriptive statements into eight categories on the basis of their degree of fit. This resulted
in seven clusters of prototypes including dysphoria,
schizoid, antisocial, obsessional, paranoid, histrionic,
and narcissistic. They argued that this methodology
was clinically relevant because it is built on clinicians strengths of observations and the richness
of psychological experiences that would not otherwise be captured by structured interviews or selfreport instruments. Although using very different

THE ROLE OF PERSONALITY DISORDER IN SEXUAL OFFENDING

methodology, a similar outcome can be seen in the

use of the Psychopathy Check List-Revised (Hare,
1991). Hare took the initial traits described by
Cleckley and operationalized them in an instrument
that has proven to demonstrate good inter-rater reliability and validity. The discussion of psychopathy
is addressed in a separate chapter and only noted
here as a potential methodology to more accurately
describe underlying personality traits and/or disorder on a continuum of traits that has empirically validated support.

PR EVA LENCE OF PER SONA LIT Y

DISOR DER

Prevalence studies of personality disorders have been

limited and constrained by the same methodological
issues related to diagnostic issues. Studies have varied substantially in estimates of frequency of specific
disorders (Mattin & Zimmerman, 2001). Of note is
that APD, the most common personality disorder
associated with criminal behavior, is the most frequently studied personality disorder. Prevalence rates
of APD vary from 2.5% to 3.5% of the population.
Most patients with Personality Disorder also had Axis
I disorder (Maier, Minges, Lichtermann, & Heun,
1995). Swanson et al. (1994) found individuals meeting the criteria of APD were three times more likely
to also be diagnosed with an Axis I disorder although
the majority of these were substance abuse disorders.
Nonetheless, 25% of patients with APD had an Axis I
diagnosis of a mood disorder.
Despite the limitations in diagnostic validity and reliability regarding personality disorders,
forensic clinicians are often required to assess personality disorders and proffer opinions in a variety
of legal proceedings. Sexual Violent Predator legislation has now been enacted in a number of states
and Dangerous Offender legislation is in effect
in Canada. Individuals may be declared a Sexual
Violent Predator (SVP) if they meet the criteria of
having a psychiatric illness or a personality disorder
that renders them more likely to engage in sexual
offending behavior in the future (Tucker & Brakel,
2003). Individuals may be declared a dangerous
offender (DO) if they demonstrate a pattern of persistently aggressive behavior risking death, injury or
severe psychological damage to others through failing to restrain his or her behavior in the future.

147

Further, many risk instruments used in predicting

whether an individual will reoffend rely heavily on
diagnoses of APD or other personality disorders.
In SVP, DO or other sentencing hearings, the
prosecution may be required to prove that an accused or convicted person meets the criteria for personality disorder as a threshold test to be declared
likely to reoffend with a resultant different penalty
than might be imposed if the person fails to meet
the criteria. Considerations of dangerousness are
often reflected in longer jail sentences that may
be at the upper level of what is appropriate for the
offense. Testimony in sentencing or SVP hearings
often involves debate over whether a person meets
the minimum criteria for APD or any other personality disorder. The controversies over diagnosis, reliability, and validity are not simply academic exercises
but rather carry meaningful and possibly severe consequences for affected individuals. It is incumbent
upon the forensic clinician involved in such processes
to be fully familiar with the limitations in the diagnosis of personality disorder, especially when using
a categorical approach such as DSM-IV. In keeping with ethical standards (AAPL Ethics Code) the
forensic clinician has a duty to explain the current
limitations in diagnosis.

PER SONA LIT Y DISOR DER

IN SE X UA L OFFENDING

A number of studies of sexual offenders have pointed

to personality disorder or at least personality traits
as being predictive for sexual recidivism by sexual
offenders. While much of the research has focused
on the use of the PCL-R as a measurement of psychopathy (Serin, Milloux, & Malcolm 2001; Seto &
Barbaree, 1999), other personality traits and disorders have also been identified as predictive for sexual
reoffending (Craig, Brown, & Stringer, 2003).
Hanson (2004) has updated a meta-analysis that
involved a total of 31,000 sexual offenders in various
recidivism and follow-up studies. The strongest predictor was sexual deviancy although it was recognized
that not all sexual offenders in fact had enduring patterns of sexually deviant fantasy or behavior. The
other factors predictive for future reoffending tended
to be personality traits including antisocial orientation, intimacy deficits, and sexual attitudes. In many
of the studies any personality disorder was grouped

148 ASSESSMENT AND DIAGNOSIS

with the APD categories. Specific subtraits included

difficulties in self-regulation such as lifestyle instability and impulsivity, unstable employment, substance
abuse, and hostility. Intimacy deficits and conflicts in
intimate relationships also predicted for reoffending.
In review of the data, it appears that the definitions
of personality disorder were more broadly applied and
not necessarily conformed to DSM-IV categories.
What perhaps is more relevant, especially for clinical psychiatry, is the identification of specific traits
that have been identified as predictive for reoffending as these will understandably be the focus of clinical attention for both treatment purposes and risk
assessment.
Studies using various personality inventories have
demonstrated marked heterogeneity and variability
among sexual offenders. Earlier studies failed to differentiate between sexual offenders and nonsexual
offenders (Ridenour, 1997). Studies comparing sexual offenders with nonsexual violent offenders demonstrated that sexual offenders tended to be more
introverted than violent offenders (Gudjensson &
Sigurdson, 2000). In a large study comparing over
7,000 nonsexual offenders incarcerated in the Colorado Department of Corrections with almost 700
sexual offenders, sexual offenders were found to
have much more varied personality traits and psychopathology than nonsexual offenders (Ahlmeyer,
Kleinsasser, Stoner, & Retzlaff, 2003). Sexual offenders had higher incidence of schizoid, avoidant, depressive dependent, self-defeating, and schizotypal traits
while most nonsexual offenders had more classical
symptoms compatible with APD. Multivariate analysis demonstrated that traits consistent with dependent, narcissistic, antisocial, and schizotypal scales
were the most differentiating between the groups.
Sexual offenders also had more affective symptoms
with significant overlap between mood disorders,
anxiety, and post-traumatic stress disorders. The
authors concluded that while sexual offenders and
other offenders had high rates of psychopathology,
the sexual offenders were more broadly pathological
with increased evidence of social inadequacy, dependency, and affective disturbances. Comparisons between child molesters and rapists showed increased
rate of psychopathology in child molesters.
Recent efforts to subdivide sexual offenders into
more homogenous groups have helped further our
knowledge about specific subtypes of offenders.
Assessments of individuals with and without deviant

sexual fantasies (Curnoe & Langevin, 2002) compared sexual offenders with reported deviant fantasy
with those who did not demonstrate symptoms of
deviant fantasy. Those offenders who acknowledged
deviant fantasy showed significantly elevated MMPI
scales Sc, Pd, Mf, and Pa. Individuals with deviant
fantasies also scored higher on social and emotional
alienation and had higher history of family discord
with evidence of increased general neuroticism. The
authors raised the question as to whether individuals
with deviant fantasy retreated into the deviant fantasies to escape the reality of their limited social and
family involvement.
Issues of psychopathy in sexual offenders are
described elsewhere in this text. What is evident
from the general literature is the high rate of nonsexual offending behavior committed by sexual
offenders. In studies examining antisocial attitudes,
however, sexual offenders tended to endorse fewer
antisocial or criminal attitudes than did nonsexual
offenders (Mills, Anderson, & Kroner, 2004). Within
the sexual offender group, child molesters endorsed
fewer antisocial attitudes than rapists although these
differences disappeared when controlled for age.
Incarcerated sexual offenders with antisocial attitudes have higher rates of general and major infractions than sexual offenders who score lower on
antisocial orientation (Caperton, Edens, & Johnson,
2004). An interesting study out of Finland comparing
antisocial attitudes and testosterone levels amongst
sexual offenders demonstrated a positive correlation
between APD and the mean saliva testosterone levels
(Aromaki, Lindman, & Eriksson, 2002).
Studies comparing child molesters with controls
and/or other sexual offenders consistently demonstrate that child molesters show higher rates of
psychopathology than the offenders who assault teenagers or adults (Cohen, Gans, & McGeoch, 2002;
Kalichman, 1991). Likewise, elderly sexual offenders were differentiated from nonsexual offenders by
increased rates of schizoid, obsessivecompulsive,
and avoidant traits and relatively fewer antisocial
traits (Fazel, Hope, ODonnell, & Jacoby, 2002).
In examining the antisocial dimension in sexual offenders, one would assume that those who
murdered and/or exhibited sexual sadistic behaviors
would likely be higher on measurements of antisocial behavior or psychopathy. In a study of 20 sexually sadistic serial murderers, Warren et al. (1996) in
fact found that 65% had no prior arrest history, unlike

THE ROLE OF PERSONALITY DISORDER IN SEXUAL OFFENDING

the pattern of other sexual offenders who have a high

rate of nonsexual offenses. The authors argue that
sexually sadistic serial murderers form a distinct subgroup that does not fit comfortably within our continuums. In contrast, Langevin (2003) studied 33 sex
killers compared to 80 sexually aggressive, 23 sadists,
and 611 general sexual offenders and found sexual
killers showed higher rates of antisocial orientation and behavior as well as showing higher rates of
paraphilic behaviors. The most common associated
diagnosis was APD but he that found only 15.2% of
the group met the criteria of psychopathy. He also
noted high rates of neuropsychiatric impairment
and academic underachievement and possible learning disorders. Berger et al. (1999) studied 70 sexual
offenders including 19 diagnosed with sadistic personality disorder. There is a high overlap between
the diagnosis of sadistic personality disorder, APD,
and borderline personality disorder. A factor analysis revealed four major factors that did not support a
separate diagnosis of sadistic personality disorder as
a discreet category but rather as an important subdimension of an APD category. Our understanding
of sexually sadistic killers is curtailed by the limited
numbers available for study that likely in turn lead to
sample biasing.
Increasing interest has been given to identification and treatment of adolescent sexual offenders
(OShaughnessy, 2002). Adolescent sexual offenders
are clearly a heterogeneous group who are difficult
to differentiate from other nonsexual offending delinquent youth. Attempts at developing typologies and
path analysis have demonstrated that adolescent sexual offenders who assault prepubescent victims had
increased deficits in psychosocial functioning compared to offenders choosing teen or peer-related victims (Hunter, Figuerdo, Malamuth, & Becker, 2003).
The data also indicated high rates of significant
depression and anxiety. Attempts at subclassifying
adolescent sexual offenders into those who are primarily antisocial versus those who demonstrate deviant sexual arousal have been entertained (Becker &
Murphy, 1998; Seto & Barbaree, 1997). Butler et al.
(2002) did affirm that adolescent sexual offenders
who only committed sexual offenses had fewer conduct disorder symptoms before the offense than
those who also engaged in other antisocial behaviors.
Studies generally support the model that adolescent sexual offenders in particular had difficulties
in intimacy and social competence and that sexual

149

misbehavior in this group may be more suggestive of

compensatory behavior than the true beginnings of
paraphilia or APD (Hunter & Figuerdo, 2000).

PER SONA LIT Y T R A ITS IN

SE X UA L OFFENDING

Attempts at differentiating sexual offenders have not

been successful in clearly identifying a particular
subgroup but rather have been instrumental in identifying specific traits that seem to be more relevant to
certain types of offending. Traits including impulsivity and compulsivity as well as traits related to impairment in empathy and impairment in social intimacy,
and relationship seem to be most frequently identified
in the literature as being relevant in the assessment,
and in particular, treatment of sexual offenders.
Impulsivity
Various studies, however, have held different definitions of impulsivity as a personality trait. Moeller
et al. (2001) argue for three descriptive dimensions
of impulsivity including (1) decreased sensitivity
to negative consequences of behavior, (2) rapid
unplanned reactions to stimuli before complete
processing of information, and (3) lack of regard
for long-term consequences. Impulsivity is seen
more as a predisposition or part of a general pattern
as opposed to a single act. They argued for treatment of impulsivity as a trait disturbance through
pharmacological interventions affecting serotonin
regulation. Swann et al. (2002) identified two subdimensions of impulsivity related to psychiatric illness.
Reward delay impulsivity was defined as the inability
to wait for a larger reward. Rapid response impulsivity
was defined as behavior occurring without adequate
reflection or assessment of context. Rapid response
type of impulsivity was clearly associated with lifetime Axis I or Axis II diagnoses but reward delay
impulsivity was not clearly associated with psychiatric
impairment. Impulsivity has in turn been associated
with deficits in serotonin functioning in individuals
with borderline personality disorder (Coccaro, 2001)
and APD (Dolan, 2001). What is noted, however, is
that a dimensional relationship between serotonin
function and impulsivity seems to be applicable and
raises the question as to whether serotonin agents may
benefit in offenders with higher impulsivity scores.

150 ASSESSMENT AND DIAGNOSIS

Disorders of impulsivity have been implicated in

a wide variety of psychiatric disorders including conduct disorders, personality disorders, substance abuse
disorders, bipolar disorders, and various disorders of
impulse control (Coccaro, 2001).
The trait of impulsivity must be clearly differentiated from the behavior of failure to control a sexual
impulse. Different definitions of impulsivity have
been used in the literature. Prentky and Knight (1986)
identified three measures including a general lifestyle
of impulsive behavior, the capacity to anticipate consequences for ones behavior, and a third dimension
they described as a sense of transiency with unstable
employment and aimlessness. They noted that many
rapists in fact planned their activities quite carefully
whereas other sexual offenders who appeared more
aggressive or angry engaged in unplanned or more
spontaneous sexual assaults. They postulated that the
planned sexual assault was more consistent with individuals whose assault arose from underlying fantasies
that had been rehearsed. They anticipated that sexual
offenders with higher impulsivity often reacted out of
anger and attacked victims of opportunity. The lifestyle of impulsivity domain manifested in individuals
with high frequency of antisocial behavior in adolescence and adulthood and closely correlated with antisocial personality traits. Such individuals were clearly
involved in serious sexual offenses. The final subtrait,
transiency, was uncorrelated with the other measures
and more closely associated with child molesters who
had significant social and interpersonal defects characterized as schizoid-like and seclusive.
Cohen et al. (2002) questioned whether pedophiles displayed an impulsive aggressive disorder
because of failure to control sexual impulses. They
used standardized measurements of impulsivity as
well as positron emission tomography (PET) scans
in a small group of child molesters and controls.
There were no differences on executive functioning
although some of the scales supported an increase in
impulsive personality traits in pedophiles. Overall,
however, the data was more suggestive of broad interpersonal deficits amongst child molesters.
Compulsion
Sexual offending behavior has been postulated as
being related to the underlying compulsive behavior
(Bradford, 2001). Bancroft and Vukadinovic (2004)
critically reviewed the concepts of sexual compulsivity

and impulsivity and studied a small sample of selfdefined sex addicts. This study revealed increased
rates of sexual interest while individuals were in states
of depression or anxiety and that out of control sexual
behavior seemed to be the product of multiple factors
thought to be more related to mood than compulsivity. Raymond et al. (2002) investigated compulsive
sexual behavior defined as excessive sexual behavior
or thoughts that lead to subjective distress or social or
occupational dysfunction. In his small sample, 88%
met the criteria for an Axis I disorder with predominant Mood and Anxiety Disorders. The group demonstrated more traits of impulsivity than compulsivity
although it is evident that mood and anxiety disorders
seemed to be more relevant to their behavior. Small
case studies using serotonin uptake inhibiting antidepressants have demonstrated improvement in sexual
functioning in individuals with compulsive behaviors (Aboush, 1999). The role of impulsivity and/or
compulsivity in sexual offensive behaviors appears to
be important in some offenders. Larger scale studies
are required before any meaningful conclusion can
be drawn about the overall significance of these traits
to general sexual offending. While lifestyle impulsivity certainly is clearly associated with antisocial
behaviors in individuals who commit both sexual and
other nonsexual offenses, there is no clear association between impulsivity traits and sexual offending
behavior.
Empathy
The role of empathy or lack of empathy in sexual
misbehavior is quite complicated. Hanson (2004) in
his meta-analysis did not find the lack of empathy to
be significantly related to reoffending. By the same
token, clinicians would be hard-pressed to accept
that a sexual offender who clearly lacks any empathic
awareness or concern regarding his victims would be
anything less than a significant risk to reoffend. The
apparent failure of correlation with lack of empathy
and subsequent offending may be more related to
difficulties in measuring empathy. Further, sexual
offenders who have normal empathy in other zones
are very effective at rationalizing their conduct to
believe their behavior is not harmful to their victims.
Goliffe and Farrington (2003) completed a review
and meta-analysis of research studies on empathy
in general offending and sexual offending. Twentyone studies measuring cognitive empathy and 14

THE ROLE OF PERSONALITY DISORDER IN SEXUAL OFFENDING

measuring affective empathy were reviewed. Low

scores on cognitive empathy were strongly related to
general offending while affective empathy scores were
only weakly related to offending. This relationship,
however, was much stronger for violent offenders and
tended to disappear after controlling for intelligence
and socioeconomic status. They concluded that
better measures of empathy were required.
Fernandez and Marshall (1999) developed a Child
Molester Empathy Measure (CMEM) that designed
questions to assess empathy towards the child injured
in a car accident versus molested by an unknown
assailant versus molested by the offender himself. In
the study of 61 child molesters, the CMEM suggested
relative deficit in empathy towards the offenders own
victims but intact empathy to the other victims. In a
follow-up study (Marshall, Hamilton, & Fernandez,
2001) child molesters showed greater cognitive distortions and empathy deficits towards their own victims
compared to a sample of nonsexual offenders and
nonoffending controls. There was a close association
between the apparent lack of empathy and scores on
a cognitive distortions scale. In contrast, Curwen
(2003) examined reliability and validity of three scales
including empathic concern, perspective taking,
and personal distress subscales of the Interpersonal
Reactivity Index. The results were counterintuitive and the authors advised caution in interpretation because of the likelihood of socially desirable
responding contaminating the results. Hanson (2003)
offered a model to think through the problems of perceived empathy deficits in sexual offenders. In noting
the lack of empirical foundation to any relationship
between measures of victim empathy and reoffending, he concluded that we needed to have a different
understanding of empathy deficits in a particular individual consistent with the heterogeneity of offenders
and their different types of deficits. Specifically, he
noted that some offenders simply are indifferent to
the pain they may be causing the victims while others
simply fail to appreciate that they have caused harm
or are too ashamed to admit it. He argued that treatment should focus specifically on those deficits of
empathy in the particular individual.
Interpersonal Relations
Core to any deficit in personality functioning or
personality disorder are deficits in interpersonal relationships. A number of studies have demonstrated

151

impaired abilities to form and maintain adult attachments (Araji & Finklehore, 1985[1995 is correct];
Marshall & Barbaree, 1990; Marshall, 1996). Marshall
(2000) viewed the impaired development of interpersonal relationships as a critical factor in the genesis of sexual offending. Marshall borrowed heavily
from attachment theory to suggest that children who
form insecure attachments to their parents develop
impaired self-esteem and self-image as well as difficulties in social skills and building and maintaining relationships. Their need for attention led them
to be vulnerable to other forms of abuse including
sexual abuse. As the child matured, the sexual fantasy
became contaminated with the previous sexual abuse
experiences. As they experienced difficulties in attaining and maintaining stable interpersonal relationships
due to their self-esteem and relationship deficits, they
would turn more to sexual fantasies as a retreat. This
in turn led to increased sexual preoccupation and an
increased vulnerability or risk for sexual offending
behavior, especially if accompanied by disinhibition.
This model emphasized the confluence of multiple,
different factors leading to impairment in personality functioning and interpersonal skills in addition to
development of deviant sexual fantasies.
A number of studies have documented the subjective reports of increased rates of sexual abuse in
the background of sexual offenders (Ryan, Miyoshi,
Krugman, & Fryer, 1996; Wolfe & McGee, 1994;
Worling, 1995). For the same reason, it is clear that
the vast majority of individuals who have been sexually abused as children do not become sexual offenders but rather display evidence of personality disorder,
substance abuse difficulties, or anxiety and mood
disorders (Kendall-Tackett, Williams, & Finkelhor,
1993). Observations by Marshall on the interaction
between impaired parentchild relationships and sexual abuse, however, have been in part supported by
subsequent research. Craissati et al. (2002) studied
sexual offenders with a measurement of parent bonding and demonstrated a significant increased rate of
affectionless control style of parental bonding with
sexual offenders even without any history of sexual
abuse. Stirpe et al. (2003) reviewed the combined
childhood victimization experiences with family of
origin characterized in a Canadian forensic hospital and noted significant increase in reported sexual
abuse by child molesters compared to other types of
offenders. Child molesters also reported increased
rates of physical discipline at home. Lambie et al.

152 ASSESSMENT AND DIAGNOSIS

(2002) looked at the problem by examining resiliency in those child sexual abuse survivors who did
not go on to become offenders compared to a group
who were offenders. Consistent with the theory by
Marshall, was the observation that the nonoffender
group was less likely to have fantasized and/or masturbated about the sexual abuse and had greater family
and social supports and better relationship with peers.
Lee et al. (2002) researched an Australian group and
found similar support with data that demonstrated
childhood emotional abuse and family dysfunction as
well as childhood sexual abuse were developmental
risk factors for sexual offending behavior, especially
in child molesters. The linkage between childhood
adverse experiences and personality dysfunction has
long been established. Adding the dimension of child
abuse or other exposure to inappropriate sexual activity seems to have increasing support as a significant
risk factor for the subsequent development of deviant
sexual arousal and/or sexual offending behaviors.

CONCLUSION

The two decades since the development of DSM-III

have seen a substantial growth in research on personality traits and personality disorder that has challenged our assumptions and diagnostic classifications
and has increased our awareness and understanding
of the complexity of personality formation and pathology. The previous debates on how much a personality trait is nature versus nurture have been, in part,
answered by genetic studies demonstrating significant
genetic component to core personality traits (Jang &
Vernon, 2001). It is also clear, however, that adverse
childhood events lead to increased rates of psychiatric
disorder and personality dysfunction including antisocial behaviors of all types. Research continues to
identify underlying neuro-developmental and neural
pathways and transmitters that play substantive roles
in the manifestation of personality traits and behaviors. Over the next decade it is likely that we will
move further away from viewing personality disorder
in a categorical model and will increasingly recognize the value of dimensional models emphasizing
specific identification of core traits and facets that in
turn may be more closely related to target behaviors
and treatment goals. The ability to identify specific
traits related to target antisocial behaviors has specific
value in forensic psychiatry, especially in the areas

of risk assessment and in planning and implementing treatment and management programs for violent
persons including sexual offenders. There is promise
that richer clinical information regarding personality traits and functioning will substantially improve
our current risk assessment process that relies far
too heavily on static historical factors. As we become
more adept at identifying potentially changeable factors that are empirically related to likelihood of reoffending, we will in turn be better prepared and able
to monitor these traits and/or measure the impact of
treatment and rehabilitation.
Increasing knowledge regarding genesis of personality traits related to subsequent antisocial behavior
and sexual offending also carries great potential for
the implementation of early treatment and prevention programs for youth at risk. When one looks at
many of the empirically proven risk factors for sexual
abuse, one is struck that there are substantial shared
factors that are associated with the genesis of juvenile
delinquency and general antisocial functioning as
well as substance abuse. It is probable that multiple
risk factors are required and that no single risk factor
is sufficient to explain the genesis of sexual offending
behavior. In his important paper on prediction of sexual recidivism, Hanson noted that although a number and different variety of factors are associated with
sexual offending, the breeding ground remained an
adverse family environment associated with neglect,
abuse, and lack of nurturance and guidance. This
family environment then leads to significant disturbance in personality formation and interpersonal
relationships characterized by insecure attachments,
social rejection, loneliness, and impaired social functioning. He considered that sexuality developed in
such an atmosphere of deficit of intimacy would likely
show similar deficits and even be associated with rage
or anger. This background coupled with attitudes that
permit antisocial behavior, limit empathic awareness,
or lead to indifferent attitudes about the suffering of
others would then result in sexual offending behavior. This model is consistent with current models of
personality formation and description in which various traits along a continuum coalesce to form specific
patterns of behavior.
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Part IV

Treatment

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Chapter 12

Psychological Treatment
of Sexual Offenders
William Marshall, Liam E. Marshall,
Geris A. Serran, and Matt D. OBrien

Early psychological approaches to the treatment of

sexual offenders represented a variety of theoretical
views (Barbaree & Marshall, 1998). However, very few
of these reports provided convincing evidence of their
efficacy. At that time there was little awareness of the
possibility that women could offend sexually. This
view persisted until very recently, so the focus of this
chapter will be restricted to male sexual offenders and
more specifically to adult males who offend sexually.
It was only with the advent of behavior therapy
approaches in the late 1950s that a devoted concern for empirically evaluating treatment emerged
(Laws & Marshall, 2003). These early behavioral programs focused on little more than the modification
of sexual interests, it being accepted at the time that
sexual offending resulted from acquired (through
classical conditioning) deviant sexual preferences
(McGuire, Carlisle, & Young, 1965). Indeed, Bond
and Evans (1967) declared that it was enough to simply reduce sexual interest in deviant acts to effectively
treat sexual offenders. They further claimed that

once deviant sexual interests were reduced normal

outlets for the control of sexual arousal will develop
(p. 1162). Quite soon after this declaration, clinicians
working with sexual offenders began to realize that
the assumption that normal interests would simply
emerge, was naive. Marshall (1971) was the first to
point to the fallibility of this notion. He argued that
if the goal was to have child molesters, for example,
develop normative sexual interests, then it would
be wise to have, as part of treatment, training in the
skills, confidence, and attitudes necessary to function
effectively in adult sexual relations. Subsequently
numerous other clinicians made similar claims and,
as a consequence, the 1970s saw an expansion of
behaviorally-based programs to include modifications
of distorted cognitions, enhancements of the capacity
for empathy, and (albeit rather limited) social skills
training (for a history of these early developments, see
Marshall & Laws, 2003).
Leading the way in the 1970s was Gene Abel,
an American psychiatrist who was instrumental

159

160 TREATMENT

in convincing various funding agencies to support

research directed at furthering the understanding
of sexual offenders and in developing treatment programs for these men. Descriptions of the psychological treatment approach by Abel (Abel, Blanchard, &
Becker, 1978), had the effect of encouraging those
providing psychological treatment of sexual offenders
to include a broad range of targets in their programs.
Over the subsequent years these approaches, soon
called cognitive behavioral programs, continuously
expanded the range of treatment targets.
In the early 1980s, Janice Marques (1982) introduced the field of sexual offender treatment to the
relapse prevention approach of Alan Marlatt (1982)
that he used with substance abusers. On the basis of
its intuitive appeal, rather than sound evidence, the
relapse prevention (RP) approach was rapidly adopted
by almost all cognitive behavioral programs in North
America. The focus of RP was primarily on strategies
for maintaining offense-free behavior after discharge
from treatment. Clients were taught skills to escape
from, or avoid, risky situations. The emphasis was on
developing a set of avoidance plans to minimize risk.
The views underlying the RP, and the strategies
associated with such an approach, was detailed in a
book edited by Richard Laws (1989). Later the RP
approach was criticized in a series of papers by Ward
and his colleagues (Ward & Hudson, 1996; Ward,
Hudson, & Marshall, 1994; Ward, Hudson, & Siegert,
1995) culminating in another edited book (Laws,
Hudson, & Ward, 2000) in which a broad range of
authors took issue with almost every facet of the RP
approach. In that book, Marshall and Anderson (2000)
demonstrated that there was no convincing evidence
that the RP model enhanced the effectiveness of cognitive behavioral treatment. More importantly, the
evaluation by Marques et al. (2005) of her own rather
restricted RP program, failed to demonstrate any benefits within a random controlled trial. This ought to
have ended the romance among sexual offender treatment providers with the RP model but, unfortunately,
evidence does not always drive therapeutic endeavors,
and RP lives on as the framework around which most
current psychological programs operate (see survey by
McGrath, Cumming, & Burchard, 2003).
As a result of changes in etiological theories of sexual offending (see Ward, 2006 for a review of such
theories and their changing face over the past 30
years), as well as research indicating a broad range of
dysfunctional attributes of these clients, and clinical

innovations that introduced more effective procedures for changing behavior, current treatment approaches target a quite comprehensive range of issues
with quite sophisticated procedures. Included in treatment are procedures aimed at: changing distorted
cognitions; enhancing empathy; increasing selfesteem; equipping offenders with better coping skills;
providing them with knowledge about healthy sexual functioning and about the features and benefits
of enhanced intimacy; and reducing deviant sexual
interests while increasing sexual arousal to adult consenting sex (see Marshall, Anderson, & Fernandez,
1999 for a detailed description of these current treatment targets). Some of these comprehensive programs
appear to be more effective than others.

CON T EN T IOUS ISSUES

Several issues have emerged in recent years that have

generated disagreement and discussion. As is often
the case in science, some of these debates, while not
yet resolved, have served to increase awareness of the
complexities of psychological treatment with this difficult population and have led to the development of
gradually divergent treatment approaches. We will
consider some of these issues here.
As mentioned earlier, despite the evidence suggesting that RP approaches may not be effective, many
programs remain steadfastly wedded to this model.
Among other things, this model emphasizes the need
to (a) help each client develop a detailed analysis of
his pattern of offending; (b) assist each offender in
identifying a broad range of what are called high risk
situations which are derived from his patterns of
offending; and (c) work with each client to develop
strategies for avoiding his high risks or escaping from
unanticipated risks. The offense analysis is primarily concerned with identifying the offenders specific
thoughts, feelings, and behaviors that occur within his
typical offense chain. From this the client is assisted
in recognizing the kinds of situations or events that
put him at risk to reoffend and then he is given help
in generating an extensive list of avoidance plans.
Critics of the RP approach have, among other
things, suggested that this is a far too sophisticated
process for most of the clients seen in sexual offender
treatment programs (Ward & Hudson, 1996). Perhaps
more importantly it has been suggested that the
emphasis on avoidance goals is misplaced. Mann

PSYCHOLOGICAL TREATMENT OF SEXUAL OFFENDERS

and her colleagues (Mann, 1998; Mann, Webster,

Schofield, & Marshall, 2004) have demonstrated
that having approach goals rather than avoidance
goals as the primary targets of sexual offender treatment is most effective. Basic psychological research
had already demonstrated that avoidance strategies
are not only difficult to maintain, they are associated
with repeated disappointments resulting in gloomy
prospects regarding the future (Austin & Vancouver,
1996; Wegner, 1994). Approach strategies, on the
other hand are easier to maintain and typically generate optimism about the future (Emmons, 1999).
This recent emphasis on approach goals is consistent with another recently introduced concept.
Ward, in a series of papers (Ward & Gannon, in press;
Ward & Marshall, 2004; Ward & Stewart, 2003; Ward,
Vess, Collie, & Gannon, 2006) has provided evidence
that humans characteristically seek what has been
called a good life which is described as being made
up of the pursuit of a list of needs covering various
areas of life functioning (e.g., knowledge, mastery,
autonomy, inner peace, relatedness, happiness, sexual satisfaction). Ward suggests that sexual offenders
commit their offenses in the vain hope of achieving
some or all of these goals; that is, he proposes that
sexual offenders are seeking to meet, by their offending, the same needs that all other people seek to meet.
From this Ward concludes that treatment should
aim at assisting each sexual offender in identifying
a unique set of positive (i.e., approach) goals that will
meet his needs. Therapists can then plan treatment
around providing each offender with the knowledge,
skills, self-confidence and attitudes necessary to meet
his needs in prosocial ways. It is Wards belief that
such an approach will eliminate the need to stamp
out deviance. He argues that a focus on the promotion of specific goods or goals in the treatment of sexual offenders (i.e., developing a good life) is likely to
automatically eliminate . . . risk factors (Ward et al.,
2006, section in parentheses added). This approach to
treatment is consistent with claims made by Marshall
some time earlier (1989, 1996) and detailed in the
latest book by him and his colleagues (Marshall,
Marshall, Serran, & Fernandez, 2006).
Ward has consistently set his Good Lives Model
approach to treatment in opposition to the so-called
Risk/Needs Model. This latter model is most
clearly spelled out by Canadian researcher Don
Andrews and his colleagues (Andrews & Bonta,
2001; Gendreau & Andrews, 1990). The Risk/Needs

161

Model derives from a series of comprehensive metaanalyses of what works in the rehabilitation programs
for all types of offenders, and involves three principles: (1) the Risk Principle which states that treatment intensity should be adjusted according to each
offenders risk level (high, moderate, or low); (2) the
Need Principle which states that treatment should
address primarily (or perhaps even only) those potentially modifiable factors that have been shown to predict risk (i.e., the so-called dynamic risk factors); and
(3) the Responsivity Principle that points to the importance of adjusting the treatment approach to the
unique features (e.g., motivation, learning style, culture, and day-to-day fluctuations) of each individual.
Ward believes that the Good Lives approach,
through enhancing the clients skills necessary to
attain his good life, would eliminate the issues relevant to the need principle. In fact, all of the features
identified so far in research on dynamic risk factors,
and therefore appropriate treatment targets within
the Risk/Needs model, can be seen as targets for
treatment consistent with the goals of the Good Lives
Model. The basic disagreement between the two
models is that Wards approach emphasizes generating approach goals whereas the Risk/Needs Model
has been seen by many as more consistent with treatment based on the Relapse Prevention Model. Recent
research by Mann and Webster (2002) has offered
support for Wards views. They found that many sexual offenders who refuse treatment said they would
willingly enter a program if it focused on giving
them a better life (i.e., a program that enhances their
chances of attaining a good life), rather than simply
addressing their offending.
This shift in focus suggested by Ward also fits
well with recent research indicating a significant role
for therapeutic processes in the treatment of sexual
offenders, but so also does the Risk/Needs Model
with its emphasis on responsivity. Unless the therapist
has the skill to readily adapt to the idiosyncrasies of
each client (i.e., enact the responsivity principle), and
motivate the client to build a better life (i.e., the good
life), his/her effectiveness will be reduced.
Several researchers have recently examined the
influence of process features in the treatment of sexual offenders. Beech and his colleagues (Beech &
Fordham, 1997; Beech & Hamilton-Giachritsis,
2005) demonstrated that it was only those treatment
groups that functioned cohesively and encouraged
expressiveness (including emotional expressions) that

162 TREATMENT

generated the sought-after treatment changes. Cognitive behavioral treatment groups that did not have
these features, failed to produce benefits. Pffflin
et al. (2005) also found that emotional expressiveness
was crucial to the attainment of beneficial treatment
changes with sexual offenders. An examination of
the influence of the therapists behaviors in two studies (Marshall, Serran, Fernandez, Mulloy, Mann, &
Thornton, 2002; Marshall, Serran, Moulden, Mulloy,
Mann, & Thornton, 2003) revealed that therapists
who were empathic, warm, rewarding, and somewhat
directive, produced maximal benefits in their sexual
offender clients. In addition, Marshall et al. found
that an aggressive confrontational approach essentially
eliminated any positive changes that might otherwise
have occurred. Drapeau (2005) found that sexual
offenders reported that while they found some of the
procedures employed during treatment to be helpful,
they believed it was the way the group therapist responded that was critical to them deriving benefits from
the program. Essentially these offenders identified
as crucial, the same therapist features that Marshall
et al. (2002, 2003) had demonstrated to be effective.
Clearly the behavior of therapists plays a vital role
in successful treatment programs for sexual offenders. Indeed, in the study by Marshall et al. (2002) the
influence of the crucial therapist features was quite
dramatic, accounting for as much as 60% of the variance in beneficial changes. This is dramatically more
than is typically found in psychotherapy with other
problem behaviors (usually approximately 20 to 25%)
(Martin, Graske, & Davis, 2000). No doubt this is
because sexual offenders are typically reluctant clients, at least in the early stages of treatment. Sexual
offender therapists, therefore, need to have good motivational skills which characteristically include the
display of warmth, empathy, and rewardingness. The
introduction to the field of motivational interviewing
approach by Miller and Rollnick (1991) and by Mann
and her colleagues (Mann, 1996; Mann, Ginsberg, &
Weekes, 2002; Mann & Rollnick, 1996) provided specific guidelines for engaging sexual offenders.
An additional contentious issue concerns the
debate about the value, or otherwise, of providing
therapists with detailed treatment manuals. When
treatment is provided in several locations by the same
service, it is usually considered necessary to ensure
that all treatment providers deliver the same program.
Similarly, agencies providing funding to evaluate
treatment consistently demand that treatment integrity be guaranteed, again requiring detailed treatment

manuals. Such manuals have become so widespread

that some programs describe their treatment as psychoeducational (Green, 1995), where treatment
involves a rather heavy emphasis on the imparting
of knowledge and where all clients get precisely the
same program. In treatment evaluation, those who
advocate the use of the Random Controlled Trial
design, likewise insist on the use of a highly detailed
treatment manual.
This one size fits all approach has been critically
evaluated by Laws and Ward (2006) and found to be
seriously wanting. In fact, this manualized approach
defies the responsivity principle of the Risk/Needs
Model as well as the recent research findings showing the important influence of the therapist. The flexibility needed to follow the responsivity principle is
eliminated by the requirement that the therapist rigidly follow the detailed manual, and as a result the
influence of the therapists style of delivery is diminished. In addition this one size fits all approach
contradicts the idea that pretreatment assessments
or case formulations (Drake & Ward, 2003) should
guide differential foci in treatment on individuallydetermined needs. A more flexible approach, as
demanded by both the Risk/Needs Model and the
Good Lives Model, fits better with current knowledge
about sexual offenders and their needs, than does the
overly manualized approach.
The combination of the responsivity principle
from the Risk/Needs Model, Wards Good Lives
Model, motivational interviewing, and the importance
of therapeutic processes, has moved psychological
treatments for sexual offenders to a new, and hopefully
more effective, plane. This new approach has been outlined in two recent publications (Marshall et al., 2006;
Marshall, Ward, Mann, Moulden, Fernandez, Serran,
& Marshall, 2005). These two publications provide
details of this more positive approach which downplays the need to focus on the offenders past offensive
behaviors and shifts the emphasis to the future and to
the development of a more fulfilling life. The following section briefly describes this recent approach.

A N IN T EGR AT ED
POSIT I V ELY- OR IEN T ED
T R E AT MEN T PROGR A M

First it is important to note that to be fully effective,

a psychological treatment program must include
the use of medications where necessary. Not only

PSYCHOLOGICAL TREATMENT OF SEXUAL OFFENDERS

do many sexual offenders have comorbid disorders

(Marshall, in press a) that require both medications
and an adjustment to the treatment approach (i.e.,
the responsivity principle), some have such a strong
sexual drive, or are so sexually preoccupied, that
medications are required to either reduce libido or
to reduce the compulsivity associated with sexual
expression. The various antiandrogens or hormonal
treatments can usefully serve to reduce sex drive intensity, while the selective serotonin reuptake inhibitors
(SSRIs) can reduce compulsivity (Bradford, 2000;
Greenberg & Bradford, 1997). However, it is necessary to develop guidelines for deciding when these
medications are required. Bradford (2000) has described his algorithm for deciding when to use medications, and with whom to use these drugs, and we
(Marshall & Hillen, 2002) have developed a guide
to assist in similar decisions within a prison setting.
Over the past 20 years fewer than 10% of our clients
have been placed on antiandrogens or an SSRI.
Table 12.1 describes the offense-specific treatment
targets and the offense-related problematic issues. All
sexual offenders participate in psychological treatment that addresses the offense-specific targets while
those who have problems with one or another of the
offense-related issues are placed in one or another
specialist-led programs.
Since there are numerous books that outline in
detail the approaches to each of the offense-related
problems (e.g., Brown, 2005; Carich & Calder, 2003;
Marshall et al., 1999; Marshall et al., 2006), we will
provide only a brief description of the procedures
involved in targeting the issues. The reader should
note that these procedures are implemented in a
maximally effective way when the therapist displays
empathy and warmth, is rewarding, and provides
some degree of directiveness (see studies by Marshall
et al., 2002, 2003, for the research bases for this claim).
Table 12.1 Treatment Targets
Offense-specific

Offense-related

Self-esteem.
Life history.
Acceptance of responsibility.
Offense pathways.
Coping/mood management.
Social and relationship
skills.
Sexual interests.
Self-management plans.

Substance use/abuse.
Anger management.
Cognitive skills
(Reasoning and
rehabilitation).
Other psychological
problems.

163

A motivational approach that is future- oriented and

that encourages the client to be optimistic about his
future, is also essential.
Self-Esteem
This is targeted first to enhance the clients belief
that he has the strengths necessary to change. Also
low self-esteem is predictive of relapse among sexual offenders (Thornton, Beech, & Marshall, 2004).
We refer to our clients as men who have committed a sexual offense and we insist they use the same
descriptor rather than referring to themselves as rapists or child molesters or exhibitionists. This serves to
distinguish the client from his offensive behavior and
reduces feelings of shame which have been shown
to stand in the way of change (Tangney & Dearing,
2002). We also encourage clients to increase the
range and frequency of their social activities and
we assist them in identifying the small pleasures
they enjoy; both these procedures have been shown
to increase self-esteem (Marshall & Christie, 1982;
Marshall, Christie, Lanthier, & Cruchley, 1982). In
addition, we elicit from each client a list of at least
4 to 6 positive statements about himself and have
him rehearse these statements several times each
day. We have shown the combination of all these
procedures to be effective in enhancing overall levels of self-confidence in sexual offenders (Marshall,
Champagne, Sturgeon, & Bryce, 1997). An increase
in self-esteem in sexual offenders is significantly correlated with improvements in empathy, intimacy, and
loneliness (Marshall, Champagne, Brown, & Miller,
1997) and with reductions in deviant sexual arousal
(Marshall, 1997).
Autobiography
Concurrent with enhancing self-esteem, clients are
instructed to begin the process of generating an
account of their life history. This autobiography is to
encompass childhood, adolescence, and adult experiences focusing on issues such as relationships (including sexual relations), health, education, work, and
leisure. From this the therapist helps the client identify events or problematic ways of living that can create a state where sexual offending seems attractive.
Acceptance Of Responsibility
This is a process that continues throughout treatment and involves firm but supportive challenges of

164 TREATMENT

antisocial or offense-supportive views or attitudes.

However since denial bears no relationship to longterm recidivism (Hanson & Bussire, 1998; Hanson &
Morton-Bourgon, 2004), clients should not be vigorously pressed to agree with every detail of the official
statement of the offense. The goal is not so much
rehashing the past but rather encouraging clients to
take responsibility for all aspects of their life, most
particularly their future.
Pathways To Offending
Therapists should begin quite early in treatment
to help each client develop a set of pathways that
describe the steps involved in their offending. Two
sets of factors are relevant have: (1) Background factors that describe the disruptive events in their life
(e.g., problems in adult relationships, loss of job,
financial difficulties, psychological and emotional
disorders) that might make them vulnerable to temptations to offend; and (2) the typical steps they take
to offend when they are in their vulnerable state.
Ward and Sorbello (2003) have outlined an empirically derived model describing several pathways that
generates sexual offending, and the accuracy of this
model has been independently confirmed (Bickley &
Beech, 2002; Yates, Kingston, & Hall, 2003). The
main point of Wards model is that each offender may
follow different pathways on different occasions; that
is, sexual offenders do not seem to maintain a specific
modus operandi nor is their need to offend constant
nor always driven by the same background factors.
This is important to keep in mind when identifying
future potential risks; clients must be encouraged to
develop a generic disposition toward risk rather than
generate a limited list of specific risk factors derived
solely from past experiences.
Victim Harm/Empathy
Research suggests that sexual offenders are not deficient in general empathy but rather they appear to
suspend empathy toward their victims (Polaschek,
2003). Accordingly sexual offenders lack of empathy
for their victims can be best construed as yet another
of their distorted cognitions that serves to allow
them to continue to offend. Many sexual offenders,
particularly child molesters, claim to have information indicating that their victim has not suffered any
consequences of the abuse. In our view there are two

reasons why it is pointless to challenge clients on this

issue. First, the therapist has no way of demonstrating that the victim did suffer damaging consequents
however much he/she may believe that to be true;
and second, it seems irrelevant to discuss possible
harm in the past when what we are attempting to do
is alert the offender to the very real possibility of harm
should he offend again in the future. Consequently
the best approach is to attempt to instill in the offender the idea that he can never be sure what the
consequences to a future victim may be but he can
be confident based on the evidence that the chances
of harm are high. This is best achieved by having the
group of offenders generate a list of all possible consequences to sexual abuse and the kind of features
(often seemingly benign) that increase the negative
consequences.
Nevertheless it may be useful to sensitize the client to the possibility that he has harmed his past victims. To do this, most programs have offenders write
hypothetical letters from and to one of their victims.
These letters should contain the specification of negative consequences and an indication of responsibility
by the offender. These procedures have been shown
to effectively enhance victim empathy (Marshall,
OSullivan, & Fernandez, 1996).
Relationship Skills
The assumption underlying numerous theories of
sexual offending is that these men lack the skills,
confidence, and the attitudes necessary to meet their
needs prosocially so they turn instead to deviant
behaviors in a vain attempt to satisfy these vaguely
understand needs (Marshall & Marshall, 2000; Smallbone, 2006; Ward, Hudson, & McCormack, 1997).
If these theories are correct, and there is considerable evidence indicating a lack of intimacy and poor
attachment in sexual offenders (Bumby & Hansen,
1997; Marshall, 1993; Ward, Hudson, & Marshall,
1996), then obviously increasing the capacity of these
men to function effectively in intimate relationships
should be an essential feature of sexual offender
treatment.
In fact training in general social skills has long been
part of such treatment programs (Abel, Blanchard, &
Becker, 1978; Barlow, 1974; Marshall, 1971). Recently
treatment has focused more specifically on training
relationship skills with sexual offenders with most programs simply adopting procedures that have been

PSYCHOLOGICAL TREATMENT OF SEXUAL OFFENDERS

developed within the more general field of marital

and relationship counselling (Jacobson & Margolin,
1979). Assisting sexual offenders to develop skills related to communication, reciprocity, empathy, sexuality, and shared leisure activities is an essential feature
of sexual offender treatment programs as are procedures to help them learn how to deal with being
alone or with feelings of jealousy. Comprehensive
approaches such as these have been shown to markedly increase the capacity for intimacy among sexual
offenders as well as reduce their experience of loneliness (Marshall, Bryce, Hudson, Ward, & Moth, 1996).
Coping and Mood Management
Clients are provided a description of both functional
and dysfunctional coping styles (see Parker & Endler,
1996) and assisted in identifying their typical style.
They are taught how to employ good problem-solving
skills and are given the opportunity to role-play possible responses to situations from their past with which
they previously did not effectively cope. Where necessary, training in specific coping skills is introduced.
It is quite common, for example, for rapists to respond
to problems with anger while child molesters are frequently unassertive (Segal & Marshall, 1985), and
both groups tend to turn to sex to deal with distressing
experiences (Cortoni & Marshall, 2001).
In addition, sexual offenders have problems regulating their emotions (Ward & Hudson, 2000) and
these difficulties have been identified as dynamic risk
factors for sexual offending (Hanson & Harris, 2000).
Emotional dysregulation has been shown to be related
to various problems (Lewis & Haviland-Jones, 2000)
many of which characterize sexual offenders. On
the basis of a combination of therapeutic approaches
that encourage emotional expression and the development of emotional regulation (e.g., Greenberg &
Pavio, 1997; Kennedy-Moore & Watson, 1999) we have
developed a component of our program that specifically addresses these issues (Marshall et al., 2006).
We have evaluated these two components of our program (i.e., coping and mood management) and found
that, indeed, they do produce the sought-after results
(Serran, Firestone, Marshall, & Moulden, in press).
Sexual Interests
Behavioral procedures for reducing deviant sexual interests and enhancing interests in appropriate

165

sexual activities include: foul odor aversion, ammonia

aversion, covert sensitization, orgasmic reconditioning, and satiation therapy. These procedures have
been described in detail elsewhere (Laws & Marshal,
1991; Marshall, Marshall, & OBrien, in press), but,
although they are in common use in sexual offender
treatment programs (see McGrath et al., 2003), the
evidence supporting their efficacy is generally rather
weak. Satiation therapy (Marshall, 1979; Marshall &
Lippens, 1977) has the strongest empirical support
although there are well-controlled single case studies
demonstrating the effectiveness of some of the other
procedures. As noted earlier in this chapter, medications (e.g., antiandrogens, hormonal agents, and the
SSRIs) can also be helpful in altering problematic
sexual interests and their expression.

SELF-M A NAGEMEN T PL A NS

Earlier we pointed to recent changes in the focus

and emphases in sexual offender treatment. These
changes are nowhere more evident than in this final
stage of treatment where the introduction of the
Good Lives Model and the focus on approach goals,
has substantially altered this final element in treatment. It is still considered essential to identify some
risk factors but the emphasis is on developing future
goals, and the skills necessary to strive toward these
goals, rather than on traditional relapse prevention
plans. Child molesters, for example, must avoid being
alone with children, and rapists must avoid situations within which they previously offended (e.g., the
hitchhiker rapists must avoid driving alone where possible). Since the offenses of exhibitionists are not so
situationally-bound (they often seize opportunities to
expose in a wide variety of circumstances), risky situations are more difficult to identify, but it is possible to
identify some circumstances to avoid.
The Good Lives Model identifies nine areas of
functioning (see Table 12.2) that have been shown
in the general psychological research literature to be
functionally related to the achievement of a fulfilled
life (Deci & Ryan, 2000; Emmons, 1999; Schmuck &
Sheldon, 2001). Every target of sexual offender treatment is, in essence, providing these clients with the
skills, self-confidence, and attitudes necessary to
embark on the pursuit of each clients, individuallydesigned, good life. In the final stage of treatment,
the therapist helps the client organize his future

166 TREATMENT

Table 12.2 Focus of the Good Lives Model

A. Human needs are propensities in various areas of
functioning that determine the necessary conditions
for well-being and fulfillment.
B. Areas of functioning that are typically pursued in people
who are moving toward fulfillment are as follows:
1. General healthy/optimal functioning.
2. Knowledge.
3. Mastery.
4. Autonomy.
5. Inner peace.
6. Relatedness.
7. Spirituality.
8. Happiness.
9. Creativity.

goals, identify each step in the plans necessary to

move toward these goals, and pursue any future skills
training (e.g., upgrade his education) that is required
to achieve his goals.
In addition, the therapist works with the client
to develop a support group, the members of which
will assist him in reintegrating back into society.
Each member of the support group should have an
identified set of responsibilities commensurate with
the support persons capacities. Some will be professionals (e.g., probation or parole supervisor, treatment provider) while others will be family or friends.
Wilson and his colleagues (Wilson & Picheca, in press;
Wilson, Stewart, Stirpe, Barrett, & Cripps, 2000) have
developed what they call Circles of Support and
Accountability for sexual offenders released from
prison at the end of their sentence where there would
otherwise be no supervision. They have shown this
to be effective in reducing recidivism in these high
risk offenders, and the program has been adopted by
others.

CONCLUSION

Evaluating the long-term effectiveness of sexual

offender treatment is beset with difficulties (Barbaree,
1997) and few programs have the resources or endurance to conduct a satisfactory evaluation. Some
maintain that psychological treatment with sexual
offenders has not yet been satisfactorily demonstrated
to be effective (Rice & Harris, 2003), but these authors
seem to set standards for what they would regard as

satisfactory evaluations at a level beyond what most

programs can implement. For example, they claim
that the only basis for inferring treatment effectiveness rests on conducting a Random Controlled
Trial (RCT). This design requires that volunteers
for treatment be randomly allocated to treatment or
no-treatment, and then released to the community
for several years to determine how many reoffend. The
practical, ethical, and design problems with this
approach have been spelled out quite clearly both in
the general clinical literature (Persons & Silberschatz,
1998; Seligman, 1995, 1996) and in the offender literature (Hollin, in press; Marshall, 2006, in press b), so
we will not elaborate those discussions here.
The view taken by the committee appointed by
the Association for the Treatment of Sexual Abusers (Hanson, Gordon, Harris, Marques, Murphy,
Quinsey, & Seto, 2002) was that evaluations relying
on official recidivism data and having a reasonably
satisfactory comparison group, could enter a metaanalysis designed to determine the effects of treatment with sexual offenders. From a worldwide search
43 such studies were located, which, when combined,
demonstrated an overall effect for treatment on both
sexual and general recidivism. A further examination
showed cognitive behavioral programs produced the
most benefits and a subsequent, larger meta-analysis
by Lsel and Schmucker (2005) demonstrated even
greater effects for such programs. We (briefly reported
in Marshall et al., 2006) recently evaluated our program operated in a Canadian federal prison. The
actuarially calculated risk level of sexual offenders
in this evaluation was 16.8% for sexual offenses and
40% for general nonsexual offending. Of our 534
treated sexual offenders released into the community for an average of 5.4 years, only 3.2% reoffended
sexually and only 13.6% committed a subsequent
nonsexual offense. Similar findings for the effectiveness of other sexual offender programs operated
within Canadian federal prisons have been described
(Barbaree, Langton, & Peacock, 2004; Looman,
Abracen, & Nicholaichuk, 2000; Nicholaichuk, Gordon,
Gu, & Wong, 2000).
There is, therefore, evidence that at the very least
encourages optimism about the value of psychological treatment with sexual offenders. On the basis of
accepting that sexual offender treatment has been
shown to be effective, Marshall and McGuire (2003)
demonstrated that the effect sizes of sexual offender
treatment was comparable to the effect sizes produced

PSYCHOLOGICAL TREATMENT OF SEXUAL OFFENDERS

by medical treatments for some common disorders

and comparable to the treatment of various other psychological problems. Finally, when sexual offender
treatment is effective, it not only saves future possible victims from suffering, it is also financially costeffective (Marshall, 1992; Prentky & Burgess, 1990).

References
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Chapter 13

Orchiectomy
Richard B. Krueger, Michael H. Wechsler,
and Meg S. Kaplan

This chapter aims to review the rationale and data

supporting bilateral orchiectomy as a possible treatment modality for sex offenders. Although the idea of
orchiectomy, or surgical castration, evokes strongly
negative emotional responses in many individuals, several reviews of biological treatments for sex
offenders examining recidivism data from European
studies have concluded that castration had very significant positive effects on recidivism (Bradford,
1985; Freund, 1980; Meyer & Cole, 1997). A recent
meta-analysis by Lsel and Schmucker (2005)
reviewed 69 studies and found that surgical castration and hormonal medication showed larger effects
on sexual recidivism than psychosocial intervention.
Finally, a recent review of pharmacotherapy in the
treatment of sex offenders suggested that it might not
be surprising if a comeback for surgical castration
would occur (Rsler & Witztum, 2000) because of
its efficacy and the low rates of recidivism reported
by outcome studies.

171

Orchiectomy was selected as the title for this

chapter because it more properly reflects the nature
of the therapeutic procedure that will be discussed in
depth. Orchiectomy (Hensyl, 1990, p. 1096) comes
from the Greek, orchis, or testis, and ektome, or excision, and is referred to, alternatively, as orchidectomy,
orchectomy, or testectomy, and consists of the removal
of one or both testes.
The term castration comes from the Latin stem
castrare meaning to castrate, prune, expurgate, deprive of vigor (Simpson & Weiner, 1989, p. 959) and
has a broader meaning which includes mutilation,
which undoubtedly has contributed to its negative
associations. Castration for control, domination, punishment, mutilation, social advancement, and political reasons has been practiced since antiquity and
has been the subject of several recent reviews (Ayalon,
1999; Marmon, 1995; Ringrose, 2003; Scholz, 2001;
Taylor, 2000; Tougher, 2002; Tsai, 1996; Winslade,
Stone, Smith-Bell, & Webb, 1998). Although

172 TREATMENT

castration is a term which is referred to in much of

the literature cited in this article, unless otherwise
indicated, it should be understood that insofar as can
be determined bilateral orchiectomy was performed,
and not a more extensive procedure.
Some of the literature also refers to medical castration by which is meant the use of hormonal or
gonadotropin-releasing hormone agonist (GNRH)
therapy to reduce testosterone to castrate levels.
Finally, some of the literature on the treatment of
prostate cancer refers to androgen deprivation therapy, which has the aim of reducing testosterone to
castrate levels, and which can be accomplished by
surgical or medical castration.

HISTORY

Europe
The first therapeutic castration based on a psychiatric indication was performed in 1892 by August
Forel in Zurich for an imbecilic man who was on
the verge of autocastration because of neurologic
pains in his testes (Sturup, 1972). Denmark pioneered legalizing this treatment in 1929, followed
by Germany (1933), Norway (1934), Finland (1935),
Estonia (1937), Iceland (1938), Latvia (1938), and
Sweden (1944) (Bradford, 1985; Heim & Hursch,
1979; Le Marie, 1956). Heim and Hursch (1979)
reported that Switzerland, the Netherlands, and
Greenland practiced this treatment without any legal
mandate, sometimes quite extensively. For instance,
Heim (1981) reported that the procedure was widely
used in Switzerland and that in the Zurich region
alone more than 10,000 patients had been castrated
for various psychiatric reasons since 1910. Heim and
Hursch (1979) reported that in Germany between
1934 and 1944 at least 2800 sex offenders were
subjected to compulsory castration and that subsequently in West Germany, between 1955 and 1977,
800 sex offenders were castrated. They also reported
1100 cases of castration in Denmark since 1929. This
procedure was also used in the Netherlands (Sturup,
1968a).
Castration has not been used in most countries
for the treatment of sex offenders for several decades
(Gijs & Gooren, 1996), although Germany was
reported (Wille & Beier, 1989) to have been conducting five castrations annually since 1980 and the

Czechoslovakian republic was reported, in a paper

presented at a conference in 1995, to have conducted
84 such procedures since 1976 (Gijs & Gooren, 1996).
United States
In the late 1800s castration for criminals in the
United States was more a subject of discussion in
the penal literature than a practice, but many cases
were reported (Gugliotta, 1998). Dr. Sharp in 1899
in Indiana began experiments on convicts (Le Marie,
1956). Although described as castration, his procedure, in fact, involved only vasectomy to prevent the
loss of secretions from the testes and thus preserve the
loss of the elixir of life to promote well-being and
health. More than 450 vasectomies were performed
on incarcerated men, both with and without explicit
legal sanction (Gugliotta, 1998).
Elsewhere in the United States castration was
practiced in California from 1937 to 1948. A study
reporting on the outcome of 40 castrated males was
recently published (Weinberger et al., 2005), but other
reports suggest that that total number of inmates subjected to this procedure was in the neighborhood of
400 (Linsky, 1989).
More recently in 1996, in the United States,
California became the first of nine states passing
contemporary legislation authorizing the use of
either medical or surgical castration for certain sex
offenders (Scott & Holmberg, 2003). Of these nine
states, four permit the use of medical castration only
(Georgia, Montana, Oregon, and Wisconsin); four
allow either medical castration or voluntary surgical
castration (California, Florida, Iowa, and Louisiana);
and only one (Texas) provides voluntary surgical
castration as the only treatment option (Scott &
Holmberg, 2003). While medical or surgical castration is described as mandatory in five of these states
(Scott & Holmberg, 2003), issues of informed consent
are often not addressed by these statutes. Moreover,
we have been able to locate only one published
description from one of these states, Oregon, on the
use of these statutes (Maletzky, Tolan, & McFarlan,
2006). This group reported on a 5-year follow-up of
men referred under Oregon House Bill 2500 enacted
in 1999, for evaluation as to whether medical treatment with medroxyprogesterone acetate (MPA) was
indicated to reduce their risk. Two hundred seventyfive men were evaluated, and sexual recidivism was
established. Of these, 79 men were advised to receive

ORCHIECTOMY

MPA and did, in fact, received it; none of this group

recidivated sexually. One hundred forty-one were not
referred for MPA treatment and 14% recidivated sexually; 55 were advised to have MPA treatment, but for
a variety of reasons did not receive it, and 18% of this
group recidivated sexually. This study lends support
to the efficacy of antiandrogen treatment in reducing
sexual recidivism. The lack of other published reports
or information from the other eight states suggests
that these laws are not being utilized.

R ECEN T CASES OF SE X OFFENDER S

U NDERGOING ORCHIECTOM Y

Aside from sporadic case reports of orchiectomy in

the medical literature (Alexander, 1993; Joseph, 1993;
Silcock, 1993) (of a British pedophile) or news media
(CBS News, 2004) (of a pedophile in Texas) the authors
know of only six recent cases , three of these were performed in canada, two on sex offenders (Bradford,
2006, personal communication) and another for the
treatment of autoerotic asphyxia (Fedoroff, 2006, personal communication), three were performed in texas
on individuals offered surgical castration under the
recent Texas statute (Winslade, 2008, personal communication) Thus, the use and study of this procedure have fallen off extensively.
Ethical Issues and Use of Castration
for Other Conditions
Castration has also quite continuously been the topic
of many ethical debates and reviews (Alexander, 1993;
Bingley, 1993; Bund, 1997; Cook, 1993; Eastman,
1993; Finch, 1993; Freund, 1980; Gaensbauer, 1973;
Gandhi, Purandare, & Lock, 1993; Heim & Hursch,
1979; Hicks, 1993; Icenogle, 1994; Joseph, 1993;
Klerman, 1975; Silcock, 1993; Tancredi & Weisstub,
1986; Taylor, 1993). In the United States, opponents
of castration legislation cite First Amendment concerns involving the protection of a persons freedom
of speech (including sexual expression); violation of
the Eighth Amendments ban on cruel and unusual
punishment; and violation of the Fourteenth Amendments guarantee of due process and equal protection
(subjecting prisoners to castration without adequate
process of protection) (Scott & Holmberg, 2003).
However, although the use of castration is controversial for sex offenders, it has achieved the status of

173

an accepted surgical treatment for a variety of medical

conditions. The Nobel Prize in physiology or medicine was awarded to Charles Huggins in 1966 for his
investigations during the 1940s into the role of sex
hormones on prostate cancer and for his use of bilateral orchiectomy to treat patients with metastatic prostate cancer. (Corbin & Thompson, 2003; Huggins &
Hodges, 2002). Although hormonal therapy and
GNRH agonists have largely supplanted the use of
castration for prostate cancer, it is still a common
urological procedure. Unilateral orchiectomy constitutes standard of care treatment for testicular cancer.
Furthermore, voluntary castration for a variety of
motivations, including a feeling of control over ones
sexual urges and appetite, a sense of calmness, and
cosmetic reasons, has been described with 23 of 234
respondents to an Internet survey in 2002, indicating
that they had actually undergone castration for some
of these reasons (Wassersug, 2004). A treatise on the
psychological and other advantages of castration was
published recently (Cheney, 2004).

A NIM A L A ND PR IM AT E ST UDIES

Rat and Canine Studies

Research studies in rats demonstrate that castration
results in a loss of sex drive and an abolishment of
mating behavior, and that this can be restored by
testosterone (Davidson, Stefanick, & Sachan, 1978).
Beach (1976) provided a review and rationale for crossspecies comparison of sexual behavior and described
a sequential reduction in ejaculation, intromission,
and mounting in males of a variety of species following castration. He also summarized experiments on
rats and dogs suggesting that previous sexual experience was not related to the variation in the effects of
castration on animals (Beach 1970).

Primate Studies
The effects of castration in primates have been
reviewed by Dixson (1998, pp. 392397). Chemical
or physical castration has been studied in six species,
with quite attenuated sexual functioning being uniformly demonstrated. For example, castration of sexually experienced adult male rhesus monkeys results
in a decline in sexual behavior, reversible with testosterone (Dixson, 1998, pp. 392393). In the first 2 to

174 TREATMENT

4 weeks frequencies of ejaculation and intromission

are reduced; mounting behavior declines more gradually. However, there is marked individual variability with 5 out of 10 male rhesus monkeys studied by
Phoenix (Phoenix, 1980; Phoenix, Slob, & Goy, 1973)
still capable of intromission and three with ejaculatory responses, 1 year after the operation. Loy (1971)
observed a castrated male rhesus monkey still capable
of mounts, intromissions, and an ejaculatory pause
characteristic of intact males 7 years after operation.
Taken together, these data suggest that orchiectomy can markedly reduce sexual behavior in rodents
and primates, but that its effects can be readily
reversed by exogenous testosterone and there is much
individual variation, with some animals having sexual functioning extinguished and others continuing
with it.

HUM A N ST UDIES OF CAST R AT ION FOR

had undergone unilateral orchiectomy for testicular

cancer, studying sex hormone levels and performing
visual erotic stimulation (VES) tests and cavernosal
artery duplex ultrasonography. They found that after
a diagnosis of testicular cancer, sexual dysfunction
was considerable, but within 1 year after treatment
there was some improvement, and the results of the
VES test suggested that sexual dysfunction was more
psychological than organically based. Jonker-Pool
et al. (2001) performed a meta-analysis of 36 studies
of individuals treated for testicular cancer. Four of
these studies reported on groups treated with unilateral orchiectomy followed by surveillance, with 25%
of subjects reporting a loss of desire, 24% orgasmic
dysfunction, 16% ejaculation dysfunction, and 11%
a decrease in sexual activity. Unilateral orchiectomy
has no effect on the endocrine system. The clinical
experience of one of the authors (Wechsler, 2006,
personal communication) is that patients recover
quite well psychologically over time.

MEDICA L CONDIT IONS

Case Studies by Kinsey

PROSTAT E CA NCER ST UDIES

Kinsey et al. (1953, pp. 731745) reviewed a large

amount of mostly anecdotal evidence on the effects
of castration, including some of the European castration literature, and noted that there was large variability in the effects of the procedure. They described
one male from their own studies who was married
and normally sexually active 30 years after castration.
They also noted that at 50 years of age, 7% of males
were impotent and sexually unresponsive, whether
castrated or not, and concluded that although castration was generally associated with reduced sexual
functioning, castrated males were still capable of
being aroused by tactile or psychological stimuli, and
that the data did not justify an opinion that the public
may be protected from socially dangerous types of sex
offenders by castration laws.

Studies of individuals treated with prostate cancer

provide data that is more relevant because castration
is bilateral. The classic form of androgen deprivation
is surgical castration by bilateral orchiectomy, which
is the most immediate method of reducing circulating testosterone by >90% within 24 hours (Maatman,
Gupta, & Montie, 1985; Miyamoto, Messing, &
Chang, 2004). Another summary indicates that surgical castration, estrogens and LHRH agonists equally
decrease plasma testosterone to between 5% and 10%
of its original value (Baltogiannis, Giannakopoulos,
Charalabopoulos, & Sofikitis, 2004). However, the
adrenal glands still produce testosterone, estimated at
5% to 10% of the total amount (Sanford et al., 1977;
Santen, 2003; Young & Landsberg, 2001).
Side effects of this procedure are loss of libido
and potency, hot flashes, osteoporosis, loss of muscle
mass, fatigue, weight gain and anemia, and psychological symptoms associated with definitive castration
(Miyamoto et al., 2004; Schroder, 1997).

T EST ICUL A R CA NCER ST UDIES

Treatment of testicular cancer provides some information on the psychological effects of castration.
For patients with early stage testicular cancer, radical unilateral orchiectomy is virtually always the primary therapeutic intervention (Jones & Vasey, 2003).
Van Basten et al. (1999) reported on 21 patients who

Patient Preference of Medical over Surgical

Treatment for Prostate Cancer
While orchiectomy is a relatively simple procedure
with minor risks (Loblaw et al., 2004), it has fallen

ORCHIECTOMY

out of favor because of its psychological impact and

the existence of viable medical alternatives (Mcleod,
2003; Sharifi, Gulley, & Dahut, 2005). Despite this,
some authors have suggested that it is underused
(Hellerstedt & Pienta, 2003; Miyamoto et al., 2004).
Potosky et al. (2001) used questionnaires to assess
quality of life issues, and compared men who had
received surgical castration with men who had
received medical castration with LHRH agonists.
Men who chose LHRH agonist therapy reported
greater problems with their overall sexual functioning
than orchiectomy patients, despite both groups having a similar pretreatment level of functioning. The
group receiving medical castration perceived themselves as less likely to be free of cancer. The authors
suggested that these differences might have been
partially related to regular injections that served as a
constant reminder to the presence of disease. They
also suggested that preference for injections over
surgery might have been because of fear of permanent mutilation, the ability to discontinue injections,
and/or the loss of a masculine self-image. Another
study suggested that patients preferred this approach
for reasons of convenience and cost (Chadwick,
Gillatt, & Gingell, 1991).
It is clear, however, that when patients are given the
choice of medical or surgical castration, most choose
medical approaches first (Cassileth et al., 1989).
Studies of the Effects of Castration
on Sexual Functioning in Patients
Treated for Prostate Cancer
Greenstein et al. (1995) reported on a study of 16 men
who had undergone physical (10, with posttreatment
maintenance with flutamide) or hormonal (6, treated
with diethylstilbestrol) castration. The mean interval from castration was 21 months. All patients had
penile plethysmography while provided with erotic
visual stimulation. Four of these patients achieved
functional erections; all four of these had been physically castrated. All patients reported good erections
and strong libido before castration with libido being
markedly decreased after castration. In all patients
the onset of erectile dysfunction was noticed a few
weeks after castration. No patient reported spontaneous erections following castration and none had
attempted intercourse.
Rousseau et al. (1988) administered a questionnaire and reported on biological and sexuality changes

175

in prostate cancer patients receiving flutamide

with either surgical or medical castration with an
LHRH agonist. Serum concentrations of testosterone were decreased to approximately 5% of pretreatment values with no difference in levels being
found between those receiving orchiectomy and
those with medical castration. The only difference
was that there was a 2 to 3 week delay before castrate levels of serum androgens were achieved with
LHRH agonists. In fact, a flare reaction is usually
observed with the onset of GNRH agonist therapy
for prostatic cancer, with a surge of testosterone
during the first week or so after a depot injection,
and some urologists will block this with a 1-week
course of bicalutamide or a similar agent. Chabner
et al. (2006) in Goodman & Gilmans Textbook the
Pharmacological Basis of Therapeutics suggest a 2 to
4 week administration of androgen receptor blocking (ARB) agents (p. 1388) for this purpose. Other
authorities using GNRH agonists for the control
of sexual behavior have suggested that ARB agents
may be used, or that, as an alternative to using ARB
agents, patients or their caregivers may be advised
of the risk of hypersexuality and appropriate protective measures could be taken (Krueger & Kaplan,
2001). A major reduction in their interest for sexual
intercourse was noticed by 70% of subjects; however,
20% of patients reported continuing sexual activity
and interest, although the time from initiation of
treatment to the assessment of current functioning
was not specified.
CostBenefit Analyses
Several cost-benefit studies have been performed on
the use of different types of antiandrogen therapies
for the treatment of prostate cancer (Hellerstedt &
Pienta, 2003). A recent study evaluated the costeffectiveness of six androgen suppression strategies to
treat advanced prostate cancer. (Bayoumi, Brown, &
Garber, 2000). Most provided similar outcomes
in both survival and quality of life estimates. The
annual cost of monotherapy with a GNRH agonist
was $4995 in 2000; the cost has now fallen to approximately $3000. Orchiectomy had a one-time cost
of $3360, which now in New York City is an outpatient procedure costing between $1500 and $2000.
Cost concerns of medical castration led to the
suggestion of surgical castration as an alternative
(Oefelein & Resnick, 2003).

176 TREATMENT

Degree of Androgen Suppression

in Prostate Cancer
Androgen deprivation therapy in the treatment of
prostate cancer has the aim of achieving serum testosterone levels as low as possible so as to minimize
androgenic stimulation of prostate cancer cells. Serum
testosterone concentrations that correspond to castration levels have been set at less than 50 ng/dL
(1.7 nmol/L), given variability of values in various
reference laboratories (Bubley et al., 1999; Sharifi,
Gulley, & Dahut, 2005). Most men, however, achieve
levels below 20 ng/dL (0.7 nmol/L) after orchiectomy
and it has been suggested that castration levels be
redefined to use this as a threshold (Sharifi, Gulley, &
Dahut, 2005). Two studies suggested that for individuals treated with GNRH agonists who did not
achieve castrate values of less than 20 ng/dL surgical castration should be considered (Oefelein, Feng,
Scolieri, Ricchiutti, & Resnick, 2000; Oefelein &
Resnick, 2003), although it is generally held that
surgical and medical castration result in equivalent
suppression of testosterone.

BIOLOGICA L A ND BEH AV IOR A L

EFFECTS IN CAST R AT ED
SE X OFFENDER S

In Czechoslovakia Zverina et al. (1991) examined

84 castrated sexual delinquents 1 to 15 years after
castration. Eighteen percent of subjects were capable
of occasional sexual intercourse, and 21% lived in a
stable heterosexual relationship. One-half had occasional erections in the morning. More than a third
masturbated occasionally. One quarter of the subjects
had objections to the results of the castration, most
frequently because sex was lacking in their life. The
authors did not observe serious physical or mental
consequences of castration in the examined men.
In Denmark Sturup (1968, 1968) reported on 900
cases, and found that asexualization was present in
97% of castrated individuals, with 90% of individuals being satisfied with the operation. Castration was
seldom followed by obesity, but there was a gynecoid
distribution of fat. Hot flashes and sweating were
common; beard and body hair were diminished but
not head hair. Some individuals reported an increase
in head hair. It was noted that diminished vitality,
energy, and initiative was not definitely seen, and

several of the men were noted to have increased

energy and to have built new careers. Although it was
noted that serious psychological consequences were
not observed, at least 5, or 1.8%, of the men committed suicide.
In Germany Heim (1981) authored one of the
most detailed studies of the effects of castration on sex
offenders released from prison. He studied 39 men
who had consented to castration while imprisoned
in West Germany. The mean age of the subjects at
castration was 42.5 years, and the median time since
release from prison was 4.3 years. Sexual desire and
sexual arousability were perceived by the subjects as
having been considerably impaired by castration, and
the frequency of coitus, masturbation, and sexual
thoughts were perceived as strongly reduced after castration. However, 11 of 35 castrates stated they were
still able to engage in sexual intercourse, and rapists
proved to be more sexually active after castration than
homosexual or pedophiliacs. The results of this study
led him to conclude that there was a strong effect on
sexual behavior only if castration were performed on
males between 46 and 59 years of age and that the
sexual manifestations of castration varied considerably between individuals.
In Norway Heim and Hursch (1979) and Bremer
(1958) reported on a group of 244 Norwegian castrates, 102 of which were sex offenders. A questionnaire interview with the castrate and/or information
from those in contact with him and an analysis of
documentary sources was conducted. In 66% of 157
persons for whom the effect of castration on sexual
function could be judged, all sexual interest, reactivity, and activity had disappeared. Of 103 cases, 72%
reported the effect immediately or just after the operation and 28% reported that it took a few months to a
year for their sexual urges to disappear. However, 34%
of the total group reported that their sexual interest
and reactivity persisted for more than a year. Problems
were reported in 18% of subjects after an observation
period of 6 to 15 years, with weight gain, development of an aged appearance, climacteric symptoms,
weakness, and deteoriation in general health. There
was an operative mortality of 2%, which nowadays
would be considered extremely high and surgically
unacceptable.
In Switzerland Heim and Hursch (1979) described
details of a study by Cornu (1973), consisting of 127
sex offenders from Switzerland who were evaluated
by psychiatrists and who had lived as castrates for at

ORCHIECTOMY

least 5 years after release from prison, with a comparison group of 50 who had refused to have their
testes removed. Follow-up was 5 to 35 years. Criminal
records and files from the court, police, and psychiatric hospitals were examined and 68 castrates were
interviewed and medically examined. Cornu estimated the recidivism rate as being 4.13% after castration, in comparison with 52% in group of men
who had had castration recommended to them, but
refused, 10 years earlier. Of the 68 castrates, 63%
said their libido and potency had been extinguished
quickly after castration; 26% said there was a gradual
decline; and 10% said they were able to have sexual
intercourse 8 to 20 years after they were castrated.
On medical examination, 51% were extremely overweight; gynecomastia was present in 10%; hair on
the body was reduced in 63%. Thirty four percent of
the castrates were adjudged to have a castrate face,
apparently because their skin had become softer,
more pliable, and slacker. Sixty subjects had X-rays of
their vertebral column and 82% of these had osteoporosis diagnosed. Forty-three percent mentioned bone
pains, mainly in the vertebral column.
Of the 68 castrates 28% indicated that they had
not experienced any psychological disorders; 40%
had the opinion that castration had favorably influenced their moods, specifying that they felt calmer,
happier, and more active than before the operation.
Thirty two percent said that they felt miserable, with
some indicating that they felt depressed, irritable, isolated, or maimed. Twenty two percent thought their
capacity for work had deteriorated after castration;
16% thought that it had improved; and 61% thought
there had been no change. Three men committed
suicide. Seventy one percent said they were content
with the operation because their abnormal sex drive
had vanished, confinement was prevented, their state
of health had improved, or marriage was possible
for the first time; 16% were ambivalent; and 13% felt
effeminate and mutilated.

R ECIDI V ISM ST UDIES

A review of the recidivism literature is summarized

in the accompanying table (Table 13.1). By todays
standards for conducting prospective clinical trials,
most of these studies suffer from significant methodological difficulties. The subject groups are heterogeneous, not well described, and not exclusively

177

sex offenders. Some individuals appeared to have had

schizophrenia or mental retardation as primary diagnoses. Assignment was not random and treatment was
not blinded. Length of time at follow-up was not clear
and outcome measures, whether rearrest or reconviction, were often not specified. There also are not
for the most part good comparison or control groups.
However, at the time these trials and studies were
conducted, the methodology was current and acceptable. Furthermore, standards applicable to clinical
trials are not necessarily appropriate for forensic populations. There are severe limitations on the conduct
of research studies on such populations. Randomized
and treatment blinded designs in situations where an
outcome variable would involve victimization of an
adult or child face substantial ethical challenge from
institutional reviews boards. And many recidivism
studies today use survival analysis techniques, which
do not require control groups. It is clear that these
studies are one of the most important sources of information concerning the effects of androgen deprivation therapy on sexually aggressive behavior. They
do provide the equivalent of a series of retrospective
analyses of open clinical trials conducted over very
long periods of time (in many instances greater in
duration of follow-up by a factor of at least three, compared with contemporary clinical studies (Bradford,
2006, personal communication), with assessments
of the effects of this treatment on the most critical
behavioral variable, commission of another sexual
offense.
Czechoslovakia produced 2 studies (Taus &
Susicka, 1973; Zverina, Zimanova, & Bartova, 1991)
with small numbers, 5 and 84. Few details are available, but there were only 3 offenders relapsed out of
these two groups for a very low recidivism rate.
Denmark yielded several studies (Hansen, 1991;
Hansen & Lykke-Olesen, 1997; Le Marie, 1956;
Ortmann, 1980; Sand, Dickmeiss, & SchwalbeHansen, 1964; Sturup, 1968, 1972; Weinberger et al.,
2005), many with poorly defined or no control groups.
All report a low recidivism rate with the largest by
Sand who reported on 900 patients castrated from
6 to 30 years earlier and found a relapse rate of 1.1%,
compared with relapse rates in comparison groups
of 9.7%, 16.8%, or 50% depending on the study and
group.
Germany has produced a number of detailed studies (Heim, 1981; Heim & Hursch, 1979; Langelddeke,
1963, 1968; Wille & Beier, 1989) that again support

Table 13.1 Summary of Surgical Castration Studies and the Effects of Castration on Recidivism for Sexual Crimes
Nation/Study

Number of Subjects

Diagnoses

Precastration Crime
Rate

Follow-up Period
(Years)

Post Castration
Recidivism
(No. and/or %)

Recidivism of
Noncastrates

Notes

Czechoslovakia
(Taus & Susicka
1973)

Sexually dangerous
deviations

Unknown

No comparison
group

Article in Czechoslovakian;
English summary only
consulted.

Czechoslovakia
(Zverina et al.
1991)

84

Sexual offenders

100% reoffense
rate

115

3 offenders; 3.6%

No comparison
group

Article in Czechoslovakian;
English summary only
consulted.

Denmark
(Le Marie, 1956)

139 castrated out of

3,185

96 guilty of sexual
offenses

Unknown

10

Of 91, two
relapsed

16.8% recidivism
rate for whole
sample

Discussed in Bradford, 1985

and Ortman, 1981.

Denmark
(Ortman, 1980)

738 castrated sex

offenders

Half indecent
offenses against
children

Unknown

22 52 years

1.4%2.4%

9.7% or 16.8% or
50% depending
on comparison
group

Patients were castrated during

30-year period 19291959;
this larger group included
LeMaries 1956 group. Time
at follow-up and comparison
groups not given.

Denmark
(Sand et al., 1964)

900

42%, two or more

convictions;
44% mental
defectives;
25% psychopaths
13% sexually
abnormal

Unknown

6 to more than 30
years

10 (1.1%) were
real sexual
recidivists;
another 10
were borderline
cases

No comparison

Report also cited by Sturup,

1968.
This group encompasses the
groups reported by Le Marie
and Ortman.
Ortman (1980) reports relapse
rate of 9.7% in follow-up
study of noncastrated
offenders in Denmark.
Report cited in Sturup
(1968). 90% of subjects
satisfied with their operation.

Denmark
(Sturup, 1968)

38 (18 of these
castrated)
11 non castrates

Rapists

Unknown

1324 yrs
3 months13yrs

0 of 11 castrated
1 of 5 not
castrated
No recidivism

1 of 5 not castrated
recidivated;
information
on others not
available

Group consists of all rapists

received at Herstedvester
Detention Center from 1935
to 1964; this group appears
to be different from other
groups studied in Denmark.
Forced castration was
never performed.

Denmark (Hansen,
1991; Hansen, &
Lykke-Olesen,
1997)

43 (21 castrated, 22 not)

No information

Unknown

More than 15 years

10% (after 2
subjects took
exogenous
testosterone)

36%, 8 of 22 not
castrated; sexual
reoffense

Cited in Weinberger et al.,

2005; Hansen, 1991;
Hansen, & Lykke-Olesen,
1997.

Germany
(Langeluddeke,
1963; 1968)

1,036 castrated released

into the community
1,618 (same group,
reported in Sturup)

84% two or more

convictions

Unknown

6 weeks20 years
20/30

2.3%
46 2.8%

685 noncastrated
released into
the community;
39.1% reoffended

Langelddeke, 1963, also

reported by Heim &
Hursch, 1979 and Sturup,
1972; 65% of 58 castrated
males reported immediate
decrease of libido; 17%
gradual; 18% could have
intercourse 20 years after
castration.
Primary reference and cited in
Sturup, 1972.

Germany (Heim
1981)

39 released offenders
from group reported
by Langelddeke

31% rapists;
51% pedophiliacs;
3% sexual murders;
15% homosexuals

15% first offenders

85% 2 or more
sexual crimes

4 months13 years;
median time
since release from
prison 4.3 years

No reported
recidivism

No comparison
group

64% had additional Protective

measures imposed because
they were exceptionally
dangerous.
Frequency of coital behavior,
rate of masturbation,
frequency of sexual thoughts
strongly reduced after castration. 31% of castrates were
still able to engage in sexual
intercourse.

Germany (Wille &

Beier, 1989)

104 (25% of all

orchidectomized sex
offenders between
1970 and 1980)

70% pedophiles;
25% aggressive
sex offenders; 3%
exhibitionists;
2% homosexual

Unknown

11 years

3% maximum

46% noncastrated
applicants
(permission not
granted or application canceled
by applicant)

75% reported decreased sexual

interest, libido, erection,
and ejaculation within
6 months; 10% remained
sexually active for years
at diminished level; 15%
reported sexual outlets over
longer period of time.
70% satisfied; 20%
ambivalent; 10% not
satisfied.
(continued)

Table 13.1 Continued

Nation/Study

Number of Subjects

Diagnoses

Precastration Crime
Rate

Follow-up Period
(Years)

PostCastration
Recidivism
(No. and/or %)

Recidivism of
Noncastrates

Notes

The Netherlands
(Fischer van
Rossum)

237

Unknown

Unknown

Unknown

3 1.3%

Unknown

Cited in Sturup, 1960 and in

Meyer& Cole, 1997. Primary
reference unavailable.

Norway (Bremer
1959, Part 1
and 2)

244 studied
102 males
28 females

13 rapists;
79 pedophiles;
10 others
of females; 13
promiscuity; 14
for behavioral
disturbances

58%
Unknown

110 years

2.9%

No comparison
group

Concluded indications for

castration were too broad;
that it did not work for
females; and that it showed
promise for sex offenders.

Sweden (Kinmark,
1949)

66

Unknown

Unknown

Unknown

00

Unknown

Cited in Sturup, 1968 and

Meyer & Cole, 1997.
Primary reference unavailable.

Sweden (Lidberg
1968)

241

About half were

first-time sex
offenders

Unknown

Unknown

Unknown

Also cited in Sturup, 1972.

Switzerland
(Hackfield,
Wolff, Colle)

83

Unknown

Unknown

Unknown

6 7.2%

No comparison
group

Cited in Sturup, 1972. Primary

reference unavailable.

Switzerland
(Cornu, 1973)

127

77% 2 or more
convictions

Unknown

535 years

7% or 4%

N = 50 (52%)

Cited in Heim & Hursch,

1979. Younger castrates
appeared to have higher
risk of recidivating than
older. Primary reference
unavailable.

United States,
(Weinberger
et al. 2005)

60

27.5% based on 40
of 60 subjects; 1
or more arrests or
convictions

Unknown

2 months13 years

0%

No comparison
group

Reports follow-up 44
convicted sex offenders
who underwent surgical
castration in San Diego
County, California, between
1937 and 1948.

ORCHIECTOMY

castrations positive effect on recidivism. The largest,

by Langeluddeke, reporting on patients in the community who had been castrated from 6 weeks to
20 years earlier reported a recidivism rate of 2.3%
compared with a rate of 39.1% in 685 patients who
were not castrated and released into the community. It should be noted that many of those castrated
were under the Nazi regimen and were castrated
involuntarily; this included individuals who were
homosexuals.
A study is reported to have been done in the
Netherlands (Meyer & Cole, 1997; Sturup, 1968) but
details of this are not available beyond aggregate data.
Bremer (1958) reported on a group of 244 individuals castrated in Norway, 28 of whom were women,
concluding that the indications, which, in addition
to sex offenses, included schizophrenia and epilepsy,
were too broad but that the procedure offered effective medical therapy to a subgroup of sex offenders.
Information is available from Sweden (Bremer,
1958; Lidberg, 1968; Meyer & Cole, 1997; Sturup,
1968), Switzerland (Cornu, 1973; Heim & Hursch,
1979; Sturup, 1972), and the Netherlands (Meyer &
Cole, 1997; Sturup, 1968) which also suggest a dramatic effect on recidivism.
Finally, in California Weinberger et al. (2005)
reported on the follow-up of 40 sex offenders castrated in San Diego County during the period 1937
to 1948, none of whom reoffended.
By way of summary it would appear that effects on
sexual interest and functioning begin almost immediately in the majority of patients, but that some report
the maintenance of sexual functioning for a long
period of time, and that the effects of castration have
great individual variability. However imperfect, this
castration literature supports the assertion that castration has a profound effect on sexual functioning and
on recidivism of sexual crime.

DESCR IP T ION OF PROCEDUR E ,

MOR BIDIT Y A ND MORTA LIT Y,
SIDE EFFECTS, A ND THEIR
M A NAGEMEN T

Castration is a safe procedure that can be performed

under local anesthesia as an outpatient. Anesthesia
is injected into the inguinal cord. Sedation is often
used. With the patient in a supine position bilateral
incisions are made in the scrotum and the testicular

181

artery, vein, and cord are ligated and then the testes
are removed. Patients tolerate the procedure well.
The procedure takes approximately half an hour to
perform. As a rule, prostheses are not used. Morbidity
includes bleeding, infection, and pain. Mortality is
virtually nonexistant nowadays.
Hot flashes are commonly experienced with castration in medical patients. They usually require no
treatment. However, estrogen, progesterone, or cyproterone acetate, each of which has its own risks and side
effects, may ameliorate symptoms (Spetz, Zetterlund,
Varenhorst, & Hammar, 2003). Clonidine and antidepressants can also be tried. However, this has not been
reported to be a symptom that has been treated in the
various studies of GNRH agonists with male sex offenders (Briken, Nika, & Berner, 2001; Krueger & Kaplan,
2001; Kruger & Kaplan, 2006; Rosler & Witztum,
1998; Saleh, Niel, & Fishman, 2004; Schober et al.,
2005; Thibaut, Cordier, & Kuhn, 1993; 1996).
Osteoporosis is a significant side effect of patients
with paraphilias treated with antiandrogen therapy
(Grasswick & Bradford, 2003) and of men treated
with medical or surgical castration for prostate cancer (Oefelein & Resnick, 2004). Oefelein and Resnick
(2004) reported on the incidence and management
of this side effect in patients treated for prostate cancer, indicating that this is a significant side effect and
that vitamin D (800 IU/d), calcium supplementation (1200 mg/d), weight-bearing exercise, parenteral
estrogen therapy, and bisphosphonate therapy can be
used. For paraphiliacs or sex offenders treated with
GNRH agonists, bisphosphonate therapy, such as
alendronate, has been used in conjunction with calcium and vitamin D. This has, in the experience of
one of the authors (Krueger, 2006, personal communication), resulted in no apparent decrease in bone
density according to bone density scans performed at
baseline and then yearly.
Another risk of androgen deprivation therapy is
that castrated patients, if they develop prostate cancer, would have a much worse prognosis. Low serum
free testosterone has been reported to be a marker
for high grade prostate cancer (Hoffman, DeWolf, &
Morgentaler, 2000) and a recent study comparing
finasteride, an inhibitor of 5A-reducates that inhibits
the conversion of testosterone to dihydrotestosterone,
the primary androgen in the prostate, with placebo,
suggested that this prevented or delayed the appearance of prostate cancer, there was an increased risk of
high-grade prostate cancer. There is also a suggestion

182 TREATMENT

that the initiation of androgen suppressive therapy in

men over 65 may be associated with increased cardiac
events (DAmico et al., 2007).

ETHICA L A ND INFOR MED

CONSEN T ISSUES

A comprehensive review of the legal and ethical

issues inherent in orchiectomy is beyond the scope
of this chapter. However, some discussion of these
issues is provided. Although several states have passed
legislation (Scott & Holmberg, 2003) mandating
chemical or physical castration, as far as can be determined these laws have not been used. Orchiectomy
is a surgical procedure and, as such, for its ethical
application, requires informed consent. Basic elements of informed consent for a medical or surgical
procedure are the capacity to understand the nature
of the procedure and its risks and benefits, the provision of information, and that a decision be freely
made. (Applebaum & Gutheil, 1991). Clearly, if an
individual refuses to subject himself to such a procedure and/or to give his consent, then to proceed with
castration would violate medical ethical guidelines
and be considered unethical.
Some have pointed to the existence of a choice
of prison or orchiectomy as being inherently coercive (Gaensbauer, 1973; Klerman, 1990). Indeed,
within the United States criminal justice system,
all of plea-bargaining could be said to be inherently
coercive, requiring a choice of an admission of guilt
or taking the risk of trial and a substantially longer
prison sentence, yet this is considered legal and
ethical. However, one can reason that sex offenders
start from a different moral baseline than individuals who have not committed a sexual crime, in that
they have victimized other individuals, and this fact
mitigates against the coercive elements inherent
in a choice of prison or castration (either medical or
surgical) (Shajnfeld, 2008; Wertheimer, 1987).
Additionally, the choice of castration may be offered to an individual, and he may refuse it, but it cannot be forced onto a person. Accordingly, we would
hold that presentation of a choice to an individual
convicted of a sex offense and in need of such treatment as an alternative to incarceration is medically
and morally ethical. Indeed, a case was recently
reported of an individual with pedophilia who, faced

with 10 years of failure of cognitive behavioral therapy to stop him from repeatedly sexually acting out
when released into the community, successfully sued
to receive chemical castration (Krueger & Kaplan,
2006) He was then able to live in the community
while treated with GNRH agonists without other sexual victims for the subsequent 10 years that he was
treated. We would agree with Klerman, who emphasizes that prisoners should be allowed this option
(Klerman, 1975).

COMPA R ISON OF ORCHIECTOM Y W ITH

LONG -T ER M GNR H SU PPR ESSION

Orchiectomy has several advantages over medical

castration. Cost is one evident factor with orchiectomy being undoubtedly less expensive than GNRH
agonists, but not necessarily progesterone. However,
GNRH agonists have a side effect profile which is
substantially better than the more traditional androgen suppressing agents (estrogen, progesterone, cyproterone acetate, or flutamide) (Rosler & Witztum,
1998; Rsler & Witztum, 2000) and GNRH agonists
would seem to be the most evident equivalent to
surgical castration. Other authorities point out that
there has been much greater experience with more
traditional androgen suppressing agents with thousands of sex offenders in past or current treatment
with such agents, and that such agents may cause less
side effects related to androgen deprivation and are
more capable of titration (Bradford, 2006, personal
communication).
Many of the effects and side effects of orchiectomy
and of GNRH agonist medication are related to the
removal of testosterone, but there are some medication specific risks to the GNRH agonists as well as
to the other antiandrogens, such as progesterone or
cyproterone acetate that would not exist with orchiectomy. Any exogenous substance can cause an allergic
or anaphylactic response, and such responses have
been reported with GNRH agonists (Raj, Karadsheh,
Guillot, Raj, & Kumar, 1996). Skin reactions have
also been reported (Neely et al., 1992) (Labarthe,
Bayle-Lebey, & Bazex, 1997; Monasco, Pescovitz, &
Blizzard, 1993) although careful examination and
consideration of injection technique, or a switch to
another of the GNRH agonists with a different compound and different vehicle could resolve this. More

ORCHIECTOMY

serious side effects, such as pure red cell aplasia

associated with leuprolide (Maeda et al., 1998) have
been reported. The occurrence of these serious side
effects could be avoided with different pharmacological agents or surgical castration. Some patients may
prefer surgical to medical castration, choosing this to
avoid injections or for other personal reasons.
Clearly, the obvious advantage of GNRH agonists
is that they are reversible and they do not entail the
psychologically adverse effects of castration. Additionally, GNRH agonists may be lowered in dosage or
the time interval between injections may be extended,
allowing for some titration to allow for an increase in
testosterone and the facilitation of unproblematic
sexual behavior, if it is determined that this is appropriate, although experience with this is limited, and
current dosage packaging limits the flexibility of
titration. Castration would not allow for this option.
However, many individuals discussed in the aforementioned studies, although castrated, were able to
retain some sexual functioning, and it is not certain
that sexual functioning will completely disappear
with surgical castration. Further, while add-back
therapy with testosterone to castrated sex offenders
is a possibility, one study (Hansen, 1991; Hansen &
Lykke-Olesen, 1997) reported a relapse with this treatent. and it would be important to carefully consider
and weigh the risks and benefits of such therapy
before initiating it in this population.

T R E AT MEN T A ND MONITOR ING

CONSIDER AT IONS

It should be emphasized that castration by itself is

not an exclusive or final treatment. Patients who are
castrated can still function sexually, with erections,
intromission and ejaculation, and perpetrators can
victimize individuals without using a sexual organ.
Rather, castrations main effect is to decrease or abolish the intensity of sexual cravings so as to allow a
concomitant increase in volitional capacity to maintain self-control (Berlin, 2005). This implies that an
individual has to be willing to acknowledge that his
sexual behavior is a problem and to be motivated and
to agree to make it a target of treatment. One has to
form an alliance with the patient in this effort.
Additionally, continual monitoring of testosterone, monitoring for osteopenia or osteoporosis with

183

bone density assessments, and periodic laboratory

and physical examinations are all required to follow
individuals treated with this modality. Treatment to
prevent osteopenia and/or osteoporosis with bisphosphonoates, calcium and vitamin D, are required
medically as well as other treatments, including psychotherapy and sex offender specific therapy. Other
modalities, such as ongoing monitoring by parole,
housing, social services, and vocational rehabilitation, are important as well. Indeed, it may be that
these other elements may contribute as much as or
more than medical or surgical castration to reducing recidivism, and future research should configure
study designs so as to assess the effects of sex offender
therapy and other elements of a treatment plan, as
well as medical or surgical castration, on recidivism
of sexual crimes.
The largest open trial involving the use of a
chemically castrating agent, tryptoreline, (Rosler &
Witztum, 1998) relied on, among other measures,
the self-report measure of the Bancroft Sexual
Interest and Activity Scale (Bancroft, Tennent,
Lougas, & Cass, 1974; Tennent, Bancroft, & Cass,
1974) and testosterone levels, both of which demonstrated change (a reduction in testosterone and in
sexual interest and activity, as measured by a Likert
scale and by asking the number of ejaculations a
subject had experienced in the week before the
questionnaire) related to GNRH treatment. These
scales could be used to assess outcome and monitor
a patient.
However, a recent study (Schober et al., 2005)
reported on the use of leuprolide acetate to treat pedophiles, using testosterone levels, sexual interest preference by visual reaction time, penile tumescence,
and polygraphs to assess the effects of leuprolide
acetate. Subjects were noted to be deceptive regarding increased pedophilic urges and masturbatory
frequency and it would be important to incorporate
some of these objective modalities into treatment
assessment and monitoring. Given the possibility
of surreptitious anabolic steroids (Harris, Phoenix,
Hanson, & Thornton, 2003, p. 65), it would also be
important to screen for these in an ongoing way. Some
in the United States have suggested that a urologist
be involved in such treatment (Schober, Byrne, &
Kuhn, 2006) and others that an internist or family
doctor offers an initial medical assessment for clearance for such treatment.

184 TREATMENT

Fundamentally, it cannot be said that castration

is a be all and end all measure, and once castrated,
society can be done with a sex offender. The marked
individual variation in the effects of castration, with
some individuals able to retain some sexual functioning, with a capacity for erections and ejaculation,
and a motivation for sexual activity, even years after
being castrated, suggest that it is critical to assess the
actual effects of castration on the patient on whom
it is performed. To this end, self-report scales, plethysmography, polygraphy, laboratory and clinical
assessment, and observation should be utilized in an
ongoing way.

CONCLUSION

Animal and human studies show that the main effect

of orchiectomy is a substantial reduction in sexually
motivated behavior, but this can have great individual
variation. However, all studies on orchiectomy of sex
offenders support its efficacy in reducing recidivism.
Furthermore, it should be clear that orchiectomy is
not a cure-all for sex offenders, nor is it something
that can be utilized without a system of aftercare that
would include extensive provisions for monitoring,
treatment, and support.
Orchiectomy for the treatment of sex offenders has
had a dark history, in many instances being performed
on individuals against their will or who because of
other reasons were unable to consent. Moreover, psychiatry has a history in the century past of utilizing
treatments, such as frontal lobotomy or extremely
high-dose neuroleptics, that were ultimately established as being extremely harmful and of limited or
no therapeutic value. Use of orchiectomy to treat sex
offenders in Europe has virtually disappeared and in
the United States, although several states have passed
laws mandating surgical (or medical) castration for a
variety of sexual crimes, contemporary usage of surgical castration has also ceased.
However, orchiectomy s usage in the past century
also antedated the modern era of biological treatment with much greater rigor in the classification
of psychiatric disorders and research design and
it can be anticipated that the future will bring better designed studies to objectively assess the effects
of medical, if not surgical, castration, as well as the
effects of other treatment modalities.

In spite of current pharmacological practice in the

treatment of sex offenders, which includes serotoninselective reuptake inhibitors and other androgen suppressing agents (see other chapters in this volume), as
well as, more recently, GNRH agonists, cost considerations as well as medical ones suggest that orchiectomy could be a desirable alternative. Given the great
number of sexual crimes and victims and the great
expense sex offenders create for society, almost nothing is spent on research involving the biological treatment of sex offenders. This chapter should make clear
that such treatments, including orchiectomy, have
great promise and should be the subject of further
consideration and investigation.
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Chapter 14

Pharmacological Treatment
of Paraphilic Sex Offenders
Fabian M. Saleh

Sex offenders represent a heterogeneous population.

A subgroup of sex offenders suffers from sexual disorders known in the sexological and psychiatric literature as paraphilias. According to the revised fourth
edition of the Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association,
2000) the essential features of a paraphilia are recurrent, sexually arousing fantasies, sexual urges, or
behaviors generally involving (1) nonhuman objects,
(2) the suffering of oneself or ones partner, or (3)
children or other nonconsenting persons that occur
over a period of at least 6 months (Criterion A).
DSM-IV-TR also suggests that for some individuals
paraphilic fantasies or stimuli are obligatory for erotic
arousal and are always included in sexual activity.
For other individuals, paraphilic preferences appear
only episodically. Of the nine paraphilias listed in the
DSM (see Table 14.1), pedophilia and exhibitionism
are the most prevalent in outpatient settings (Abel,
1989). (Paraphilias are discussed in Chapter 2.)
Treatment of paraphilic sex offenders (i.e., sex
offenders who suffer from one or more paraphilias) is

multifaceted, and by present standards, encompasses

psychologically, and where appropriate, biologically
based therapies (Saleh & Guidry, 2003). This chapter
will focus on the pharmacological treatment of paraphilic sex offenders. In particular, it will examine and
review relevant data on the efficacy and safety of
medications that reduce levels of androgens. Data on
less established medications, such as the serotonergic
antidepressants, will be reviewed briefly.
The following vignette describes the case of a
paraphilic sex offender who improved in his overall
level of functioning following treatment with leuprolide acetate (Saleh, 2005). This case presentation
serves to frame some of the issues that will be discussed in this chapter.

CASE E X A MPLE

J.F., a 19-year-old, single male, was referred for a psychosexual and risk assessment after being convicted
of several incidents of public masturbation and

189

190 TREATMENT

Table 14.1 Paraphilic Disorders

as Listed in DSM-IV-TR
Exhibitionism
Fetishism
Frotteurism
Pedophilia

To reduce the risk for medication-related side effects, leuprolide was eventually decreased to 3.75 mg
per month. This was not associated with reoccurring paraphilic symptoms. Indeed, follow-up after
18 months revealed sustained improvement over
time. To date, J.F. has remained symptom free. He
has not reoffended sexually.

Sexual masochism
Sexual sadism
Transvestic fetishism
Voyeurism
Paraphilia not otherwise specified

indecent exposure involving postpubertal teenage

girls. Following a comprehensive psychiatric work-up,
J.F. was diagnosed with a paraphilic disorder, best
characterized as Paraphilia Not Otherwise Specified.
He did not present with a comorbid mental illness or a
substance abuse disorder. On mental status examination, J.F. endorsed deviant sexual fantasies and urges
involving exhibitionistic and nonconsensual sexual
acts. He also reported a 3-year history of heightened
sexual drive, masturbating numerous times a day, up
to 46 times a week, to age appropriate, and occasionally deviant, sexual fantasies. On penile plethysmograph testing, J.F. showed deviant sexual arousal to
exhibitionistic and rape stimuli (see Figures 14.1 and
Figure 14.2). (Penile plethysmography is discussed in
Chapter 7.)
Because of his presentation, and following a
pretreatment work-up (see following text for more
details), J.F. was started on leuprolide acetate (7.5 mg
per month) and flutamide. The latter medication
was prescribed at a dose of 750 mg per day for 4
weeks. After about two weeks into the treatment, J.F.
reported a decrease in the intensity and frequency of
his paraphilic symptoms. His self-report of decreased
sexual arousal was consistent with subsequent PPG
findings, which showed no arousal to paraphilic stimuli (see Figure 14.3 and Figure 14.4).
By the third week, serum free testosterone level
decreased from 140.40 to 31.6 pg/ml (J.F.s hormone
profile is shown in Table 14.2). Total sexual outlet,
as measured in this instance by the frequency of
orgasms per week, decreased after about 3 months to
an average of two to three times a week. J.F. reported
relief from intrusive sexual fantasies as well as superior work performance and improved interpersonal
relationships.

R AT IONA LE FOR PH A R M ACOLOGICA L

T R E AT MEN T A ND DI AGNOST IC
WOR K-UP

Not all sex offenders will benefit from testosteronelowering medications. For example, offering an antiandrogen to a patient with schizophrenia or bipolar
disorder would be inappropriate if the sexual offending behavior was a manifestation of a psychotic or
manic episode. Antipsychotic medications or anticonvulsants (i.e., mood stabilizers) would be the treatment of choice in these cases (Smith & Taylor, 1999).
Similarly, offering a testosterone-lowering medication to a developmentally delayed sex offender who
offended because of a lack of understanding of, for
example, the age of consent would be ill-advised.
Counselling and psychosexual education would be
the intervention of first choice in this latter case. On
the other hand, failure to prescribe a testosteronelowering medication to a symptomatic sex offender
with paraphilic proclivities or an idiopathic paraphilic
disorder could have devastating consequences for
both the offender and the target of the offenders
paraphilic interest (e.g., prepubescent children). Indeed,
to mitigate a paraphilic sex offenders risk for sexual
recidividism, testosterone-lowering medications should
be made available to sex offenders who present with
intense sexual urges or cravings for paraphilic activities. Suffice to say that any treatment decision should
follow and be based on the results of a comprehensive
diagnostic and medical work-up (Saleh & Guidry,
2003; Bradford, Boulet, & Pawlak, 1992).
Diagnostic Work-Up
Although the importance of a psychiatric and phenomenological interview cannot be overemphasized,
a multimodal approach is recommended when evaluating sex offenders. This is particularly important
given that sex offenders, with or without paraphilias,
can be unreliable and self-serving reporters. As such,

10

20

30

40

50

60

70

80

Media Off

103.6

Media On

Percentage

Default 5 : Exhibitionism
106.0
105.5
105.0
104.5
104.0
103.5
103.0
102.5
102.0
101.5
101.0
100.5
100.0
99.5
99.0
98.5
98.0
97.5
97.0
96.5
96.0
95.5

90 100 110 120 130 140 150 160 170 180 190 200
Time

Figure 14.1 Pretreatment arousal response to a stimulus describing exhibitionistic activity.

113.5

Media Off

Media On

Percentage

Default 13: Adult Rape

117.0
116.0
115.0
114.0
113.0
112.0
111.0
110.0
109.0
108.0
107.0
106.0
105.0
104.0
103.0
102.0
101.0
100.0
99.0
98.0
97.0
96.0
95.0
94.0
93.0

10

20

30

40

50

60

70

80

90 100 110 120 130 140 150 160 170 180 190 200 210
Time

Figure 14.2 Pretreatment arousal response to a stimulus describing rape of an adult woman.

191

Default 8: Adult Female Rape

106.00
104.00

96.00

Media Off

98.00

End Trial 7

100.00
Start Trial 7

Millimeters of Stretch

102.00

94.00
92.00
90.00
88.00
86.00
1340

1380

1360

1400

1420

1440

1460

1480

1500

1520

Channel

Current

Max

Min

Mean

Channel

Current

Max

Min

Mean

% of Erection

Empty

Empty

Empty

Empty

EarClip

1512.70

1553.52

1473.58

1511.66

87.95

96.56

85.92

91.20

CM

4919.83

4929.11

4908.88

4919.17

4973.90

4984.71

4965.79

4974.42

Aux

0.00

0.00

0.00

0.00

Millimeters
BP / Volume

1540

Default 20: Exhibitionism

106.00
104.00

96.00
94.00

Medial Off

98.00

End Trial 16

100.00
Start Trial 16

Millimeters of Stretch

102.00

92.00
90.00
88.00
86.00
3280

3300

3320

3340

3360

3380

3400

3420

3440

Channel

Current

Max

Min

Mean

Channel

Current

Max

% of Erection

Empty

Empty

Empty

Empty

EarClip

1512.70

87.95

96.56

85.92

91.20

CM

4919.83

4973.90

4984.71

4965.79

4974.42

Aux

0.00

Millimeters
BP / Volume

3460
Min

Mean

1553.52

1473.58

1511.66

4929.11

4908.88

4919.17

0.00

0.00

0.00

3480

Figure 14.3 and 14.4 Following treatment with leuprolide acetate and consistent with J.F.s self-report of
decreased arousal, J.F. did not show arousal to any of the paraphilic stimuli.

192

PHARMACOLOGICAL TREATMENT OF PAR APHILIC SEX OFFENDERS

Table 14.2 Hormonal Profiles Prior to and During

Leuprolide Acetate/Flutamide Therapy
Reference Range in Adult Males
Luteinizing hormone (LH):
1.59.3 mIU/mL
Follicle stimulating hormone (FSH)
1.418.1 mIU/mL
Testosterone (T): 241827 ng/dL
Free testosterone (Free T):
47244 pg/mL
Free testosterone concentration
is derived from a mathematical
expression based on constants for
the binding of testosterone to sex
hormone binding globulin

Hormonal Levels
in J.F.

193

complete physical, and where indicated, neurological

examination (Bradford, 2000; Saleh & Guidry, 2003).
Baseline laboratory tests include the following:

Complete blood count

Serum electrolytes
Calcium and phosphate
Lipid profile
Fasting glucose
Liver function test: aspartate aminotransferase
(AST), alanine aminotransferase (ALT), gammaglutamyl transpeptidase (gamma-GT), alkanine
phosphatase, albumin, and total protein
BUN and creatinine
Thyroid stimulating hormone (TSH)
Parathyroid hormone (PTH)

Pretreatment
LH

2.71

FSH

<1.0

333.58

Free T

140.40

About 3 weeks into leuprolide therapy

LH

1.64

FSH

<1.0

110.26

Free T

31.6

4 months into leuprolide therapy

LH

0.87

FSH

4.8

56.22

Free T

11.9

one should correlate, where possible, clinical data

(self-report and clinician-administered measures
see Table 14.3) with collateral information, such
as victim statements, police reports, prior mental
health and medical records, juvenile and adult criminal records, and forensic reports. Along the same
lines, treatment responses should be correlated with
hormonal and penile plethysmography data (Saleh,
2005) (Violence risk assessment is discussed in
Chapter 5).
Medical Work-Up
To exclude active medical conditions and minimize
the risk for medication-induced side effects, patients
considered for antiandrogen therapy should have a

Indices for the following hormones should also be

obtained:

Free and total serum testosterone (T)

Progesterone
Estradiol
Follicle stimulating hormone (FSH)
Luteinizing hormone (LH)
Prolactin

Other tests that should be considered are urinalysis, urine toxicology, and a pregnancy test in women.
Moreover, before starting treatment with one of the
testosterone-lowering agents, patients should have a
baseline bone densitometry evaluation (dual energy
X-ray absorptiometry) and a baseline 12-lead electrocardiogram (with long rhythm strip). The foregoing tests should be repeated, at a minimum, at 6- to
12-month intervals to reduce for medication-related
side effects. Likewise, vital signs (heart rate and blood
pressure) and weight should be measured at baseline
and then on a monthly basis.

Informed Consent
As with any other form of therapy, informed consent
should be obtained before treatment (Berlin, 1989).
First, a patient should be given adequate information
with regard to the risks and benefits of the proposed
treatment. Similarly, the risks and benefits of alternative treatments and of no treatment should be thoroughly reviewed. Equally important are the second
and third element of the informed consent doctrine.
In fact, for a consent to be valid it has to be given

Table 14.3 Selected Assessment Tools

Instrument

Content

Psychopathology-related measures
Psychopathy ChecklistRevised (Hare, 2003)

The PCL-R is a clinical rating scale used to assess psychopathy.

The PCL-R comprises 20 items scored on a 3-point scale
(0 = item does not apply, 1 = item applies somewhat,
2 = item definitely applies). Total scores range from 0 to 40;
Scores higher than 30 are considered diagnostic of psychopathy

The Michigan Alcohol Screening Test

(Sletzer, et al., 1975)

The MAST is a self-report inventory used in the general

population to identify incidence or behaviors indicative of
alcohol abuse. This measure contains 25 YesNo questions
and yields an overall score ranging from 0 53

Montgomery-Asberg Depression Rating Scale

(Montgomery & Asberg, 1979)

Montgomery-Asberg Depression Rating Scale measures overall

severity of depressive symptoms. This measure is sensitive to
change and uses a 10-item checklist, with items rated on a six
point scale

The Hamilton Anxiety Rating Scale (Hamilton, 1959)

The Hamilton Anxiety Rating Scale is a measure of global

anxiety, consists of 14 items that are rated on a 5-point scale,
from 0 = no to 4 = severe, grossly disabling symptoms
(Hamilton, 1959). Total scores range from 0 to 56, with scores
greater than or equal to 14 indicating clinically significant
anxiety (American Psychiatric Association, 2000)

The Yale Brown Obsessive Compulsive Scale

(American Psychiatric Association, 2000)

The Y-BOCS is a clinician-administered scale that measures the

severity of obsessive-compulsive symptoms. It is divided into
two subscales: the Obsessions subscale and the Compulsions
subscale

The Global Improvement Scale (Guy, 1976)

The Global Improvement Scale is a seven-point and

rater-administered scale that measures general improvement.
It ranges from a very much improved to very much worse

Measures of Sexual Functioning

Bradford Sexual History Inventory

Bradford Sexual History Inventory is semistructured interview

schedule that asks about a wide range of deviant and
nondeviant sexual thoughts and activities commonly
encountered in clinical and forensic settings

Greenberg Sexual Preference Visual Analogue

Scale (Greenberg, 1991)

The GVAS is a self-report instrument that is used to assess the sexual

preference of a sexual offender. The scale forces the sex offenders to
choose between adult males, adult females, young girls, and young
boys. It produces four scores indicating the degree of sexual preference for women, men, young girls, and young boys

Sexual Interest and Sexual Activity Rating Scale

(Bancroft et al., 1974)

The Sexual Interest and Sexual Activity Scales record the degree
of sexual interest and the frequency of sexual activity during
the week preceding the assessment. The Sexual Activity Scale
is a measure of sexual activity defi ned as the number of orgasms
in the last 7 days. The Sexual Interest scale serves to rate the
patients general sexual interest on a five-point Likert scale

The Wilson Sex Fantasy Questionnaire

(Baumgartner et al., 1988)

This is a self-report measure of sexual fantasies. The 40

sexual fantasy items are categorized into four fantasy subtypes
consisting of 10 items each. They assess themes ranging
from the normal and innocuous to the deviant and
potentially harmful.

Penile Plethysmograph (Blanchard et al., 2001)

The PPG is both a screening tool and an outcome tool. Penile

tumescence is a good indicator of sexual arousal that is commonly
used to identify individuals with deviant sexual arousal

194

PHARMACOLOGICAL TREATMENT OF PAR APHILIC SEX OFFENDERS

voluntarily without undue influence or coercion. This

is particularly important in this population given
that the majority of prospective patients is either on
probation or parole at the time of referral. Finally, a
patient has to be competent to give informed consent.
Indeed, if a patient does not possess the requisite abilities to give informed consent and is deemed incompetent (e.g., developmentally delayed and/or mentally
ill paraphilic sex offender), informed consent needs
to be obtained from a substituted decision maker
(Cooper, 1986).

Testosterone-Lowering Treatments
Among the biologically based treatments one has to
distinguish between orchiectomy (surgical removal
of the testes) and pharmacotherapy (Stompe, 2007).
It is important to point out here that data pertaining
to orchiectomy provide the basis for our understanding of the mechanism and benefits of testosteronelowering medications in paraphilic sex offenders.
For example, Langelddecke (1963) presented data
on 1036 sex offenders who were offered orchiectomy.
More than half of the cohort declined orchiectomy
and served as the control group (N = 685). Recidividism rates declined to 2.3% for the orchiectomized
offenders. That is, compared to 80% for the untreated
group, only 24 out of 1036 reoffended following
orchiectomy. Follow-up periods ranged from 6 weeks
to 20 years. Fifty-eight offenders reported a complete cessation of their sexual drive. Fifteen reported
a gradual decline in their sexual functioning, and
16 maintained erectile and orgasmic functioning
despite having undergone orchiectomy. As reported
by Sturup (1968), Sand et al. (1964) presented recidividism data on a cohort of 900 castrated sex offenders who were reexamined over a 30-year period.
Follow-up inquiries approximated 4000. Similar to
the data presented by Langelddecke, recidividism
rates were in the 2% range. These, and similar studies, show that orchiectomy causes a substantial decrease in sexual recidivism, with recidividism rates
ranging from 1% to 3% for orchiectomized sex offenders versus a staggering 50% to 60 % for controls
(i.e., nonorchiectomized sex offenders) (Orchiectomy
is discussed in Chapter 13).
Although rather effective, the use of orchiectomy
has become superfluous with the introduction of the
below described hormonal treatments. Estrogens

195

were among the first medications made available to

this population. Although effective in ameliorating
paraphilic symptoms, their use was limited because
of their feminizing and carcinogenic properties
(Foote, 1944; Golla & Hodge, 1949). Estrogen therapy
was eventually superseded by the progesterone derivates, medroxyprogesterone and cyproterone acetate,
respectively (Bancroft, Tennent, Loucas, & Cass,
1974; Money, 1968). Though less adverse effect prone
than the estrogens, medication compliance remained
a problem with the progesterone derivates. The pharmacological treatment of the paraphilias has changed
during the last decade. In fact, the introduction of
newer agents, especially the luteinizing hormonereleasing hormone agonists, has clinicians a new
alternative in the treatment of paraphilic sex offenders (Briken, Nika, & Berner, 2001; Krueger & Kaplan,
2001; Rosler & Witztum, 1998).
The next section of this chapter will briefly review
data on the selective serotonin-reuptake inhibitors
(SSRIs). It will be followed by a more in depth discussion of the testosterone-lowering medications
cyproterone acetate, medroxyprogesterone acetate,
and the luteinizing hormone-releasing hormone
agonists. (The neurochemistry and neurobiology of
human sexual behavior is discussed in Chapter 4 and
see Chapter 7 also.)

SELECT I V E SEROTONIN
R EUP TA K E INHIBITOR S

While the role of serotonin (5-HT) in sexual behavior has been extensively studied in animals, research
in humans has been relatively scant. Similarly, neurobiological data linking serotonin to the paraphilias
is limited. Indeed, it remains to be seen whether
serotonin plays a specific role in the pathophysiology of the paraphilias. On the other hand, a growing body pharmacological data suggest that increased
serotonin levels in the central nervous system may
adversely impact sexual behavior, causing various
forms of sexual problems (i.e., sexual dysfunctions).
Antidepressant-induced sexual side effects, specifically those related to SSRI use, range anywhere from
2.7% to 75% (Baldwin, Thomas, & Birtwistle, 1997;
Patterson, 1993; Stark & Hardison, 1985), and include
decreased libido, erectile difficulties, ejaculation failure, and delayed or absent orgasm (Rothschild, 2000).

196 TREATMENT

Because of the foregoing, this class of antidepressants has been increasingly used to treat sex offenders presenting with paraphilic disorders. Although
certainly intriguing, it is critical to take the following
caveats into account when considering an SSRI for
this subgroup of sex offenders:
1. Almost all SSRI-related sexual dysfunction data
derive from studies involving male and female
patients afflicted with depressive and anxiety
disorders, and not paraphilias (Rothschild, 2000;
Williams et al., 2006).
2. Sexual dysfunction, even in patients taking
SSRIs, is a multifactorial phenomenon, and is
caused or exacerbated by a myriad of conditions
including but not limited to the psychiatric illness itself (depression or anxiety), co-occurring
general medical illness (thyroid disease, diabetes mellitus, cardiovascular disease, atherosclerosis, etc.), concomitant medication use
(antihypertensives, anticholinergics, antihistamines, anticonvulsants, etc.), drug of abuse and/
or alcohol, psychological stress (recent involvement with the courts, interpersonal conflicts,
etc), and finally halo effect (Baldwin, 2004;
Keltner, McAfee, & Taylor, 2002; Lauman,
Michael, & Gagnon, 1994). In other words,
cause and effect between SSRIs and sexual
dysfunction is not an explicit and unequivocal
phenomenon (Williams et al., 2006).
3. The four phases of the normal human sexual
response cycle (desire, excitement, orgasm, and
resolution) are not equally affected by SSRIs. In
males, ejaculatory dysfunction and delayed or
absent orgasm are a more common occurrence
than SSRI-emergent decreases in sexual desire
(Ashton, Hamer, & Rosen, 1997; Keltner et al.,
2002; Seidman, 2006; Williams et al., 2006).
4. SSRI-emergent sexual side effects are dosedependent and reversible. With the exception
of fluoxetine (an SSRI with a long half-life), sexual functioning improves within a few days following medication discontinuation (Rothschild,
1995; Zajecka, Mitchell, & Fawcett, 1997;
Hirschfeld, 1999; Zajecka, 2001). Likewise, it
is important to note that some patients develop
tolerance to SSRI-induced sexual side effects
(Zajecka, 2001).
5. Lastly, and probably most importantly, approximately 90% of surveyed patients discontinue or
drop out of treatment because of SSRI-related
sexual side effects (National Depression ManicDepression Association, 2000). That is, SSRIinduced sexual side effects may contribute to

poor treatment adherence and medication

noncompliance (Keltner et al., 2002).
Although treatment of paraphilic sex offenders with
SSRIs holds promise, and might be an option in carefully selected and highly reliable patients, the lack of
placebo-controlled studies and unambiguous biological data, linking serotonin to the paraphilias, limits
our ability to draw meaningful conclusions on the
efficacy of these medications at this point in time.
In fact, with the exception of a few open-label and
retrospective studies (see subsequently), clinical trials assessing the efficacy of SSRIs in paraphilic sex
offenders are nonexistent.
Selected Studies Pertaining to
SSRIs and the Paraphilias
In an open-label trial of 3 months duration, Kafka and
Prentky (1992) treated 20 patients, diagnosed with
either paraphilia or nonparaphilic sexual addictions,
with fluoxetine (mean dose 39 mg per day). Paraphilic
symptoms decreased after 4 weeks, yet conventional
(normophilic) sexual behavior was maintained.
Although the results of this trial are interesting, a
placebo effect cannot be ruled out. In another open
label study, Kafka (1994) treated a cohort of 24 men,
diagnosed with paraphilia or paraphilia-related disorders, with sertraline (25 to 250 mg per day). Patients
presented mostly with noncontact paraphilias, such
as exhibitionism, fetishism, transvestic fetishism, telephone scatologia, and voyeurism. Mean duration of
sertraline treatment ranged from 4 to 64 weeks. Partial
responders (n = 4) received augmentation with lithium, methylphenidate, or trazodone. Sertraline nonresponders (n = 9) were switched to fluoxetine with
doses ranging from 10 to 80 mg per day. Three men
on fluoxetine required methylphenidate augmentation. Of the cohort, 71% improved with either sertraline or fluoxetine. Side effects of sertraline included
gastrointestinal distress, fatigue, increased depression, sexual dysfunction, and headache. Side effects
of fluoxetine and sexual recidividism rates were not
reported. Limitations of this study included, among
other things, the use of several agents with different
pharmacodynamic properties and the lack of a control group.
In an open-label dose titrated study, Bradford et al.
(1995) treated a homogeneous group of 18 pedophiles
with sertraline using a mean daily dose of 131 mg.

PHARMACOLOGICAL TREATMENT OF PAR APHILIC SEX OFFENDERS

Treatment response was based on patient self-report

and penile plethysmograph data. Similar to the aforementioned study, deviant sexual arousal was reduced,
whereas normophilic arousal was preserved, and even
increased in two patients.
Cyproterone Acetate
Cyproterone acetate (CPA) is not available in the
United States. CPA is an antiandrogen with both antiandrogenic and antigonadotropic properties (Gilman
et al., 1990; Goldenberg et al., 1991). It has been used
in the treatment of severe hirsutism, androgenetic
alopecia, idiopathic precocious puberty, and prostate
cancer (Jurzyk, Spielvogel, & Rose, 1992; OBrien,
Cooper, Murray, Seeman, Thomas, &. Jerums, 1991;
Pavone-Macaluso et al., 1986). Since the mid- to late1960s, CPA has also been used to treat hypersexual,
sexually aggressive, and paraphilic patients. Similar
to cimitedine, CPA exerts its antilibidinal effects by
competitively blocking testosterone and dihydrotestosterone binding to peripheral and central androgen
receptors. CPA also prevents binding of dihydrotestosterone to intracellular receptor sites and thus blocks
the translocation of the androgen receptor complex
into the cell nucleus (Brotherton, Burton, & Shuster,
1974; Goldenberg et al., 1988; Krogh, 1992; Reynolds,
1989).
CPA can be administered orally and intramuscularly. Oral dosages range from 50 to 200 mg per day,
while intramuscular dosages range from 300 to 700 mg
per injection. The latter has been given on a weekly or
biweekly basis (Reilly, Delva, & Hudson, 2000).
With regard to its pharmacokinetic properties
(see Table 14.4), oral CPA is slowly and poorly
absorbed from the gastrointestinal tract (Jurzyk
et al., 1992). After being metabolized in the liver to
15--hydroxycyproterone (its main metabolite), CPA
is excreted via the urinary and gastrointestinal tract.
The side effects of CPA are dose dependent
(Laschet & Laschet, 1975; Neuman et al., 1970) and

197

include nausea, vomiting, diarrhea, constipation, breast

tenderness, galactorrhea, decreased libido, thrombophlebitis, hypochromic anemia (rare), hypercalcemia, fatigue, lethargy, and weakness. Late or delayed
side effects include gynecomastia, depression, benign
nodular hyperplasia of the breast, and hypospermia
(low semen volume). Elevated liver enzymes (AST,
ALT, LDH), fatal hepatitis (Blake, Sawyerr, Dooley,
Scheuer, & McIntyre, 1990; Levesque et al., 1989),
decreased response to ACTH (with lowered cortisol levels), as well as carbohydrate metabolism dysregulations have also been reported with the use of
CPA. Moreover, CPA treatment has been associated
with lipid abnormalities, decreased spermatogenesis, headaches, weight gain, hot flashes, night sweats,
and ophthalmologic abnormalities (Goldenberg &
Bruchovsky, 1991; Jurzyk et al., 1992).
Selected Studies Pertaining to CPA
As reported by Bradford (2001), Laschet and Laschet
(1971) treated a large cohort of 110 sexually deviant
men, diagnosed with pedophilia, exhibitionism, or
sexual sadism, with either oral (100 mg per day) or
intramuscular (300 mg every other week) CPA. About
50% of the cohort had histories of sexual offending behavior. Follow-up periods ranged from 6 to
50 months. Eighty percent of the patient population,
receiving oral CPA, reported a substantial decrease
in sexual drive, erections, and orgasm. Side effects
included weight gain, depression, and feminization.
Of note, in some cases, treatment response was maintained following medication discontinuation.
In a double-blind placebo crossover study, Bradford
and Pawlak (1993a) treated a cohort of 19 sex offenders with either oral CPA or placebo. All subjects met
DSM-III-R criteria for pedophilia. Pretreatment
sexual recidividism rates were high, averaging 2.5
sexual offenses per subject. Subjects were randomly
and double-blindly assigned to receive either CPA or
placebo. Three subjects completed the full 13 months

Table 14.4 Pharmacokinetic Properties of CPA

Molecular Structure/
Chemical Name

Bioavailability

Maximum Plasma
Half-Life

Metabolized

Main Metabolite

C24H29ClO4/
6-Chloro-1,2-methylene-3,
20-dioxopregna-4,
6-dien-17-yl acetate

100% after oral

administration

38 +/ 5 hours (oral
CPA)
82 +/ 21
(intramuscular CPA)

Hepatically

15--hydroxycyproterone

198 TREATMENT

trial period. Although not statistically significant,

deviant sexual arousal, as measured by penile plethysmography and self-report, decreased in all subjects
with active drug treatment.
In a follow-up study, Bradford and Pawlak (1993b)
evaluated sexual arousal patterns of 17 pedophilies
via penile plethysmography. Responses to pedophilic
(mutually consenting and coercive) stimuli were significantly suppressed following treatment with CPA.
As indicated above, treatment with CPA decreases
paraphilic symptoms and deviant sexual arousal
within a relatively short period of time. And similar to
what has been observed in orchiectomized patients,
treatment with CPA substantially reduces recidivism
rates (16% to 0% with treatment vs. 50% to 100%
without treatment) (Appelt & Floru, 1974; Baron &
Lenger, 1977; Davies, 1974; Fahndrich, 1974; Horn,
1972).
Medroxyprogesterone Acetate
Medroxyprogesterone acetate (MPA), the counterpart of CPA in the United States, is a potent synthetic
progestational agent which has been used as a contraceptive in women of childbearing age (DepoProvera). It has also been used to treat cancerous
processes involving the endometrium, the breasts,
and the kidneys (e.g., endometrial, renal cell carcinoma, hormonal- dependent carcinomas of the breast
in postmenopausal women). Since the late-1960s,
MPA has been used in the treatment of paraphilic
sex offenders because of its testosterone-lowering
propertiesvia induction of testosterone-A-reductase
and dose- dependent inhibition of gonadotropin secretion (Albin, Vittek, & Gordon, 1973; Berlin & Schaerf,
1985; Camacho, Williams, & Montalvo, 1972).
MPA can be administered orally and parenterally.
Dosages range from 60 to 100 mg per day (for the
oral formulation) and 200 to 500 mg per week (for
the intramuscular formulation), respectively (Berlin,
1983; Berlin, & Meinecke, 1981; Gagne, 1981; Hucker,
Langevin, & Bain, 1988; Meyer, Collier, & Emory,

1992). The pharmacokinetic properties of MPA are

shown in Table 14.5.
As true for all testosterone-lowering agents, MPA
can cause a number of side effects, including but not
limited to hypertension, thromboembolism, breast
tenderness, galactorrhea, weight gain (Amatayakul,
Sivasomboon, & Thanangkul, 1980), nightmares,
hot flashes, acne, alopecia, hirsutism, hyperglycemia, diabetes mellitus, and hypogonadism. Cushings
syndrome (Dux, Bishara, Marom, Blum, & Pitlik,
1998; Shotliff & Nussey, 1997) and gallstones (Meyer,
Walker, Emory, & Smith, 1985) have also been
reported in patients taking MPA.
Selected Studies Pertaining to MPA
Berlin and Meinecke (1981) reported data on 20 male
paraphilic patients treated with intramuscular MPA
(150 mg every other week to 600 mg per week).
Diagnoses included pedophilia, sexual masochism, sexual sadism, voyeurism, and exhibitionism.
Although three patients relapsed during the MPA
trial, 90% of the cohort reported a decrease in paraphilic symptomatology. One relapse was believed to
be related to alcohol abuse. Recidivism rates were
substantially higher for those patients who discontinued treatment against medical advice (10 out of 11
relapsed). Incidence of side effects was not reported.
In an open clinical trial, Gottesman and Schubert
(1993) treated a heterogeneous cohort of seven
male paraphilic patients with oral MPA, using dosages ranging between 60 to 80 mg per day for about
15.33 months. Patients were diagnosed with both
noncontact (exhibitionism, voyeurism, telephone
scatologia, transvestic fetishism, compulsive masturbation, and sexual masochism) and contact paraphilias (pedophilia, zoophilia, and sexual sadism).
One patient was diagnosed with chronic paranoid
schizophrenia. Testosterone levels and self-report
ratings were the primary outcome measures (e.g.,
number of ejaculations per week, morning erections,
frequency of paraphilic activities, preoccupation with

Table 14.5 Pharmacokinetic Properties of MPA

Molecular Structure/
Chemical Name

Bioavailability

Maximum Plasma Half-Life

Metabolized

Pregn-4-ene-3,20-dione, 17
(acetyloxy)-6-methyl-, 6 ()

Orally and parenterally

Between 3060 hours

Hepatically

PHARMACOLOGICAL TREATMENT OF PAR APHILIC SEX OFFENDERS

paraphilic fantasies). A two-tailed sign test was used

to compare pretreatment with posttreatment measures. Paraphilic symptoms decreased in all patients,
with serum testosterone levels paralleling changes in
patients self-reports. None of the patients relapsed
during this trial.
In a naturalistic follow-up study, Kravitz and colleagues (1995) treated a heterogeneous cohort of 29
paraphilic patients with intramuscular MPA. Dosages
ranged from 300 to 900 mg per week. In addition to
pharmacotherapy, patients attended weekly group
psychotherapy sessions. Treatment response was measured via self-report ratings. All patients reported a
decrease in paraphilic symptoms. Side effects included
muscle cramps, weight gain, headaches, fatigue, drowsiness, sleepiness, and lethargy. Four patients experienced depressive and anxiety-related symptoms.
Of note, one patient suffered a nonlethal episode of
pulmonary embolism and another patient recidivated
during the trial period.
In a retrospective study, Meyer et al. (1992) presented data on a heterogeneous cohort of 40 patients,
presenting with pedophilia (n = 23), exhibitionism
(n = 10) and rape behavior (n = 7). Treatment
consisted of intramuscular MPA, sex offender group
therapy, and individual psychotherapy. MPA was
given for up to 12 years with dosages ranging from
400 mg to 800 mg per week. Thirty-two percent of
the MPA treatment group presented with comorbid
psychiatric disorders, primarily personality disorders.
Twenty-one patients, presenting with similar clinical
characteristics, but refusing MPA therapy, served as
the control group. Eighteen percent reoffended while
on MPA. Reoffense rates were higher for those who
refused or discontinued MPA (58 vs. 35). MPA related
side effects included: excessive weight gain (33%),
malaise (3%), migraine headaches (3%), leg cramps
(6%), hypertension (8%), gastrointestinal symptoms
(6%), and gallbladder stone formation (10%). Three
subjects (8%), suffering from obesity, developed diabetes mellitus.
Although MPA and CPA have somewhat different
pharmacodynamic properties (see the preceding text),
both agents seem to be equally effective in reducing
paraphilic symptoms.
In a 28-week double-blind, placebo-controlled
trial, Cooper et al. (1992) treated seven pedophilic
men with MPA, CPA, or placebo. Six subjects presented with at least one comorbid paraphilia, including sexual sadism, sexual pyromania, exhibitionism,

199

fetishism, transvestic fetishism, or zoophilia. Treatment

outcome was correlated to self-report, observed behavior, hormonal, and penile plethysmograph data. Both
medications were equally effective in ameliorating
paraphilic symptoms. Maximum treatment effects
were reached by the eighth week. Clinically significant side effects were not reported. None of the subjects recidivated during the duration of the study.
Luteinizing Hormone-Releasing
Hormone Agonists
Leuprolide acetate (leuprolide), a synthetic and potent
nonapeptide analog of endogenous gonadotropinreleasing hormone (GnRH analogue), has been used
to treat advanced prostate cancer, estrogen-dependent
disorders (i.e., endometriosis and uterine fibroids),
and central precocious puberty (Conn & Cowley,
1991; Smith, 1986; Williams et al., 1983). Given their
testosterone-lowering properties, GnRH analogues
have also been used to treat paraphilic sex offenders.
Luteinizing hormone-releasing hormone (LH-RH)
agonists exert a kindling effect on the pituitary gland,
which in turn causes an initial, but transient, increase
in gonadotropin and hence testosterone and dihydrotestosterone secretion. This initial surge in sex
hormone production can be attenuated or averted
with the concurrent administration of an antiandrogen (MPA, CPA, flutamide). Continuous treatment
with the LH-RH agonist eventually results in a down
regulation of GnRH receptors and thus sex hormone
production. In fact, testosterone and dihydrotestosterone (estrone and estradiol in premenopausal women)
decline to prepubertal (postmenopausal) levels within
2 to 4 weeks (Briken, Hill, & Berner, 2003; Rich, &
Ovsiew, 1994). Hormonal levels return to pretreatment levels following medication discontinuation. As
an example for the LH-RH agonists, the pharmacokinetic properties of leuprolide acetate are described
in Table 14.6.
In contrast to CPA and MPA, leuprolide lacks oral
bioavailability and thus has to be given intramuscularly. Doses range from 3.75 to 7.5 mg per month or
11.25 to 22.5 mg every 3 months. Although LH-RH
agonist therapy is less likely to cause steroid-induced
side effects, a number of adverse effects have been
described. These include but are not limited to hot
flashes, headaches, peripheral edema, dizziness,
anorexia, nausea, vomiting, diarrhea, constipation,
muscle and bone pain, blurred vision, paresthesias,

200 TREATMENT

Table 14.6 Pharmacokinetic Properties of Leuprolide Acetate

Chemical Name

Bioavailability

Elimination Half-Life

Metabolized

Metabolites

5-oxo-l-prolyl-histidyll-tryptophyl-l-seryl-ltyrosyl-d-leucyl-l- leucyll-arginyl-N-ethyl-lprolinamide acetate

Lacks oral bioavailability

3 hours

Hepatically
by peptidase

Inactive Dipeptide,
Tripeptides, and
Pentapeptide

acne, rash, seborrhea, alopecia, breast tenderness,

testicular atrophy, and urinary dysfunction. Serious,
but less common side effects are hematological, cardiovascular, and metabolic in nature, and include
leukopenia, pure red cell aplasia, pulmonary embolism, thrombosis, myocardial infarction, arrhythmias,
gastrointestinal bleed, hypertriglyceridemia, hyperphosphatemia, and bone demineralization (see the
following text). Erythema multiforme, gynecomastia, and anaphylaxis (Dickey, 1992) have also been
reported. Because of its side effect profile, leuprolide
should not be given to patients sufferings from congestive heart failure, gastrointestinal ulcers, and pituitary gland abnormalities (Morsi, Jamal, & Silverberg,
1996).
Osteopenia and osteoporosis
Long-term treatment with a GnRH analogue can
cause hypoandrogenism, which in turn has been associated with a decrease in bone mineral content and/
or bone mass (Dickey, 2002; Grasswick & Bradford,
2003; Krueger & Kaplan, 2001). Therefore, patients
presenting with risk factors for osteoporosis (e.g.,
family history of osteoporosis, low body mass index,
heavy abuse of alcohol or nicotine, chronic use of steroids, etc.) should be closely monitored for signs of
osteopenia. Patients, who present with pretreatment
osteopenia or osteoporosis, should be referred to an
endocrinologist to determine the etiology of their
metabolic abnormality.
Prophylactic treatment with calcium, vitamin D,
and a biphosphonate agent, such as alendronate,
should be considered in those patients who require
long-term GnRH analogue therapy.
Selected Studies Pertaining to the
Luteinizing Hormone-Releasing
Hormone Agonists
Dickey (1992) described the case of a patient with
pedophilia, voyeurism, exhibitionism, and fetishism.

Treatment with high dosages of intramuscular MPA

(550 mg per week) and CPA (500 mg per week) had not
shown satisfactory results. Consequently, leuprolide
acetate was prescribed at a dose of 7.5 mg per month.
Masturbation to deviant sexual fantasies decreased
after about 2 weeks, and more importantly, deviant
sexual activities ceased completely. Side effects were
not reported.
Krueger and Kaplan (2001) treated a heterogeneous cohort of 12 sexually disordered men with leuprolide acetate, using a dose of either 3.75 or 7.5 mg
per month for a period of 6 months to about 5 years.
Psychiatric comorbidity was prevalent among the
cohort (e.g., substance abuse, mood, and personality
disorders). All subjects reported a decrease in paraphilic symptoms. Testosterone levels decreased to
prepubertal levels. Side effects included erectile and
ejaculatory dysfunction, gynecomastia, nausea, and
depression. Three subjects, on long-term leuprolide
therapy, showed a decline in their bone mineral density indices.
Briken et al. (2001) treated 11 paraphilic patients,
diagnosed with pedophilia, sexual sadism, and sexual impulsiveness, with leuprolide acetate (11.5 mg
every 3 months). Personality and learning disorders
were prevalent among the cohort. (Six patients were
previously treated with CPA.) Frequency of sexual
fantasies and sexual activity decreased with leuprolide acetate treatment. Side effects included but
were not limited to weight gain, depression, and
pain at the injection site. Sexual recidivism rates
were zero.
In a case report series, Saleh et al. (2004) treated six
treatment-resistant male paraphilic patients, ranging
in age between 18 and 21 years, with monthly intramuscular injections of leuprolide acetate (7.5 mg/
month). Patients met DSM-IV-TR diagnostic criteria
for at least one paraphilic disorder. Comorbidity
was prevalent and consisted of conduct disorder,
attention-deficit/hyperactivity disorder, bipolar disorder, and Tourettes disorder. Three patients had
histories of mild to moderate mental retardation,

PHARMACOLOGICAL TREATMENT OF PAR APHILIC SEX OFFENDERS

and one patient was diagnosed with Klinefelters

Syndrome (for a review on paraphilic patients with
Klinefelters Syndrome see Berlin, 1983). Treatment
outcome was based on self-report data and staff
observations. All patients, except for one, reported
a substantial decrease in paraphilic symptoms. One
patient required augmentation with MPA for residual
pedophilic symptoms. Clinicians rated four patients
as much improved and two as moderately improved.
Clinically significant side effects were not reported.
Triptorelin, another long-acting LH-RH agonist,
has also been shown to be effective in the treatment of the paraphilias (Rosler & Witztum, 1998;
Thibaut, Cordier, & Kuhn, 1993). In an open label
study, Thibaut et al. (1993) described the cases of six
paraphilic subjects presenting with either pedophilia
or exhibitionism. One subject was diagnosed with
both exhibitionism and sexual sadism. Moreover,
three subjects carried a diagnosis of mild to moderate
mental retardation, two subjects were diagnosed with
a personality disorder, and one subject was diagnosed
with mixed bipolar disorder. Treatment consisted of
monthly intramuscular injections of 3.75 mg triptorelin and monthly psychotherapy sessions. CPA at
a mean dose of 200 mg per day (mean duration
4.5 months) was given in conjunction with triptorelin to counteract the initial surge in testosterone
secretion. Frequency and intensity of deviant sexual
fantasies and activities decreased with treatment.
Follow-up periods ranged from 7 months to 3 years.
Although usually well tolerated, a few patients developed hypoandrogenism-related side effects.
One patient relapsed within 10 weeks after withdrawing from treatment.
In an uncontrolled observational trial (the largest
study to date), Rosler and Witztum (1998) treated 30
paraphilic men (mean age of 32 years) with monthly
intramuscular injections of 3.75 mg triptorelin and
supportive psychotherapy. Patients were treated for
a period of 8 to 42 months. Twenty-five patients
presented with severe pedophilia, whereas five
patients had other paraphilias. Comorbidity was
prevalent among the cohort and consisted of psychotic illnesses such as schizophrenia or schizoaffective disorder (n = 6), personality disorders
(n = 9), and affective disorder (n = 2). Two patients
had obsessive-compulsive disorder. Seven men had
previous trials with CPA. Treatment outcome was
based on self-reports, using questionnaires, such
as the Intensity of Sexual Desire and Symptoms
Scale as well as the Three Main Complaints

201

Questionnaire. Paraphilic symptoms decreased

within a relatively short time period in all but one
subject. Frequency of deviant sexual behavior
decreased to zero. Testosterone levels decreased
to prepubertal levels, paralleling the decrease in
paraphilic symptomatology. Levels returned to baseline values within 2 months after discontinuation of
triptorelin. Treatment effects persisted over time in
patients receiving triptorelin for 12 or more months.
Three men discontinued treatment because of side
effects. Bone mineral density indices decreased in
11 men. Other side effects included progressive erectile failure (n = 21), unrelenting hot flashes (n = 6),
decreased growth of facial and body hair (n = 3), as
well as asthenia and muscle tenderness (n = 2).
In a placebo-controlled, blinded, 2-year study,
Schober and colleagues (2005), treated five pedophiles
with leuprolide acetate (22.5 mg every 3 months for a
total of four injections). Subsequently, patients were
given four consecutive placebo injections (normal
saline injections every 3 months for 1 year). Outcome
measures included self-report, penile plethysmograph,
polygraph, and visual reaction time data. None of the
patients reoffended and all favored treatment over
placebo. During the placebo phase of the study, three
patients had reoccurring pedophilic symptoms. Hot
flashes and weight gain were the most common side
effects; breast tenderness was a less common reported
occurrence. None of the patients dropped-out off
treatment. (Table 14.7)

CONCLUSION

In the era of evidence-based medicine, treatment

decisions should be based on accurate diagnosis and
unambiguous scientific and treatment data. This is
particularly important when it comes to symptomatic
paraphilic sex offenders. Prescribing a medication
to a paraphilic sex offender that has little-to-no real
impact on his or her underlying paraphilia could have
devastating consequences for both the offender (e.g.,
sexual recidivism, civil commitment as a sexual predator, etc.) and the public at large. As described in this
chapter, testosterone-lowering medications reduce
the frequency, severity, and intensity of paraphilic
symptoms within a short period of time. Similarly,
and even more importantly, sexual recidividism
rates in sex offenders treated with these agents parallel those of orchiectomized offenders (Berlin, &
Meinecke, 1981; Berlin et al., 1991; Ortman, 1980).

Table 14.7 Studies from 1985 to 2005 Using Leuprolide Acetate or Triptorelin
Study (author & year of
publication)

Paraphilia Diagnosis or
Diagnoses

Type of
LH-RH Treatment

Previous
Testosterone-Lowering
Medications

Duration of
Follow-up Period

Pertinent Findings

Allolio et al., 1985

Pedophilia

Leuprolide

CPA

No follow-up

Greater efficacy than CPA

Rousseau et al., 1990

Exhibitionism

Triptorelin, flutamide

None

6 months

Sexual functioning maintained despite

prepubertal testosterone levels.
No significant side effects reported

Dickey, 1992

Exhibitionism,
pedophilia, voyeurism,
fetishism

Leuprolide

MPA 550 mg per week and

CPA 500 mg per week

6 months

Paraphilic behaviors ceased No side effects

reported

Marcus et al., 1993

Exhibitionism

Leuprolide

MPA

No follow-up

Cooper & Cernowsky, 1994

Pedophilia

Leuprolide

CPA, placebo

4 years

Greater efficacy than CPA Outcome

measure included penile plethysmograph

Thibaut et al., 1993, 1996

Pedophilia (4),
exhibitionism (1),
exhibitionism/sexual
sadism (1)

Triptorelin

CPA (5)

17 years

Two patients relapsed following

discontinuation of treatment

Gottesmann & Schubert,

1993

Rape (1), pedophilia

(1), exhibitionism (1),
fetishism(1)

Leuprolide

MPA (3)

10 months

Greater efficacy than MPA

Rsler & Witztum, 1998

30

Pedophilia (25), other (5)

Triptorelin

CPA (9), antidepressant (7),

narcoleptics (9), lithium(2)

Up to 42
months

Greater efficacy than CPA SSRIs. Decrease

in bone mineral indices in 11 patients.
Two patients relapsed after switching
to CPA

Briken et al., 2001

11

Sexual sadism (4),

pedophilia (4), sexual
impulsiveness (3)

Leuprolide

CPA (6)

1 year

Personality and learning disorders prevalent.

Greater efficacy than CPA. Sexual
recidivism rates zero

Krueger & Kaplan, 2001

12

Pedophilia (6), mixed (6)

Leuprolide

MPA (2), antidepressant (9),

other (7)

Up to 57
months

Psychiatric comorbidity prevalent.

No relapses. Three patients, receiving
long-term leuprolide therapy, developed
osteopenia

Grasswick & Bradford,

2003

Sexual sadism, pedophilia

Leuprolide

CPA

4 years

Mild and reversible osteoporosis

Saleh et al., 2004

Pedophilia (5),
Paraphilia NOS(1),
sexual sadism (1),
frotteurism (2)

Leuprolide

Antipsychotic (5) medications,

mood stabilizing
agents (3), lithium (1),
antidepressants (3),
MPA (1)

Up to 16
months

High comorbidity for psychiatric disorders.

Hypoandrogenism-related side effects. One
patient required augmentation with MPA.
No relapses reported

Saleh, 2005

Paraphilia NOS and

hypersexuality

Leuprolide

None

6 months

Outcome measure included penile

plethysmograph. Serial hormonal
profiles

Schober et al., 2005

Pedophilia

Leuprolide

12 months

Decrease in masturbation to pedophilic

imagery and pedophilic urges
Pedophilic interest as measured did not
change

Adapted and updated from Briken, et al., 2003.

204 TREATMENT

Notwithstanding the aforesaid, and despite the

growing body of literature describing the beneficial
effects of the testosterone-lowering medications,
it is critical to point out that testosterone-lowering
medications should not be considered a panacea for
all sexual offending behavior. It is also important to
bear in mind that these medications are not devoid
of side effects. Quite to the contrary, not only is there
a dearth of long-term safety data, but these medications can cause serious, and sometimes, irreversible
side effects. As such, testosterone-lowering medications should be only used in carefully selected and
closely monitored sex offenders suffering from genuine paraphilic disorders.
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Part V

Juveniles

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Chapter 15

Forensic Evaluations of Juvenile Sex

Offenders
Charles Scott

Forensic expertise is often requested in situations

involving a juvenile sex offender. But what does the
term forensic actually mean and how does this
evaluation process differ from the provision of clinical care? The American Academy of Psychiatry and
the Law (AAPL) provides the following definition of
forensic psychiatry in its Ethics Guidelines (American
Academy of Psychiatry and the Law, 2005):

This chapter outlines important issues in conducting

the forensic evaluation of a juvenile sex offender and
special types of evaluations that may be requested
when a juvenile is charged with a sexual offense in
either a juvenile or an adult court.

CONDUCT ING THE FOR ENSIC

EVA LUAT ION

Forensic Psychiatry is a subspecialty in which scientific and clinical expertise is applied in legal
contexts involving civil, criminal, correctional,
regulatory matters, and in specialized clinical
consultation in areas such as risk assessment or
employment.

Step One: Clarify the Request

The mental health professional must have a clear
understanding of what they are being asked to do.
In particular, is the requested evaluation for treatment purposes or for a legal purpose? Understanding
this question in advance is necessary to avoid serving as both treatment provider and forensic expert,
a concept known as dual agency or dual role. If the
clinician has treated the youth before or following
the alleged offense, he or she should generally avoid

Although clinical assessment skills are important

when conducting a forensic examination of a juvenile sex offender, providers must be aware that having clinical expertise is vastly different than having
the requisite skills to perform a forensic examination.
211

212 JUVENILES

providing an expert witness opinion on any forensic legal issue. The AAPL Ethics Guidelines for the
Practice of Forensic Psychiatry address this potential
conflict as follows (American Academy of Psychiatry
and the Law, 2005):
Psychiatrists who take on a forensic role for
patients they are treating may adversely affect
the therapeutic relationship with them. Forensic
evaluations usually require interviewing corroborative sources, exposing information to public
scrutiny, or subjecting evaluees and the treatment
itself to potentially damaging cross-examination.
The forensic evaluation and the credibility of the
practitioner may also be undermined by conflicts
inherent in the differing clinical and forensic
roles. Treating psychiatrists should therefore generally avoid acting as an expert witness for their
patients or performing evaluations of their patients
for legal purposes.
In situations where the mental health professional
is asked to provide an expert witness opinion, they
should evaluate if they have the appropriate expertise
in the area requested. Ones expertise can be assessed
by evaluating their particular knowledge, training,
experience, skills, or education related to the referral
question. In addition, the evaluator must understand
the relevant legal standard, the skills to evaluate the
juvenile in relationship to this standard, the capacity to apply information to the legal construct, and
the capability to effectively translate and communicate their findings in the context of the legal system
(Grisso, 1998a).
The examiner should also carefully determine the
exact party requesting the evaluation. Is the evaluation being requested by the court, the defense attorney, the prosecutor, the family, or as a consultation
to a treatment team? One must also understand who
is responsible for paying for the evaluation and any
limitations on compensation. Finally, the evaluator
should inquire into any specific deadlines regarding
when the evaluation must be conducted, date any
written report must be submitted, and any proposed
trial dates for expert testimony.
Step Two: Understand the Juveniles Legal
Rights regarding the Interview
The mental health professional should determine
all parties that must be notified in advance of the

assessment and if any special approval or consent

is required before meeting with the juvenile. The
answer to this question is necessary so that the evaluator can adequately inform the youth, their legal
guardian, and their attorney regarding the parameters
of confidentiality. When appropriately informed, the
juveniles attorney has the opportunity to educate his
client on the nature of the evaluation, the extent of
confidentiality, and the potential for self-incriminating statements. Some jurisdictions allow the attorney
to be present during certain types of evaluations.
In these situations, it is helpful to communicate in
advance to the attorney the general nature of the
interview and to explain that interference or disruptions may potentially contaminate the interview and
should be avoided.
In general, a juveniles statements to mental health
professionals who are requested by the court and/or
the prosecutor to conduct a forensic evaluation are
not confidential. The practitioner may be asked
to prepare a report or testify in court regarding the
evaluation and any opinions. In addition to obtaining
an oral consent to the interview, the evaluator should
consider providing the youth, their parent, and their
attorney a written statement outlining the nature of
the evaluation, the reason for the evaluation, the parties who will likely have access to the evaluation, and
the parameters of confidentiality. In those situations
where the interview is either audio- or videotaped, the
consent process should also be recorded (Nye, 1992).
Failure to adequately inform the juvenile defendant regarding potential consequences of the interview may result in the court excluding statements
made by the defendant. For example, in the Canadian
case R. v. MacDonald, an adult defendant was interviewed by a psychiatrist retained by the prosecution
two days after the defendant had requested legal
counsel (R. v. MacDonald, 2000). The psychiatrist
later testified that he had informed the defendant that
he was hired by the police, that his statements were
not privileged or confidential, that the defendant was
not required to speak with him, and that he could contact his attorney for legal advice. Although the defendant was unable to reach his attorney by phone that
same day, he agreed to proceed with the interview.
The defense counsel challenged the use of statements
made by the defendant during the psychiatric evaluation emphasizing that the prosecution had used the
psychiatrist to obtain evidence regarding the defendants mental state at the time of the offense without

FORENSIC EVALUATIONS OF JUVENILE SEX OFFENDERS

notification of the defense counsel. On appeal, the

Ontario Superior Court of Justice held that the psychiatrist had not adequately informed the defendant
regarding the true purpose of the visit and the potential results of the interview. According to the Court,
the defendant was deprived of a meaningful and free
choice regarding his participation in the evaluation
and statements he made to the psychiatrist were
therefore not admissible. In addition, the Court noted
that the defendant had not been allowed a reasonable
opportunity to obtain legal advice regarding his rights
related to the interview request.
To avoid any misconception about the forensic
examination, the evaluator may wish to prepare in
advance a statement regarding their role. The exact
statement may vary depending on who has retained
the expert. An example of a nonconfidentiality warning for a prosecution-or court-retained examination is
as follows (Giorgi-Guarnieri et al., 2002):
I am a physician and psychiatrist who has been
asked by [the court or the prosecuting attorney]
to evaluate you in regards to ______________.
(The examiner should provide clear age appropriate language that details the exact nature of the
referral question). Although I am a psychiatrist,
I will not be treating you. My purpose is to provide an honest evaluation, which you, your parent (or guardian), or your attorney may or may not
find helpful. You should know that anything you
tell me is not confidential, as I may be requested
to testify in court or to prepare a report that the
judge, the prosecutor and your attorney will read.
It is important that you be honest with me. You
dont have to answer every question, but if you
choose not to answer on, your refusal will be noted
in my report. Do you have any questions? Do you
agree to continue with the interview?
For those evaluators who are retained solely by the
defense attorney, their findings are generally disclosed
only when the defense attorney determines that this
is in the best interest of their client. Therefore, the
explanation provided to the juvenile in this circumstance differs. An example of a confidentiality warning in a jurisdiction where the defense evaluator is
working under the attorneyclient privilege reads
(Giorgi-Guarnieri et al., 2002):
I am a physician and psychiatrist who has been
asked by your defence attorney to evaluate you

213

in regards to ____________________. (The

examiner should provide clear age appropriate
language that details the exact nature of the referral question). Although I am a psychiatrist, I will
not be treating you. My purpose is to provide an
honest evaluation, which you, your parent (or
guardian), or your attorney may or may not find
helpful. If your attorney feels my opinion is helpful, what you tell me will be revealed in a report
or in testimony in court. If your attorney feels my
opinion is not helpful to your case, only you, your
attorney and I will know what we discussed. It is
important for you to be honest with me. You dont
have to answer every question, but if you choose
not to answer one, your refusal will be noted in my
report. Do you have any questions? Do you agree
to continue with the interview?
Even if a youth does not wish to have an attorney,
one is appointed for her or him. Should a juvenile
refuse legal counsel and demand to represent him
or herself, then the evaluator must follow jurisdictional guidelines governing this extremely rare situation. Depending on the age of the juvenile, whether
they are in adult versus juvenile court, and the legal
standard governing competency to represent oneself,
there is a remote possibility that an evaluator could
be required to work with the juvenile acting as their
own legal counsel.
The examiner must also communicate to the
juvenile those situations that legally mandate sharing
of specific information. For example, if the juvenile
makes a threat to harm a third party, many jurisdictions require reporting this information so that the
potential victim can either be warned or steps may
be taken to protect the victim. Furthermore, if the
youth is presently involved in other offenses, such as
ongoing sexual abuse of a sibling or another youth,
then notification of Child Protective Services or
appropriate child welfare agencies is likely required.
In most jurisdictions, there is no legal requirement to
notify authorities regarding past crimes committed.
However, if the juvenile communicates prior criminal behavior despite the nonconfidentiality warning,
such statements could result in an investigation of
potential additional charges.
If the examiner determines that the juvenile is so
mentally ill that they cannot participate in the examination or that the examination would result in present
harm, then the examiner may need to end the interview and notify appropriate parties of their concerns.

214 JUVENILES

Furthermore, if the evaluator discovers that the youth

is suicidal or homicidal at the time of the interview,
then appropriate clinical interventions and notification of third parties are generally required even when
the examination is for legal purposes.
Providers who treat a juvenile accused of a sexual
offense should be aware of the distinct possibility that
their treatment notes will be requested by a forensic
evaluator. In particular, the juvenile may provide
information relevant to a mental health defense that
does not require mandatory disclosure to third parties. For instance, a juvenile may report that they
were using drugs at the time of the offense or may
fake psychiatric symptoms to help create a mental
health defense. All of this information may be discoverable if a court orders the release records of the
treatment provider. Providers who receive a subpoena
for their treatment records should consider reviewing
this request with their risk management office or legal
counsel to determine the legality of the request. In
addition, informing the legal guardian and juveniles
attorney (if they are not aware) of the request may
assist in ensuring that the youth has not waived his or
her privilege to confidentiality.
Step Three: Obtain Necessary
Collateral Information
Collateral records and interviews are important when
assessing the juvenile sex offender. When court
appointed, juvenile court policies should outline the
party responsible for obtaining consents from the
court client when the evaluator requests records or
permission to speak to third parties. Depending on
the nature of the evaluation, state statute, court policy,
and/or parental consent may determine the extent to
which collateral information may be redisclosed. In
situations where there is no governing policy, the evaluator should consider seeking a legal opinion from the
courts legal officer or their own attorney in regards to
obtaining and rereleasing collateral records and information from collateral informants (Nye, 1992).
Specific collateral records usually reviewed by the
forensic examiner include police reports and witness
statements regarding the alleged offense, the juveniles legal history, prior psychiatric treatment, previous juvenile court interventions, medical records,
academic performance, and occupational records.
The evaluator may also need evaluations from other
mental professionals before they are able to form a

forensic opinion. Such information may include

psychological testing, intelligence and educational
testing, and medical consultation.
Step Four: Communicate Findings
In all situations involving a forensic evaluation, the
examiner should preserve their interview notes and
any audio or visual recordings related to the examination. When privately retained by defense counsel,
the examiner typically provides a verbal consultation
to the retaining attorney following their assessment.
Depending on the results, the defense counsel may
request a written report or may decide not to use the
retained expert. When court appointed or retained
by the prosecution, the examiners findings are not
confidential and the examiner may be required to
either provide a written report or testify in a legal
proceeding.
When preparing a written report, the examiner
should clearly document all records and persons
interviewed, examination dates, the juveniles statements during the interview, any testing performed,
and summarized information provided by collateral
interviews. The opinion should clearly address the
specific referral question/s with language that avoids
psychiatric jargon in a manner easily understood by
a lay person.

SPECI A L T Y PES OF EVA LUAT IONS

Disposition Hearing
In juvenile court, the disposition hearing occurs after
the adjudication phase and is the aspect of the juvenile court process that most closely symbolizes the
rehabilitative intent of the juvenile justice system as it
focuses on each youths potential for positive change.
In England, this hearing is referred to as an order on
such a finding. At the disposition hearing, the evaluator informs the court of their assessment findings
and makes recommendations regarding appropriate
placement. Assessment methods and factors associated with a juveniles risk of future sexual offending
are outlined in other chapters of this book.
The evaluator may be pressured to make placement recommendations based on what is available
in the community rather than what is necessary to
provide appropriate care. Despite the treatment

FORENSIC EVALUATIONS OF JUVENILE SEX OFFENDERS

limitations in the community, the mental health professional must state what the youths actual treatment
needs without making clinical comprises due to lack
of financial resources. Second choice recommendations should be clearly defined as the best alternative
among the available resources. Failure to provide
honest recommendations exposes the forensic evaluator to a host of potential complaints to include accusations of unethical professional conduct, complaints
to licensing boards, and a potential malpractice suit
(Nye, 1992).
Waivers to Adult Court
In many countries, juveniles who are of a certain age
and/or have committed a certain offense can be transferred, or waived, to an adult court for their trial. If
found guilty in adult court they can also face an adult
sentence. In the United States, the most common
mechanism for transferring a youth from juvenile
court to adult court involves a judicial waiver (also
known as a discretionary waiver, bind-over, certification, transfer, or remand hearing). In the 46 states with
a judicial waiver mechanism, a juvenile court judge
decides whether to transfer the youth to adult court
for prosecution. Because this hearing required information about the youth and their background where
information is presented to the judge, this particular
hearing represents the waiver process most likely
to involve input from a mental health professional.
Before beginning the judicial waiver evaluation, the
clinician should request a copy of his or her states
statute defining criteria for a judge to consider when
determining if a youth should be tried as an adult. In
general, most state statutes require the mental health
clinician to evaluate two key areas: (1) the youths risk
of future dangerousness; and (2) the youths amenability to treatment. Because a waiver hearing may
result in the juvenile being tried in adult court, the
report should address the juveniles competency to
stand trial in adult court if not specifically required
by the examiners jurisdiction (Benedek, 1985).
In some U.S. states, legislatures have passed statutes that automatically place youth of a certain minimal age who have committed a specified offense in
the adult court system, a process known as legislative
waiver. Although states vary in defining what offenses
qualify for transfer, they generally involve violence,
such as murder, manslaughter, and/or rape. No consideration of future dangerousness or amenability to

215

treatment is considered in a legislative transfer as the

transfer is automatic once predefined criteria are met
(Scott, 2002).
In England and Wales, juveniles may be transferred from the jurisdiction of the juvenile system to
that of the Crown Court (adult court) under section 53
of the Children and Young Persons Act 1933. Initially,
this Act limited the offenses qualifying for transfer
to murder, manslaughter, and wounding with intent
to cause grievous bodily harm. However, in 1961
the range of offenses was extended by the Criminal
Justice Act to include those offenses for which an
adult could be sentenced for 14 years or more. This
expansion allowed juveniles charged with robbery,
arson, burglary, and some sexual offenses to be tried
by the Crown Court (Morris & Gelsthorpe, 1993).
In contrast to the aforementioned trends in both
the United States and Great Britain, Canada passed
the Youth Criminal Justice Act (YCJA) in 2003, which
eliminated the transfer hearing. Instead, a possible
adult sentence can be imposed only after the youth has
been found guilty in juvenile court. While the YCJA
does lower the presumption of an adult sentence to
youth 14 years of age or older, each province has the
authority to set the age at 15 or 16 years should they so
choose (Department of Justice, Canada, 2007).
Waiver of Miranda Rights
When police take a juvenile suspected of committing a sex offense into custody they are interested in
obtaining a statement or confession from the youth
regarding their involvement in the alleged offense.
According to the U.S. Supreme Court holding in
Miranda v. Arizona, suspects must be informed
that they have a constitutional right to avoid selfincrimination and the right to an attorney during
questioning. These rights have been extended to
youth involved in juvenile court proceedings (In re
Gault, 1967; Kent v. United States 1966). In some
states, police officers must arrange for the youth to
have contact with a parent, guardian, or other interested adult when the youth is advised regarding the
waiver of his or her Miranda rights during police questioning. When determining if a constitutional right
has been waived, the U.S. Supreme Court articulated
in Johnston v. Zerbst (1938) that any such waiver must
be done voluntarily, knowingly, and intelligently.
The forensic evaluator may be requested to determine whether an alleged juvenile sex offender had

216 JUVENILES

the capacity to waive his or her Miranda rights when

giving a statement or confession. If a youth is assessed
as not having the requisite ability, his or her statements may ultimately be deemed inadmissible. Two
key areas for the evaluator to consider in evaluating a
juveniles waiver of Miranda rights include (1) the circumstances under which the youth made the confession; and (2) characteristics of the particular youths
capacity to make a waiver. In examining the conditions of confinement when the youth waived his or
her right, the evaluator should review the length of
time the youth was detained without the opportunity
to communicate with others, the physical conditions
of the holding environment, any contact with other
persons (particularly adults), access to food, water,
and other basic necessities, and any behaviors by officers that may have resulted in fear or created an environment of coercion (Grisso, 1998b).
The second component of this forensic evaluation requires the evaluator to carefully examine the
individual juveniles capacity to waive his or her
Miranda rights. Three important areas suggested by
Grisso (1998b) to review when assessing this capacity include the youths ability to comprehend the
Miranda warning, the ability to grasp the significance
of rights in the context of the legal process, [and] the
ability to process information in arriving at a decision
about waiver. Comprehension of the Miranda warning addresses the youths ability to understand the
warning and to appreciate that they are not required
to answer police questions. To understand the significance of the Miranda warning, the juvenile must
not only recognize that he or she has a right to have
an attorney present but also that the defense counsel
serves as his or her advocate. The ability to process
the warning requires some capacity for abstract reasoning as the youth must weigh short-term and longterm consequences of the decision to waive the right
to self-incrimination.
Important collateral records in this assessment
may include mental health evaluations, interviews
with parents, delinquency records, police investigation reports, and audio and/or videotapes of the
youths questioning and confession. If the evaluator
has concerns regarding the youths cognitive abilities,
cognitive measures of intellectual ability, and academic records may be indicated. Four standardized
assessment tools to evaluate a youths ability to comprehend and appreciate the Miranda rights have been
developed by Dr. Thomas Grisso in collaboration

with the National Institute of Mental Health. These

tools include the Comprehension of Miranda Rights,
Comprehension of Miranda RightsRecognition,
Comprehension of Miranda Vocabulary, and the
Function of Rights in Interrogation. Grisso recommends that in addition to information about the
youths psychosocial background information, the
evaluator should include sections that specifically
describe the juveniles current ability to comprehend
the Miranda warnings and their significance, an
explanation of any discovered deficits and their relationship to the youths capacity to waive the Miranda
rights, a discussion addressing the possibility of dissimulation and malingering, and a description of
those conditions involving the police encounter,
disclosure of the Miranda rights, and the juveniles
response.
Competency to Stand Trial Evaluations
The substantive standard for competency to stand
trial (CST) in the U.S. was established by the United
States Supreme Court in Dusky v. United States (1960).
The Dusky court defined the test of competency to
stand trial as whether the accused has sufficient present ability to consult with his lawyer with a reasonable
degree of rational understanding and whether he has
a rational as well as factual understanding of the proceedings against him (Dusky v. United States, 1960).
This standard focuses on two primary areas: (1) the
individuals cognitive abilities to understand the trial
process; and (2) the individuals ability to assist their
attorney in their defense (Voigt, Heisel, & Benedek,
2002).
Although the Dusky standard did not specifically
state that a mental disease or defect is necessary to find
trial incompetency, the vast majority of state statutes
require some type of mental disorder as the predicate
basis for an incompetency to stand trial finding. The
CST examination focuses on the presence of mental
health symptoms at the time of the interview. The
presence of a mental illness alone, however, does not
automatically render a person incompetent to stand
trial. The evaluator must illustrate the relationship
of the mental illness to specific deficits in the defendants understanding of the trial process or ability to
cooperate with their attorney in their defense.
Numerous CST assessment instruments have
been utilized in the adult population to assist the
evaluator in assessing competency and these include

FORENSIC EVALUATIONS OF JUVENILE SEX OFFENDERS

the Georgia Court Competency Test (GCCT), the

Competency Assessment Interview (CAI), the Interdisciplinary Fitness Interview (IFI), the Computer
Assisted Competency Assessment Tool (CACAT), the
MacArthur Competency Assessment Tool-Criminal
Adjudication (MacCAT-CA), and the Competency
Assessment for Standing Trial for Defendants with
Mental Retardation (CAST-MR). McGarry et al.
(1973) highlighted 13 areas to review when assessing
trial competency.
Grisso et al. (1987) recommend that a juveniles
trial competence be questioned if any one of the following conditions are present: (1) age 12 or younger;
(2) prior diagnosis/treatment for a mental illness or
mental retardation; (3) borderline intellectual functioning or learning disability; and (4) observations that
youth has deficits in memory, attention, or interpretation of reality. In a descriptive review of 136 juveniles
aged 9 to 16 years who were referred for evaluation
of trial competency in South Carolina, Cowden and
McKee (1995) found that 80% of youth aged 9 to
12 years were incompetent to stand trial, nearly 50%
of those aged 13 and 14 were trial incompetent, and
approximately 25% of 15- to 17-year-olds were incompetent to stand trial. Cooper (1997), in another study
of juvenile offenders in South Carolina, found that
a majority of juvenile offenders of all ages had significant deficits in their competence-related abilities.
Juveniles aged 13 and below and those with low average or below average IQ scores were particularly at
risk. The significance of these findings is that an opinion that a given juvenile is incompetent to stand trial
may be based solely on deficits due to developmental
immaturity, rather than to a specific diagnosis or cluster of symptoms. In this case, the opinion will need to
set forth, rather than a specific diagnosis, those specific abilities that are limited in a particular case.
Assessment of Insanity
(Criminal Responsibility)
Insanity is a legal, but not psychiatric, term. The
insanity evaluation determines whether a person is so
mentally disordered that they are not blameworthy or
criminally responsible for the behavior. In contrast to
CST evaluations that focus on a defendants present
mental capacity as related to their understanding and
participation in the legal process, an insanity evaluation involves a retrospective evaluation of a persons
past mental state at the time of their alleged offense.

217

Because a juvenile court adjudication of delinquency

was not traditionally considered a criminal conviction, raising the defense of insanity to excuse a juveniles delinquent behavior is not a common practice
in juvenile court. However, an understanding of the
criminal responsibility evaluation remains important
for two reasons: (1) Some jurisdictions now permit an
insanity defense in juvenile court; and (2) juveniles
who are transferred to adult court are eligible for the
insanity defense when applicable.
The most common test of insanity in the United
States is known as the MNaghten standard that
was developed in 1843 following the trial of Daniel
MNaghten. Mr. MNaghten was found not guilty by
reason of insanity after he attempted to assassinate the
prime minister of Britain and instead shot his secretary Edward Drummond. Queen Victoria, angered
by the legal outcome in this case, ordered her 15 Law
Lords to draft a new standard of criminal responsibility. The new standard recommended by the Lords
was as follows:
To establish a defence on the ground of insanity, it
must be clearly proved that at the time of the committing of the act, the party accused was labouring
under such a defect of reason, from the disease of
the mind, as not to know the nature and quality
of the act he was doing, or if he did know it, that
he did not know he was doing what was wrong.
(Miller, 1994, p. 199; MNaghtens Case, 1843).
This test is often referred to as the right/wrong test or
cognitive test because of its emphasis on the defendants ability to know, understand, or appreciate
the nature and quality of their criminal behavior or
the wrongfulness of their actions at the time of the
crime.
Canadas insanity standard represents a more
narrow version of the MNaghten standard in that
an analysis of the defendants understanding of the
nature and/or quality of their actions is not required.
For purposes of finding a person insane, section
16 of the Canadian Criminal Code states that the
courts must determine whether the accused, because
of a disease of the mind, was rendered incapable of
knowing that the act committed was something
that he ought not to have done (Criminal Code,
R.S.C., 1985). In reviewing whether the test should
be restricted solely to a defendants knowledge of the
legal wrongfulness of their actions, the Canadian
Supreme Court ruled that the insanity standard:

218 JUVENILES

ought to be interpreted simply in sense of what

one ought not to do, for whatever reason, legal or
moral. In practice, this has the effect in most cases
that where an accused is capable of knowing that
his or her act is legally wrong, he or she will be
held liable to the criminal process, regardless of
what his or her moral appreciation may have been
(R. v. Chaulk, 1990).
A second insanity test used in some jurisdictions is
known as the irresistible impulse test. In essence, this
test asks the evaluator to determine if the offenders
mental disorder rendered them unable to refrain
from their behavior, regardless if they knew the
nature and quality of their act or could distinguish
right from wrong. A major criticism of this test has
been the broadness of its scope. In other words,
because a defendant did not refrain from a particular criminal behavior, mental health clinicians could
use this as evidence that they could not resist their
impulse, thereby concluding that all criminal behavior not resisted equalled insanity. Despite its current
unpopularity as a measure of criminal responsibility, this test survives, in part, as both Virginia and
New Mexico combine the irresistible impulse test with
the MNaghten test (Giorgi-Guarnieri et al., 2002).
A third test used in only two jurisdictions in the
United States is known as the Durham rule or product test. This insanity test derived from a D.C. Circuit
case where Judge Bazelon allowed a finding of insanity if the defendants unlawful act was a product of
a mental disease or defect. As with the irresistible
impulse test, the product test expanded those eligible
for a finding of insanity and rapidly fell out of favor.
It is currently used in only two jurisdictions in the
United States, New Hampshire and the Virgin Islands
(Giorgi-Guarnieri et al., 2002).
A final test of insanity was developed in 1955 by
the American Law Institute (ALI) when formulating
the Model Penal Code. This test states,
A person is not responsible for criminal conduct
if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity
either to appreciate the criminal of his conduct
or to conform his conduct to the requirements of
the law. (Giorgi-Guarnieri et al., 2002; ALI Model
Penal Code, 1985).
This test involves both a cognitive arm (appreciates
the criminality of his conduct) and a volitional arm
(ability to conform behavior).

A mental health professional requested to conduct an insanity evaluation of a juvenile sex offender
should consider the following guidelines. First, the
evaluator should request that the attorney or court
provide them the exact language of the insanity statute as there are subtle yet important differences in the
wording among the various states. Second, it is important to understand how mental disorders or defects
are defined. The exact definitions of mental disease
and mental defect are usually found in either case law
and/or and statutes. The examiner should carefully
review if any disorders are prohibited from consideration for the insanity defense. Diagnoses commonly
excluded include voluntary intoxication with alcohol
or other drugs, personality disorders, and adjustment
disorders. Psychotic disorders, such as schizophrenia,
schizoaffective disorder, or mood disorders with psychotic features are the most common diagnoses that
qualify for an insanity defense. Although some youth
in early adolescence may demonstrate premorbid
symptoms of a significant thought disorder, they may
not meet formal diagnostic criteria for a DSM-IV
thought disorder, thereby making it difficult for them
to meet the mental disorder requirement of an insanity defense.
Third, the examiner must closely review all of the
defendants statements regarding their alleged crime
as well as available police reports and witness statements regarding the offense. Additional collateral
records that may be important include prior mental
health and medical records, academic records and
any educational testing, and detailed social background history from family members and individuals
who know the juvenile.
Even if the juvenile sex offender meets the jurisdictional criteria for a mental disorder or defect, having a
mental disorder does not equate with the legal definition of insanity. Once the evaluator has determined if
the juvenile meets the criteria for a qualifying mental disorder or defect, the evaluator must determine
the relationship, if any, between the mental illness
or defect and the alleged crime. Understanding the
motivation behind the juveniles actions is a critical
component of the insanity evaluation. The evaluator should obtain the juveniles account of the crime
in great detail by asking the youth to describe their
thoughts, feelings, and exact behaviors before, during, and after the alleged crime. It is important that
the evaluator consider all rational, rather than psychotic, motives for the criminal offense. For example,
if a juvenile commits an armed robbery to obtain

FORENSIC EVALUATIONS OF JUVENILE SEX OFFENDERS

money to buy drugs, the fact that they are depressed

will unlikely establish a sufficient relationship between their mental state and their criminal behavior
for purposes of the insanity defense. The final area
the examiner must consider is whether the juveniles
mental state at the time of the crime meets the jurisdictional requirements for an insanity defense. As
outlined earlier, there are various tests of insanity and
it is feasible that youth may qualify for the insanity
defense in one state but not in another.
In those jurisdictions that utilize some form of
the MNaghten test, the examiner should carefully
review if the juvenile meets the criteria for each component of this test according to the precise governing
language. In some states, the defendant must be so
impaired from a mental illness that they are unable
to know the nature and quality of their actions, or are
unable to distinguish right from wrong. In general,
an individual would have to be extremely impaired so
as to not be aware of or know his or her actions. For a
juvenile sex offender charged with the rape of a young
child, even the presence of a significant mental illness would unlikely render the individual so impaired
that he did not know that he was engaged in some
type of sexual activity. Evidence indicating that the
juvenile sex offender knew the nature of his or her
actions would include statements telling the victim
to undress or to get ready for sexual activity, wearing
a condom, or bringing a weapon for the purpose of
coercing the victim into sexual activity.
The more easily met component of the MNaghten
test involves whether the juvenile was able to know
or distinguish right from wrong at the time of the
offense. Evidence that the juvenile knew or understood the wrongfulness of his or her behavior would
include wearing a disguise during the sexual offense
to hide identity, taking the victim to a secluded or
private area, attempting to hide or destroy evidence,
threatening to harm the victim if they tell, having
the victim shower in an attempt to remove any bodily
fluid that could be used as evidence, lying to investigators regarding his or her actions, and fleeing from
the scene so as not to be discovered.
The insanity standard in some jurisdictions requires an analysis of the individuals ability to refrain
from his or her actions or to conform their conduct to
the requirements of the law. This analysis focuses on
how the juveniles mental disorder or defect affected,
if at all, his or her ability or capacity to control the
behavior. In this context, the forensic examiner is
evaluating if the juvenile had the ability to refrain

219

from the behavior and chose not to. Evidence that

the juvenile had the ability to refrain from unlawful
sexual behavior would include delaying initiation
of the sexual activity when learning that others are
unexpectedly present or stopping sexual activity during a surprised interruption.

CONCLUSION

The forensic evaluation of a juvenile sex offender

requires specialized knowledge and expertise by the
examiner. The evaluator must possess a clear understanding of the exact nature of the interview, the
legal standard governing the interview, parameters
of confidentiality, and the scientific literature that
supports any opinions and recommendations rendered. In contrast to a clinicians treatment relationship with his or her client, the forensic examiners
primary goal is to report objective information to the
requesting party. In this manner, the forensic evaluator plays an invaluable role in helping the legal system determine how to best balance the safety needs
of the community with the treatment needs of the
juvenile offender.
References
ALI Model Penal Code, 4.01 (1985).
American Academy of Psychiatry and the Law. (2007).
Ethical guidelines for the practice of forensic psychiatry. [Online] Adopted May 2005. Available at:
http://aapl.org/pdf/ETHICSGDLNS.pdf.
Benedek, E. P. (1985). Waiver of juveniles to adult court.
In E. P. Benedek (Ed.). Emerging issues in child
psychiatry and the law, (pp. 180190). New York:
Brunner/Mazel.
Cooper, D. K. (1997). Juveniles understanding of
trial-related information: Are they competent
defendants? Behavioral Science and the Law, 15,
167180.
Cowden, V. L. & McKee, G. R. (1995). Competency to
stand trial in juvenile delinquency proceedings:
cognitive maturity and the attorney-client relationship. University of Louisville Journal of Family Law,
33, 629690.
Criminal Code, R. S. C., (1985), c.C-46.
Department of Justice, Canada. (2007). Youth Criminal
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gc.ca/en/ps/yj/repository/2overvw/2010001a.html.
Grisso, T. (1998a). Preparing for evaluations in delinquency cases. In Forensic evaluation of juveniles,
(pp. 135). Sarasota: Professional Resource Press.
Grisso, T. (1998b). Juveniles waiver of Miranda rights,
In Forensic evaluation of juveniles, (pp. 3782).
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220 JUVENILES
Grisso, T., Miller, M., & Sales, B. (1987). Competency to
stand trial in juvenile court. International Journal
of Law and Psychiatry, 10, 120.
Giorgi-Guarnieri, D. & Janofsky, J., Keram, E., Lawsky, S.,
Merideth, P., Mossman, D., et al., (2002). AAPL
practice guideline for forensic psychiatric evaluation of defendants raising the insanity defence.
Journal of the American Academy of Psychiatry and
the Law, 30, S3S40.
McGarry, A. L., Curran, W. J., Lipsett, P. D., Lelos, D.,
Schwitzgebel, R. K., Rosenberg, A. H., et al,
(1973). Competency to stand trial and mental
illness. Washington, D.C.: National Institute of
Mental Health, Center for Studies for Crime and
Delinquency. HEW Publication HSM 739105.
Miller, R. D. (1994). Criminal responsibility. In R. Rosner
(Ed.), Principles and practice of forensic psychiatry,
(pp. 198215). New York: Chapman & Hall.
Morris, A. & Gelsthorpe, L. (1999). Juveniles-laws and
facilities in the United Kingdom. In J. Gunn & P. J.
Taylor (Ed.), Forensic Psychiatry-Clinical, Legal &
Ethical Issues (pp. 210251) (1993; reprint, Woburn,
MA and Oxford: Butterworth Heinemann).

MNaghtens Case 10 Cl. & F. 200, 8 Eng. Rep. 718

(H.L. 1843).
Nye, S. G. (1992). Professional concerns. In M. G.
Kalogerakis (Ed.), Handbooks of psychiatric practice
in the juvenile court, (pp. 131136). Washington,
D.C: American Psychiatric Association.
R. v Chaulk S.C.J. No. 139, p. 241. (1990).
R. v MacDonald O.J. No. 1833, Ontario Superior Court
of Justice, 2000.
Scott, C. L. (2002). Juvenile Waivers to Adult Court.
In D. H. Shetky & E. P. Benedek (Ed.), Principles
and Practice of Child and Adolescent Psychiatry,
(pp. 289295). Washington, D.C.: American Psychiatry Association Press.
Dusky v. United States 362 U.S. 402 (1960).
Voigt, C. J., Heisel, D. E., & Benedek, E. P. (2002). Stateof-mind assessments: competency and criminal
responsibility, In D. H. Shetky & E. P. Benedek
(Ed.), Principles and practices of child and adolescent forensic psychiatry, (pp. 297305). Washington,
D.C.: American Psychiatric Publishing.

Chapter 16

Juvenile Sexual Offenders:

Epidemiology, Risk Assessment,
and Treatment
Ernest Poortinga, Stewart S. Newman, Christine E.
Negendank, and Elissa P. Benedek

In recent years more attention is being paid to juvenile sex offenders, even in the context of lower rates
of violent crime committed by juveniles. The media
portrayal of the juvenile sex offender has included
children, adolescents, girls, boys, healthy children,
and children with physical and emotional disabilities.
The publics concern about juvenile sex offenders has
waxed and waned in proportion to the number and
heinousness of sex crimes reported during a given
time period. The publics attitude toward the juvenile sex offender has vacillated between attempts to
understand, treat, and rehabilitate the offender, to a
wish to incarcerate and punish the youthful offender.
In this chapter we explore the phenomena of the juvenile sex offender from three perspectives. We realize
that this is but a limited picture of a multidimensional
phenomenon and that there are other areas worthy of
an in depth discussion. We have chosen to focus on
the epidemiology of juvenile sex offenders, the recidivism potential of offenders, and the current available
treatment models, as these areas of interest seem to

distinguish the juvenile offender from the adult. We

leave the discussion of the developmental, biological,
psychodynamic, and sociocultural factors that lead to
juvenile sexual offending to others.

CASE E X A MPLES

Case 1Ralph and Josh

Ralph is a 13-year-old male admitted to an acute adolescent inpatient psychiatric unit because of aggression toward other children in his foster care home.
He was accused of bullying the younger children for
lunch money. He showed little remorse or regret for
this behavior. He was in foster care because his biological father had been convicted of Criminal Sexual
Conduct for sexually assaulting Ralph when Ralph
was 8 years old.
Josh is also 13 years old and a male. He was admitted to the same inpatient unit because of worsening

221

222 JUVENILES

aggression related to his pervasive developmental disorder. His outpatient psychiatrist told the treatment
team that much of Joshs aggression seemed to be
attention seeking in nature. On one of his weekend
visits to his parents home his father noticed that Josh
perseverated on sexual terms such as, Ralph made
me kiss his penis. The more alarmed his father
became, the more Josh perseverated. Soon, he would
speak of little else. His father decided to file a medical malpractice suit against the hospital, alleging
improper supervision of the adolescents.
Case 2Jake
Jake, a 16-year-old, is convicted of criminal sexual
conduct for performing fellatio on a 9-year-old boy
while he and other young boys were in his bedroom
playing a game of Truth or Dare. Jake readily
admitted to pulling the young boys pants down and
performing oral sex for a few minutes. This was corroborated by other children who were in Jakes bedroom. Jake had a history of being sexually abused by
his own father until the age of 7. He had been convicted 4 years earlier for fondling a young girl and had
multiple episodes of past inappropriate sexual behavior. He had been placed on probation after the incident with the young girl. It was unclear if he had been
provided with treatment but he and his mother had
been instructed that he could not be left alone with
young children during the course of his probation.
Jakes probation had been completed 1 year before
the most recent incident. Jake has multiple past
psychiatric diagnoses including mild mental retardation, attention-deficit/hyperactivity disorder (ADHD),
mood disorder, not otherwise specifiied, and pervasive developmental disorder. On interview he did not
appear to understand the wrongfulness or illegality
of performing fellatio on a young child despite his
past conviction for fondling. He appeared immature
and maintained an odd child-like affect throughout
the course of the interview even when talking about
possible consequences of his actions.
Case 3Ronald
Ronald is an 8-year-old white male diagnosed with
borderline intellectual functioning and learning disabilities, referred for an outpatient psychiatric evaluation due to behavioral problems in school. His special
education teacher notes that Ronald has shown a

decline in academics over the previous 12 months.

He now has difficulty with following directions,
attending to tasks, and respecting the personal space
of peers. The content of his speech and drawings he
makes in class are often violent themes. His special
education teacher had previously worked as a receptionist in a psychologists office, and was convinced
the child was currently psychotic. The child came to
the evaluation with his father, who described a long
history of poor frustration tolerance, hyperactivity,
and impulsivity. The father had not observed violent behaviors at home. The evaluation revealed no
evidence of psychosis. There was no history of physical or sexual abuse. The symptoms at presentation
were suggestive of pervasive developmental delay or
ADHD as well as some cognitive limitations. After
3 days of the evaluation, the psychiatrist received a
call from the childs school. The child had been
inappropriately touching a younger peer during gym
class, goosing this boy per the report of the gym
teacher. The school requested an immediate reevaluation by the psychiatrist to assure the safety of other
students in the school. The school official expressed
fears of having a sexual predator at their school.

EPIDEMIOLOGY OF JU V ENILE
SE X OFFENDER S

Epidemiology is sometimes defined as the branch

of medicine that investigates the causes and control
of epidemics. Demography is the study of the vital
statistics of human populations, as size, growth, density, and distribution. In this section of the chapter
we discuss one system of classification of offenders
in an attempt to isolate some of the factors leading
to the epidemic nature of this societal problem. We
examine the sex, gender of the offender, age of the
victim, gender of the victim, relationship issues, use
of violence, and psychiatric comorbidity. It may be
possible to diminish the incidence of juvenile offenders by controlling some of these factors, in particular
psychiatric comorbidity.
One out of every five sexual assaults involves an offender below the age of 18 (FBI, 2004). Persons below
the age of 18 commit one-third to one-half of sexual
assaults against children (Snyder & Sickmund, 1999)
(Hunter, Figueredo, Malamuth, & Becker, 2003).
Compared to violent offenders, sexual offenders
start offending at a younger age and are more likely

JUVENILE SEXUAL OFFENDERS

to continue offending as they age (Caldwell, 2002).

Juveniles who sexually offend are a heterogeneous group
in terms of victim and offense characteristics, developmental histories, sexual experiences, cognitive functioning, and psychiatric illnesses (Knight & Prentky, 1993).

CL ASSIFICAT ION OF JU V ENILE

223

offenders against peer or adult victims and are

less likely to be under the influence of alcohol
or drugs at the time of their offense (Hunter
et al., 2003).
2. Peer or Adult Victims. This group prefers victims who are their own age or older, female,
and often unacquainted. They tend to display
high levels of aggression, with frequent use of
weapons and frequent injury to victims.

SE X OFFENDER S

Several methods exist for classifying juvenile sex

offenders:
By Age of Sex Offender
The average age of onset of offending by juvenile sex
offenders is between 12 and 15 years with a median
age of 14 to 15 years (CCJS, 1999; Ryan, 1991;
Snyder & Sickmund, 1999; Utah Task Force of the
Utah Network on Juveniles Offending, 1996). Rate of
offending is highest between ages 13 to 16 years with
a gradual decline in rate of offending through the
mid thirties (CCJS, 1999; Snyder & Sickmund, 1999).
Children younger than 12 years may also sexually
assault other children. Compared to older offenders, these youngsters are more likely to have been
the victims of physical or sexual assault (Silovsky &
Niec, 2002) and more likely to be female (Friedrich,
Davies, Feher, & Wright, 2003). Thus, preteen sexually intrusive behaviors should be considered quite
different than adolescent sexual offending.

By Gender of Offender
Ninety to 97% percent of juvenile sex offenders are
male (Campbell & Lerew, 2002; Mathews, Hunter,
Jr., & Vuz, 1997). Female juvenile sex offenders tend
to have an earlier age of onset and more severe victimization histories (Mathews et al., 1997).

By Age of Victim
Classification by age of victim yields two main groups:
1. Child Victims. These sexual offenders prefer
victims who are much younger than himself or
herself, male, and well known or related to the
offender. These offenders rarely display high
levels of aggression. They also have greater
deficits in psychosocial functioning than do

By Gender of Victim
Female victims are far more prevalent (Hunter &
Figueredo, 1999; Rasmussen, 1999) but some studies
show male victims representing up to 25% of the sample (Rasmussen, 1999; Wieckowski, Hartsoe, Mayer, &
Shortz, 1998).

By Relationship to Victim
Victims are often acquaintances or relatives
(Rasmussen, 1999; Ryan, 1991; Wieckowski et al., 1998).
The opportunity to offend may be provided by babysitting, and rarely are strangers assaulted (Fehrenbach &
Smith, 1986; Smith & Monastersky, 1986).

By use of Violence
While juvenile sex offenders may force victim compliance with intimidation, threats of violence or physical force (Miranda & Corcoran, 2000), they tend to
be physically violent less often than adult offenders
(Knight & Prentky, 1993). A sample of 91 juveniles in
Minnesota found that close to 40% used significant
aggression in their sexual offenses (Miner & Siekert,
1997).

By Sexual Offense Characteristics

Acts perpetrated by juvenile sex offenders compose a
wide range of behaviors. More than 50% of the acts in
a study of Maine juveniles (Righthand & Hennings,
1989) involved oralgenital contact or attempted
or actual vaginal or anal penetration. Miranda and
Corcoran (2000) compared the offense characteristics of male juvenile and adult sexual offenders. They
found that juveniles were more likely to participate
in intrafamilial sexual abuse (67% vs. 21%) and used
force more frequently than did adults. Juveniles were
less likely to engage in penetration (13% vs. 41%).

224 JUVENILES

By Psychiatric Comorbidity
Since paraphilias and sexual deviancy syndrome are
believed to impact the behavior of adult sex offenders, (Saleh & Berlin, 2003) it stands to reason that the
effects may be similar for juveniles who commit sexual offenses. Paraphilias are psychiatric disorders with
deviant and culturally nonsanctioned sexual fantasies, thoughts and/or behaviors (DSM-IV). Data from
recent studies suggest that the etiology of paraphilias
may be biological (Quinsey, 2003).
Some of these juveniles may also suffer from
symptoms of mental illness. Recent surveys (Becker,
Kaplan, Tenke, & Tartaglini, 1991; Galli et al., 1999;
Myers & Blashfield, 1997) found incidence rates for
Major Depression of up to 42% in juvenile sex offenders. A recent Irish study reported high scores on the
anxiety/depression and attention subscales of the
Child Behavior Checklist for juveniles participating
in sex offender treatment programs (OHalloran &
Carr, 2002). Impulsivity scores were not significantly
different between the sex offender group and normal
controls (OHalloran & Carr, 2002).
Conduct disorder and substance abuse are commonly
diagnosed in juvenile sex offenders but incidence rates
may not differ significantly from other juvenile offenders (Kavoussi, Kaplan, & Becker, 1988; Lewis, Shankok,
& Pincus, 1979; Lightfoot & Barbaree, 1993; Tarter,
Hegedus, Alterman, & Katz-Garris, 1983).
According to Shaw, there are essentially four kinds
of juvenile sexual offenders. The classifications by
Shaw are examples of the systems discussed earlier.
His first three offender types (offenders with true
paraphilias such as frotteurism, offenders with strong
antisocial personality disorders, and offenders who
are compromised by a psychiatric or neurobiological
disorder) are examples of classification by psychiatric comorbidity. Shaws final category (2002), youth
with impaired social skills who turn to younger children for sexual gratification is a combination of classification by victim characteristics and psychiatric
comorbidity.

FACTOR S ASSOCI AT ED W ITH

JU V ENILE SE X OFFENDING

A number of nonpsychiatric factors have been found

to be associated with juvenile sex offending. Chief
among these factors is a history of being a victim

of physical and/or sexual abuse. Incidence rates for

sexual abuse victimization range from 47% to 66%
(Johnson & Shrier, 1985; Longo, 1996). One study
found that 19% of juvenile sex offenders had been
physically abused before their own offense (Johnson &
Shrier, 1985). The relationship between victimization
and subsequent offending is more complex than simple cause and effect. Hunter and Figueredo (1999)
found four variables that mediated this relationship:
higher rates of the abusive incidents; lower level of
perceived family support following disclosure of the
abuse; long period of delay between abuse and disclosure of the abuse; and finally, younger age at the time
of victimization. Moreover, juveniles who have been
exposed to physical abuse by a father or stepfather had
higher levels of anxiety and depression than juveniles
who were not exposed to such abuse. The same high
rates of anxiety and depression were present in juveniles who witnessed violence against females (Hunter
et al., 2003).
To address the relationship between sexual victimization and subsequent sexual offending, Friedrich
et al (2003) studied a group of 620 children aged
2 to 12 years who had a confirmed history of being
sexually abused. They were compared to a control
group of nearly 1700 preteen children with no abuse
victimization history. With sexually intrusive behaviors as the dependant variable, sexual abuse was not
the primary predictor. Rather, a model incorporating family adversity, modeling of coercive behavior,
child behavior, and modeling of sexuality appeared to
explain most of the variance in the sexually intrusive
behavior.
Biological factors have been examined more
extensively in adult rather than juvenile sex offenders. These factors have been reviewed elsewhere in
this book.
Measures of neuropsychological functioning were
compared between a group of 60 adolescent sex offenders and 60 nonsexual delinquent offenders. Both
groups demonstrated a pattern of frontal executive
dysfunction, scoring well below average on word association and trail-making tests but close to average on
Tower of London and Wisconsin Card Sorting measures. Test scores did not correlate with IQ scores.
The authors concluded that there is likely a subset of
juvenile sex offenders who have latent neuropsychological dysfunction, manifest by increased impulsivity, poor planning, and poor verbal skills (Veneziano,
Veneziano, Legrand, & Richards, 2004).

JUVENILE SEXUAL OFFENDERS

R ECIDI V ISM A ND R ISK ASSESSMEN T
OF JU V ENILE SE X UA L OFFENDER S

An understanding of the rate of recidivism and the

factors leading to recidivism is critical in prevention.
No single test or interview question will predict the
potential for recidivism. It is critical to understand
factors associated with recidivism that influence the
potential for repeat sexual offenses. In this section of
the chapter we first present an overview of the known
rates of recidivism. We also discuss the range of variables that can be used in an attempt to assess risk and
predict recidivism, recognizing that risk assessment
of juvenile sexual offenders is an imperfect science.
The Federal Bureau of Investigations national
incident-based reporting system indicate that approximately one out of every five sexual assaults and onethird of sexual assaults of children below the age of
12 years are perpetrated by an offender below the
age of 18 years (Snyder & Sickmund, 1999). In addition, nearly one-half of adult sexual offenders report
committing sexual offenses before the age of 18 years
(Groth, Longo, & McFadin, 1982).

R AT ES OF R ECIDI V ISM

Studies of sexual and nonsexual recidivism of juvenile

sex offenders range greatly depending on the study
design. Variables in studies of recidivism include
methodological design, type of referral offenses, length of the follow-up period, impact of clinical interventions, nature of the population being investigated
and measures of recidivism (Sipe, Jensen, & Everett,
1998; Worling & Lngstrm, 2003). The variability in
the measurement of recidivism is dependent on the
victims willingness to report the crime, the ability of
police and/or child protection agencies to investigate
the complaint, the decision of police to press charges
that reflect the sexual nature of the crime and the
accurate and timely entry of the charge into a computerized database. Accurate recidivism data is also
dependant on the sexual charges not being dropped
or altered to a nonsexual charge through plea bargaining (Worling & Lngstrm, 2003). Higher rates of
sexual recidivism are generally associated with longer
follow-up periods and stricter measures of recidivism
(Nisbet, Wilson, & Smallbone, 2004).
Studies of juvenile sex offenders report sexual
recidivism rates of 0% to 37%. Along with sexual

225

recidivism data, multiple studies have also examined

nonsexual offense recidivism rates which are consistently higher than sexual recidivism rates (32% to
65%). Mazur and Michael (1992) found a 0% recidivism rate after a short (6-month) follow-up using
self-report data with 10 adolescents participating
in community-based group treatment. Nisbet et al.
(2004) studied 292 adolescent male sex offenders
for which adult rearrest and reconviction data were
obtained with a mean observation time of 7.3 years;
25% (75) of the adolescents received additional sexual convictions before their 18th birthday. As adults,
9% (14) of the sample was alleged to have sexually
offended and 5% were reconvicted for sexual offenses.
Of the 14 subjects reconvicted for sexual offenses, 11
(79%) also received new convictions for nonsexual
offenses.
Sipe et al. (1998) examined adult arrest records
of a group of adjudicated male sexual offenders. The
sexual offender group included of 164 subjects ranging from age 11 to 18 years at the time of admittance
into the study. Subjects were followed for 1 to 14 years
after turning 18 with a mean age of 24 years at the
time of data collection. Of the juvenile sex offenders 9.7% were arrested as adults for sexual offenses
and 32.6% were arrested for nonsexual offenses.
Smith and Monastersky (1986) studied 112 adolescent males who had been referred to a juvenile sex
offender program. Length of follow-up ranged from
17 to 49 months with an average time of 28.9 months;
14% of subjects committed a sexual offense in the
follow-up period according to juvenile justice system
records.
Rasmussen (1999) followed 170 first-time juvenile
sexual offenders for 5 years; 14.1% of the sample committed a sexual offense and 54.1% committed a new
nonsexual offense. Lngstrm and Grann (2000) studied 46 sex offenders aged 15 to 20 years old. Rates
for sexual recidivism was 20% and general recidivism
was were 65% with a mean time of risk being 5 years.
Finally, Rubenstein et al. (1993) followed up 19 juvenile
sexual offenders and 58 nonsexual offenders into adulthood. The follow-up period was 8 years after release
from the juvenile justice system. Of the sample, 37%
was found to have criminal records for sexual assaults as
adults. The high rate of sexual recidivism in this study
may have been related to the inclusion of juveniles in
the study who were described as very assaultive.
Few studies have examined the impact of sexual
offender treatment on recidivism rates. There is some

226 JUVENILES

controversy as to whether specialized treatment for

juvenile sexual offenders affects recidivism rates,
especially for nonsexual crimes (Berlinger, 1998;
Milloy, 1998). However, as discussed by Worling &
Curwen (2000), many early studies did not include
a comparison group, had short follow-up times,
and used conservative measures of recidivism. Two
studies that used comparison groups and less conservative measures for recidivism report promising
findings for specialized sexual offender treatment programs (Bourduin, Henggeler, Blake, & Stein, 1990;
Worling & Curwen, 2000). Worling and Curwen collected data on 58 offenders participating in at least
12 months of treatment in a community-based specialized treatment program. The participants were
compared to 90 adolescents who received only an
assessment, refused treatment or dropped out of the
program before 12 months. Follow-up time ranged
from 2 to 10 years. Recidivism rates for the subjects
who completed at least 12 months of treatment for
sexual, violent nonsexual, and nonviolent offenses
were approximately 5%, 19%, and 21% compared to
18%, 32%, and 50% for controls. There was a 72%
reduction in sexual recidivism and a 41% reduction
in nonsexual offense recidivism. These findings were
comparable to those of Borduin et al. (1990) who
found an 83% reduction in sexual assault recidivism
and a 50% reduction in nonsexual recidivism after
specialized treatment. Both of the treatment interventions in the earlier studies involved comprehensive
treatment emphasizing offense-specific interventions
and unique treatment approaches depending on the
strengths and needs of the adolescent offenders and
their families (Worling & Curwen, 2000).

FACTOR S ASSOCI AT ED

of a stranger victim, lack of intimate peer relationships/social isolation, and incomplete offense-specific
treatment.
Promising risk factors were described as factors
that should be examined for risk assessment even
though empirical support was limited. Promising risk
factors included problematic parentadolescent relationship/parental rejection and attitudes supportive of
sexual offending. Possible risk factors were described
as risk factors currently viewed by some researchers to
be related to sexual recidivism in adolescents but were
considered speculative secondary to lack of empirical
support and opposing expert opinion. Caution was
therefore advised when relying on these factors for
risk assessment. Possible risk factors included a highstress family environment, obsessive sexual interests/
sexual preoccupation, impulsivity, selection of a male
victim, negative peer associations and influences,
environment supporting an opportunity to reoffend,
past sexual assault against a child, threats or use of
excessive violence or weapons during sexual offense,
indiscriminate choice of victims, unwillingness to
alter deviant sexual interests/attitudes, interpersonal
aggression, antisocial interpersonal orientation, and
recent escalation in anger or negative affect.
Unlikely risk factors were described by the authors
as risk factors that should not be used in risk assessment at present secondary to contradictory empirical evidence. Unlikely risk factors included denial
of sexual offense, lack of victim empathy, history of
nonsexual crimes, penetrative sexual assaults, and
the offending adolescents own history of child sexual
abuse. Worling and Curwen (2000) indicate that
promising, possible, and unlikely risk factors may,
in the future, be found to relate to adolescent sexual
reoffending with further research and/or improved
measurement techniques.

W ITH R ECIDI V ISM

Worling and Lngstrm (2003) completed a comprehensive review of empirical and professional literature
of factors associated with recidivism in adolescents
who offend sexually. They divided risk factors for sexual reoffending into supported, promising, possible,
and unlikely risk factors.
Supported risk factors were defined as risk factors with the most defensible empirical evidence.
Supported risk factors included deviant sexual interest, prior criminal sanctions for sexual assaults, past
sexual offenses against two or more victims, selection

R ISK ASSESSMEN T

Assessments of adolescents who sexually offend are

used to assist in various determinations at multiple
decision points within the juvenile justice system
(Prentky, Harris, Frizzell, & Righthand, 2000). These
determinations include, but are not limited to, preadjudicatory diversion, potential prosecution of the adolescent, sentencing, dispositional and case planning,
the level of treatment interventions and the decision
if community notification is necessary (Worling &

JUVENILE SEXUAL OFFENDERS

Lngstrm, 2003; Prentky et al., 2000). Many jurisdictions have amended community notification laws
to exclude juvenile offenders. Other jurisdictions
determine notification on a case by case basis and
may go so far as to charge the juvenile as an adult.
(DesLauriers & Gardner,1999). Two complicating
factors in risk assessment of juvenile sex offenders
are the heterogeneity of the population (Bourke &
Donohue, 1996; Knight & Prentky, 1993) and the
lack of empirically based studies on the development
and validation of risk assessment measures (Prentky
et al., 2000).
A comprehensive assessment of adolescents who
offend sexually is a complicated and time-consuming
task (Zonana & Abel, 1999) ideally performed by
trained evaluators who are experienced in the assessment of adolescents who offend criminally and their
families. Evaluators should have adequate knowledge
of relevant sexual offender research regarding etiology, assessment, treatment, and recidivism and be
aware of the static and dynamic factors which may
contribute to sexual reoffending. Multiple methods
of data collection should be used and should cover
both sexual and biological domains of the adolescents functioning (Worling & Lngstrm, 2003).
Proposed modalities of risk assessment include clinical interviews, collection of collateral information,
psychological testing, empirically guided checklists,
phallometry, visual reaction time (VRT) using the
Abel Assessment for Sexual Interests, and polygraph
testing (Abel, Jordan, Rouleau, Emerick, BarbozaWhitehead, & Osborn, 2004; Blanchette, 1996;
Worling & Lngstrm, 2003; Zonana & Abel, 1999).

227

sexual recidivism are being studied. When dynamic

risk factors such as criminal attitudes, denial of
responsibility, rationalization, deviant sexual fantasies, cognitive and perceptual distortions, social skill
and problem solving deficits, and coping style (Kenny
et al., 2001) change they result in a corresponding
increase or decrease in recidivism risk that is thought
to be important for treatment planning and intervention (Hanson & Harris, 2000).

CLINICA L IN T ERV IEW

The clinical interview is the face-to-face interaction with the adolescent who has sexually offended.
Although the clinical interview should not be used
solely for risk assessment (Grove, Zald, Lebow,
Snitz, & Nelson, 2000; Hanson & Bussiere, 1998)
it is an important component of the evaluation
(Blanchette, 1996). The clinical assessment should be
performed by a specialized, well-trained, and experienced evaluator with appropriate personal skills
(Blanchette, 1996; Worling, 2004). The evaluator
should also be culturally knowledgeable and sensitive
to aide in the understanding of adolescents who have
offended sexually, their families, and their communities (Zonana & Abel, 1999). The clinical interview
should ideally help to determine which dynamic factors are present at the time of the evaluation and how
these factors may increase or decrease the risk for
recidivism. This will allow for further clarification of
treatment approaches (Blanchette, 1996).

COLL AT ER A L INFOR M AT ION

STAT IC V ER SUS DY NA MIC FACTOR S

Static risk factors are highly stable or historical factors that do not change over time. Dynamic risk factors are changeable characteristics that may affect
an individuals recidivism risk or treatment plan
(Hanson & Harris, 2000). Long-term recidivism in
adult sexual offenders has been best predicated by
static factors (i.e., early childhood experiences,
offense history, personality characteristics, and disorders) and may indicate ongoing reoffense potential (Hanson & Bussiere, 1998; Kenny, Keogh, &
Seidler, 2001). However, static risk factors are not
considered useful in directing therapy and therefore
dynamic and potentially modifiable risk factors for

Collateral information is considered critical in the

risk-assessment of juvenile sexual offenders. Obtain ing collateral information allows for the generation of a hypothesis which can then be explored
during the clinical interview (Blanchette, 1996).
The examination of collateral information can
identify discrepancies between an adolescents selfreporting and information obtained from other
sources that will need further clarification and
understanding (Zonana & Abel, 1999). Collateral
information should include interviews with parents, family, and friends. These interviews should
be combined with information contained from
police reports, court transcripts, reports from the

228 JUVENILES

victim, presentence and postsentence disposition

reports, psychological and psychiatric reports, case
management documentation, and discussions with
other mental health professionals familiar with
the adolescents case (Blanchette 1996; Worling &
Lngstrm, 2003).

PSYCHOLOGICA L T ESTS

Psychological tests that have been used in risk assessment of the adolescent sexual offender include multiple self-report measures. These measures include the
Adolescent Cognition Scale (Hunter et al., 1991) and
the Adolescent Sexual Interest Card Sort (Becker &
Kaplan, 1988). The Adolescent Cognition Scale is a
true-false test developed to assess the presence of distorted cognitions regarding sexual behaviors (Hunter
et al., 1991; Zonana & Abel, 1999). The Adolescent
Sexual Interest Card Sort is used to detect deviant
sexual interests. The test presents sexual vignettes
during which the adolescent rates their level of
sexual arousal. (Hunter, Becker, & Kaplan, 1995;
Zonana & Abel, 1999; Rosner, 2003). General psychological assessment measures used in risk assessment of the adolescent sexual offender include the
MMPI-A (Archer, 1997), Child Behavior Checklist
(Achenbach, McConaughy, & Howell, 1987), Beck
Depression Inventory (Beck & Ward, 1961), Matson
Evaluation of Social Skills in Youngsters (Matson &
Esveldt-Dawson 1983), and the Multiphasic Sex
Inventory (Nichols & Molinder, 1984; Rosner, 2003).

EMPIR ICA LLY GUIDED CHECK LISTS

In addition to clinical judgment, actuarial methods

are being developed to aide in risk assessment of
juvenile sex offenders. Actuarial methods eliminate
the disadvantages of subjective clinical judgment in
assessing risk (Barbaree, Seto, Langton, & Peacock,
2001; Quinsey, Harris, Rice, & Cormier, 1998).
Hanson and Bussiere (1998) found that unstructured
clinical judgments were, on average, only modestly
related to sexual recidivism. Berlin et al. (2003) have
argued that actuarial methods represent a form of
profiling that can be used only to identify a group of
persons to be considered for possible civil commitment, and do not feel actuarial methods can be used
to accurately predict the likelihood of future acts of

sexual violence with respect to any specific individual

within such a group. However, it is generally held that
actuarial assessments are superior to unstructured
clinical judgment when conducting risk assessments
of individuals who sexually offend (Barbaree, et al.,
2001; Grove et al., 2000; Hanson, 2000a; Worling,
2004). Specific structured assessments for juvenile
sex offenders include the Juvenile Sex Offender
Assessment Protocol-II (J-SOAP-II) (Prentky &
Righthand, 2003) and The Estimate of Risk of
Adolescent Sexual Offense Recidivism (ERASOR)
(Worling & Curwen, 2001). The J-SOAP-II is a 28
item structured risk assessment measure involving 16
static and 12 dynamic items designed to assess the risk
of sexual reoffense of males aged 12 to 18 years. The
items are classified into four scales that include sexual drive/preoccupation, impulsive/antisocial behavior, intervention, and community stability/adjustment
items. Authors of the J-SOAP-II stress that, at the present time, secondary to a lack of adequate data on
sexual recidivism risk in large numbers of sexual reoffenders, the J-SOAP-II is not an actuarial scale but an
empirically informed guide. The authors also point
out the importance of reassessing juvenile sexual
offenders at a minimum of every 6 months secondary
to rapid changes in cognitive development and life
circumstances in adolescents (Prentky & Righthand,
2003).
The Estimate of Risk of Adolescent Sexual
Offense Recidivism (ERASOR) was designed to
assist evaluators to estimate the risk of sexual reoffense for individuals aged 12 to 18 years and contains 25 risk factors with 16 of the 25 factors being
dynamic (Worling & Curwen, 2001). The 25 risk
factors are classified into the categories of sexual
interests, attitudes, and behaviors; historical sexual
assaults, psychosocial functioning, family/environmental functioning; and treatment. Because the
ERASOR contains multiple dynamic factors that
need to be reassessed over time, the final risk estimate derived from using the ERASOR should be
used for short-term risk (at most 1 year) and should
not be used to predict long-term risk (Worling &
Lngstrm, 2003). Authors of both the J-SOAP-II
and ERASOR emphasize that the earlier structured
risk assessment measures should not be used as sole
measures for reoffense risk but should be included
as part of a comprehensive risk assessment involving case-specific risk factors (Prentky & Righthand,
2003; Worling & Lngstrm 2003).

JUVENILE SEXUAL OFFENDERS

PH YSIOLOGIC T EST ING

Physiologic testing of adolescent sex offenders has

included plethysmography and the measurement
of VRT by use of the Abel Assessment for Sexual
Interests (AASI) (Abel et al., 2004). Plethysmography
is the phallometric assessment of sexual arousal by
measuring penile circumference (Zonana & Abel,
1999). VRT is the amount of time an individual looks
at slides of potentially sexual stimuli and has been
proposed as an alternative to plethysmography. The
AASI examines VRTs of inappropriate sexual stimuli. In addition, the AASI records subjective ratings
of sexual interests and obtains a sex offender specific
questionnaire which includes the adolescents sexual
history and interests (Abel et al., 2004).
The use of VRT and plethysmography in adolescents is controversial secondary to exposure to nude
photographs or sexually explicit audiotapes during the
testing. In addition, there is a lack of empirical research
regarding the reliability and validity of plethysmographic assessment in sexually offending adolescents
(Abel et al., 2004). However, some studies of validation
of plethysmography in sexually offending adolescents
have been performed with promising results and suggest
further research is indicated to assess the use of plethysmography in this population (Becker & Hunter, 1992;
Seto, Lalumiere, & Blanchard, 2000). Standardized
procedures for the use of phallometric equipment have
been developed by the Association for the Treatment
of Sexual Abusers (ATSA, 1997) and guidelines for the
testing procedure have been proposed by the National
Task Force on Juvenile Sexual Offending (NAPN,
1993). Zonana and Abel (1999) stressed the importance
of following these guidelines and procedures for practitioners using phallometric assessment in the assessment
of sexually offending adolescents.
VRT as measured by the Abel Assessment for
sexual interest (AASI) and has been successfully
compared to plethysmography in the assessment of
adult child molesters (Abel, Huffman, Warberg, &
Holland, 1998). Research has begun to support the
use of VRT in adolescent male child molesters (Abel
et al., 2004). Results of a study of 1704 adolescent
males undergoing evaluation or treatment for sexual
paraphilias indicated that the amount of time child
molesters viewed slides was significantly longer than
nonmolesters and viewing times of molesters was significantly correlated with the number of victims and
the number of times they carried out acts of child

229

molestation. An independent study has questioned

the use of VRT in the assessment of adolescent sexual offenders secondary to the lack of independent
studies supporting the reliability of VRT (Smith &
Fischer, 1999). However, Smith and Fischer (1999)
believe that these techniques may prove useful with
further refinement and also point out strengths of the
visual stimulus slides over plethysmography such as
the use of clothed models and the absence of penile
apparatus. Furthermore, these techniques are potentially useful in women.

T R E AT MEN T OF JU V ENILE
SE X UA L OFFENDER S

As mental health professionals, one of our goals is the

effective treatment of the mental health issues associated with the juvenile sexual offenses. There is much
we do know as scientists and clinicians, and much that
we still have to learn, with regard to balancing the
community risks presented by the juvenile offender
and the benefits of treatment. In this section we discuss
available treatment options and the risks and benefits
associated with those options, as well as the associated
treatment outcomes. All juvenile offenders are not alike
and the selection of appropriate treatment depends on
an understanding of the offender, the factors which
favor rehabilitation in a particular offender and those
which suggest that treatment rehabilitation is not possible, and the need to protect the community.
There exists good evidence to support the treatment of juvenile sexual offenders. Studies have
demonstrated that treatment is effective in ending
the cycle of abusive sexual behaviors by offenders.
Studies show a significant percentage of offenders
will respond to treatment (Becker, 1994; Becker &
Hunter, 1997; Bremer, 1992; Dwyer, 1997; Hall,
1995). Recidivism rates for untreated sexual offenders have been seen to be higher than those who
complete a treatment program (Gallagher & Wilson,
1999; Hanson, 1998; Hanson, 2000; Hanson et al.,
2002; Marshall & Barbaree, 1988; Rubenstein,
Yeager, Goodstein, & Lewis, 1993). The economic
burden to the community is decreased through
treatment (Prentky & Burgess, 1990). Treatment programs are less expensive than residential or institutional placements (Farrell & OBrien, 1988). Costs
are also reduced through the prevention of further
offenses. Garrett et al. (2003) also demonstrated

230 JUVENILES

that offenders report positive experiences of group

treatment.
Treatment modalities for sexual offenders include
psychotherapeutic modalities, including cognitive
behavioral interventions such as psychoeducation,
behavior modification, relapse prevention, and psychosocial therapies. Multiple studies have shown a combination of cognitive-behavioral approaches (Frost,
2004; Jennings & Sawyer, 2003; Laws, 1998; McGuire,
2000; Marshall, Fernandez, Hudson, & Ward, 1998;
Pithers & Marques, 1983; Pithers, Kashima, Cumming,
& Beal, 1988; Sawyer, 2000; Sawyer, 2002) and group
therapy modalities to be the most effective interventions.
Psychopharmacology may be utilized as an adjunct to
treatment of some juvenile sexual offenders.

Table 16.1 Goals for the Treatment of the Juvenile

Sexual Offender

T R E AT MEN T PL A NNING

are also at high risk for nonsexual crimes. Factors

used in assessing recidivism risk include the frequency and diversity of the offenses, severity of
aggressive-sadistic behavior, the premeditation versus impulsivity of the offenses, the level of psychological, neurological, and developmental disability,
history of antisocial or violent behaviors, motivation
for treatment, cognitive and emotional resources,
and support systems (Hunter & Figueredo, 1999;
Prentky et al., 2000; Rasmussen, 1999; Worling &
Curwen, 2000).
Consideration for placement in a more restrictive
environment should be on the basis of factors that
might suggest a higher risk for recidivism or difficulty
in complying with treatment. Offenders who display
a consistent need to deny the offenses, demonstrate
a lack of remorse or empathy for the victims, have
severe comorbid psychopathology, or a high degree of
sexual compulsivity or deviant arousal are candidates
for a more restrictive treatment setting. Offenders
who perpetrated frequent sexual offenses, perpetrated a diverse range of offenses, have multiple victims, or have a history of previous violent behaviors or
previous arrests will also likely require placement in
a more restrictive environment (Hunter & Figueredo,
1999; Rasmussen, 1999).

The primary task in the treatment of a juvenile sexual offender is the protection of the community (Shaw,
1999, 2001). Treatment is undertaken with the ultimate outcome of ending the offending behavior in
the immediate sense, but also in doing so preventing
these juveniles from becoming adult offenders in the
future. The juvenile sexual offender population is
not homogenous, but instead presents a wide variety
of etiologies, comorbidities, and treatment needs. An
integrated approach, addressing the emotional, behavioral, and developmental issues that a juvenile sexual
offender presents, is the recommended approach for
any treatment endeavor (Becker, 1994; Schwartz, 1992;
Shaw, 1999). This reflects increasing evidence that sexually abusive behavior is not simply a disorder of sexual arousal or paraphilia in the strictest sense (Prentky
et al., 2000; Schwartz, 1992; Weinrott, 1996). Treatment
must also specifically addresses the unique needs and
resources of the offender and be tailored to these needs.
Shaw et al, (1999) reviewed relevant literature (Becker,
1994; Becker & Hunter, 1997; Hunter & Figueredo,
1999) to summarize a number of goals for the treatment of a juvenile sexual offender, as listed in Table
16.1. Inherent in treatment planning is also a decision
regarding the level of care required, speaking directly
to the need to protect the community.
In protecting the community, the clinician must
weigh the potential for recidivism, and use this
in determining recommendations for treatment.
Recidivism encompasses both sexual and nonsexual criminal acts, as most juvenile sexual offenders

Confronting the offenders denial

Decreasing deviant sexual arousal
Facilitating the development of nondeviant sexual
interests
Promoting victim empathy
Enhancing social and interpersonal skills
Assisting with values clarification
Clarifying cognitive distortions
Teaching the juvenile to recognize the internal and
external antecedents of the sexual offending behavior
Adapted (with permission) from The American Academy of Child
and Adolescent Psychiatry Practice parameters for the assessment
and treatment of children and adolescents who are sexually abusive
of others, 1999.

TR E ATA BILIT Y OF JU V ENILE

SE X UA L OFFENDER S

Decisions about treatment for juvenile sexual offenders must take into account multiple factors unique

JUVENILE SEXUAL OFFENDERS

to each individual. Factors that influence the treatability of the offender are summarized in Table 16.2.
An assessment of these factors assists the clinician in
making a reasoned decision regarding the level of
care required, the optimal setting for the delivery of
that care, and the resources required. This will also
allow for stratification of priorities within treatment,
such as aggressive treatment of psychiatric comorbidity before introducing the offender to a group therapy
setting.
The heterogeneous nature of the juvenile sexual
offender population is due in part to the fact that these
offenders are still children. Being children, they continue to grow and learn, continue to internalize social
experiences, and continue to develop in a cognitive
and moral sense. The sexually abusive behaviors may
be tied to the juveniles continuing experimentation
with sexual practices, and the lack of a firmly established pattern of normal sexual arousal. These attributes may contribute to better treatment outcomes on
juveniles, and are summarized in Table 16.3.

PSYCHI AT R IC COMOR BIDIT Y

There have been multiple studies demonstrating the

frequency and range of psychiatric comorbidity in
the juvenile sexual offender population, as discussed
earlier in this chapter. Frequency of both Axis I and
Axis II disorders is high. Assessment of these factors
and their contribution to the risk of recurrence for the

Table 16.2 Factors Influencing Treatability of Juvenile

Sexual Offenders
The level of understanding of the seriousness of the
offense
The motivation to discuss and understand the offense
The capacity for empathy and human relatedness
The severity of comorbid psychopathology
The entrenchment of deviant sexual arousal patterns
The type and frequency of the sexual offending behavior
The aggressiveness of the sexual offense
The degree of characterological impairment
The nature of the treatment program
Adapted (with permission) from The American Academy of Child
and Adolescent Psychiatry Practice parameters for the assessment
and treatment of children and adolescents who are sexually abusive
of others, 1999.

231

Table 16.3 Why Adolescent Offenders May Be More

Amenable to Treatment Than Adult Offenders
The adolescent offenders deviant pattern of sexual
offending behavior is less deeply ingrained
The adolescent offender is still exploring alternative
pathways to sexual gratification
The adolescent offenders central masturbatory fantasy is
still evolving and is not fully consolidated
The adolescent offender is available for learning more
effective interpersonal and social skills
Adapted (with permission) from The American Academy of Child
and Adolescent Psychiatry Practice parameters for the assessment
and treatment of children and adolescents who are sexually abusive
of others, 1999.

juvenile is essential. The impact that these disorders

may have on the juveniles ability to successfully participate in and complete a treatment program must
not be discounted. Treatment of the comorbid psychiatric disorders according to appropriate standards
of care can improve the global level of function of the
juvenile, and allow for treatment to then focus on the
sexually abusive behaviors.

COGNIT I V E BEH AV IOR A L

IN T ERV EN T IONS

The therapeutic interventions seen to be most effective with juvenile sexual offenders can be broken
down into three broad groups under the rubric of
cognitivebehavioral interventions. Psychoeducational interventions focus on providing the offender with
information that allows understanding of the maladaptive nature of the offenses and assist in correcting this. Behavioral interventions work to diminish or
extinguish deviant sexual arousal patterns that have
developed in the offenders. Relapse prevention interventions disrupt the sexual assault cycle, described
by Ryan et al. (1987). Individualized treatment plans
may draw on any combination of these interventions,
dictated by the needs of the offender.
Psychoeducational interventions include didactic
sessions in which relevant and accurate information
is presented to the offender. Education on normal
sexual development and practices allows for discussion of deviant sexual practices and the development of sexually aggressive behaviors. Cognitive
restructuring corrects the cognitive distortions that

232 JUVENILES

support irrational beliefs that lead to sexually aggressive behaviors and clarify sexual values. This connects with efforts to teach empathy towards victims,
and also explore the impact offending has on the
individual. Offenders are provided with skills for coping with aggressive and sexual impulses, anger, and
difficulty with socialization. Relaxation techniques,
assertiveness training, and development of appropriate social skills provide means to negotiate appropriate sexual relationships (Becker & Hunter, 1997;
Green, 1988).
Behavioral interventions are utilized to decrease
or extinguish deviant patterns of sexual arousal in
offenders. Various techniques have been used with
varying level of success. Covert sensitization asks the
offender to imagine a negative stimulus in an effort to
extinguish the pleasurable response from specific preferred deviant stimuli (Cautela, 1966). Assisted covert
sensitization incorporates the use of a noxious stimulus, such as an odor (Maletzky, 1974). Similarly, in
olfactory conditioning a noxious odor is paired with
a deviant stimulus to elicit a classical conditioned
response. Imaginal desensitization uses relaxation
techniques to disrupt the arousal cycle that a deviant
stimulus might begin (McConaughy, Blaszczynski,
Armstrong, & Kidson, 1989). Sexual arousal reconditioning pairs sexual arousal with appropriate, nondeviant sexual stimuli. Satiation techniques can be
either verbal or masturbatory. The offender is asked to
masturbate to ejaculation in response to appropriate
sexual stimuli. After this experience the offenders is
then asked to masturbate again to deviant sexual stimuli, or to dictate on audiotape deviant sexual imagery
for at least 30 minutes. If the offender again becomes
aroused, they are asked to return to the appropriate
sexual stimuli. The technique assumes that the deviant stimuli become boring and are then abandoned
(Schwartz, 1992).
The relapse prevention model, originally developed for substance abuse treatment, is based on an
understanding that both immediate determinants
and covert antecedents can contribute to relapse
(Larimer, Palmer, & Marlatt, 1999). Relapse prevention has been adapted for use in sexual offender
treatments (Mann & Thornton, 1998; Marques &
Nelson, 2000). For sexual offenders, these factors
can contribute to a relapse into the sexual assault
cycle. Treatment focuses on interfering with the sexual assault cycle through the use of positive coping

strategies and proactive avoidance of potential triggers or high-risk situations. Offenders are encouraged
to identify high-risk situations or emotional states,
and to modify life-style factors that contribute to the
sexual assault cycle (Shaw, 1999).

PSYCHOSOCI A L IN T ERV EN T IONS

Psychosocial interventions take an interpersonal

approach to the treatment of the juvenile sexual
offender, and are complementary to both cognitivebehavioral and psychopharmacological interventions.
Offenders can be engaged in group therapy with other
offenders, with family members in family therapy, or
in more traditional individual therapy settings. Many
of these modalities are used in concert with one
another in various treatment programs.
Group therapy is one of the most common therapeutic settings for the treatment of juvenile sexual
offenders. Groups are usually divided by age to provide some commonality in the social and developmental tasks and struggles of the group members.
Divisions into early childhood, middle childhood,
preadolescent, and adolescent groups is typical
(Shaw, 1999). Groups are usually segregated by gender as well, as there is little advantage in mixing
the sexes (Shaw, 1999). Participating in a group
with other sexual offenders prevents minimization,
denial, or rationalization of the sexual offenses.
The group members, being offenders themselves,
are less willing to tolerate such obfuscation and can
more easily confront the peer. The group therapy
process is often the setting in which psychoeducational interventions are presented and worked with.
The group process serves as the milieu in which the
offender can begin to develop positive peer relationships, practice social skills, and develop positive self
regard. The participants can also develop a sense of
trust within the group, allowing for the discussion
of more difficult or threatening issues (Schwartz,
1988). The group leaders can model appropriate
interactions for the members, and serve a source of
authority for the offender to develop an appropriate
relationship with.
Family therapy incorporates many of the same
processes as group therapy, with the member of the
group being drawn instead from the offenders own
family. Focus of the therapeutic work is on the family

JUVENILE SEXUAL OFFENDERS

dynamics that may contribute to the development or

persistence of sexually abusive behaviors (Schwartz,
1988; Shaw, 1999). The majority of the experiences
and information about gender roles, sexuality, and
relationships come out of the family setting (Bischof,
Smith, & Whitney, 1995). The therapy can also work
to develop more positive communications styles and
coping skills within the family unit. Stress is also
placed on the familys role in supporting and assisting
the offender to control the sexually abusive behaviors
and prevent relapse. In cases where there is incest,
and the offender will remain in the nuclear family,
family therapy can be very effective (Shaw, 1999). It
has been shown (NAPN, 1993) that treatment programs that involve family members are more likely to
be effective than those which do not, thereby decreasing recidivism.
It has been noted that families vary in their motivation towards treatment of juvenile sex offenders
and the degree to which they can assist in the process
(Gray & Pithers, 1993). It has been recommended that
parents be counselled to adopt the attitude of knowledge is power (Gray & Pithers, 1993). Families are
given an opportunity to discuss the losses and feelings
associated with learning of the juveniles offenses,
and their participation in the treatment process is
actively facilitated. It is recommended that families
are provided with a variety of resources regarding
treatment of juvenile sex offenders. These should
include written information on relapse prevention,
cognitive distortions and the consequences of sexual
abuse; educational videotapes of adolescent abusers
discussing their relapse process and the need to be
held responsible; literature on the recovery process
of sexual abuse victims; referrals to treatment groups
for adult sexual abuse survivors; opportunities to be
included in sessions of the adolescent abuser groups;
referrals to support groups of parents of abusive adolescents; and attention to the concerns of the offenders
nonabusive siblings in the treatment process (Gray &
Pithers, 1993).
Individual therapy is not a first line intervention
in the treatment of juvenile sexual offenders. While
the confidential therapeutic dyad can facilitate the
development of trust in the therapist to explore individual psychodynamics, in this population several
disadvantages develop. The therapist can be more
easily manipulated, there is less confrontation and
hence denial is less readily dismantled, and the secret
nature of the sexual assaults is reinforced within the

233

treatment (Schwartz, 1988). Therapists must be on

guard for efforts by the offender to manipulate, minimize, deny, or distort. Confrontation of erroneous
information in a firm but nonjudgemental manner
is essential. For offenders who may be acting out
traumas from being sexually abused themselves, individual therapy is a valuable additional method for
exploring and working through these feelings (Shaw,
1999).

PSYCHOPH A R M ACOLOGICA L
IN T ERV EN T IONS

The two predominant pharmacological treatment

options for sexual offenders include serotonin modulating agents and hormonal modulating agents
(Bradford, 1995). More recently, novel treatments
including naltrexone and stimulant augmentation
have also appeared. None of these agents are suitable
as the sole treatment provided to a juvenile sexual
offender. Instead, these agents may have a role in the
comprehensive integrative treatment approach that
includes the cognitive behavioral interventions discussed earlier.
Kafka has advanced the monoamine hypothesis
of pathophysiology of paraphilic disorders (Kafka,
1997a; Kafka, 2003). It is based largely on the clinical observations that suggest that paraphilic behaviors and sexual offending can be best understood
as disorders of sexual appetitive behavior disorders
(Kafka, 1997). He notes that the monoamine neurotransmitters, including dopamine, serotonin, and
norepinephrine, are key substances in the regulation
of normal human and mammalian sexual behaviors
(Kafka, 1997; Kafka, 2003; Owens & Nemeroff, 1999).
Medications that affect these neurotransmitters can
be seen to have significant sexual side effects, and can
modulate sexual appetitive behaviors (Kafka, 1997;
Kafka, 2003). Studies suggest that sexual offenders
as a group display significant comorbidity of psychopathology which has monaminergic dysregulation as
its etiology. Finally, studies have shown that agents
that modulate the monoamine neurotransmitters can
be effective in decreasing paraphilic symptoms and
behaviors (Bradford, 1999).
Much of the current pharmacologic treatment evidence involves the use of selective serotonin reuptake
inhibitor (SSRI) medications. The SSRIs were developed as antidepressant medications, but the approved

234 JUVENILES

indications and off-label usages have expanded their

clinical applications. The SSRIs are used to treat
obsessive compulsive behaviors, and are also recommended in the treatment of paraphilias and compulsive sexual behaviors (Bradford, 1999; Coleman &
Cesnick, 1992; Greenberg & Bradford, 1997; Kafka,
1994; Stein et al., 1992). The SSRIs have also been
shown to reduce sexual arousal, drive, and preoccupations. Impulsivity and aggressive behaviors have
also been associated with serotonergic dysfunction
in several studies. Fluoxetine is the most studied
of these agents, and currently is also the only FDA
approved antidepressant medication for use in children (Kafka & Prentky, 1992; Perilstein, Lipper, &
Friedman, 1991). Yet a study by Greenberg et al.
(1996) demonstrated no difference between fluoxetine, sertraline, and fluvoxamine. All were seen to
be equally effective. A study utilizing nefazodone
also demonstrated efficacy in adult males with nonparaphilic sexual compulsive behaviors (Coleman,
Gratzer, Nesvacil, & Raymond, 2000). Nefazodone
was also associated with a lower incidence of sexual
side effects compared with SSRIs (Coleman et al.,
2000). In this study, 11 of 14 adult men reported good
control of or remission of their sexual obsessions and
compulsions at doses of nefazodone averaging 200 mg
daily (Coleman et al., 2000).
The addition of a stimulant medication, methylphenidate, has been shown to be effective in
augmenting the action of the SSRIs for decreasing paraphilic behaviors (Kafka & Hennen, 2000).
Twenty six men with paraphilias or paraphilia-related
disorders were screened for a history of ADHD symptoms that persisted into adulthood. For these men, the
addition of methylphenidate to SSRI pharmacotherapy had a statistically significant effect on the total
sexual outlet and the time spent per day on paraphilic
behaviors. While this study was done with adults, the
vast majority of psychostimulant medications have
proven safety for use in children. Stimulant augmentation may soon become a major therapeutic modality for the treatment of juvenile sexual offenders.
Hormonal modulating agents can be broadly
classified into two groups, the antiandrogens and
the luteinizing hormone-releasing hormone agonists (LHRH agonists). The antiandrogens include
medroxyprogesterone acetate (MPA), Provera, and
cyproterone acetate (CPA). MPA has become the
more widely used agent in the treatment of sexual
offenders in the US. It is a progestagen that induces

testosterone reductase in the liver, thereby reducing circulating testosterone levels. It also appears to
block the secretion of luteinizing hormone (LH) and
follicle stimulating hormone (FSH). It can be given
orally or intramuscularly. It has been shown to significantly reduce deviant sexual fantasies, urges, and
behaviors at dosages of 200 to 400 mg IM (Reilly,
Delva, & Hudson, 2000). All of the studies with MPA
have been done with men, however. The use of MPA
in adolescents is controversial due to the side effects
of treatment, including disruption of normal pubertal
development.
Though unavailable in the United States, CPA is
the most widely studied of the hormonal modulating agents. Like MPA, it blocks the secretion of LH
and FSH from the pituitary. Unlike MPA, CPA is
considered a true antiandrogen as it is also a competitive inhibitor of testosterone and dihydrotestosterone receptors. Multiple studies in adult males have
shown it to be effective in reducing sexual arousal,
deviant sexual fantasies and urges, masturbation, and
paraphilic behaviors (Reilly et al., 2000). Additionally,
it has been noted that CPA seems to affect deviant
sexual arousal differently than normophilic arousal,
perhaps suggesting its superiority to MPA for treatment. As with MPA, the potential side effects make
the use of CPA controversial with children.
The LHRH agonists include triptorelin and leuprolide, among others. These agents act by inducing secretion of GRH at the hypothalamus. This
results in an initial rise in circulating gonadotropin-releasing hormone (GRH) levels, but then a
subsequent reduction of GRH to nearly zero (Reilly
et al., 2000). This causes a drop in testosterone
and dihydroxytestosterone levels to those seen in
castrated men (Bradford, 1995, 2000; Reilly et al.,
2000). These agents have been studied in adult
sexual offenders only, and use of these agents in
adolescents is controversial due to the impact on
sexual development these agents will have. Several
studies have shown these agents to be effective in
offenders where other agents have not shown benefit
(Dickey, 1992; Rosler & Witztum, 1998; Rousseau,
Couture, Duptont, Labrie, & Couture, 1990;
Thibaut, Cordier, & Kuhn, 1993).
Naltrexone has also been shown to be effective in
reducing paraphilic symptoms and behaviors in adolescent sexual offenders (Ryback, 2004). Naltrexone
is a semisynthetic opiate antagonist used in the treatment of substance use disorders, obsessive compulsive

JUVENILE SEXUAL OFFENDERS

disorder, impulse-control disorder, and bulimia nervosa. It has been suggested that the inhibition of dopamine release in the nucleus accumbens by naltrexone
accounts for its efficacy in treating impulse-control
disorders (Kim, 1998). In an adolescent male offender
sample, 15 of 21 patients found naltrexone helpful for
reducing arousal, masturbation, and fantasies. Effects
were noted at dosages of 150 to 200 mg daily, and no
benefit was seen with higher doses. When a subset of
the patients had naltrexone discontinued, paraphilic
symptoms and behaviors returned. Of the six patients
who did not respond to naltrexone, five responded
well to leuprolide. These offenders were noted as a
group to have more victims, violent fantasies, thought
process problems, adult and child victims, and were
hospitalized longer compared to the offenders who
responded to naltrexone (Ryback, 2004).

A F T ERCA R E

While treatment for sexually aggressive behaviors

may be successful, the offender will never be cured.
Ongoing care is a necessary requirement to prevent
recidivism in the juvenile sexual offender population.
As with treatment planning, an integrative approach
meeting the unique needs of the individual is most
appropriate. Continued care may include placement
in a specialized setting, community-based outpatient
treatment programs, and ongoing psychiatric and psychotherapeutic treatment.

CONCLUSION

The biological factors that have been examined in

adult sex offenders should be studied in juveniles.
With increasingly sophisticated tools for neuroimaging, such as functional magnetic resonance imaging
and positron emission tomography scanning available
to contemporary researchers, one can be optimistic
that biological correlates for sex offending may be
found. Of particular interest would be correlating
the complicated statistical model of Friedrich (2003)
with neuro-imaging studies to better characterize the
relationship between victimization and future sex
offending.
Risk assessment of sexually offending juveniles is a
complicated and time-consuming process that should
be performed by knowledgeable clinicians. Further
research is needed to test the reliability and validity of

235

recidivism risk factors and risk assessment measures.

For the future of recidivism risk and treatment outcomes, researchers should focus on evidence-based
outcomes. Does the use of structured instruments
improve risk management and reduce recidivism
in meaningful ways? Which risk factors provide the
strongest evidence for recidivism? Are there qualitative aspects of juvenile sex offense recidivism that can
improve the efficacy of treatment?
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Abel, G. G., Jordan, A., Rouleau, J., Emerick, R.,
Barboza-Whitehead, S., & Osborn, C. (2004). Use
of visual reaction time to assess male adolescents
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Chapter 17

Juveniles Who Sexually Offend:

Psychosocial Intervention
and Treatment
Jeffrey L. Metzner, Scott Humphreys,
and Gail Ryan

Juveniles perpetrate a significant percentage of all

sexual violence and child sexual abuse in the United
States and the United Kingdom. Juveniles account
for 17% of arrests for sexual assault and for approximately 24% of sexual assault against victims aged
12 to 17 years (Federal Bureau of Investigation, 2001;
Rich, 2003). More than half of male and 15% to 25%
of female child sexual abuse victims were molested
by a juvenile (Farber, Showers, Johnson, & Joseph,
1984). Criminal statistics from England and Wales
indicated that during 2000, persons below the age of
21 years constituted approximately 18% of the total
number (3943) of offenders found guilty of sexual
offenses (Dent & Jowitt, 2003; Home Office, 2000).
Of these 717 young offenders, 17.4% were between
the ages of 10 and 15 years, 47.5% were between 15
and 18 years old, and 35% were between the ages of
18 and 21 years (Dent & Jowitt, 2003) The number
of young people convicted of sexual offenses is
just a subset of the total number of young persons
who exhibit sexually abusive behaviors due to the
241

underreporting of abusive acts and small arrest rates

in this population.
Although there are similarities related to the nature
of the sexual offenses committed, important distinctions exist that distinguish sexually abusive youths
from adult sex offenders (Becker, 1998; Becker &
Hicks, 2003; Masson & Hackett, 2003). In addition
to juveniles who are known to have sexually offended
exhibiting a lower frequency of sexually abusive acts,
their developmental growth is less complete and
more flexible than that of their adult counterparts.
Research in this area suggests that the sexual interests
and patterns of sexual arousal of juveniles are less fixated than those of older adult offenders (Veneziano &
Veneziano, 2002). Reasonable arguments have been
made to refer to these young people as children or
adolescents who have been sexually abusive in contrast to the term juvenile sex offenders. This modification in descriptive language was an important
change recommended in the National Task Force on
Sexually Offending revised report in 1993 (National

242 JUVENILES

Task Force on Juvenile Sexual Offending, 1993). The

latter term can be construed to mean that such persons will always be sex offenders. Not only is this presumption not supported by data, the fact that juveniles
are developmentally in the process of identity formation suggests that identifying them as sex offenders
may be both inaccurate and counterproductive to
the goal of preventing them from continuing to sexually offend. Therefore, children and adolescents who
have committed sexual offenses or have been sexually
abusive will be referred to as sexually abusive youths
or juveniles throughout this chapter.
There is sparse and sometimes conflicting data
regarding juveniles who commit sex offenses. Ryan
et al. (1996) summarized information obtained from
the National Adolescent Perpetration Network Uniform Data Collection System (UDCS), which contains data based on clinical interviews for over 1600
juveniles referred for evaluation and/or treatment to
90 sex-offender-specific programs in 30 states. In this
sample youth ranged in age from 5 to 19 years with a
modal age of 14 years. Approximately 25% reported
earlier sexually abusive behavior before age 12. The
juveniles were likely to be White and living with two
paternal figures at the time of the offense. A prior adjudication for sexual assault was unlikely, although the
identified assault usually did not represent the youths
first offense or first victim. Approximately one-third of
the youth had been adjudicated for nonsexual delinquent behavior before their current identified sexual
perpetration. The victim was generally not related to
the juvenile (although siblings represented the largest
victim pool) and the sexual behavior usually involved
genital touching and often penetration.
These juveniles commonly have a history of having been a victim of sexual, physical, and/or emotional
maltreatment and many have witnessed domestic
violence (Ryan, 1997). However, the most common
shared experiential variable in the Ryan et al. (1996)
sample was parental loss via abandonment, termination of parental rights, or death of a parent. Childhood
neglect was mentioned less often than abuse, but may
be more prevalent than recorded. More recently, prospective studies of abused and neglected children
have shown neglect as a more frequent precursor to
sexual offending than either physical or sexual abuse
(Widom & Williams, 1996).
Zolondek et al. (2001) administered a self-report
survey to 485 males, aged 11 through 17, being evaluated for sex offenses. In their sample, the average age

of first offense was between 10 and 12 years. Sixty

percent of the boys reported a history of molesting
with an average of 4 victims and 11 acts. Rich (2003)
summarizes the literature on sexually abusive youths
offenses in a concise manner. Statistically, the juvenile
sexual offender is most likely to be a 14-year-old boy
whose sexual abusive behaviors are directed against
children and adolescents in contrast to adults. Most
juvenile sexual offending is directed against girls and
offenses against boys are directed mostly at children
below the age of 7.
Although many adult sex offenders reported
offending as adolescents, (Becker & Abel, 1985;
National Task Force on Juvenile Sexual Offending,
1993) most sexually abusive youth do not become
adult sex offenders. Because it is not clear which
juveniles will continue offending and become adult
sex offenders, it is clinically reasonable to consider
children and adolescents who engage in sexually
abusive behaviors to be at risk of becoming adult
offenders. A comprehensive assessment and indicated
treatment should be aggressively pursued. However,
recidivism data indicate that most are at greater risk
for nonsexual recidivism as delinquent youth and do
not continue criminal behaviors as adults (Worling &
Curwen, 2000).
Among adult sex offenders, hands off paraphilias, such as exhibitionism, have the highest prevalence
(Abel, Becker, Mittelman, Cunningham-Rathner,
Roleau, & Murphy, 1987). In contrast, molestation
of significantly younger children is the sex offense
most often reported in juveniles. This may be due
to the possibility that other sexual offenses less often
result in the arrest and/or adjudication of the juvenile.
However, Ryan et al. (1996) found that 35% to 50% of
the hands off juveniles had also sexually abused a
child.
A literature review by Becker and Hicks (2003)
reported that juveniles engaged in intrafamilial sexual abuse more frequently (67%) than adults (21%),
although they were less likely to engage in penetration (13%) as compared to adults (41%), who also committed more sexually abusive acts as compared to the
youths (Miranda & Corcoran, 2000).
Sexually abusive youths often have had previous
consensual sexual experiences with similar age peers
in addition to their offending behaviors (Becker,
Kaplan, Cunningham-Rathner, & Kavoussi, 1986;
Ryan, Miyoshi, Metzner, Krugman, & Fryer, 1996).
There is only limited research relevant to the role of

JUVENILES WHO SEXUALLY OFFEND

deviant sexual interest, preference and/or arousal

among sexually abusive youths and there is no data
regarding adolescent norms. Similarly there are only
limited studies relevant to the role of pornography
among sexually abusive youths, although several studies reported that exposure to pornographic material
at a young age among these juveniles was common
(Hunter & Becker, 1994; Wieckowski et al., 1998).
Dent and Jowitt (2003) provide a summary of the
literature relevant to children and adolescents who
commit serious sexual offenses in the context of
mental health problems. A significant prevalence of
family dysfunction, learning difficulties, disordered
behavior, posttraumatic stress, and substance abuse
has been described in these populations. Clinicians
in the field also report other comorbid conditions
including, depression, bipolar disorder, and attention-deficit hyperactivity disorder. Becker et al. (1991)
examined juveniles who had committed sex offenses
and had a history of abuse themselves. They found
that 42% of sex offenders experienced major depression as measured by the Beck Depression Inventory.
These juveniles had a mean Beck score twice that of
a random sample of adolescents.
Despite this statistical picture, the sexually abusive youth population is heterogeneous, with diverse
characteristics and treatment needs. Hunter et al.
(2003) described these youth in terms of age and gender of targeted victims, the level of violence displayed
during the offense, and the socialecological context
of the offending behavior. They point out that some
youths target only children, while others assault peers
or adult females. Socialization patterns range from
affiliation with the delinquent peers to significant
social isolation (Righthand & Welch, 2001). Research
consistently reports that a majority of juveniles with
abusive sexual behaviors have significant deficits in
social competence (Righthand & Welch, 2001).
As a whole, sexually abusive youths do not appear
to differ significantly from juveniles who have
committed other types of nonsexual delinquency
(Becker & Hunter, 1997; Miner & Crimmins, 1995).
Serious delinquency tends to occur most in dysfunctional families, and they are more likely to have been
abused and to have received inadequate support and
supervision. Poor verbal skills are often present, as
are behavioral problems at school, lower academic
achievement, and higher rates of learning disabilities. It appears that they also have higher rates of
neuropsychological difficulties, particularly related

243

to planning and impulse control (Veneziano &

Veneziano, 2002). However, there does appear to be
some subgroups of juveniles who commit sex offenses,
who do differ from juveniles, and who commit other
offenses (Righthand & Welch, 2001).
There have been various attempts to classify sexually abusive youths according to their similarities and
differences, although none have yet been empirically validated. OBrien and Bera (1986) suggested
a clinically derived classification scheme for sexually
abusive youth, which was useful in identifying issues
in treatment, as follows: (a) naive experimenters,
(b) undersocialized child exploiters, (c) sexual aggressives, (d) sexual compulsives, (e) disturbed impulsives,
(f) group influenced, and (g) pseudosocialized.
A meta-analysis by Graves et al. (1996) suggested
three typologies: pedophilic, sexually assaultive,
and undifferentiated. Pedophilic youths consistently
molested young children. The sexual assault group
generally assaulted peers or older females. The undifferentiated group committed a variety of offenses
against victims, whose age ranged significantly. This
latter group was characterized as being more antisocial and with the most severe social and psychological
problems (Righthand & Welch, 2001).
Empirical research in progress supports the presence of identifiable subtypes of sexually abusive youths
with distinct developmental trajectories and unique
intervention needs (Hunter, Figueredo, Malamuth, &
Becker, 2003). Comparative analysis of adolescent
males who sexually offended against prepubescent
children with those who targeted pubescent and postpubescent females reveals that the former group has
greater deficits in psychosocial functioning, uses less
aggression in their sexual offending, and are more
likely to sexually abuse relatives. Their findings are
consistent with prior reports that many of these youths
have poor social skills and symptoms of depression
and anxiety.
Sexually abusive youths have also been categorized by gender, age, and intellectual development.
This chapter will not address issues related to sexually abusive behaviors by female youths, prepubescent
children or juveniles with developmental disabilities.
There is a sparse but growing literature relevant to
these special populations (Bumby & Bumby, 1997;
Gilby, Wolf, & Goldberg, 1989; Ryan, 1999).
The low rates of sexual recidivism in juveniles
who have committed sexual offenses imply many of
them will not go on to become adult sex offenders.

244 JUVENILES

However, there is a subset that does continue sexual

offending. This is another dimension of the heterogeneity of the population. Predictive factors for determining which juveniles will develop into adult sex
offenders have been inconclusive. Static variables relevant to risk have been identified but accurate actuarial risk prediction is very difficult with youth due
to the rapid changes of adolescence (Prentky, Harris,
Frizell, & Righthand, 2000; Worling & Langstrom,
2003). The dynamics of juvenile offending are very
changeable from day to day and over the course of
development.
Conflicting findings concerning the rates of sexual
recidivism for sexually abusive youths are present in
the literature. Recidivism in terms of sexual offenses
is not particularly high. Veneziano and Veneziano
(2002) report recidivism rates for sexual offenses have
ranged from 8% to greater than 30%, with most studies indicating ranges from 10% to 15% (Righthand &
Welch, 2001). They describe higher recidivism rates
for nonsexual offenses among this population, ranging from 16% (Sipe, Jensen, & Everett, 1998) to 54%
(Rasmussen, 1999).
A number of factors appear to affect the estimate
of recidivism among juveniles who have committed
sex offenses. These include the length of follow-up
period, the measurement of recidivism, the impact
of clinical interventions, and the nature of the population under investigation (Worling & Langstrom,
2003). Mazur and Michael (1992) reported a 0%
recidivism rate after a 6-month period, using selfreport data following community-based group treatment with 10 adolescents. In contrast to the findings
of Mazur and Michael (1992), Langstrom (2002)
found that 30% of 117 young offenders referred for a
psychiatric evaluation for the courts were reconvicted
for a sexual assault following a mean follow-up period
of 9.5 years (Langstrom, 2002). Worling and Curwen
(2000) reported that, after a mean of 6.2 years, 5%
of 58 adolescents who received treatment had subsequent sexual assaults charges compared to 18% of 90
adolescents who did not receive treatment. Gretton
et al. (2001) found that 15% of 220 adolescents who
had offended sexually received subsequent charges
for sexual assaults following community-based treatment. Because many studies report very high sexual
recidivism rates in juveniles (Awad & Saunders, 1991;
Rubenstein, Yeager, Goodstein, & Lewis, 1993) and
others identify low rates of sexual recidivism among
juvenile populations (Prentky et al., 2000; Sipe

et al., 1998), Dent and Jowitt (2003) recommend recidivism research include follow-up periods significantly
beyond 12 months. It will also be important to track
whether recidivism occurs during adolescent years or
later during adulthood.
Early offense specific treatment approaches for
juveniles were largely modeled after adult sex offender treatment programs, on the basis of the implicit
assumption that juvenile sexual offending would
portend chronic and progressively more serious patterns of sexual perpetration (Hunter & Longo, 2004;
Ryan, 1997). Generic juvenile offense-specific programming was typically offered in both institutional
and community-based settings and included a focus
on assessing and treating deviant sexual arousal and
interests, improving impulse control and judgment,
enhancing social skills and victim empathy, and
correcting cognitions that support or justify sexual
aggression (Freeman-Longo et al., 1995). Research
support for this conceptual model for all or most juveniles who commit sexual offenses has not been demonstrated (Hunter & Longo, 2004) and randomized
clinical trials have not been conducted to evaluate
the effectiveness of this approach in deterring recidivism (Hunter & Becker, 1999).
With evidence supporting the heterogeneity of
the population and clinical experience identifying
a broad spectrum of diagnostic differences, current
standards call for individualized and comprehensive
evaluation and differential treatment plans (Colorado
Sex Offender Management Board, Colorado Division
of Criminal Justice, 2003). There is also clinical
consensus that well-informed caregiver involvement
benefits the supervision and treatment process.

ASSESSING THE R EL ATIONSHIP

A ND THE ACT

Identifying juveniles who commit sex offenses can

be somewhat confusing. The problem stems from a
general lack of understanding as to what constitutes
an abusive or exploitive relationship between two
children. Clear definition of what constitutes a sexual
offense when the victim and the perpetrator are both
children is imperative to be able to properly identify
and treat juveniles who perpetrate sex offenses.
When an adult offends against a child, there is
an inherent inequality of the relationship. In almost
all societies, adult sexual contact with children and

JUVENILES WHO SEXUALLY OFFEND

adolescents is prohibited by law and by societal

norms. Societies and the law recognize that adults
have much greater power than children and therefore
true consent by the child to be sexual with an adult is
not possible. As a result, adultchild sexual relationships are always illegal until the younger person is
beyond a legally defined age of consent. When a
juvenile commits a sexual offense, it is often the case
that the offender and the victim are relatively close
in age. It is generally accepted to be abuse when an
older adolescent has a sexual relationship with a significantly younger child. Defining abuse involving
two children of similar ages is more difficult. When
a juvenile is sexually involved with another juvenile,
the nature of the relationship and interaction must be
closely examined to determine whether it is abusive
or not.
Such an evaluation is very challenging. We do not
know enough about what constitutes normal childhood or adolescent sexuality and behavior. Research
in this field was historically discouraged and it is
difficult to obtain human subjects approval for any
inquiry into child and adolescent subjects sexuality.
Historically, sexuality in childhood has been denied
and repressed by the culture in the United States.
Only recently have we begun to critically examine the
characteristics of child and adolescent sexual relationships. Ryan (2000a) reviewed the literature regarding
childhood sexuality and attempted to define normal
from abnormal. Before the 1980s most research came
from less repressive cultures. Subsequent studies have
included surveys of adult recollection of childhood
sexual experience, adult observations of the sexual
behaviors of children, and interviews with juveniles
who have perpetrated sexual offenses. Ryan (2000a)
and Ryan et al. (1988) describe a range of prepubescent and postpubescent sexual behaviors as illustrated
in Table 17.1.
Thinking of sexual behaviors along a continuum
such as that summarized in Table 17.1 provides guidance to determine when a childs sexual behavior
warrants closer investigation. However, the behavior
itself is usually not sufficient to determine whether
the behavior is problematic or not, and whether an
interaction between two children is abusive or exploitive. In defining abusive behaviors, more information about the relationship and interaction of the two
children should be gathered and analyzed.
Generally, an age difference of 5 years or more is
assumed to be exploitive, the assumption being that

245

Table 17.1 Sexual Behaviors in Prepubescent and

Postpubescent Children
Prepubescent Children
Normal/Developmentally Expected
Genital or reproductive conversations with peers or similar
age siblings
Show me yours/I will show you mine with peers
Playing doctor
Occasional masturbation without penetration
Imitating seduction (i.e., kissing, flirting)
Dirty words or jokes within cultural or peer group norm
Requiring Adult Response
Preoccupation with sexual themes (especially sexually
aggressive)
Attempting to expose others genitals
Sexually explicit conversations with peers
Sexual graffiti (especially when chronic or impacting
individuals)
Sexual innuendo/teasing/embarrassment of others
Precocious sexual knowledge
Single occurrences of peeping/exposing/obscenities/
pornographic interest/frottage
Preoccupation with masturbation
Mutual masturbation/group masturbation
Simulating foreplay with dolls or peers with clothing on
(i.e., petting or French kissing)
Requiring Correction
Sexually explicit conversations with significant age
difference
Touching genitals of others without permission
Degradation/humiliation of self or others with sexual
themes
Inducing fear/threats of force
Sexually explicit proposals/threats including written notes
Repeated or chronic peeping/exposing/obscenities/
pornographic interests/frottage
Compulsive masturbation/task interruption to masturbate
Masturbation which includes vaginal or anal penetration
Simulating intercourse with dolls, peers, animals, with
clothing on
Always Problematic; Requiring Intervention
Oral, vaginal, anal penetration of dolls, children, animals
Forced exposure of others genitals
Simulating intercourse with peers with clothing off
Any genital injury or bleeding not explained by accidental
cause
(continued)

246 JUVENILES

Table 17.1 (Continued)

Postpubescent Children
Normal
Sexually explicit conversations with peers
Obscenities and jokes within cultural norm
Sexual innuendo, flirting and courtship
Interest in erotica
Solitary masturbation
Hugging, kissing, holding hands
Foreplay (petting, making out, fondling)
Mutual masturbation
Monogamous intercourse
Requiring Adult Response
Sexual preoccupation/anxiety (interfering with daily
functioning)
Pornographic interest
Indiscriminate sexual contact with several partners in a
short period of time
Sexually aggressive themes/obscenities
Sexual graffiti (especially when chronic or impacting
individuals)
Embarrassment of others with sexual themes
Violation of others body space
Single occurrences of peeping/exposing/frottage with
friends of similar age
Mooning and obscene gestures
Requiring Correction
Compulsive masturbation
Degradation/humiliation of self or others with sexual themes
Attempting to expose others genitals
Chronic preoccupation with sexually aggressive pornography
Sexually explicit conversations with significantly younger
children
Touching genitals without permission (i.e., grabbing, goosing)
Sexually explicit threats (verbal or written)
Illegal Behaviors Defined by Law; Requiring
Immediate Intervention
Obscene phone calls, voyeurism, exhibitionism, frottage,
and sexual harassment
Sexual contact with significant age difference
(child sexual abuse)
Forced sexual contact (sexual assault)
Forced penetration (rape)
Sexual contact with animals (bestiality)
Genital injury to others
Ryan, 2000.

the difference in ages and development is sufficient

to give the older member control over the younger.
This is a difficult measure to use when the children
are closer in age. Also, it provides little guidance as
to what constitutes exploitive behavior. By examining
the dynamics between the two children, the evaluator can better determine whether a particular act is
abusive or exploitive. When evaluating juveniles who
are referred due to sexual behavior problems or adjudication for a sexual offense, it is important to first
consider the relationship between the two juveniles.
Kempe (1980) defined sexual abuse as the involvement of dependent, developmentally immature children, or adolescents in sexual activities that they do
not fully comprehend, to which they are unable to give
informed consent, or that violate the social taboos or
family roles. In evaluating sexual behavior that occurs
between two juveniles, determination that an interaction has been abusive is based on three characteristics
of the relationship: consent, equality, and coercion
(National Task Force on Juvenile Sexual Offending,
1993; Ryan et al., 1996).
Consent
Consent, as a legal construct, is defined as beyond the
competence of juveniles (Ryan, 1997). Juveniles process decisions differently than adults. It has been suggested that this difference in decision-making process
is not due to intelligence or mental illness but due to
emotional and intellectual immaturity. There is little
data relating to the capacity of a child to consent to a
relationship. However, we know juveniles frequently
lack the capacity to proceed in court related matters.
The MacArthur Juvenile Adjudicative Competence
Study revealed that adolescents aged 11 to 13 years
were three times more likely to be seriously impaired
on evaluation of competence-related abilities than
were young adults aged 18 to 24 years. Juveniles aged
14 to 15 years were twice as likely to be impaired.
Adolescents younger than 15 years were less likely to
recognize risks inherent in different choices and were
less likely to think of the long-term consequences of
their choices (Grisso, Steinberg, Woolard, Cauffman,
Scott, & Graham, 2003).
When evaluating a sexual interaction between
two juveniles, examination of the relationship and the
interaction in question can suggest the presence or
absence of consent. The elements of consent are generally defined as follows: an understanding of what is

JUVENILES WHO SEXUALLY OFFEND

being proposed, knowledge of societal standards for

what is being proposed, awareness of potential consequences, and assumption that either agreement or
disagreement will be respected (National Task Force
on Juvenile Sexual Offending, 1993). Notably, the
perceived cooperation or compliance of the victim
is not sufficient to determine consent because juveniles who offend typically use nonphysical methods
to coerce their victims (Ryan et al., 1996). The determination of consent requires a thorough assessment
of the elements of consent in the interaction of the
two youths at the time of the act (Ryan, 1997). When
the two juveniles understanding of each element is
similar, and both choose to participate without coercion, the interaction may be defined consensual,
even though their decision may not be completely
informed and the behavior may involve unknown
risks/consequences for the children.
Equality
The assessment of equality focuses on power and
control. Obviously, this may be defined by similarities or differences in age or size. But, the evaluation
is more difficult when the two children are similar
in age and size. Other factors should be considered
including intelligence, emotional experience, popularity among peers, and whether the relationship is
mutually respectful. Roles may play a large part in
the balance of equality. When one juvenile who has
been put in charge (e.g., to babysit a younger child),
the imbalance of power and authority may have been
created by their roles. When a child is designated as
leader of his peer group, there is a shift of power toward
that child (Ryan, Metzner, & Krugman, 1990).
Coercion
Coercion involves one person putting pressure on the
other person to engage in sexual activity. Obviously,
a child who is much larger or stronger may coerce
the other in a physical way. But, coercion ranges from
aggressive physical threats or actions to subtle, nonaggressive forms such as bribery or manipulation. Most
sex offenses perpetrated by juveniles are verbally
coercive (Ryan et al., 1996); however, threats may
be implied rather than stated explicitly. Also, mental
or physical tricks under the guise of a game may be
used. Threats of loss of property, esteem, or relationship can be impressively coercive to a child. A threat

247

of loss of love, relationship, or esteem can be as coercive as the loss of privilege or threat of punishment
(Ryan, 1997).

A SSESSMEN T OF PER PET R AT ION

The assessment of a juvenile accused of a sexual

offense is a complex process. A thorough clinical
interview by a clinician knowledgeable in sexual perpetration issues is required and must be differentiated
from interview for law enforcement or child protection purposes. The clinical assessment must address
the patients emotional make-up and behavior including the following: life story, history of sexual learning,
experience, and behaviors, and other problematic
behaviors such as interpersonal or self-destructive
abusive behaviors and substance use, his cognitive
abilities and personality traits, and the presence of a
mental health disorder. The assessment should address treatment recommendations, placement decisions, types of treatment interventions, and levels of
supervision. Amenability to treatment, community
safety, potential to reoffend, and living arrangement
options must each be considered.
In the mid-1980s, highly structured offensespecific assessment tools were developed. In response
to the development of these offense-specific models,
there was a tendency for clinicians to concentrate on
offense-specific assessments and treatment. Unfortunately, the juveniles psychosocial development and
psychiatric needs were frequently overlooked while
focusing exclusively on the offense behaviors.
Recently, more information has been gathered
regarding offense patterns in these juveniles and the
generality of their abusive behaviors has been illuminated. For many of these juveniles, there is a lack of
specificity toward sexualized aggression. Focusing
on the sexualized behavior exclusively puts the treating clinician at risk of missing the larger problem:
the juveniles pattern of abusive and dysfunctional
responses in many different settings and the wider
range of harmful behaviors. Research already referenced in this chapter has indicated the presence of
comorbid psychiatric illness, other forms of delinquent law violations, and psychosocial problems that
can be missed when focusing exclusively on the referring behavior.
Abusive youths may come to the attention of clinicians at several points through their legal process. The

248 JUVENILES

National Task Force on Juvenile Sexual Offending

(1993) has summarized differences in the purpose of
each phase of involvement:
1. Pretrial (investigative)
2. Presentencing (dangerousness/risk; placement/
prognosis; treatment issues/modes; levels of
restriction/supervision)
3. Treatment needs (planning and progress in
treatment)
4. Release/termination from treatment (community safety and successful application of treatment tools)
5. Monitoring and follow-up
The nature of the assessment depends on the referral question to be answered. This section will focus
on pretrial and presentence evaluations. Referrals at
this point are usually initiated by social services or the
police. This is a good opportunity to gain the cooperation of the family because this is usually a time
of crisis. When the juvenile or family is interviewed
during this phase, they may be more likely to be open
because of the imminent threat, real or perceived, of
incarceration. However, the family may deny or minimize problems during this time, which would certainly affect the reliability of the information obtained
from them (Ryan et al., 1990).
The charge of a sexual offense involves serious
legal and socially stigmatizing consequences. This
would be overwhelming for anyone, but particularly
for someone immature. Through the process, the
juvenile will experience a variety of complex emotions. Several common defenses used to relieve such
stress can affect the integrity of the evaluation. For
example, many juveniles have a tendency to deny or
minimize their sexual offenses (Benda, Corwyn, &
Toombs, 2001). This significantly complicates the
interview. For this reason and many others, the use of
multiple sources of information is critical to an accurate history in addition to multiple interviews with
the juvenile. Interviews with the juveniles parents are
essential to the assessment process.
Collateral data can help provide information as to
the juveniles interest in treatment, degree of accepting responsibility, and range of denial and abusive
behavior. With juveniles who have committed sex
offenses, this collateral information should include
police reports, victim statements, victim therapist
reports, agency investigative summaries, and presentence investigation reports.

The assessment of the juveniles home can provide invaluable information. The primary focus of
the home assessment should be whether the environment provides adequate supervision of the juvenile to provide safety for others in the home and the
community. Are both parents at home? How much
time are they away during weekdays and weekends?
Who is left in charge of the juvenile when they are
away? Special attention should be paid to younger
siblings or other children who may be at risk of being
victimized (Center for Sex Offender Management,
1999). The juveniles family resources should be
evaluated. The amount of emotional support the
juvenile can expect from his family will be important to his treatment. Out-of-home placement is
frequently required when the victim or potential
victims live in the same home or in close proximity
to the juvenile.
The parents should be interviewed. As collateral
informants, their perceptions of the juveniles developmental history and current functioning can be
important to formulation of the juvenile. In addition,
the family attitude toward the offense needs to be
assessed. Whether they are too lax or too punitive can
have an effect on how the juvenile responds to treatment. It is also helpful to know how involved they
plan to be in the juveniles treatment (Ryan, 1997).
Forensic interviews with juveniles accused of
sex offenses are often performed by adult psychiatry
trained clinicians with little expertise in child psychiatry. The impact of subtle differences in interview
style can have very dramatic, and often undesirable,
effects when interviewing a juvenile. The tendency
of the juvenile to shutdown and refuse to participate
can be very frustrating to the interviewer. The clinicians tone through the interview is important. Ryan
(1997) suggests an interactional style with a nonjudgmental approach that is respectful of the youth
as an individual, while maintaining an awareness of
the youths motivation to manipulate the interview.
A calm, straightforward, matter-of-fact style will yield
more information than direct confrontation or poorly
timed questions regarding why or whether the juvenile committed the offense in question. Providing
information and language as a basis for talking about
sexual issues must precede direct questions to avoid
eliciting inaccurate statements that the youth is then
committed to defend.
The evaluation should be conducted over multiple interviews, which allows the juvenile to become

JUVENILES WHO SEXUALLY OFFEND

somewhat more comfortable with the interviewer.

In general, the initial interview should be used for
obtaining history from the juvenile that is not as emotionally charged as compared to the history relevant
to the sexual perpetration.
The initial interview is often conducted without the parents being present. The juvenile may be
embarrassed to talk about his/her behavior in the
presence of parents. The juvenile may also fear additional punishment from the parents.
Joint interviews with the juvenile and his parents
are also useful in obtaining more accurate history
and a better understanding of psychodynamic issues.
Discrepancies between the juveniles report and
information obtained from parents and other sources
should be investigated and understood.
The assessment should be comprehensive and
include the factors described in Table 17.2.
The setting of the assessment will usually be determined by the juveniles clinical state and legal status.
An inpatient psychiatric evaluation may facilitate
completion of a comprehensive evaluation in a relatively brief period of time but is not cost-effective. A
residential treatment setting may offer the advantages
of an inpatient evaluation without the higher cost.
Culture is an important factor and should be considered in understanding sexually aggressive youths
and their families and communities. The evaluator
should keep in mind that cultural sensitivity does not
equate to acceptance of abusive behavior (National
Task Force on Juvenile Sexual Offending, 1993).
Assessments of these juveniles are complicated
and time consuming. They are best performed over
a longer period of time. A significant reason for this is
the length of time it takes to develop a working relationship with the juvenile and family. Using multiple
interviews to form an assessment also provides the
evaluator with information relevant to coping skills
and credibility issues.

249

Table 17.2 Factors of a Comprehensive Assessment

Victims statements
Background information (including family, educational,
medical, psychosocial, developmental, and psychosexual
histories)
Progression of sexually aggressive behavior over time
Dynamics/process of victim selection
Intensity of sexual arousal during and after the offense
Use of coercion, force, violence, and weapons
Spectrum of injury to the victim, (that is, violation of trust,
fear, physical injury)
Sadistic elements
Ritualistic elements
Number of categories of deviant sexual interest
Reported use of sexually deviant fantasies
Deviant nonsexual interests
History of assaultive behaviors
Issues related to separation/loss
Sociopathic characteristics
Psychiatric diagnosis (i.e., affective disorders, personality
disorders, attention deficit disorder, and posttraumatic
stress disorder)
Presence of developmental disorders
Behavioral warning signs
Identifiable triggers
Irrational thinking
Locus of control
Attributions of responsibility
Degree of denial or minimization
Understanding of wrongfulness
Concern for injury to the victim
Quality of social, assertive, and empathic skills
Familys denial, minimization, and response
Effects of alcohol/drugs and pornography on deviant
sexual behavior
History of sexual victimization, physical or psychological abuse
Family dysfunction
Reported ability to control deviant sexual interests
Mental status examination

PSYCHOLOGICA L T EST ING

Psychological testing of those who sexually offend has

been widely used and can be helpful in assessment,
but is limited by the heterogeneous nature of these
youth and their behaviors. The specific applicability
of psychological testing in these juveniles is promising but no clear and consistent indication has been
found. Researchers are trying to elucidate the role of

Organicity/neuropsychological factors
Becker & Abel, 1985; National Task Force on Juvenile Sexual
Offending 1993.

psychological testing more clearly. At present, psychological testing serves to add a norm-based reference of
personality and behavioral traits to the general assessment of these juveniles.

250 JUVENILES

Many psychological tests are commonly used with

juveniles; however, because of the heterogeneity of
juveniles who have committed sex offenses, there
is no profile that distinguishes these juveniles from
other juveniles who do not sexually offend (Bourke &
Donohue, 1996). Although not predictive, psychological tests can be useful in assessing characteristics
such as whether the juvenile tends to recognize and
respond with socially desirable responses, or malingers. Information gained from a juveniles personality
profile may also allude to possible psychopathology.
Identifying personality traits can be important in
developing the optimal treatment strategy.
The psychological test most commonly used with
juvenile sexual offenders is the Minnesota Multiphasic Personality InventoryAdolescent (MMPI-A)
(Butcher et al., 1992). Because of the heterogeneity
of juveniles who have committed sex offenses, there
is no MMPI or other psychological test profile that
distinguishes these juveniles from juveniles who
do not sexually offend (Bourke & Donohue, 1996).
Although it is not predictive, the MMPI-A can be
useful in assessing whether the juvenile is dishonest
or malingering. The information gained from the
juveniles personality profile may allude to possible
psychopathy. These traits can be important when
developing the optimal treatment strategy.
The Multiphasic Sex Inventory (MSI) (Nichols &
Molinder, 1984) is an assessment instrument used to
evaluate sexual interests, knowledge, fantasies, and
behaviors. It was designed for clinical and treatment
purposes to assess the type and level of sexual deviance among juvenile sex offenders. The MSI can be
helpful in providing clinical information by identifying psychosexual and personality characteristics
(Sorensen & Johnson, 1996). In a study of 101 male
offenders, aged 12 to 19 years, Butz and Spaccarelli
(1999) examined the level of force as a possible characteristic to classify adolescents who commit sexual
offenses. They divided the juveniles into three classes:
rapists (those who use force), nonrapists, and deniers.
They administered the MSI to the three groups.
Rapists reported significantly more sexual assault fantasy/predatory behavior, greater preoccupation with
children, and more paraphilias than did nonrapists
and deniers.
Scales of psychopathy have emerged as an important factor in the study of adult criminal behavior
including sexual offenses. Identification of psychopathy traits during adolescence is controversial and can

have unintended consequences in both legal dispositions and service provision. However, there may be
an association between psychopathy traits and the
level of violence used during sexual offense, as well as
increased risk of adult criminality. In a chart review,
Gretton et al. (2001) obtained psychopathy ratings for
220 males (age 12 to 18 years) who were treated in
an offense-specific treatment program. Using charges
and convictions, they compared the psychopathy
scales to 5-year recidivism rates. They found adolescents with high psychopathy scores were three times
more likely to commit a reoffense of any kind than
those with a low psychopathy score. However, the
study did not find high psychopathy scores to be significantly predictive of sexual offense recidivism.
A more promising and comprehensive approach
may be the Multidimensional Assessment of Sex and
Aggression (MASA) (Knight, Prentky, & Cerce, 1994).
This is a computerized, self-report inventory that covers multiple domains, and a juvenile version has been
validated. The questionnaire focuses on attitudes and
behaviors in many areas of the individuals life, and
includes methods for assessing response biases, random responding, and dissimilation. Given the juvenile version of this instrument is so new, very little
information is available regarding its applicability for
juveniles who commit sexual offenses (Righthand &
Welch, 2001).

PENILE PLETH YSMOGR A PH Y/

ME ASUR EMEN T OF SE X UA L A ROUSA L

Attempts to assess the sexual arousal of adolescents

present a moral and ethical quagmire. Phallometric
assessment (by penile plethysmography [PPG])
remains an area of controversy in the assessment of
juveniles who have committed sex offenses.
Some investigators consider phallometric assessment the best means to assess individuals arousal
patterns, (Weinrott, 1998); but controversy exists
regarding the invasiveness of the testing, nature and
variability of the stimuli used, and lack of comparison to any control group of juveniles who have not
sexually perpetrated. With the lack of adequate studies, the role of phallometric assessment with juvenile
populations is unclear. The lack of norms is a very
complex problem due to the ethical complications of
administering this testing to a control group. However,
Weinrott (1998) points out that it may be possible to

JUVENILES WHO SEXUALLY OFFEND

evaluate juveniles with stimuli that are less sexually

explicit, since juveniles tend to have a low threshold
of response to even mild sexual stimuli.
At this time, laboratory assessment of arousal may
be most useful in individual cases, during treatment,
as a means of evaluating the accuracy of the youths
self-awareness and their ability to suppress unwanted
arousal using various strategies learned in treatment.
Although adults often express concern that PPG
assessments are too invasive, some youth report that
the technology of a laboratory assessment is less intrusive than many of the verbal questions discussed in
treatment sessions.

ASSESSING SE X UA L IN T ER ESTS

Computerized assessment instruments are promising. The Abel Assessment for Interest in Paraphilias
describes a pattern of the juveniles sexual interest on
the basis of visual reaction times (VRT) when viewing slides of potentially sexually evocative stimuli
(Abel Screening, Inc., 1996). Computer assessments
such as the Abel Assessment may have the advantage
of being less invasive than phallometric assessment;
however, there continue to be controversies regarding whether there is sufficient data to support the
VRT as reliable and valid for juveniles (Smith &
Fischer, 1999). Nonetheless, computer-aided assessments represent a relatively recent development, and
as research continues, their place in the assessment
of juveniles who commit sexual offenses may become
more evident.
Polygraphy
Polygraph testing has been used with this population
of juveniles to facilitate more complete disclosure of
history and description of abusive behaviors. It can
also be used to monitor compliance with conditions
of probation and treatment contracts. Although the
use of polygraph testing in juveniles who have sexually offended is relatively common in many jurisdictions, clear criteria for the circumstances under which
a youth should be tested are not always clearly articulated. There are potential unintended consequences
that must be considered when considering administration of a polygraph examination. For example,
information regarding sexual or abusive behavior
revealed in preparation or explanation of a polygraph

251

exam can lead to additional investigation and legal

jeopardy.
The National Task Force on Juvenile Sexual
Offending (1993) emphasizes that it is critical that
submissions to polygraph examinations be voluntary and with the full informed consent of the youth,
parent, or legal guardian.
The purpose and use of information gleaned from
the preparation and processing of results should be
made clear as well as potential consequences associated with the outcome. The national task force also
points out that some organizations ethical codes
restrict the use of instruments without empirical evidence of reliability and validity. Evidence supporting
the reliability and validity of polygraph testing in juveniles who have committed sexual offenses is limited
(Hunter & Lexier, 1998). Both false positives and false
negatives appear with some regularity and the therapeutic consequences of these errors are unknown
(Bonner et al., 1998). When polygraphs are ordered as
a condition of probation, clinicians must be clear that
the purpose is related to risk assessment and supervision, not a therapeutic intervention.

R ISK ASSESSMEN T

The criminal justice system is chiefly concerned with

protecting the community. Most juveniles who commit sexual abuses come to the attention of treating
clinicians as a result of their involvement with the
courts. As a practical matter, it is important to understand the concerns the courts may have relating to
these youths. As a result of their charge to protect the
community, the courts are interested in the likelihood of reoffense. Within the criminal justice system,
decisions relating to future care and containment
are based upon perception of risk factors relating to
recidivism. Expertise of clinicians can be helpful to
the court in determining reasonable preadjudicatory
planning and ongoing treatment recommendations.
As previously summarized, sexual assault recidivism rates vary widely throughout the literature.
The recidivism rates for nonsexual offenses also vary
widely with the literature reporting rates from 16% to
54% (Sipe et al., 1998).
Historically, decisions related to risk assessment
have been based on subjective experience rather than
objective data. This approach has provided suboptimal results. Using subjective factors to determine

252 JUVENILES

risk leads to inconsistency and bias (Hoge, 2002).

Dependence on clinical experience rather than objective data is driven by the paucity of useful research
findings in this area. A meta-analysis of follow-up
studies of adolescents who have committed sexual
abuses was done by Cottle et al. (2001). They found
that only nine studies met the criteria for inclusion in
the analysis and four of these studies were never informative for each of the risk factors examined. In the
studies examined, associations between risk factors
and recidivism were weak. However, research in the
area of risk assessment for juveniles who have committed sex offenses is developing. Although much of
the data remains inconclusive or conflicting, numerous promising risk factors are being identified and
gaining empirical support.
History of assaults against more than one victim
is one of the more consistently supported risk factors
for recidivism. However, the literature examining
this risk factor is relatively sparse. Rasmussen (1999)
reported the number of female victims was significantly related to sexual offenses 5 years after release.
In a 9-year postrelease follow-up of 126 adolescents
aged 15 to 20 years, Langstrom (2002) found those
who offended against two or more victims were two to
three times more likely to recidivate than adolescents
with one known victim.
Deviant sexual interest is one of the most strongly
supported risk factors for reoffense. However, there
is conflicting data in the literature, which makes it
difficult to conclude this as a true risk factor for recidivism. In a follow-up study over an average 6-year
period, Worling and Curwen (2000) found that selfreported sexual interest in children (including past
or present sexual fantasies involving children, child
victim grooming behaviors, and intrusive sexual
assault activities with children) was a significant risk
factor for sexual reoffending. In a study comparing
adolescents with a previous charge for sexual offending (sexual recidivists) to those charged for the first
time, Kenny et al. (2001) found that sexual assault
recidivists were significantly more likely to report
deviant sexual fantasies that reflected force or young
children. Schram et al. (1991) reported adolescents
rated by clinicians as most likely to have deviant sexual interests were significantly more likely to reoffend
sexually. Research relating to deviant sexual interest
in youth that have sexually offended has been based
largely on noninvasive data collection methods such
as clinical interviews and rating scales.

There is very limited research regarding PPG

measurements in this population. Gretton et al.
(2001) administered PPGs to 186 adolescent males
who had confessed to sex offenses. Her group reported
that deviant sexual interest was not related to sexual
assault recidivism. More research is needed before
deviant sexual interest can be accepted or refuted as a
predictive factor of recidivism.
Prior convictions for sexual assault represent
another risk factor with predictive potential. There
is limited research in this area. Schram et al. (1991)
found that adolescents with at least one prior conviction for a sexual assault were significantly more likely
to reoffend sexually. Langstrom (2002) also reported
that a history of previous sexual offenses, including
prior convictions, was related to sexual assault recidivism. However, although the data are suggestive that
the presence of prior convictions may be promising
as a potential risk factor, the extent of significance is
inconclusive.
Selection of a stranger-victim as a risk factor is supported by limited, but consistent, data. Two studies
found that the selection of stranger victims was moderately but significantly associated with sexual reoffending for adolescents (Langstrom, 2002; Smith &
Monastersky, 1986).
A lack of peer relationships and lack of involvement in prosocial activities may be risk factors for
sexual offending. The literature has supported a link
between social isolation and general offending. In a
meta-analysis of research with adolescents in the general population, as well as identified young offenders,
Lipsey and Derzon (1998) noted that a lack of involvement in social activities was a robust risk factor for
violent offending. There is increasing evidence for
a link between social isolation and sexual offending. In a 5-year follow-up study of adolescents who
had offended sexually, Langstrom and Grann (2000)
reported adolescents with limited social contacts were
at least three times more likely to be reconvicted for
a sexual crime.
A number of other risk factors have been examined but the data collected is less promising than
those risk factors already mentioned. Problematic parentadolescent relationships and parental rejection
have been shown to have a moderate relationship to
recidivism Worling & Curwen (2000). Another concerning factor involves the adolescent having an attitude supportive of sexual offending. Characteristics
of this type of attitude include blaming the victim

JUVENILES WHO SEXUALLY OFFEND

or believing that the victim somehow invited the

assault. High-stress family environment, impulsivity, sexual preoccupations, environments supportive
of opportunity to reoffend, and the use of violence
or excessive threats during the act should be considered to be potential factors related to risk of reoffense
(Worling & Langstrom, 2003).
It is necessary to be aware of factors that likely
contribute to recidivism. However, it is equally important to have knowledge of which factors suggested by
empirical evidence are not related to an increased risk
of reoffense. The most notable example of this is the
abusive child denying the offense. Denial of sexual
offense has long been accepted as a factor related to
increased likelihood of recidivism. Notably, denial of
sexual offense appears on most recidivism assessment
guidelines. However, available studies indicate that a
juvenile who denies his sexual offense is less likely
to recidivate (Kahn & Chambers, 1991; Langstrom &
Grann, 2000; Worling, 2002). A number of theories
have been asserted to explain this, seemingly counterintuitive finding. One of the more widely accepted
explanations suggests that juveniles who deny their
offenses are more likely to have antisocial traits and
therefore a tendency toward general criminal activity. So, their sex offense was more likely the result
of an opportunistic criminal activity rather than
deviant sexual interest. The lack of relationship
between denial of the offense and recidivism has also
been reported in the adult sex offender literature.
(Hanson & Bussire, 1998). Other factors that appear
to not be predictive of recidivism include a lack of
victim empathy (Langstrom & Grann, 2000; Smith &
Monastersky, 1986), sex assault involving penetration (Langstrom, 2002), history of nonsexual crimes
(Kahn & Chambers, 1991; Lab, Shields, & Schondel,
1993; Langstrom, 2002), and the offending adolescent
having a history of sexual abuse (Hagan & Cho, 1996;
Rasmussen, 1999; Worling & Curwen, 2000).
Despite inconclusive data regarding risk factors,
there are many promising possibilities that may
develop into a definitive set of risks for recidivism.
Importantly, many of the intuitive and subjective factors previously thought to be associated with recidivism have been shown to have little or no support
based on empirical evidence. Some researchers have
suggested that actuarial risk prediction for juveniles
may never be validated due to the heterogeneity and
rapid growth and change which are characteristic of
adolescence.

253

T R E AT MEN T

Understanding the complex nature of sexually deviant

behavior requires an eclectic, multimodal approach.
Intervention must include offense-specific interventions which have often been provided in a group
setting (National Task Force on Juvenile Sexual
Offending, 1993). However, offense-specific treatment is only part of a more comprehensive strategy
that must be implemented to optimize outcomes and
ultimately decrease the risk of recidivism. An effective treatment plan evolves from a comprehensive
assessment of multiple influences affecting an adolescents mental life. The presence of a mental disorder
should be determined and treated. It is necessary to
consider factors from the adolescents life story with
positive experiences being stressed and the effect of
negative experiences managed. Cognitive abilities
and personality traits shape the psychotherapeutic
maneuvers that can be applied in various treatment
settings. A comprehensive treatment plan must consider all aspects of the youths functioning and environment using approaches from disease, personality,
cognitive, and life story perspectives.
Models for treatment of juveniles who commit
sexual offenses have evolved as our knowledge of the
population has increased. Two main factors drive
treatment protocols: (1) this is a heterogeneous population, and (2) the sexual offense is often the most
obvious or referring symptom in a larger pattern of
abuse. However, there are often many other symptoms of dysfunction which have gone unidentified
or untreated, but which may be very relevant to both
the initiation and maintenance of sexual and abusive
behaviors. Every adolescent who presents for treatment needs to be considered as a unique individual,
and treatment plans must address factors influencing the adolescents current and future functioning,
including patterns associated with all types of abusive
behaviors and assets which support healthier, prosocial adaptation. Focusing exclusively on the history
of past behaviors may have the unintended consequence of reinforcing the negative sense of self and
fail to create a dissonance for abusive behaviors.
Static risk factors may be of critical importance in
initial decision making regarding community safety,
placement, and supervision, as well as the intensity
and restrictiveness of the treatment setting, but it is the
acute and chronic dynamic factors which are changeable over the course of treatment (Ryan, 2000).

254 JUVENILES
CONFIDEN TI A LIT Y

Except in well-defined situations, traditional therapeutic relationships have usually guaranteed confidentiality to patients. Because sexual abuse occurs in
secret and secrecy allows it to continue, executing a
waiver of the right to confidentiality carries a strong
therapeutic message to the youth and family regarding the need to give up the secrecy which has supported the abusive behavior. Many programs require
a signed waiver of confidentiality, while others use
extensive releases, before admission to enable the
treatment provider to be in frequent open communication with all the systems and individuals who interact with the adolescent (Ryan et al., 1990). Such open
communication is often a condition of court ordered
treatment for youth on probation being provided in
community-based settings.

MEN TA L ILLNESS

There is little data regarding the prevalence of mental

illness in this population, the effect of proper diagnoses and treatment of mental illness, and its relationship to recidivism in this population. However,
intuitive presumption and clinical experience suggest that the symptoms of co-occurring disorders can
affect an adolescents behavior in a number of ways.
For example, attention-deficit hyperactivity disorder (ADHD) and bipolar disorder can contribute to
impulsivity and less resistance to abusive impulses.
An adolescent with major depression may care less
about himself and have less concern for the personal
consequences resulting from his behaviors. He may
also be more self absorbed and thus less aware or
less caring of the impact of his behavior on others.
Emotional reactivity or dissociation associated with
anxiety of post-traumatic stress disorder (PTSD) may
contribute to aggressive, hypersexual, and dysfunctional behaviors.
When sexual and/or abusive behaviors have been
used as compensatory coping strategies to express or
defuse untreated mental health issues or disorders,
the effect on cognition may make it more difficult for
the adolescent to recognize dysfunction or process
alternative coping mechanisms. It is important to
strive for correct diagnosis and effective treatment of
co-occurring disorders which might impede successful participation in treatment. It is also important for

the youth to come to understand diagnostic meaning

and treatment interventions that prove helpful during
treatment to address and support continued success in
long-term relapse prevention plans. Failure to include
necessary medical management of ongoing psychiatric disorders in aftercare plans may jeopardize treatment gains and contribute to the risk of relapse.

PH YSIOLOGICA L ASPECTS OF
T R E AT ING SE X UA L BEH AV IOR
PROBLEMS

Although the sexual offenses committed by juveniles

appear to be a product of dysfunctional coping, combined with a capacity to be abusive, more than physiological sexual deviance per se, there is a subset of
youth who sexually offend who report problematic
levels of arousal, in terms of frequency, intensity, or
intrusive thoughts. Symptoms of hypersexual drive
may be associated with numerous psychiatric diagnoses or may be a product of reinforcement and conditioning. For some youth it is difficult to engage and
progress in treatment without first achieving some
reduction of sexual arousal. Cognitive interventions
and behavioral reconditioning strategies can be
helpful for some, but are not always sufficient.
Drive-Reducing Medications and Selective
Serotonin Reuptake Inhibitors
There is minimal data regarding the use of drive
reducing medications in juveniles who have committed sexual offenses. There is still debate in the adult
literature regarding who is most helped by these
medications, but there is some consensus supporting the use of drive reducing medication for some
paraphilic adults (Bradford, 1998). Only a subgroup
of the juveniles who commit sexual offenses have
hypersexual or deviant fixations, and there are significant ethical considerations in doing research with this
population. For many youth, use of an antiandrogen
medication is counterindicated because they have not
reached their mature stature and bone growth might
be affected. However, in some instances hormonal
treatments may be useful, with close oversight from
the prescribing physician. Saleh et al. (2004) examined the effect of Leuprolide Acetate in six young
adults (aged 19 to 20 years) convicted of aggressive
sexual offenses and been refractory to treatment.

JUVENILES WHO SEXUALLY OFFEND

These young adults subjectively reported a decrease

in deviant sexual fantasy. Four of the subjects had
no side effect while one suffered a loss of ejaculation and another experienced retrograde ejaculation.
No clinically significant signs of osteopenia were
evident on DEXA scan after 1 year.
Several characteristics may be considered indicators for consideration of drive-reducing treatment.
Adolescents who may benefit from this pharmacotherapy might include those who have pathologically
increased sexual drives, intrusive or abusive sexual
interests, or who have impaired cognitive abilities
that preclude appreciation of the consequences of
their behavior for self and others and have a history of
acting on deviant sexual impulses. Given the paucity
of data regarding drive reduction in adolescents who
sexually offend, it is not possible to make an evidencebased argument for which of these individuals will
respond best to this treatment.
The presence of co-occurring mood disorders
sometimes results in treatment of depressive symptoms with selective serotonin reuptake inhibitors
(SSRIs) or tricyclics. The side effect of decreased sexual arousal which is sometimes associated with these
medications can be a welcome relief for the hypersexual teen whose arousal has driven problematic
behaviors. Although not normally prescribed as drivereducing medications, there is a growing awareness of
this potential for use in individual cases of treatment
with juveniles who have sexually offended.

PSYCHOTHER A PY: R EL AT IONSHIP,

E X PER IENCE , A ND EN V IRONMEN TA L
CONSIDER AT IONS

Neglect has often been ignored in understanding the

behavior of adolescents. The commonly held belief
that a history of being sexually abused is the major
historical risk factor for sexual abuse perpetration
draws attention away from other major risk factors. It
is not just the bad things that happen that create risk,
but also the absence of positive experiences and relationships. Widom and Williams (1996) demonstrated
that childhood neglect and witnessing family violence
may precede sexual offending even more often than
physical abuse and sexual abuse. This has significant
treatment implication because while it is not possible to undo past experiences, it is possible to create a
more supportive environment for the adolescent.

255

Personality traits, cognitive abilities, prior experiences, and social situation will all have an impact
on treatment. The goals of the treatment process are
(1) to clearly define the abusive nature of past sexual behavior (i.e., lack of consent, inequality, use of
coercion); (2) to aid the juvenile in understanding
the process or context associated with the offending
behaviors; (3) to develop skills and strategies for the
juvenile to intervene in this process; (4) to motivate
the juvenile to use these tools; and (5) to increase
empathic foresight in future interactions. Achieving
these goals will help the youth gain control over
abusive impulses and will increase the safety of others in the community.
Lane (1991) describes five distinct phases of treatment in an offense-specific treatment unit: (1) penetrating denial concerning the sexually abusive
behaviors, (2) identifying the adolescents sexual
abuse cycle, (3) helping the adolescent deal with
unresolved emotional issues, (4) providing retraining
in the areas of skill deficits, and (5) facilitating the
adolescents reentry into the community.
Although recent research suggests that denial may
not be directly correlated with sexual recidivism, it
is difficult to work on a problem that has not been
named.
However, the focus in discussing past offenses has
shifted from detailed disclosure of the sexually explicit
details to more of the dynamic risks associated with
future behaviors. The youths ability to make accurate
attributions of responsibility regarding their own and
others behaviors and to recognize the harm caused
by abusive sexual behaviors is the necessary precursor to their being able to work on defining abuse, recognizing predictable precursors, and understanding
empathic cues, even if they do not fully disclose every
past behavior.
The offense-specific treatment of juveniles who
have committed sexual offenses is often done in a
group setting.
This is cost effective in that a lot of the group work
provides education and skill building. One of the
main advantages of the group setting is the effectiveness of the group dynamic to confront denial in other
members with similar abuse patterns, while also providing the support that comes from knowing that they
are not alone. Ideally, groups are led by cotherapists,
both, male and female. Having both male and female
therapists will manage the likelihood of transference
issues being elicited by the therapists gender.

256 JUVENILES

The duration of treatment may range from a shortterm, psychoeducational intervention to a very complex long-term process that may last from 1 to 3 years.
The needs and issues for each youth are informed by
the individualized assessment and there should be differential treatment plans for each youth. The focus,
needs, and goals will not be the same for each individual in the group, but their exposure to those differences is congruent with their need to recognize that
the needs and desires of others are not always congruent with their own. Nonetheless, a significant concern
in bringing any group of delinquent youth together is
the risk of deviance training or the negative influence of delinquent peers. Therapists must take responsibility for constantly assessing peer interactions within
the group treatment setting to control for unintended
reinforcement, and some youth will require individual
therapy and/or family interventions before they become
able to successfully function in a group with peers.
Issues to be addressed in the treatment of adolescents who have sexually offended include the
following (National Task Force on Juvenile Sexual
Offending, 1993):
1. Acceptance of responsibility for behavior
2. Identification of pattern or cycle of offense
behavior
3. Effective interventions to interrupt the sexual
abuse cycle
4. Victimization (e.g., sexual abuse) and issues
for the offender
5. Capacity for empathy with others, especially
past victims
6. Interpersonal power and control issues
7. Role of sexual arousal in offenses
8. Sexual identity
9. Consequences of offending
10. Family issues that support offending behaviors
11. Cognitive distortions related to offending
behaviors
12. Expression of feelings
13. Skill deficits (social and academic)
14. Substance use/abuse
15. Relapse prevention
16. Management of concurrent psychiatric disorders
Effective treatment intervention requires intersystem cooperation and the support of the legal system.
Clinicians generally agree that a mandatory treatment model is the most effective way to address the
juveniles reluctance to change and the need for external controls from the court, parents, or protective

services system. The courts involvement requires

that the juvenile take responsibility for behavior and
demonstrate change. Mandated treatment can result
from diversion programs, conditions of probation, or
treatment plans related to dependency and neglect
proceedings. Court-ordered treatment should be
enforceable for at least 2 years because of the length
of time required for adequate treatment and the frequency of premature termination of treatment when
not mandated (Hunter & Figueredo, 1999).

THE CYCLE

The concept of an abuse cycle has been helpful for

many adolescents as the cornerstone of the cognitive
aspects of their treatment (Lane, 1991). Situational,
affective, cognitive, and behavioral factors are considered to understand patterns associated with the individuals offending behaviors and to recognize predictable
precursors which can then be handled differently.
Initially viewed specifically as a sexual abuse
cycle, the similarity of patterns associated with
many dysfunctional behaviors illustrates habituation
of behaviors which provide some immediate gratification, even when there are also negative consequences. The pattern is triggered by a situation that is
perceived by the adolescent in a manner that causes
emotional stress, feeling diminished, vulnerable, and
unable to cope. This feeling in turn contributes to
the adolescent expecting something bad to occur,
which often results in him feeling threatened emotionally and/or physically. It is common for the youth
to become reclusive during such times in an attempt
to avoid the anticipated negative occurrence. During
this isolation, projection, and externalizing cover the
vulnerable feeling with anger and the adolescent fantasizes about retaliation (How can I get backmake
others feel as bad as I do?) or compensation (How can
I feel better?). These fantasies can become the basis
for a plan which develops into the offense. When the
motivation is retaliatory, the behaviors may be deliberately abusive, accompanied by a conscious desire to
inflict pain, whereas the compensatory motive may
simply disregard the victims needs and fail to anticipate the abusive impact of the behaviors (Ryan, Lane,
Davis, 1987).
It is helpful to think of the factors that contribute to abusive behaviors in terms of the possibility of
them being altered through treatment. Ryan (2000b)

JUVENILES WHO SEXUALLY OFFEND

Table 17.3 Types of Factors That May

Contribute to Abusive Behaviors
Static (Historical/Unchangeable)
Condition at birth
Permanent disabilities
Family of origin
Early life experience
Stable (Life Spanning/Less Changeable)
Temperament
Intellectual potential
Physical attributes
Heritable neurological characteristics
Dynamic (Change/Manage/Moderate)
Situations
Thoughts
Feelings
Behaviors

suggests dividing these factors into static, stable, and

dynamic categories (see Table 17.3).
Because we cannot change the past, the static and
stable risk factors are difficult to modify. However,
these factors may represent major obstacles for the
adolescent to overcome as he/she progresses through
the treatment process. These should be considered
when assessing the adolescents assets and weaknesses
in the development of a comprehensive treatment
plan. As in all therapeutic relationships, it is important to consider the patients temperament when
modifying a pattern of behavior.
Adolescents personality and behavioral characteristics represent dynamic traits that are still malleable.
Similarly, plethysmography evidence suggests that
juvenile sexual offenses are not usually reflections
of fixated interests or deviant sexual arousal. Much
more than in the adult population, treatment of juveniles should concentrate on the more dynamic and
changeable traits of these children. Prentky et al.
(2000) describes the reduction of dynamic risks in
terms of what might be observable in the treatment
process: accepting responsibility, internal motivation
to change, understanding the cycle, showing empathy
and remorse, decreased cognitive distortions, anger
management, stability in home and school, support
systems, and quality peer relationships.

257

A SSESSMEN T OF T R E AT MEN T
OU TCOMES

As treatment progresses, the adolescent should

become proficient in defining all abuse and develop
vigilance which makes it less likely that he may
engage in, or be a victim of, abuse without defining
it as such. The adolescents knowledge and use of the
abuse cycle is important in achievement of this goal.
Through the use of the cycle, the adolescent will
more readily identify when he or she is experiencing
stress and immediately define fantasies about abuse,
enabling them to interrupt the progression of these
fantasies before they act on impulse.
The youth should begin to demonstrate the ability to be empathic during their daily interactions.
They should be able to recognize the cues in self
and others which indicate needs and emotions. The
adolescent should take responsibility for his or her
own behavior while not accepting responsibility beyond his or her control or trying to assume control of
others.
Neglect and isolation are major risk factors for
abusive behavior. A very important skill to counter
these risks is the ability to create and maintain psychologically safe, empathic relationships. Prosocial
relationship skills, and especially ones own ability to
establish intimacy, closeness, and trustworthy relationships, demonstrates and supports a belief in the
value of such relationships. A positive self-image is
reliant on mastery of the developmental skills which
enable individuals to be separate and independent,
while a sense of personal competency supports personal responsibility.
Table 17.4 provides a treatment outcomes summary that is congruent with the outcomes required
for successful completion of treatment under the
Colorado State Standards (2003).

CONCLUSION

Juvenile sexual offenses cause tremendous harm to

victims in the community, as well as legal jeopardy
and social stigma for the youth. Awareness of the incidence and prevalence of juvenile offenses are recent phenomena, and community reactions are often
harsh and punitive. It had been assumed that youth
who sexually offended were expressing deviant sexual

258 JUVENILES

Table 17.4 Observable Outcomes

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Consistently defines all abuse (self, others, property)

Acknowledges risk (foresight and safety planning)
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Relevant to Increased Health
Prosocial relationship skills (closeness, trust, and
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Positive self-image (able to be separate, independent and
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Celebrates good and experienced pleasure (able to relax
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Works/struggles to achieve delayed gratification (persistent
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Adaptive sense of purpose and future

preferences and would likely continue offending as

adults. However, research has demonstrated that most
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functioning. At the same time, treatment must hold
youth accountable for their behaviors and the harm
they have caused, which they often resist acknowledging. A coordinated, multidisciplinary approach must
be supported with the power of the juvenile courts
order to achieve the best outcomes.

JUVENILES WHO SEXUALLY OFFEND

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Part VI

Special Populations

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Chapter 18

Substance Abuse and

Sexual Offending
Peer Briken, Andreas Hill, and Wolfgang Berner

This chapter considers the effects of acute and chronic

substance use on sexual offending. A significant proportion of sexual offenders suffer from substance
use disorders. However, it remains unclear if sexual
offenders differ in a characteristic way from other
offender groups. Substance use seems to be more
prevalent in rapists than in child molesters and more
frequent in nonparaphilic than in paraphilic sexual
offenders. The nature of the relationship between
substance use and sexual offending is complex and
confounded with several factors (dose, experience
with the substance, social setting, personality factors,
subjective expectancy of the substance effects, brain
disorders etc.). Acute and long-term effects of alcohol probably play a contributive but not a primary
causal role in sexual offending. The literature concerning drugs is reviewed but currently insufficient
to draw conclusions. Substance abuse plays a significant role in risk assessment and relapse prevention
and should be considered in treatment options more
specifically.

Many pathways play a role in the development

of sexual offending. This article, describes different aspects in which they are related to alcohol and
drugs and will focus on the epidemiology, acute- and
long-term effects as well as on therapy and risk assessment. Theoretical explanations of sexual offending
consider both distal and proximal influences. When
examining alcohol and drugs as distal factors, we will
describe the relationship between long-term consumption as well as the influence of beliefs about
the effects of the used substances (expectancies).
Proximal models focus on characteristics of the specific situations in which the offense occurs, such as
whether substance consumption played a role or not.
Substance abuse and intoxication may also be used as
an excuse for engaging in antisocial behavior, including sexual offenses. In addition, certain personality
characteristics (e.g., impulsivity and antisocial behavior), neurobiological vulnerabilities, or neuropsychiatric disorders may increase the propensity to both
substance abuse and sexual offending.

265

266 SPECIAL POPULATIONS

ASSESSMEN T A ND DI AGNOSIS

Assessment requires a thorough review of the psychiatric, medical, and criminal history. Most alcohol and
drug abusers do not present themselves because of their
substance-related problems. Shame and denial, but also
using substance disordersespecially intoxicationsas
an excuse for sexual offending is common. Self-report
questionnaires such as the Michigan Alcohol Screening
Test (Selzer, 1971), semistructured interviews such as
the Addiction Severity Index (McLellan et al., 1992),

or structured interviews (such as the SCID-I-interview)

can be used. Physical examination (e.g., to detect ascites
or track marks of heroine use), laboratory testing (e.g., to
test liver enzymes, MCV, CDT, hepatitis, urine, blood,
or hair toxicology), and also neuropsychological examination can be useful.
The currently used definitions of intoxication,
substance abuse and dependence are described in
Table 18.1 (according to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text
Revision, 2000, American Psychiatric Association).

Table 18.1 DSM-IV Criteria for Intoxication, Substance Abuse, and Dependence
Intoxication

Substance Abuse

Substance Dependence

Dysfunctional changes in
physiological functioning,
psychological functioning,
mood state, cognitive process, or all of these, as a consequence of consumption
of a psychoactive substance;
usually disruptive, and often
stemming from central nervous system impairment

(A) A maladaptive pattern of

substance use leading to
clinically significant impairment
or distress, as manifested by
one (or more) of the following,
occurring within a 12-month
period:
(1) recurrent substance use resulting
in a failure to fulfill major role
obligations at work, school, or
home (e.g., repeated absences or
poor work performance related to
substance use; substance-related
absences, suspensions, or
expulsions from school; neglect
of children or household)
(2) recurrent substance use in
situations in which it is physically
hazardous (e.g., driving an
automobile or operating a
machine when impaired by
substance use)
(3) recurrent substance-related
legal problems (e.g., arrests for
substance-related disorderly
conduct)
(4) continued substance use despite
having persistent or recurrent
social or interpersonal problems
caused or exacerbated by the
effects of the substance (e.g.,
arguments with spouse about
consequences of intoxication,
physical fights)
(B) The symptoms have never
met the criteria for substance
dependence for this class of
substance

(A) A maladaptive pattern of substance use,

leading to clinically significant impairment
or distress, as manifested by three (or more)
of the following, occurring at any time in
the same 12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts
of the substance to achieve intoxication
or desired effect
(b) markedly diminished effect with continued
use of the same amount of the substance
(2) withdrawal, as manifested by either of the
following:
(a) the characteristic withdrawal syndrome
for the substance (refer to criteria (A) and
(B) of the criteria sets for withdrawal from
the specific substances)
(b) the same (or a closely related) substance
is taken to relieve or avoid withdrawal
symptoms
(3) the substance is often taken in larger amounts
or over a longer period than was intended
(4) there is a persistent desire or unsuccessful
efforts to cut down or control substance use
(5) a great deal of time is spent in activities
necessary to obtain the substance (e.g.,
visiting multiple doctors or driving
long distances), use the substance (e.g.,
chain-smoking), or recover from its effects
(6) important social, occupational, or
recreational activities are given up or
reduced because of substance use
(7) the substance use is continued despite
knowledge of having a persistent or
recurrent physical or psychological
problem that is likely to have been caused
or exacerbated by the substance (e.g.,
current cocaine use despite recognition of
cocaine-induced depression, or continued
drinking despite recognition that an ulcer
was made worse by alcohol consumption)

SUBSTANCE ABUSE AND SEXUAL OFFENDING

METHODOLOGICA L ISSUES A ND
EPIDEMIOLOGY OF PSYCHOACT I V E
SUBSTA NCE A BUSE A ND DEPENDENCE
IN SE X UA L OFFENDER POPUL AT IONS

There are a lot of methodological issues to consider

when interpreting the epidemiological data on psychoactive substance abuse and dependence in sexual offenders. These concern, first of all, the samples
studied and the diagnostic measures used. Second, it
is the question whether the offenses and offenders analyzed constitute representative samples. Intoxicated
offenders may be overrepresented because of an
increased likelihood to be arrested. Third, it has to
be considered how many nonoffenders have alcohol
or drug problems and do not commit sexual violence
or how often substance abuse is associated with violent or nonviolent crime in general. It is questionable
how often episodes of substance abuse occur without
a sexual offense in investigated sexual offenders.
Another important factor that influences the interpretation of data are the consumption patterns of the
victim. Approximately one-half of all sexual assault
victims report that they were drinking alcohol at the
time of the assault, with estimates ranging from 30%
to 79% (Abbey, Ross, & McDuffie, 1994).
Recently a general population study in the United
States (Stinson, Grant, Dawson, Ruan, Huang, &
Saha, 2005) revealed prevalence rates of 7.4% for
alcohol use disorders only, 0.9% for drug use disorder only, and 1.1% for comorbid alcohol and drug use
disorders. In a representative sample of adults in the
United States, Compton et al. (2005) found prevalence rates of 30.3% for alcohol use disorders and
10.3% for drug use disorders with a high comorbidity of substance disorders with antisocial syndromes.
The prevalence rates in different prison populations
ranged between 10% and 60% for alcohol and drug
use disorders (Nika & Briken, 2004).
The rates of drinking by violent offenders during or
immediately before commission of a violent crime are
generally above 50% (Volavka, 2002). It is important
to make a distinction between short effects of alcohol
and the diagnosis of substance abuse or dependence.
For example a major longitudinal prospective study of
a New Zealand birth cohort (Arseneault, Moffitt, Caspi,
Taylor, & Silva, 2000) could show that alcohol dependence marginally increased the risk for violent crime
(odds ratio 1.9), but the increase was largely explained
by actual alcohol use shortly before offending.

267

Depending on the sample studied and the measures used, the estimates for alcohol and drug abuse
among sexual offenders have ranged from approximately 10% to about 60% (Allnut, Bradford, Greenberg, & Curry, 1996; Peugh & Belenko, 2001). Various
studies estimate that between 40% to 90% of rapists
and 30% to 40% of child sexual abusers were intoxicated at the time of the offense (Peugh & Belenko,
2001). In a nonclinical population 4.8% of male and
1.3% of female students (N = 71,594) (self-)reported
a history of sexual violence perpetration (Borowsky,
Hogan, & Ireland, 1997). Sexual aggression was associated with experiencing intrafamilial or extrafamilial sexual abuse, witnessing family violence, frequent
use of illegal drugs, anabolic steroid use, daily alcohol use, gang membership, high levels of suicide risk
behavior, and excessive time spent hanging out.
A survey of DSM-IV psychiatric disorders among
criminal defendants referred for court-ordered
forensic psychiatric evaluations in the United States
(Cochrane, Grisso, & Frederick, 2001) suggested
different prevalence rates among sexual offenders
compared to other offender groups for diagnoses of
mental retardation (11% vs. 2%), psychotic disorders
(16% vs. 32%) but not for substance use disorders
(42% vs. 48%).
Substance use disorders seem to be more common in rapists than in child abusers. Using the data
from a national inmate prison survey by Peugh and
Belenko (2001) relying on self-reports, among sexual offenders (N = 1273) two of three had a history
of alcohol and drug use, abuse, or addiction. While
rates of drug use were lower alcohol use was similar
to that in other violent offenders (N = 4933). Drug
and alcohol users stemmed more often from substance abusing family environments and had more
often a history of childhood abuse, were more likely
single, and previously involved in nonsexual crimes.
Nonsubstance using perpetrators had more often
victimized children. Some studies (Abracen et al.,
2000; Langevin & Lang, 1990) used the Michigan
Alcohol Screening Test (MAST; Selzer, 1971).
With reference to the MAST scores Abracen et al.
(2000) found severe levels of alcohol use in more
than 40% of rapists and child molesters but only in
approximately 4% of their comparison group of violent nonsexual offenders. Langstrm et al. (2004)
investigated the psychiatric morbidity diagnosed
during hospital admissions (using ICD-9/10 criteria) prior an index sexual offense from a nationwide,

268 SPECIAL POPULATIONS

representative cohort in Sweden (N = 1215) with a

retrospective follow-up design. Alcohol (2.7% within
1 year before the index offense; period prevalence
7.8%) and drug use (0.7% within 1 year before the
index offense; period prevalence 2.8%) disorders
were the most frequent diagnoses significantly more
common in rapists than in child molesters (P<.001).
In a recently published study Firestone et al. (2005)
compared incest offenders whose victims were less
than 6 years of age (N = 48) with incest offenders
with adolescent victims (12 to 16 years; N = 71). The
group with younger victims had a greater history of
substance abuse and more current problems with
alcohol, reported poorer sexual functioning, and
was more psychiatrically disturbed than members of
the other group.
In sexual homicide perpetrators prevalence rates
range between 25% and 58% for alcohol use disorders
(Hill, Habermann, Berner, & Briken, 2007; Langevin,
2003). Intoxications with alcohol at the time of the
homicide are frequent (e.g., 39.8% in Hill et al., 2007);
they are probably more frequently associated with
the nonparaphilic offender types (Briken, Nika, &
Berner, 2000; Briken, Habermann, Kafka, Berner,
& Hill, 2006) and are less often found in those with
neuropsychiatric abnormalities (Briken, Habermann,
Berner, & Hill, 2005).

COMOR BIDIT Y OF PSYCHOACT I V E

SUBSTA NCE A BUSE A ND PA R A PHILI AS

Raymond et al. (1999) investigated 45 male subjects

with pedophilia who participated in residential or
outpatient sex offender treatment programs using
the Structured Clinical Interview for DSM-IV. The
lifetime prevalence of psychoactive substance disorder was 60%. Kafka and Hennen (2002) clinically
assessed 120 consecutively evaluated outpatient
males with paraphilias (N = 88, including N = 60
sex offenders) and so-called paraphilia-related disorders (N = 32) according to DSM-IV diagnoses.
In both groups psychoactive substance abuse (40%),
especially alcohol abuse (30%), were commonly diagnosed. Cocaine abuse was statistically significantly
associated with paraphilia, and paraphilic sex offenders were more likely to be diagnosed with alcohol and
cocaine abuse. In a study by Dunsieth et al. (2004)
85% of the convicted sex offenders met the DSM-IV
criteria for a psychoactive substance use disorder.

Nonparaphilic men had shown more substance abuse

than paraphilic individuals.
Taking together the results from the different
studies a significant proportion of sexual offenders or paraphilic patients suffer from substance use
disorders. However, studies often lack appropriate
comparison groups. As a conclusion at the moment it
remains unclear, if and to what extend sexual offenders differ in a characteristic way from offenders in
general or similar sociodemographical populations
without sexual offending. Acute effects, that is, intoxications seem to be as common as in other offender
groups. Substance use may be more prevalent in
rapists than in child molesters and more prevalent
in nonparaphilic than in paraphilic sexual offender
groups.

PH A R M ACOLOGY

There are different ways to consume substances

(ingestion, sniffing, inhalation, injection) that influence the pharmacodynamic and pharmacokinetic
reactions and the resulting psychopathology. In addition, the consumers physiology, psychology, and
tolerance, the setting, and the expectations play a
major role. The relevant substances can be differentiated into CNS depressants (e.g., alcohol, barbiturates, opiates, benzodiazepines), stimulants (cocaine,
amphetamines, ecstasy), hallucinogens (marijuana,
LSD, PCP), and finally anabolics. While the consumption of all drugs (except anabolics) leads via
different pathways to a higher concentration of
dopamine in brain circuits (e.g., 35-fold increase in
cocaine, 2-fold increase in alcohol), the substances
differ in their effect on other neurotransmitter systems (e.g., cocaine has a substantial influence on the
serotonergic system). It is not within the scope of this
article to discuss the specific neurobiological features
of all substances in detail. We will focus on effects
on aggression and sexuality. Table 18.2 gives an overview about factors and mechanisms that influence the
effects of psychoactive substance use on aggressive
and sexual behavior.
Alcohol
Alcohol has complex and variable effects on sexuality,
aggression, and violent behavior depending on dose,
personality, previous experience with the substance,

SUBSTANCE ABUSE AND SEXUAL OFFENDING

Table 18.2 Factors and Mechanisms Influencing

the Effects of Psychoactive Substance Use on
Aggressive and Sexual Behavior
Personality and intelligence
Brain disorder
Expectancy about the effect of the substance
Experience with the substance (i.e., tolerance,
dependence)
Dose and bioavailability (blood and brain levels)
Effects of short-term or long-term administration
The affection of different neurotransmitter systems or
hormones
The victims activity and factors in the setting
Modified from Volavka, 2002.

and factors such as behavior and intoxication of the victim (Volavka, 2002). Alcohol may increase aggression
directly by anesthetizing the centers of the
brain that normally inhibit aggressive responding (physiological disinhibition explanation);
because people expect it (expectancy explanation); or
by causing changes within the person that
increases the probability of aggression (e.g.,
by reducing intellectual functioning; indirect
cause explanation).
In a review by Bushman (1997) meta-analytic
procedures were used to test the validity of these
three explanations of alcohol-related aggression.
The results were inconsistent with the physiological disinhibition and expectancy explanations, but
were consistent with the indirect cause explanation.
Experimental manipulations that increased aggression (e.g., provocations, frustrations, aggressive cues)
had a stronger effect on intoxicated participants than
on sober participants. Ito et al. (1996) conducted a
meta-analysis of 49 studies to investigate two explanations of how alcohol increases aggression by decreasing sensitivity to cues that inhibit it. Both, the
level of anxiety and inhibition conflict moderated
the difference between the aggressive behavior of
sober and intoxicated participants, but neither level
adequately accounted for the variation in effect
sizes. Additional analyses of three social psychological moderating variablesprovocation, frustration, and self-focused attentionshowed that the

269

aggressiveness of intoxicated participants relative

to sober ones increased as a function of frustration
but decreased as a function of provocation and selffocused attention.
The use of alcohol is believed to loosen sexual
inhibitions and contribute to increased sexual activity.
However, the actual direct and indirect effects of alcohol on sexual function are still not fully understood.
In men, high alcohol doses generally reduce physiological sexual responding, whereas low and moderate
alcohol doses increase subjective sexual arousal. Many
studies have demonstrated that men who believe they
have consumed alcohol experience greater physiological and subjective sexual arousal in response to erotic
materials depicting consensual and forced sex than
do men who believe they have consumed a nonalcoholic beverage, regardless of what they actually drank
(Crowe & George, 1989). Barbaree et al. (1983) demonstrated that alcohol intoxication produced significantly more arousal to rape scenes in normal males
than did a placebo condition. Furthermore, in laboratory studies, intoxicated men tend to retaliate strongly
when they feel threatened, and once they begin
behaving aggressively, they can only be stopped with
great difficulty (Taylor & Chermack, 1993). Wormith
et al. (1988) compared rapists and nonrapists who had
been referred for a forensic evaluation by penile circumference responses (as a psychophysiological measurement of sexual arousal) and self-reported arousal
to consenting sex, sexual assault, and physical assault.
The assessments were repeated following instructions
of the offenders to suppress their arousal and following
the ingestion of alcohol. An alcohol-by-offender type
interaction revealed that the lowering effect of alcohol on penile circumference response occurred only
among the nonrapists. The suppression instruction
paradoxically increased rapists penile circumference
response to rape and physical assault presentations
relative to consenting sexual narrations. When the
data were examined in relation to intelligence, low
IQ-rapists displayed greater responses to rape than
high-IQ rapists. Under the influence of alcohol, lowIQ rapists displayed greater arousal regardless of the
stimulus, while high-IQ rapists showed no change,
and nonrapists responded less than they did without
alcohol. Abbey et al. (2003) in their study on 113 college men who reported that they had committed a
sexual assault found that the quantity of alcohol the
men consumed during the assault was linearly related
to the level of aggression.

270 SPECIAL POPULATIONS

The anticipation of alcohol effects may especially

facilitate sexual aggression in offenders with antisocial personality traits or disorders. Aromaki and
Lindman (2001) compared rapists (N = 10) and child
molesters (N = 10) with control subjects (N = 31).
Cognitive expectancies related to alcohol use were
explored by a standard questionnaire. Alcohol abuse
was common in men convicted of both rape and
child molesting and both sexual offender groups were
the only groups to express significant alcohol-related
cognitive expectancies linked to arousal and aggression. Expectancy patterns were linked to the antisocial personality characteristics. Since antisocial and
dominance traits may be associated with higher testosterone levels and testosterone itself may enhance
the effects on alcohol (Volavka, 2002, p. 39), there
could exist biological interactions.
Discussing the long-term effects of alcohol abuse
and addiction co-occurring factors have to be mentioned and to be controlled when trying to develop
any explanation. For example, the Cloninger et al.
(1981) typology revealed that type II alcohol abusers frequently show violence and antisocial personality disorders. Antisocial personality disorder may
increase the propensity both to drink and to commit
sexual violence. In addition, hormonal factors (e.g.,
long-term abuse of alcohol leads to a testosterone
decrease), neurotransmitter interactions (e.g., a possible serotonergic dysfunction in type II alcohol abusers), and neurological symptoms (Briken et al., 2005)
can interact with each other.
At the moment it can only be concluded with
enough confidence that acute- and long-term effects
of alcohol probably play a contributive but not a
primary causal role in sexual offending (Peugh &
Belenko, 2001).
Effects of Drugs
Evidence for a linkage between drug abuse and sexual offending varies depending on the drug. Not
only pharmacological factors are important but also
social, legal, and treatment factors (e.g., the availability of methadone treatment). While on one side there
may be factors leading to an increased risk of sexual
offending via an increase in aggression or libido, on
the other side there may be drug abuse related factors that lead to a loss in libido or sexual dysfunctions. For example, Johnson et al. (2004) presented
data about the prevalence of sexual dysfunctions

(DSM-III criteria) and their association with comorbid drug and alcohol use in a community epidemiologic sample (N = 3004). The prevalence of lifetime
substance use among this population was 37%, with
males meeting more drug and alcohol use criteria
than females. After controlling for demographics,
health status variables, and psychiatric comorbidity
(depression, generalized anxiety disorder, and antisocial personality disorder), inhibited orgasm was
associated with marijuana and alcohol use. Painful
sex was associated with illicit drug use and marijuana
use. Inhibited sexual excitement was more likely
among illicit drug users. Decreased sexual desire was
not associated with drug or alcohol use. Mentioning
the role of substance abuse for sexual dysfunctions
does not implicate that a sexual dysfunction is necessarily a protective factor against sexual offending.
Sexual dysfunction in sexual offenders was rarely
investigated but may be more frequent than one
might expect (Hill et al., 2007).
On the other hand using a drug to enhance
sexual experience is common. In a study on a nonclinical population by Foxman et al. (2006) the most
commonly used substances were alcohol (83.7%),
marijuana (34.7%), ecstasy, or sextasy (ecstasy
combined with sildenafil; 8.2%), and sildenafil
(7.5%).
Psychostimulants (Cocaine
and Amphetamines)
In animals, effects of psychostimulants differ depending on species; social position in the group; and dose
of the substance. In some species low doses may elicit
aggression and sexual arousal while high doses may
have an opposite effect (Volavka, 2002). Cocaine
is used as hydrochloride salt (mostly intranasal or
in a dissolved form intravenously) or as a free base
(crack). Amphetamines were widely prescribed
until the mid 1960s as stimulants and appetite suppressants, until the dependence potential was recognized. Amphetamine derivates are still prescribable
for certain disorders (e.g., narcolepsy, attention- deficit
hyperactivity disorders). The effects of amphetamines and cocaine are very similar, both affecting
the same neurotransmitter systems. Amphetamines
stimulate catecholamine release and cocaine reduces
reuptake. Ecstasy (MDMA) and related drugs are
amphetamine derivates that also have some of the
pharmacological properties of hallucinogens. They

SUBSTANCE ABUSE AND SEXUAL OFFENDING

have become popular in party scenes because they

may enhance energy and sexual arousal.
Several studies reveal an association between
chronic or heavy cocaine or amphetamine use and
increased sexual activity and/or high-risk sexual
behaviors, and use of both is considered a risk factor for HIV infection (for a review, Ross & Williams,
2001). However, none of these studies have resolved
the question of whether psychostimulant consumption causes such behavior, or whether such behavior
and drug use are both symptoms of an underlying
risk-taking or sensation-seeking personality. Studies
investigating the role of psychostimulants in sexual
offenders specifically are missing. Clinical evidence
however suggests that chronic stimulant users may
be more likely to engage in sexual activity than users
of other drugs (e.g., opiates). Cocaine and amphetamines can also cause intoxication and delusional
disorders that may result in sexual aggressive behavior in special cases.
As a result of a small case control study Kafka and
Hennen (2000) discuss the use of the psychostimulant methylphenidate for the treatment of paraphilic
patients with a comorbid diagnosis of attention- deficit
hyperactivity disorder in combination with SSRI
antidepressants. With this combination effects on
sexual arousal and aggression should be monitored
cautiously.
Hallucinogens and Cannabis
To our knowledge there are no specific investigations
about hallucinogens and sexual offending. Cannabis
neither has a clear pharmacologic effect on neither
an increased risk for aggression nor an increase in
sexual arousability while dependence on cannabis
may be associated with a higher risk for violent crimes
(Volavka, 2002).
Opioids
Opioid use normally produces a decline in sexual
functioning in men (loss of sexual interest, complete loss of sexual functioning, [Meston & Frohlich,
2000]) as well as a short-term antiaggressive effect.
Opioids produce a decrease in sexual hormones like
testosterone that might lead to sexual dysfunction.
Withdrawal from opiate dependence on the other
side can be characterized by an increased frequency
of morning erections and spontaneous ejaculations

271

and also to dysphoria or aggression. However, to our

knowledge there are no studies reporting specifically
sexual offenses under opioid use.
Benzodiazepines
Benzodiazepines normally have sedative effects
but can occasionally produce paradoxical increase
of agitation. The benzodiazepine flunitrazepam is
extensively prescribed to patients with insomnia in
many countries, but has also become popular among
alcohol and drug abusers. Some reports indicate that
flunitrazepam is used as a date rape drug (Schwartz,
Milteer, & LeBeau, 2000; Slaughter, 2000) and suggest that it could also precipitate violent behavior.
It can be served to a prospective victim without her
knowledge because it easily dissolves in water and
is tasteless. Perpetrators choose these drugs because
they act rapidly, produce disinhibition (particularly
in combination with alcohol), muscle relaxation, and
cause the victim to have lasting anterograde amnesia
for events that occur under the influence of the drug.
Flunitrazepame is often used along with GHB
(gamma-hydroxybutyrate, liquid ecstasy). GHB is a
typical date rape agent as it is relatively easy to
obtain, and it causes a rapid relaxing and disinhibitory effect. Moreover, since it is colorless and odor
free, it is easily added to the potential victims drink.
GHB is difficult to identify in the urine as it is quickly
eliminated from the body (Smith, 1999).
Anabolic Steroids
Anabolicandrogenic steroids (AAS) are synthetic
derivatives of testosterone originally designed for therapeutic uses to provide enhanced anabolic potency
with negligible androgenic effects. The effects on
organs and the prevalence of altered behaviors in
AAS abusers have been well documented in a number of studies (Trenton & Currier, 2005). Steroids
may be used in oral or intramuscular preparations.
Commonly, steroid users employ these agents at levels 10- to 100-fold in excess of therapeutic doses and
use multiple substances simultaneously. Significant
symptoms including aggression and violence, mania,
and less frequently psychosis and suicide have been
associated with steroid abuse. Long-term steroid
abusers may develop symptoms of dependence and
withdrawal on discontinuation of AAS. In a study
by Borowsky et al. (1997), anabolic steroide use was

272 SPECIAL POPULATIONS

a factor that differentiated between sexual aggressive

and nonaggressive adolescents. Driessen et al. (1996)
reported about a single case of child sexual abuse
associated with anabolic androgenic steroid use.

A DDICT I V E-LIK E BEH AV IOR

PAT T ER NS IN THE ET IOLOGY
OF SE X UA L OFFENDING

The terminology for an addictive sexual behavior has a long tradition following the description
by Richard von Krafft-Ebings (1886) of a so-called
Hyperesthesia sexualis showing similarities to morphinism or alcoholism. Giese (1962)a prominent
German sex researcherconsidered an addictive
course as a diagnostic criterion of perversions (in that
time synonymously used for paraphilias). The guidelines he used for his definition are similar to definitions for addiction:
Decline in pure sensuality
Increase in frequency accompagnied by a decrease in satisfaction
Increasing promiscuity and anonymity of contacts
Elaboration of fantasy, practice, and refinement
Feeling compulsively addicted
Periodicity of an urging restlessness
The terms sexual addiction (Carnes, 1983), compulsive sexual behavior (Coleman, Raymond, & McBean,
2003), and paraphilia-related disorder (Kafka &
Hennen, 2002) were used to describe paraphilic and/
or nonparaphilic sexual activities (compulsive masturbation, protracted promiscuity, dependency on pornography, or telephone sex). Some sex offenders themselves describe the escalating character of paraphilic
activities as a form of addiction that absorbs them
and seems to make it impossible for them to take into
account the interests of other individuals.
Dysregulations of the dopamine system may
cause individuals to have a high risk for addictive,
impulsive, and compulsive behavioral propensities,
such as drug-using behavior, attention-deficit hyperactivity disorder, antisocial traits, and also compulsive or addictive-like sexual behavior (Blum et al.,
2000). All of the underlying psychopathological phenomena as well as normal repetitive and stimulating behavior may be connected to the mesolimbic
dopamine system. However, much more research is

necessary to clarify under what conditions a stimulus can activate and hijack this system and override
other stimuli. The ability of individuals to invest
in relationships may also enhance their ability to
exchange needs and gratification of wishes with
others and thus handle them with more control.
Probably the feedback-loops, which connect this
system with different parts of the prefrontal cortex
(including the fronto- orbital cortex), influence the
activity of the mesolimbic dopamine system in the
working-memory (according to LeDoux, 2002,
p. 245) and submit its activity under the influence
of socially preformed judgment. Beauregard et al.
(2001) demonstrated that in their impressive experiment on attempted inhibition of sexual arousal. In
their study, brain activation was measured in normal
men while they voluntarily attempted to inhibit the
sexual arousal induced by viewing erotic stimuli.
Their findings suggest that emotional self-regulation
is normally implemented by a neural circuit including various prefrontal regions and subcortical limbic
structures. Substance-induced frontal lobe dysfunction has been hypothesized to explain the impairment of self-control in addicitions (Lyvers, 2000) but
also in psychopathy (e.g., Yang, Raine, Lencz, Bihrle,
LaCasse, & Colletti, 2005).
Looman et al. (2004) investigated and discussed Marshalls (1989) theory of intimacy deficits
and insecure attachment patterns related to substance use disorders in sexual offenders and argue
that these problems may act synergistically. The
self-medication hypothesis by Khantzian (1997)
describes that individuals predisposed by biological vulnerabilities consume substances in a more or
less successful attempt to relieve psychological suffering with maybe some degree of substance specifity. From our viewpoint in a substantial subgroup
of sexual offenders, not only alcohol and drugs but
also paraphilic or nonparaphilic sexual activity may
be used to cope with negative mood states such as
depression, anxiety, loneliness, or boredom. The
pathways may act synergistically but also alternating, and may be used to facilitate sexual arousal or
aggression either as actively planned or as a more
impulsive activity. Intimacy and attachment deficits
may be underlying but unspecific roots that lead
to moderating neurobiological associations (e.g.,
serotonergic dysregulation) and vice versa. Animal
studies and observations lead to the suggestion that
factors like attachment (Beech & Mitchell, 2005),

SUBSTANCE ABUSE AND SEXUAL OFFENDING

social position (dominant or subordinate individuals), and temperament may moderate the individual
effects of drugs into one or the other direction (inhibition or disinhibition). New experiences through the
lifespan may change and moderate the balance between inhibition and disinhibition again.
Recidivism
The updated meta-analysis by Hanson and MortonBourgon (2004) again revealed that paraphilia and
antisocial traits are the major risk factor for recidivism in sexual offenders. Substance abuse (31 studies with a total N = 9166) and substance intoxication
(10 studies with a total N = 5276) during offense
were significantly correlated to recidivism in sexual
offenders but not sufficiently predictive to be used
as a single factor for risk assessment. For example, in
the follow-up study by Langstrm et al. (2004) a prior
diagnosis of alcohol abuse or dependence more than
doubled and a diagnosis of drug use disorder tripled
the odds ratio for the index offense (while the odds
ratio for personality disorders was 10.1). Evaluation of
risk assessment needs to consider a variety of factors
and in most currently used instruments alcohol and
drug use disorders is one of them.
Treatment
Treatment programs for sexual offenders rarely focus
on individual alcohol or drug problems. In the study
by Peugh and Belenko (2001), only 34% of incarcerated sexual offenders with substance problems
reported that they received a drug treatment and
21% participated in self-help groups. However, the
relapse prevention model frequently used to treat
sexual offenders was first employed as an approach
to the treatment of substance dependent patients.
It remains questionable to describe sexual offending
or paraphilias as an analogue for addictions (see the
aforementioned text). In addition, there is still little empirical evidence supporting that adoption
of the relapse prevention model for sexual offenders alone reduces recidivism or prevents relapses.
However, especially in patients with substance abuse
disorders this model may be useful to explain and
prevent both, substance abuse and the offense cycle.
This cycle is initiated by so-called seemingly unimportant decisions (Eccles & Marshall, 1999). Such
decisions may increase the probability for high-risk

273

situations. These situations themselves may have to

do with substance abuse, consumption, or a failure to
cope with problematic life situations. Looman et al.
(2004) integrate the impact of substance abuse problems with reference to intimacy problems and help
their clients to understand the way substance abuse
may result in greater problems coping with anxiety
and depression but also in the context of a criminal
lifestyle (e.g., selling drugs). Participation in self-help
groups can also be helpful.
Mandated addiction treatment can have as good
outcome as voluntary treatment (Miller & Flaherty,
2000). Sentencing may involve requirements regarding treatment and sobriety (abstinence) as terms of
probation and parole. Progress reports, treatment participation, and urine toxicological tests can be part of
such requirements.
Pharmacotherapy can include medications for
supporting abstinence, such as methadone for opiate dependence, antabuse for alcohol dependence,
and alsohypothetically more specificnaltrexone
(Kiefer et al., 2003; Ryback, 2004). Naltrexone is a
long-acting opioid used in the treatment of alcoholism, drug abuse, obsessive-compulsive disorder, and
impulse-control disorders. Ryback (2004) investigated
whether naltrexone can also decrease sexual arousal
in adolescent sexual offenders. In an open-ended prospective study, naltrexone was given to 21 adolescents
participating in an inpatient adolescent sexual offenders program. Leuprolide was given if naltrexone
was not sufficiently helpful. Fifteen of twenty-one
patients were considered to have a positive result with
decreased sexual fantasies and masturbation. Future
research should focus on the question if naltrexone is
an appropriate medication especially for sex offenders with substance use disorders and should then be
considered in pharmacological treatment algorithms
(Briken, Hill, & Berner, 2003).
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Chapter 19

Female Sexual Offenders

Wolfgang Berner, Peer Briken, and Andreas Hill

Approximately 1% of sentenced sexual offenders are

female. Investigations on victims of child molestation
reveal participation of female perpetrators in at least
a quarter of cases of male victims and in 13% of
female victims.
The spectrum of offenses of female offenders
ranges from minor forms of indecency, exhibitionism,
different forms of child molestation, and incest to all
forms of aggressive acts including rape and murder.
Male and female children are the most prominent
victims. In a high percentage of offenses the female
offender acts together with a male accomplice. Only
in rare cases a diagnosis of paraphilia is reported, far
more frequent are different forms of depression, alcohol and drug abuse, and personality disorders (borderline, antisocial, dependent). Most authors agree that
a high percentage (over 50%) of female sexual offenders were themselves victims of sexual and/or physical abuse. Conflicts with the mother and resulting
problems with womenespecially mother identity
are reported by psychodynamically oriented authors.

Only few case reports exist on effective medical

treatment with SSRI and antiandrogens. A carefully
differentiated psychotherapeutic treatment program
including group-, individual- and social-therapeutic
strategies was developed especially in Minnesota.
Studies comparing the incidence of male and
female sex offending mostly come to the result that
one sentenced female sexual offender corresponds
to approximately 100 male sexual offenders (Berner,
Karlick-Bolton, & Fodor, 1987; Groth, 1979; 0Connor,
1987; Vandiver & Kercher, 2004). Therefore, it is
understandable that most empirical studies on female
sex offending are based on much smaller samples
than studies on male sex offending, mostly with less
than 30 female offenders. According to Finkelhor and
Russel (1984) the extremely low official prevalence
of female sex offending may be the result of underreporting, as women may have more possibilities to
mask their inappropriate contact with children than
men, their offenses often happening inside the family where reporting is rare and may be less physically

276

FEMALE SEXUAL OFFENDERS

injuring. Physical injury is correlated with higher rates

of reporting, too. According to a study by Finkelhor and
Russel (1984) on representative samples of female and
male victims of sexual abuse; 24% of male victims
and 13% of female victims had been abused by female
perpetrators who either acted alone or with male partners. These figures do not allow a clear calculation of
the prevalence of female sexual offenders who were
not reported to the police. Nevertheless they corroborate the hypotheses that underreporting may play an
important role in female offending.
Taking into account that not much is known about
female sexual offending, the following chapter will
focus on the differences between male and female
sexual offending, as far as phenomenology, psychiatric diagnoses, treatment, and follow-up is concerned.

PHENOMENOLOGY

Some characteristics of female assaults simply may

be explained by the fact that women have to consider
mens superiority in physical strength while men
as perpetrators may easily impress and threat their
female victims. This can be demonstrated even in
cases of hands off offenses like exhibitionism.
Exhibitionism
Only a few cases of female exhibitionism are described in the literature. Nevertheless the differences
between these cases are exemplary. Female exhibitionism is much less stereotyped than male exhibitionism, and it is never known if it is related to direct
sexual excitement or some other indirect form of
psychologically experienced excitement or triumph
(Zavitzianos, 1971). For instance, Hollender et al.
(1977) described a case of female exhibitionism, which
on the first glance seems very similar to male exhibitionism: wearing only a raincoat she would stand in
a doorway near the club, where she worked and flash
(i.e., exhibit her breasts and genitals) before men she
had seen or met previously (p. 437). But according
to the womans explanation, she derived no sexual
gratification from this behavior. She was neither seeking sexual liaisons nor soliciting customers for future
shows. She stated that her motivation for flashing was
solely attention seeking. The effort of this woman to
draw attention to herself had a more desperate than
aggressive quality, despite her profession of being a

277

glamorous dancer. Further she flashed before men

she knew, while male exhibitionists nearly exclusively flash before women who are unknown to them.
Nearly 10 years later Grob (1985) described a case of
female exhibitionism with similar background but
nevertheless differences in more than one aspect: A
43-year-old divorced female patient exhibited breasts
and genitals to passing by truck-drivers on the highway while driving in her small car. It was not uncommon for her to spend as much as 30 minutes with a
particular truck, playing an exhibitionistic cat-andmouse teasing game, before suddenly turning off on
an exit ramp where trucks could not follow. Contrary
to the first case, this woman experienced high sexual
arousal during the act and sometimes even orgasm.
Similarities can be seen in the family background:
both women have a dynamic of early deprivation of
parental attention resulting in a profound inability
to sustain deep personal relationships and a nearly
addictive craving for a bodily experienced attention.
In the second case, constant contact to an emotionally supporting therapist could reduce the tendency
to exhibit and the attenuation of contact (for instance
to a therapist) resulted in an increased craving for
exhibitionistic activity.
Fear of being attacked by a stronger male may have
been the reason why the first of the former described
female exhibitionists only acted if she knew her male
victims and the second choose a procedure where she
easily could escape. But there may also exist a lot of
other causes for differences in male and female sexual offending. For further exploration in this field we
will examine a small sample of case histories from different clinical backgrounds:
Indecency
OConnor (1987) reported on a representative sample
of female sexual offenders who were committed to the
main female remand prison for London and South
East England between 1974 and 1985. Of these 19
women were charged with Indecency and 39 with
Indecent Assault and Indecency with Children.
Only two of these cases were clear cases of Indecent
exposure, the term used for sentencing exhibitionism at court. One indecency consisted of urinating
in public by a mentally handicapped woman who was
drunk. In a case of Outraging Public Decency a
25-year-old single woman with a history of recurrent
hypomanic episodes and several hospital admissions

278 SPECIAL POPULATIONS

exposed her genitals in public inviting passers by to

commit acts of indecency with her. Treatment of her
hypomanic mood ended this episode immediately. In
this study criminal recidivism was not reported.

Taking these two studies together we have to conclude that rape of a man by a female perpetrator is
an extremely rare event and mostly happens as group
rape, often with the help of men.

Rape

Sexual Serial Murderers

Sarrel and Masters (1982) selected four cases where

men were forced to sexual activities by physical constrains and life threatening from approximately 700
men who presented themselves to the Yale human
sexuality program with a wide variety of problems
and from over 3500 couples treated at the Masters and
Johnson institute for sexual dysfunctions. In one case,
a 27-year-old man was given a drink and afterward was
tied to a bedstead, gagged, and blindfolded by a group
of women. He was stimulated to erection and ejaculation, afterward restimulated until he was unable to
function and then threatened with castration. In a
second case two older men entrapped a 17-year-old
boy, and three older women threatened to beat him
up if he tried to get away. He was manually stimulated
and fellated until ejaculation three times before the
group let him free. In a third case, a 37-year-old man
was accosted by two women who forced him to have
intercourse and fellatio at gunpoint and only in the
fourth case a single woman forced a 23-year-old medical student to have intercourse with her by threatening him with a scalpel. The first important finding
in these cases is, that despite obviously experienced
anxiety the men were able to react sexually, and the
second, that in all four cases the victims developed
severe sexual dysfunctions after the rape.
Struckman-Johnson (1988) reports that sexual victimization against men has increased since the 1970s.
In a survey on male and female college students she
found that 43 (16%) of the 268 men in her sample
reported that they had been forced to engage in sexual intercourse on a date. Despite the fact that a similar proportion of females reported the same fact (22%)
the experience of the type of coercion was quite different. While most women reported being physically
forced (55%), the men reported coercion by psychological tactics such as verbal pressure to avoid guilt
over disappointing their partners. In several cases
men were blackmailed, but none of the male victims
was actually physically unable to escape. The most
severe examples of sexual victimization in this study
were a few men who had unwanted sex while they
were intoxicated.

Some cases of female serial killers became very

famous in the popular media. One of the best known
in England is Myra Hindley (19422002) who tortured and murdered two girls and three boys aged
between 10 and 17 years together with her partner
Ian Brady between 1963 and 1966. She met Ian Brady
when she was 18 and became dependent on him.
He gave her Hitlers Mein Kampf and the works of
Marquise de Sade and she was the person who contacted the later victims. The couple took audiotapes
from their deadly torture scenes, which were played
during the court procedures and shocked the nation
(en/wikipedia/org).
Another case is the story of Rosemary West born
in 1953 (en/wikipedia/org): She was convicted of murdering 10 teenage girls, including her own common
law step-daughter, Charmaine, and also of a serious
sexual assault on a woman. The police suspected she
was also involved in further murders for which she
has not been convicted. She killed Charmaine on her
own, but her other murders were all believed to have
been carried out with her husband and fellow serial
killer Fred West.
Rosemary West was 15 years old when she met
Fred West. She was Wests second wife and West
had murdered already before he met Rosemary. The
couple developed a habit of picking up girls from bus
stops in and around Gloucester, England, whom they
would imprison in their home for several days before
killing them. During the time of their imprisonment,
the victims were sadistically tortured. Both appeared
to be addicted to sexual sadism.
Rosemary West was brought up in a large family,
many of her siblings were in public care, and all were
abused. Rosemary West had a voracious sexual appetite and enjoyed extreme bondage and sadomasochistic sex, even more than her husband. She was bisexual,
but preferred women, and it is likely that her victims
(apart from Charmaine) were picked up mostly for her
sexual pleasure. She also worked as a prostitute, often
preferring black clients, and these clients fathered
many of her children. The Wests home was littered
with hard-pornographic videos. To the neighbors, they

FEMALE SEXUAL OFFENDERS

were motherly Rose and friendly Fred, a devoted

couple who ran a cheap rooming house.
Also in this case, the strong relationship to a
serial killing man is the prominent characteristic
and therefore differs from most cases of male sexual
murderers.
It is also important to mention that such extraordinary and extreme rare cases are not a phenomenon
of the last century alone. Similar descriptions can be
found in classical literature, for instance the case of a
Hungarian aristocrat, Elisabeth Bathory (15601614),
who killed female adolescents to take a bath in their
blood (Farin, 1989). Without male servants assisting
her she would not have been able to carry out her
cruel deeds.
Berner (1991) reported about a female patient who
tried to kill her female lover at the age of 16 years.
The girlfriend became afraid of the patient after she
enticed her in a playful mutual strangling to the
point of loosing consciousness. When the girlfriend
announced separation the patient began to act in a
very strange and irrational way reminding of a psychotic state: First she strangled cats to death, then
killed one cat with a knife, and shocked her girlfriend
with her bloody hands. When the girl turned away to
escape, the patient stabbed her in the back, injuring
her very seriously. After a year of psychiatric hospitalization she had sadomasochistic relationships to men
whom she regularly injured with razor blades. After
giving birth to a female baby the patient repressed her
sadistic impulses for years and lived a rather unhedonistic life with strong sexual inhibitions. Not long
before menopause when she was 45 and her daughter left home, the patient restarted to kill animals and
again developed urging impulses to kill a girl, which
brought her back in psychotherapy (see the following
text). In her childhood, war and flight experiences
had left their marks. After the death of her mother
due to breast cancer when she was 7 years old she was
raised in different boarding schools. The patients
father beat her heavily for dating secretly with a boy
and other disobediences.
Extra Familiar Child Molestation
Molestation of children needs much less physical
strength and is carried out more often by women
without the assistance of other persons. These cases
seem to happen more frequently than rape (Vandiver
& Kercher, 2004) but modern authors seem to agree

279

that paraphilia in the sense of pedophilia is rather

rare. This is in some contrast to Krafft-Ebing (1890)
who first described paedophilia erotica as a disorder
that can be found in women, too. Chow and Choy
(2002) recently described one rather typical example of such a pedophilic woman: A 23-year-old single
mother of two sons aged 6 and 7 years was charged for
sexual assault and sexual interference when she performed oral sex on two 4-year-old girls on two different occasions during babysitting. The first incidence
happened when she was 18; her first victim was the
4-year-old daughter of a friend. Earlier that evening,
the woman watched a pornographic video together
with her adult boyfriend, which aroused her sexually.
While bathing the little girl later she became further
aroused by touching her. After the bath she took the
girl into the bedroom, spread her legs and licked the
girls vaginal area for a few minutes. This was sexually
gratifying to her. Nevertheless, after that she went to
her boyfriend who was still sitting in the living room
to have intercourse with him. Five years laterwhile
babysitting two 4- and 5-year-old girls of some other
acquainted parentsthe woman again molested during a bath. When the 4-year-old girl did not want to
get dressed the patient felt sexually invited and teased
by the child and chased after her. Finally she caught
the 4-year-old in the bedroom, rubbed its genitals with
her finger, and again licked the whole genital area as
in the first case. Afterward she secretly masturbated
in the bathroom. The woman revealed traumatic
experiences and clinical characteristics similar to the
other cases described earlier. Her parents divorced
when she was an infant, during puberty she was sexually harassed by her mothers stepfather, her complaints about it being dismissed by the mother. She
became pregnant from her first boyfriend at the age of
15, and after giving birth to her two sons she separated
from her boyfriend, obviously just around the time of
her first assault on a little girl. As a teenager she often
broke dishes out of rage and later she complained
about problems controlling her impulsesespecially
concerning money spending. She described herself as
bisexual, more erotically interested in females than in
men, and more in girls than in women, but her desire
to have socially acceptable relationships meant that
she only had ongoing relationships with adult men.
She recalled interest in 3- to 4-year-old girls since an
early age as a child and regularly masturbated to
fantasies involving girls, although she also fantasized
about adult women and men.

280 SPECIAL POPULATIONS

This case can be contrasted with another one from

our outpatient clinic.
The now 30-year-old woman presented 5 years
ago with heavy guilt feelings for having abused a little 5-year-old boy while babysitting him. She manipulated his penis while masturbating herself. Another
symptom at that time was that she experienced an
impulse to provoke old women traveling together with
her in the bus or underground by insulting them with
obscene and devaluating words or by openly masturbating in front of them. Another problem was, that
she had recently fallen in love with one of the female
therapists concerned with her former inpatient treatment. She grew up in a family of teachers and had
three academic siblings, one older brother of her may
have abused her, but her memory of this experience
remained unclear. As a child she had severe dyslexia,
which resulted in extended conflicts with her ambivalently loved and hated mother. Her sexual orientation was homosexual but only rarely she succeeded
in establishing short relationships to beloved partners.
Because of general impulsivity and relationship problems including suicidal acts she was diagnosed with
borderline personality disorder and admitted to an
institutional treatment for years. Five years after her
first contact to our clinic she showed up again, now
with another sexual impulse. She tended to make
obscene telephone-calls, shocking randomly selected
women by insulting them with a male-like voice,
pretending she would masturbate like a man. After
ending the call she felt guilty and decided she would
never do it again, but only a short time later she again
became obsessed with the idea to repeat the act. The
paraphilic symptomatology of this patient is unspecific and cannot be classified as pedophilia or one of
the other classic paraphilic disorders.
Sarrel and Master (1982) described victims of
female babysitter perpetrators who needed treatment
because of sexual dysfunctions. In one case a male
patient reported that an older woman abused him
when he was 10 years old. He remembered erections
but no ejaculations. In his opinion the experiences
were pleasurable as long as they remained secret, but
when he informed his parents and was punished for
keeping secretly for so long, conflicts and guilt feelings began, resulting in severe sexual inhibitions
leading to treatment at special institutions.
In another example a patient was 11 years old when
a 16-year-old female babysitter pulled off his pajamas
and tried to put the patients penis in her vagina. He

had no previous sexual experiences and did not understand what happened to him. He became deeply inhibited from this time on and had no sexual experiences
till he met his wife later. There was no premarital sexuality and later an unconsummated marriage brought
both partners to sexual therapy. This patient related his
difficulties directly to the experience of sexual abuse.
Mathews et al. (1989, 1991) developed a frequently
used typology of child-molestation by women with
five subcategories that may have some relevance in
understanding the variation of motivation and differences in causation for these phenomena:
1. The so-called teacher/lover type of female
offender consists of women who fall in love
with teenage males and often remain nave
regarding the consequences and effect their
action has on their victims.
2. The exploration/exploitation type in which
a teenager fondles a younger child (during
babysitting).
3. The predisposed type where a woman with
a severe history of physical and sexual abuse
molests closely related or known children.
4. The psychologically disturbed type which
includes women with severe psychiatric impairment and/or substance abuse who are psychologically unstable at the time of the sexual
abuse.
5. The male-coerced type consisting of dependent
women participating in the molestation of children initiated by their husbands or boyfriends.
This typology is not very systematic and is based on a
small number of cases seen by the authors, but it may
have practical relevance because it is regularly cited
in literature on female sexual offending (for instance:
Correctional Service of Canada, www.csc-scc.gc.ca/
text/pblct/sexoffender/female/female-02_e.shtml).

Incest
In a publication by Sarrel and Master (1982) one case
of motherson incest and one case of sisterbrother
incest are described. Both cases came to the attention
of the authors because the male victims developed
sexual dysfunctions later in their sexual lives. Both
cases remained officially undetected, giving a hint
that, especially in offenses that take place within the
family reporting to the police and court procedures
are extremely rare.

FEMALE SEXUAL OFFENDERS

The motherson incest started when the victim

was 13 years of age and shortly after his first nocturnal emissions. The mother began playing with his
genitals, in the following months progressed from
manipulation to fellatio and even intercourse, which
in the end took place two to three times weekly until
the young man left college. Although the son never
actively approached his mother, he always responded
and enjoyed her pleasure more than his own. He felt
strongly devoted to her and developed deep guilt feelings regarding her after his first dates with peers, which
resulted in massive sexual dysfunctions and an ongoing sexual relationship to his mother until she died.
The case of sisterbrother incest started when the
brother was between 10 and 12 years and his sister
4 years older. When she stimulated him manually,
orally, and by inserting his penis in her vagina he felt
more frightened than stimulated. Later on she threatened him with a knife and he could not remember if he
ejaculated or not. Both siblings needed psychiatric help.
She was hospitalized and he entered psychotherapy
because he was unable to consummate his marriage.
Faller (1987) reported that 72% of 40 female sexual offenders molested children in polyincestuous
family situations involving at least two perpetrators
and two or more victims, with the male offender usually initiating the sexual act.

EPIDEMIOLOGY

For example, in Austria 39 to 67 sexual offenses

per 100,000 inhabitants are registered by the police
within 1 year (Berner, Karlick-Bolton, & Fodor,
1987). But only 10 to 17 offenders per 100,000 inhabitants were sentenced by court within the same
period. Between 1975 and 1980 only 0.6% to 2.6% of
all sentenced sexual offenses involved a female perpetrator, i.e., the relation between male and female sex
offenders is approximately 100 to 1. These figures
are in agreement with data from other countries, for
instance England (OConnor, 1987) or the United
States (Vandiver & Kercher, 2004). Nevertheless
some authors suppose that most female sex offenders remain undetected by law enforcement agencies
and the proportion of undetected offenses may be
higher than in male offenders as female offending is
often perceived as less serious. It has been found that
females acting with male accomplices are often not
reported (Vandiver & Kercher, 2004).

281

From the six cases found in the Austrian study

(Berner, Karlick-Bolton, & Fodor 1987) concerned
with sexual offending between 1975 and 1980 in a
catchment area of 3.5 million inhabitants, one offense
was incest on the 13-year-old son by his mother. The
incest offense was committed repeatedly and sometimes by threatening the young boy with a knife. This
female offender acted on her own. She had an alcohol problem and was without a male partner since the
death of the victims father 10 years ago. Two younger
daughters of her were given to foster parents.
The second offense was committed by a 40-yearold divorced woman who tolerated and facilitated that
her new sexual partner had intercourse with her 9and 13-year-old daughters. She did not only support
the man, but also laid herself down on the floor to
offer the marital bed for the abuse of her children.
The third registered offense was an indecent
exposure of a female offender, who was drunk and
involved in obscene interactions with other men.
The remaining three offenses consisted of assaults on
other women together with male accomplices and in
connection with prostitution.
The study by Vandiver and Kercher (2004)
reported the number of all registered adult female
sexual offenders in Texas as N = 471. In relation to
all registered male sexual offenders (N = 29,376)
this means that 1.6% of all sexual offenders were
female. This figure is very similar to the percentage
obtained in Austria. In Texas the term registered
not only includes offenders sanctioned with imprisonment but also fines and probation orders. But the
study by Vandiver and Kercher (2004) may teach us
more than just this relation between male and female
sexual offenders. In the great majority of offenses the
victims were children: indecency and sexual contact with a child (N = 155, 33%), sexual assault on
a child (N = 84, 18%), aggravated sexual assault on
a child (N = 68, 14%), indecency and exposure with a
child (N = 26, 6%). Using all the scanty data available
on such a register, including data on the victims, a hierarchical model was calculated and an additional cluster
analysis yielded six types of female sexual offenders:
1. Heterosexual nurturers consisted of 146 offenders and built the largest cluster. This group
with an average age of 30 years, exclusively victimized boys with an average age of 12 years.
The authors state that this type may coincide
with the teacherlover category proposed by

282 SPECIAL POPULATIONS

2.

3.

4.

5.

6.

Mathews et al. (1989) but also include other

forms of mentorship or caretaking roles.
These females were the least likely to have an
initial arrest for sexual assault.
Noncriminal homosexual offenders included
114 offenders who were the least likely to be
subsequently arrested after their index offense,
had the lowest average number of arrests and
were the least likely to commit an assault. The
average age was 32 years and the victims were
nearly exclusively females with an average age
of 13 years (the highest average age of all clusters). Unfortunately there was no information
about accomplices in the files, but the authors
presume a high proportion of male accomplices
in this group.
Female sexual predators included 112 offenders who were the most likely to have a rearrest
after their index offense. They were the second
youngest (average age 29 years), had the most
and relatively young victims (60% males, average age of 11 years) and showed the most similarities with female nonsexual offenders. Their
sexual offending is interpreted as part of a general criminal disposition.
Young adult child exploiters consisted of 50
offenders with the fewest number of arrests;
they were the youngest at the time of arrest
(average of 28 years), most likely to commit
sexual assault, and their victims were the youngest with an average age of 7 years. Since half
of the victims were related to the offenders
the authors presume that this group included
mothers molesting their own children (one of
the types of female offenders suggested as separate category by Mathews et al., 1989).
Homosexual criminals included 22 offenders
who had a high average number of total arrests
(10) and victimized partly older and partly
younger victims. There were no sexual assaults
in this group but a lot of forcing behavior and
compelling to prostitution. These offenders
seem more economically than sexually motivated and therefore represent the normal criminal group described by Wolfe (1985).
Aggressive homosexual offenders include only
17 offenders who were the oldest at the time of
the offense, the most likely to commit a sexual
assault, and to have the oldest victims (average
age of 31 years).

This statistical typology cannot be translated directly

in different types of psychological motivation or criminological characteristics. But it sheds some light on

the variability of causes for female sexual offending

and demonstrates thatbeside the much lower frequency of female compared to male sexual offendingthere are only few cases where sexual needs are
obvious. Criminal exploitation, revenge, and compensation for lost intimacy play a great role. The most
striking differences to male offending are the high
amounts of offenses committed with accomplices and
the fact that almost half of the victims are male.

DATA ON PSYCHI AT R IC DISOR DER S

A ND E A R LY PSYCHOLOGICA L T R AUM A

According to most authors, the majority of female

sex offenders do not receive a diagnosis of paraphilia
according DSM-IV. But personality disorders, abuse
of illegal drugs and alcohol, and depression are often
diagnosed (Faller, 1987, 1995; Kaplan & Green, 1995;
Lewis & Stanley, 2000; OConnor, 1987; Rosencrans,
1997). Some authors think that long standing psychiatric disorders can be found in a substantial
number of cases (Travin, Cullen, & Protter, 1990).
OConnor (1987) found depression, mental retardation, and sometimes schizophrenia, especially in the
group of female offenders with charges for indecency.
Since the reported studies are not representative for
female sexual offenders, comparisons with samples of
male sexual offenders (Kubik, Hecker, & Righthand,
2002) remain very hypothetical. The same is true
for comparisons of female sexual offenders (N = 11)
with female nonsexual offenders (N = 11, Green &
Kaplan, 1994). The majority of subjects in both groups
demonstrated major depression, alcohol/substance
abuse and PTSD, but the sexual offenders demonstrated more psychiatric impairment on the Global
Assessment and Functioning Scale. Both sexual and
nonsexual female offenders described negative relationships with parents, care-takers, spouses, and boyfriends; however the sexual offenders perceived their
parents as more abusive, the comparison women as
more neglecting.
Kubik et al. (2002) compared 11 adolescent
female sexual offenders with 11 female nonsexual
offenders and found only some psychosocial differences: Nonsexual offenders had higher proportions
of drug and alcohol abuse, more disruptive school
behavior, and more truancy. In the same study a
second comparison between male and female sexual offenders revealed even fewer differences. Only

FEMALE SEXUAL OFFENDERS

a history of physical (63% vs. 40%) and sexual victimization (63% vs. 50%) was more obvious in the
female sexual offender group. Female sexual offenders experienced their own sexual abuse as more serious, happening more frequently, and involving more
often more than one perpetrator and near relatives.
It resulted more frequently in post-traumatic stress
disorder (PTSD). In another study Tardif et al. (2005)
compared 13 adult females (AF, 18 years at the time
of the offense) with 15 juvenile females (JF, 12 to 17
years at the time of the offense) who sexually abused
children and adolescents. This was the total number of evaluated cases of female perpetrators seen
in the outpatient clinic of the Centre de Psychiatrie
Legal of the Institut Philippe Pinel de Montreal
during the period of 10 years (1992 and 2002): Data
on family origin revealed that social and familial
experiences were different in the two samples. The
family structure was destabilized in 46.2% of the
AF, caused by abandonment (23.1%) or death of
the father (15.4%), and multiple hospitalizations of
the mother (7.7%). AF reported a greater degree of
deprivation and rejection related to the mother due
to rejection (23.1%), lack of protection against their
own sexual (23.1%) and physical abuse (7.7%). Of
the total AF, 30.8% were affected by depressive episodes of the mother. The instability of the family
had an impact on the JF subjects as well: 60% lived
in a reconstituted family and 33% had half-siblings.
More than half of the JF lived with their mothers
(60%), the others either with their fathers (13.3%) or
in a foster home (13.3%), and only 13.3% lived with
both parents. Half of the JF experienced parental
abandonment before the age of 4 years. Psychiatric
diagnoses differed in both groups. For the AF sample
the following DSM-IV diagnoses were reported:
borderline personality disorder (30.8%), borderline
personality disorder and dysthymic disorder (15.4%),
depression and dependent personality disorder
(30.8%), and dependant personality disorder alone
(15.4%). All but two of the AF presented more than
one type of substance abuse (61.5%), suicide attempts
(38.5%), and self-mutilation (15.4%). In the group of
JF, 86.7% had been followed by a health professional
because of behavioral problems, academic difficulties, and adaptation problems, and 20% because of
their deviant sexual behavior. The main diagnoses
were learning disorder (80%), attention deficit/hyperactivity disorder (33.3%), dysthymic disorder (26.7%),
conduct disorder (26.7%), and PTSD (20%). Nearly

283

half (46.7%) of the JF had a history of both violence

against others and drug consumption. The acting out
after frustration is more directed against others in the
JF group, whereas suicide attempts and self-mutilation are more prominent in the AF. In both samples
a high percentage of physical (more than 40%) and
sexual victimization (60%) was reported.
For the authors of this study the supposed common trunk of causation of female sexual offending is
a primary disturbance of the motherchild relationship in both groups. As all but one AF had sexually
abused her own children, Tardif et al. (2005) propose
that a problematic development of maternal identity
has occurred at least in the AF-cases, but probably in
the JF cases, too:
The childhood traumas and neglect might awaken
the desire to repair the deprivations and injuries of
the past, which sets up a powerful swaying mechanism between the desire to repair and the desire to
inflict the same abuse on another child. (p. 163)

T R E AT MEN T

The literature on treatment of female sexual offenders is even more limited than that on phenomenology or epidemiology. It is focused nearly exclusively
on individual therapy, either cognitive-behavioral or
psychodynamic (Travin, Cullen, & Protter, 1990).
So far, only two exceptions could be found: one
case-report on cyproterone-acetate treatment for a
female patient with hypersexuality (Mellor, Farid, &
Craig, 1988) and one case-report on treatment with
Sertraline (a selective serotonin-reuptake inhibitor)
for a female pedophile patient (Chow & Choy, 2002).
Both reports provide promising results of pharmacological treatment and suggest further research.
Psychotherapeutic strategies for female sexual
offenders do not differ principally from those for male
sexual offenders, primarily concentrating on reducing
the risk of reoffending. Eldridge (1993) states that,
if therapy is to be effective in achieving that
end, than the offenders motivation to offend
and the way in which she or he has overcome internal and external inhibitors needs to be examined. Therapy needs to address the offender as a
thinking, feeling and behaving person and harness thoughts, feelings and behavior to prevent
re-offending. (p. 93)

284 SPECIAL POPULATIONS

These are exactly the principles of modern cognitivebehavioral programs developed for incarcerated male
sexual offenders like SOTP in England (Friendship,
Mann, & Beech, 2003) or Sex Offender Treatment
and Evaluation Project (SOTEP) in California
(Marques, Wiederanders, Nelson, & Ommeren,
2005).
Reflecting the reported data about frequent problems of dependency on an accomplice partner in
female sexual perpetrators, these problems (including
dependent personality disorder) should receive particular attention in psychotherapy with these offenders.
A second special problem more prominent in
female sexual offenders than in male is the victimto-victimizer cycle, the tendency of the perpetrator to
put a child in the same position as experienced in her
own childhood. It should also play a more important
role in treatment of female offenders than in therapy
of male offenders.
According to an overview provided by the correctional services of Canada, the most prominent treatment programs for female sexual offenders are offered
in Minnesota. The Minnesota Correctional Facility
in Shacopee developed such programs since 1984,
consisting of intensive group psychotherapy, additional couples and family therapy, and intensive twoday sexual learning seminars (Mathews, Mathews, &
Speltz, 1991). Genesis II is an outpatient program
for female sexual offenders in Minneapolis. Female
patients are mainly referred by court but also by child
protection social workers and private therapists. The
duration of treatment is 15 months on average. The
program consists of a comprehensive day treatment,
which the women attend with their preschool aged
children 6 hours a day, for a period of 8 to 12 months.
The day program provides participants with additional individual and group therapy, independent
living skills training, parenting education, adult education, sexuality education, and developmental day
care (Mathews et al., 1991).
References
Berner, W., Karlick-Bolten, E., & Fodor, G. (1987). Zur
Epidemiologie der weiblichen Sexualdelinquenz.
Forensia, 8, 139143.
Berner, W. (1991). Sadomasochismus bei einer Frau.
Zeitschrift fr Sexualforschung, 4, 4557.
Chow, E. W. & Choy, A. L. (2002). Clinical characteristics and treatment response to SSRI in a
female pedophile. Archives of Sexual Behavior, 31,
211215.

Eldridge, H. (1993). Barbaras storya mother who sexually abused. In M. Elliott (Ed.), Female sexual
abuse of children: The ultimate taboo (pp. 7995).
Colchester, Essex: Longman.
Faller, K. C. (1987). Women who sexually abuse children. Violence and Victims, 2, 263276.
Faller, K. C. (1995). A clinical sample of women who
have sexually abused children. Journal of Child
Sexual Abuse, 4, 1329.
Farin, M. (1989). Heroine des Grauens. Wirken und Leben
der Elisabeth Bathory. Mnchen: Kirchheim.
Finkelhor, D. & Russel, D. (1984). Women as perpetrators. In D. Finkelhor (Ed.), Child sexual abuse: New
theory and research (pp. 171185). New York, NY:
Free Press.
Friendship, C., Mann, R. E., & Beech, A. R. (2003).
Evaluation of a national prison-based treatment
program for sexual offenders in England and Wales.
Journal of Interpersonal Violence, 18, 744759.
Green, A. H. & Kaplan, M. S. (1994). Psychiatric impairment and childhood victimization experiences in
female child molesters. Journal of the American
Academy of Child and Adolescent Psychiatry, 33,
954961.
Grob, C. S. (1985). Female exhibitionism. The Journal of
Nervous and Mental Diseases, 173, 253256.
Groth, N. (1979). Men who rape. New York, NY: Plenum
Press.
Hollender, M. H., Brown, C. W., & Roback, H. B. (1977).
Genital exhibitionism in women. American Journal
of Psychiatry, 134, 436438.
Kaplan, M. S. & Green, A. (1995). Incarcerated female
sexual offenders: A comparison of sexual histories
with eleven female non sexual offenders. Sexual
Abuse: A Journal of Research and Treatment, 7,
287300.
Krafft-Ebing, R. V. (1890). Psychopathia sexualis, 5th
Edition. Stuttgart: Ferdinand Enke.
Kubik, E. K., Hecker, J., & Righthand, S. (2002).
Adolescent females who have sexually offended:
Comparison with delinquent adolescent female offenders and adolescent males who sexually offend. Journal of Child Sexual Abuse, 11,
6383.
Lewis, C. F. & Stanley, C. R. (2000). Women accused of
sexual offenses. Behavioral Sciences and the Law,
18, 7381.
Marques, J. K., Wiederanders, M., Day, D. M., Nelson
C., & Ommeren, A. V. (2005). Effects of a relapse
prevention program on sexual recidivism: Final
results from Californias sex offender treatment and evaluation project (SOTEP). Sexual
Abuse: A Journal of Research and Treatment, 17,
79107.
Mathews, J. K., Mathews, R., & Spelz, K. (1991). Female
sexual offenders: A typology. In M. Q. Patton (Ed.),
Family sexual abuse: Frontline research and evaluation (pp. 199219). Thousand Oaks, CA, US: Saga
Publications, Inc. viii, 246 pp.

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Mathews, R., Mathews, J. K., & Spelz, K. (1989). Female

sexual offenders: An exploratory study. Orwell, VT:
The Safer Society Press.
Mellor, C. S., Farid, N. R., & Craig, D. F. (1988). Female
hypersexuality treated with cyproterone-acetat.
American Journal of Psychiatry, 145, 1037.
OConnor, A. (1987). Female sex offenders. British
Journal of Psychiatry, 150, 515520.
Rosencrans, B. (1997). The last secret: Daughters sexually abused by mothers. Vermont: Safer Society
Press.
Sarrel, P. M. & Masters, W. H. (1982). Sexual molestation of men by women. Archives of Sexual Behavior,
11, 117131.
Struckman-Johnson, C. (1988). Forced sex on dates: It
happens to men too. Journal of Sex Research, 24,
234241.
Tardif, M., Auclair, N., Jacobs, M., & Carpentier, J.
(2005). Sexual abuse perpetrated by adult and

285

juvenile females: An ultimate attempt to resolve

a conflict associated with maternal identity. Child
Abuse & Neglect, 29, 153167.
Travin, S., Cullen, K., & Protter, B. (1990). Female sex
offenders: Severe victims and victimizers. Journal
of Forensic Sciences, 35, 140150.
Vandiver, D. M. & Kercher, G. (2004). Offender and
victim characteristics of registered female sexual offenders in Texas: A proposed typology of
female sexual offenders. Sexual Abuse: A Journal of
Research and Treatment, 16, 121137.
Wolfe, F. A. (1985). Twelve female sexual offenders.
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Zavitzianos, G. (1971). Fetishism and exhibitionism
in the female and their relationship to psychopathy and kleptomania. International Journal of
Psychoanalysis, 52, 297305.

Chapter 20

Professionals Who Are Accused of

Sexual Boundary Violations
Stephen B. Levine and Candace B. Risen

A person can earn the label sex offender by engaging

in a broad swath of socially unacceptable behaviors.
When that person is a professionala physician, mental health professional, lawyer, business executive,
teacher, clergy personthese behaviors are looked
at with particular shock, disbelief, and disappointment. When professionals sex offenses are brought
to the attention of officials, serious consequences
ensue. Within their profession, the offenders may be
punished by loss of license and job, public notoriety,
and ostracization. The professional may or may not
be given an opportunity for rehabilitation. If the professionals victim presses criminal charges, incarceration becomes a possibility. If the victim presses civil
charges, the professional may be compelled to pay a
monetary damage award. Recognition of professional
sexual misconduct is always a life changing matter
for the professional and his family. The consequences
live on.

A BROGAT ION OF T WO ETHICA L

PR INCIPLES

The offending behaviors contradict the ethical principle of beneficence, which is an injunction to strive
to help. The law codifies the expectation of beneficence by using the term fiduciary to describe
the responsibility of professionals to act in the best
interest of the clients (or patients) under their guidance. The professionals pursuit of gratification of
their sexual needs is fundamental evidence that
the clients needs have been given short shrift. The
law assumes that, at least in the long run, professional sexual misconduct also carries a large risk of
actually harming the clienteven when the sexual
behavior was consensual. Damaging the client
violates another fundamental ethical principle
nonmaleficence, which is an injunction to cause
no harm.

286

PROFESSIONALS AND SEXUAL BOUNDARY VIOLATIONS

Most of the attention to professional sexual misconduct has focused on physicians. The publics
expectation of professional integrity among medical
doctors is more widely understood than with other
professions. The avoidance of sex with a patient,
free or slave (rich or poor) has been articulated as
an ethical principle since Hippocrates days 2500
years ago (Markel, 2004). Societys current need to
punish physician sex offenders is stronger than it was
two decades ago. State medical boards are no longer
responsive to the arguments that the patient consented, was obviously not harmed, or is an untrustworthy reporter because she or he has a psychotic or
a borderline personality disorder. The boards assume
that the patient brings to the doctors office a childlike trust in the good intentions of the physician. By
violating that trust the physician tarnishes the reputation of all doctors by making it more difficult for
other patients to trust when they seek care. Ignorance
of medical ethical principles is not an acceptable
argument either. Years of immersion in the healthcare culture should have made it obvious that it
is always the doctors responsibility to respect that
trust by being dedicated to the patients welfare.
(For an excellent summary of ethical guidelines see
Roberts & Dyer, 2004).
As society has clarified its views about the ethical
violation represented by physician sexual misconduct,
its expectations have also become clearer for other
professional groups whose work necessitates a power
differential between themselves and their clients or
students. Professional behaviors in many disciplines
are expected to consistently demonstrate integrity
that is, to be consistently based on clearly apparent,
readily articulable values. Beneficence is imbedded
in the social expectations of these professionals as well.

PROFESSIONA L SE X UA L MISCONDUCT
BY MEN TA L HE A LTH PROFESSIONA LS
A ND OTHER S

Much of the literature on professional sexual misconduct refers to the sexual violations of mental
health professionals (MHPs) and is generated by
forensic psychiatrists (Simon, 2004). This literature
reflects the fact that forensic evaluations of MHPs
who have had sex with patients/clients are increasingly common. Since forensic work only occurs after
a professional has been reported to authorities, these

287

discussions cannot describe the extent of the problem. In the 1980s an attempt was made to estimate
the lifetime prevalence of professional misconduct
among various professional groups. A questionnaire
study of psychiatrists found that 16% of the anonymous responders acknowledged at least one sexual
contact with a patient (Herman, Gartrell, Olarte,
Feldstein, & Localio, 1987). Similarly studies found
that the frequency of self-report of sexual misconduct
ranged between 8% and 16%, a range that has also
been found among most physician groups (Gartrell,
Milliken, Goodson, Thiemann, & Lo, 1992). The
response rate to these questionnaires is typically low.
During the early 1990s, physicians in family medicine, obstetrics and gynecology, and psychiatry were
the most commonly brought to board attention for
sexual misconduct in Oregon (Erbom & Thomas,
1997). Both forensic and questionnaire data agree
that approximately 90% of offending professionals
are men.
In the 1980s the rash of accusations against MHPs
led to four important social changes. Psychiatric
malpractice insurance policies were redesigned to
limit the coverage for defending a claim involving sexual involvementeven if the doctor claimed
technical incompetence to manage the transference. Second, an extended debate about how long
after the end of a professional relationship a therapist
could begin a private relationship with the patient
(Appelbaum & Jorgenson, 1991) was resolved toward
never. Third, most professional state boards rewrote
their codes of ethics to strengthen the prohibition
against forming sexual liaisons with clients/patients.
Finally, state boards became harsher in response to
sexual transgressions committed by MHPs than by
physicians who deal with physical illness. They began
to conceptualize policies to foster a zero tolerance.
Boards realize that patients in prolonged psychotherapies are more likely to experience intense
erotic feelings toward their psychotherapists than are
patients under care for physical abnormalities. Boards
expect MHPs to have the skills necessary to manage
their patients feelings, ideally in a manner that benefits the patient. Incompetence is not an acceptable
excuse.
Boards are official public policy agencies. They set
and enforce standards. They are under scrutiny by the
public through newspaper articles and television programs which monitor and editorially comment on the
patterns of their decisions. In the 1980s, many boards

288 SPECIAL POPULATIONS

were accused of not doing enough to ensure the publics safety from professional sexual misconduct. The
strong political forces on Boards, however, have not
yet translated into better education of MHPs to skillfully deal with erotic feelings.
There is a painful irony here. As paradigms in
psychiatry have become more biological and psychotherapeutic interventions have become more short
term, it is likely that the skills for handling a problematic erotic transference are diminishing among
MHPs at the same time that expectations for it have
increased. Nonetheless, Boards often critically point
out that the professionals behavior before their sexual misconduct was deficient (American Psychiatric
Asociatios Ethical Principles Committee, 2005) in
that they did not
1. recognize the patients erotic feelings as they
emerged;
2. repeatedly discuss the problematic emotions as
a transference from the patients past within the
therapy;
3. seek consultation;
4. if the problem cannot be resolved, transfer the
patient to another therapist.
These solutions require doctors to admit being
overwhelmed by their countertransference. Several
increase the professionals expenses because consultation and supervision are not free (except for those
in training). The final solution, when abruptly done,
often amounts to abandoning the patient, which borders on malfeasance.

W H AT IS A BOU NDA RY?

In recent years professional sexual violations, even

those with consenting partners, have come to be
known as boundary violations among diverse groups
of professionals. Sexual boundary violations typically
begin with
1. misuse of the psychological intimacy;
2. misuse of the physical examination;
3. misuse of spiritual or religious intimacies.
These can lead to nonconsensual sexual harassment,
stalking, gross sexual imposition, as well as consensual sexual contact.
We think of a boundary as an edge, limit, a circle,
or a frame within which the well intentioned work of

the professional can proceed without the professional,

the client, or society being concerned that fraudulence, advantage-taking, or harm is underway. When
a professional acts within the socially constructed
frame of appropriate behaviors, there is, of course, no
guarantee that the patients health will be improved.
Adherence to proper boundaries only sets the stage to
maximize the potential of the professional to create
a lasting benefit for the patient in terms of symptom
relief, world view, and the conduct of life.
Ten Guidelines for Mental
Health Professionals
The boundaries are defined by relatively few rules for
the conduct of professional life. While theoretically
the rules equally apply to all health-care professionals, in actuality they do not. Specific boundaries vary
with the type of professional worka psychoanalyst
and an addiction counselor use different rules, as do a
pediatrician and an ophthalmologist. The rule, however, that is true for all health-care professionals is
sexual avoidance. The other rules for professional life
are largely intuitively understood by professionals and
lay persons alike. Most of these guidelines cannot be
stated in absolute terms (Roberts & Dyer, 2004). The
following ten guidelines are our personal synthesis of
the traditions of psychiatric ethics that can be found
in numerous articles on the subject.
1. Beneficencethe use of ones expertise exclusively to help the ill: I will act only for the
benefit of the patient. Closely linked to beneficence is the concept of nonmaleficence, First,
do no harm.
2. Abstinencethere are to be no personal rewards
for patient care other than the pleasures of the
diagnostic and therapy processes and financial
remuneration. There is to be a relative absence
of physical expression of affection between the
professional and patient.
3. Neutralitythe professionals work is to clarify
the patients options and explore the pros and
cons of each behavioral course; it is not to cause
the patient to make a choice that the professional feels is correctfor example, to influence
whether a woman has an abortion. Neutrality
is a means of fostering psychological independence or separateness in the patient. The professionals neutrality is a way of respecting and
fostering patient self-determination. The professional is expected to highly value the patients
right to determine his or her own future.

PROFESSIONALS AND SEXUAL BOUNDARY VIOLATIONS

4. Fiduciary agentThe mental health professional is expected to recognize the power

imbalance between him or her and the patient.
The power differential provides the professional with an opportunity to have too much
influence over the patient, but this influence is
expected by the law to always be in the patients
best interests.
5. Respect for patients confidentialitythe professional has an obligation not to reveal patients
personal information without their explicit permission. Respect for confidentiality is an old
time-honored tradition that forms the basis of
the doctorpatient relationship.
6. Informed consentpatients must consent to
the elements of their treatment. The professional is expected to be truthful in all ways with
the patient. This expectation means that the
professional must discuss the pros and cons of
therapy options. For all procedures in medicine
and in all forms of research, this means that an
Informed Consent document must be signed.
For informed consent to have taken place, the
patient must be cognitively intact, relatively
free of paralyzing psychological distress, and
free of coercion.
7. Singularity of purpose to the professional relationshipprofessionals are expected to avoid
dual relationships such as business partner
and psychiatrist; employer and treating psychologist, friend and addiction counselor. This
guideline means little to no other relationship
before, during, or after therapy.
8. Professional work is to take place in the proper
setting, its duration is defined (1/2 or 1 hour
sessions), its costs are reasonable and clear.
9. Asymmetry of personal disclosurea professional relationship is to be characterized by a
one-way psychological intimacy (Levine, 2003):
the patient speaks and the professional listens.
10. Patients erotic fantasies are to be discussed with
the purpose of understanding their meanings
in terms of present and past life circumstances.
Professional sexual misconduct usually contradicts all
of these rules. It is clearly unethical. Such boundary violations are typically preceded by boundary crossings.

What Is a Boundary Crossing?

Lesser departures of the therapeutic frame are referred to as boundary crossings (Epstein, Simon, &
Kay, 1992). For the MHP, for example, making a
friend of a patient by excessive personal exposure

289

of the professionals personal life circumstances is

a boundary crossing. Some boundary crossings are
deliberate and therapeutic in intent (Frick, 1994).
When a boundary crossing is recognized by the therapist as an error, the mistake can be discussed as an
error without necessarily harming the relationship.
Undiscussed crossings pose a danger to professional
work when they increase in frequency and intensity
over time. They are a slippery slope that is thought
to increase the likelihood of a sexual boundary violation. This view of boundary crossings is based on
cases that came to the attention of forensic psychiatrists (Simon, 1989). By retrospective analysis it was
recurrently observed that sex between patient and
professional was preceded by subtle forms of wordless
negotiations that tested the receptivity, nerve, and
daring of the dyad.
Many patients recognize the early boundary crossing explicitly or intuitively and leave the relationship. Their next therapist may learn about it. In this
way, colleagues come to know the boundary crossings of others and occasionally the boundary violation patterns of others. Therapists do not generally
report the colleague, however, even though the second section of the Principles of Medical Ethics with
Annotations Especially Applicable to Psychiatry states
that a physician shall . . . . strive to expose colleagues
deficient in character or competence (American
Psychiatric Association [APA], 1993). Reporting
a colleague without the patients permission may
violate confidentiality. (This does not apply when the
patient is a minor or seriously mentally or physically
handicapped. Most states have legal requirements
that transcend the professional ethical guideline
regarding confidentiality.) Reporting the colleague
with the patients permission may cause the patient
unforeseen distress and harm and change the course
of therapy. It is also dangerous because the patients
interpretation of the boundary crossing may be only
one version of what transpired. The literature makes
clear that the assessment of what is a serious boundary
crossing short of sexual misconduct can be a complex
matter (Martinez, 2000). Coworkers within the same
institution are more likely to report to their mutual
superior a colleague who seriously crosses boundaries
with a client than to a state board. It then becomes
the administrators problem.
When sexual misconduct is revealed to a new
therapist in private practice or in a different institution, he or she may rapidly recommend that the
patient report the prior professional to the board.

290 SPECIAL POPULATIONS

The new therapist assumes that this course of

action is necessary for the patients recovery and for
the good of the society. This stance requires a significant departure from therapeutic neutrality and,
however well intentioned, may emotionally backfire
and harm the patient. The patient is better served
if the therapist is open to discussing the previous
professionals sexual misconduct and maintains
therapeutic neutrality about what should be done.
Whatever the patient eventually decides to do, it will
be his or her decision. These are typically very complex circumstances involving compromised mental
health, past sexual abuse, and layers of patient guilt
for acting out on erotic transferences. Dealing with
them as though it were a simple matter of perpetrator and victim denies the patient his or her own
experience of what took place. The simple assignment of culpability is the role of the board, not the
psychotherapist.
A case in point: A middle-aged woman reports
during her first session with a therapist that she had
sexual activity with a previous therapist. At the end of
this session, the new therapist urges her to report her
previous doctor to the Board, a recommendation that
her aggrieved husband had already been urging. After
the second session, the new therapist wrote a letter of
outrage to the Board recommending that the previous therapists license be permanently revoked. As the
adjudication processes went forward and the boundary crossing doctor suffered social, financial, and
licensure losses, the patient became overwhelmed
with guilt and began stalking the doctor to apologize
and ask for his forgiveness, much in the same way
she relentlessly pushed him to have sex with her for
2 years before his misconduct. Because of the adversarial relationship with her original therapist and the
pressure of the new therapist, the patient found it
impossible to effectively deal with her feelings about
the entire matter.

THE PROGR A M FOR PROFESSIONA LS

We began this program in 1991 with the assistance of

a small foundation grant to learn more about professional sexual misconduct. The mission of the program
was two-fold: to create a standard evaluation process
that would routinely elicit an understanding of the
circumstances and motivations for the professionals
ethical breach and to formulate recommendations to

the agency that ordered the professional to have the

evaluation (Levine, Risen, & Althof, 1994).
Elements of the Evaluation
Our evaluation typically follows these steps over a
4- to 6-week period.
1. Discussion with referring agency about the reasons for evaluation and the specific questions
that they would like us to address
2. Review of the documentation concerning the
complaint and of any additional information
that the agency possesses about the situation
3. Interviews conducted by a primary evaluator. One person on our team of three sees the
person between 4 and 6 hours to determine the
history of the problem from the perspective of
the professional. This may sometimes include
an interview with the spouse of the professional. It does not include an interview with
the victim as that might create an emotional
intensity in the victim for which we can take no
professional responsibility. We do not wish to
further traumatize the victim
4. Psychometric assessment with the MMPI-III
and MCMI-2 Millon Multiaxial Personality
Inventory. Two interpretations are available
to us: one by the psychologist and one which
is generated by the computerized scoring
program
5. Case conference. The primary evaluator presents the case to the other two members of the
team and our general staff, for a refinement of
the unanswered questions and discussion of the
apparent psychodynamics of the problematic
situation
6. Interview conducted by a secondary evaluator for up to 2 hours. This interview provides
another look at the professional while attempting to answer the questions raised at the case
conference
7. Miniconference of the Program for Professional staff only to formulate conclusions and
recommendations
8. Feedback session with the professional. The
purpose is to reflect on the evaluation itself,
obtain missing information, and to give the
third member of the team an opportunity to
observe the professional before and after the
recommendations are conveyed
9. Report writingthe primary evaluator composes the report which is responded to and
signed by all three team members

PROFESSIONALS AND SEXUAL BOUNDARY VIOLATIONS

Sources of Referral
The Program for Professionals receives most of its
referrals from one of four sources. It is rarely contacted by a professional seeking help to prevent or stop
personal sexual misconduct.
1. State professional boards such as for medicine,
psychology, social work, nursing, or educationhaving received and investigated a complaint against one of its licensees, the board
seeks our opinions about the psychiatric diagnosis, motivations, public safety, and recommendations for future license restrictions. The
referral is often mandated by the board through
its Consent Agreement with the guilt-admitting
professional.
2. Hospitalsusually the chief of staff or a department chairperson refers a problematic staff
member for assistance in management, rehabilitation, and future conditions of employment.
3. Diocesebefore the clergy abuse scandal in
2002, we received numerous referrals from
Catholic institutions seeking guidance for
priests, nuns, and deacons who had behaved
inappropriately (Fones, Levine, Althof, & Risen,
1999). Of these referrals, 60% did not involve a
minor.
4. Lawyersprofessionals who have got into
trouble in one state often seek legal assistance
in relocating to another. The lawyer seeks our
assessment of the situation so that he can represent his client more expertly in suggesting
the conditions under which another state board
might be reassured about public safety. Unlike
the professionals who are referred as part of a
Consent Agreement from their state board, our
evaluations are done before the application for
licensure to a new board.

The Easy Versus the Difficult Cases

Our experience within the Program for Professionals
can be appreciated by grasping the differences
between the easy and the difficult cases that we evaluate. What makes our evaluation easy is the professionals willingness to tell us what happened in a relatively
honest and reasonably complete fashion. Almost no
one, however, can give us the full story, complete
with all the relevant past and current aspects of the
situation. Everyone is trying to salvage what is positive about their situation. While we accept practicing

291

damage control as normal evaluation behavior, it

prevents us from completely understanding the situation. Our conclusions are presented with a caveat
about the limitations of self-report. Nonetheless, the
essence of the easy situation is, Yes, I did engage in
a sexual relationship with my client. Here is what I
know about what happened and why.
The difficult case begins with the professionals
position that he is innocent, did not do anything close
to what he is accused of, is the victim of a misunderstanding or a malicious lie, or is in trouble because the
accuser is seeking revenge for some other nonsexual
matter of disagreement. It is certainly possible that a
professional can be falsely labeled by malevolent dishonest accuser. In all cases we carefully note the personal style of the professional. Falsely accused people
are usually eager to tell their stories, they give credible background accounts, speak knowledgably about
what they did do wrong, and treat us with respect.
There are those professionals, however, who demonstrate profound resistance to their evaluation and are
disrespectful of our time and intentions to help. They
present in an angry, confrontative, or insulting manner and provide sparse, incredible stories that assume
no responsibility for any bad judgments.
When this happens, we try to address the dilemma
the professional is in with us during the first session.
This may enable him to become cooperative, respectful, and an easy case. If our emphatic and clarifying
early intervention fails to elicit the professionals cooperation and his or her unpleasant unhelpful manner
continues, our clinical experience has led us to more
strongly suspect the persons guilt and speculate that
he or she is character disordered as well. For instance,
a 56-year-old physician was accused by four patients
of fondling their breasts during physical examinations in his last job of 11 months. He had held jobs
in 23 different settings. He claimed that he was never
responsible for any of his previous contracts not being
renewedall were externally caused. He came to us
knowing the evaluation fee was to be paid by the end
of the evaluation. When we told him that we did not
believe the likelihood that four women had independently misunderstood his innocent physical examination techniques and therefore could not recommend
an immediate return to work, he refused to pay for his
evaluation.
The Program for Professionals process is not a
legal finder of fact. If a professional maintains his
or her absolute innocence during the evaluation, we

292 SPECIAL POPULATIONS

explain this to the referral source. We cannot explain,

interpret, or make recommendations about what did
not happen. The Program for Professionals is best utilized for individuals who know that they have made a
serious error in judgment and behavior. We attempt
to help them explain the error to themselves and to
the referring agency.

E X PECTAT IONS FOR R E ASONA BLE

MOR A L A ND MEN TA L HE A LTH
IN THE PUBLIC SPHER E

When a professional has sex with a patient, the act

is considered egregious by various elements in society. The Program for Professionals responds by trying to determine the mind set of the professional,
the number of prior patients he or she was involved
with, and the factors that may have diminished the
professionals judgment. We assess the rehabilitation
potential and the future threat to public safety. Here
is an example of a man we felt could not be allowed
to practice medicine without a monitor present at all
times: An internist with a stocking fetish had apparently disguised his sexual interest in womens undergarments and stockings throughout his career by
providing calf and foot massages at the end of some of
his physical examinations. A patient perceived that he
had an orgasm during the massage after he placed a
knee-high stocking on one of her legs without asking
her permission. This physician had a highly compulsive paraphilia that spilled over into the conduct of
his medical life.
The public expects that licensed professionals
have a reasonable degree of moral and mental health
in their personal lives. While most men with a paraphilia express their unique sexual patterns in privacy,
some people are driven to public sexual behavior for
their greater intensity of arousal. While they may
be able to keep this pattern of behavior out of their
professional work, their sexual proclivities become
known within the community. This makes boards
quite uneasy about the professionals ultimate judgment. They worry when, if ever, the problem will spill
over to their professional life. Boards hold their professionals to a high standard of public morality and
mental health. Conviction for felonies of any sort, for
instance, often ultimately leads to a loss of license.
Here are cases that caused state boards concern for
the ultimate safety of the public: A family practitioner

surreptitiously video taped his girlfriends teenage

daughter in the bathroom; an anesthesiologist repeatedly watched his stepdaughter while she showered; a
cancer surgeon was arrested in the park for soliciting
homosexual sex; a gynecologist was arrested for exhibitionism at a mall. The Program for Professionals
was asked in these cases whether the doctor was
safe to practice medicine and what could be done to
facilitate the permanent cessation of these uninspiring misdemeanors. The worry, of course, is that these
episodes of sexual acting out will be a slippery slope
that will lead to professional sexual misconduct.

A DI AGNOSIS IS NOT THE SA ME

AS THE DY NA MICS

In our reports to the referring sources, the Program

for Professionals provides psychiatric diagnoses. Even
a thorough five axis DSM-IV-R diagnosis, however,
does not explain why the misconduct occurred. For
example, a middle-aged psychologist claimed that
a sheriffs agent raped her and was sexually abusing
many of the prisoners at the womens division of the
county jail. She provoked a costly investigation of the
sheriffs department before her suicide attempt led
to a psychiatric hospitalization where she was recognized as psychotic. She had been noncompliant
with her medications and appointments and failed
to explain to her psychiatrist what was going on in
her life. The psychologist, who did not have sex with
a patient but was preoccupied with other peoples
sexual misconduct, could not separate her patients
stories from her own perceptions. Classifying her
inappropriate behavior about sex with the sheriffs
deputy was easy once the diagnosis of psychosis was
made. To consider rehabilitation, however, her evaluation focused on what precipitated her poor handling
of her psychotic illness. After considerable confrontation, she was able to explain her humiliation over her
recent marriage to a foreign-born man whose courtship behavior immediately changed into autocratic
insistence on having his way in everything including
sexual opportunities. I was a foolfor the third time
in my life! Denial or minimization of a psychiatric
illness does not generate confidence in a boards ability to protect the publics safety. However, state medical boards often allow individuals to practice when
their mental illnesses are well-managed and they can
serve their communities without incident.

PROFESSIONALS AND SEXUAL BOUNDARY VIOLATIONS

Yes, We Can Categorize Professional

Sexual MisconductBut
After over 120 evaluations, we have learned that every
case is unique and that categories, however, generally
useful, do not take us very far in explaining ethical
laxity. Most professionals are not conspicuously mentally ill, character disordered, sexually compulsive
paraphilic addicts, facing death from a terminal
illness, or grieving the acute loss of a spouse. Those
who are, however, make dramatic case presentations.
Many cases leave us in awe of the human capacity
to give into temptation. Our best explanation then is,
We dont really know.
A 28-year-old virgin, first generation American,
religiously sexually suppressed, a nave believer in
peoples inherent goodness, lost his medical license
because he gave too many opiods to a woman he did
not recognized as a prostitute. She managed to entice
him to trade more drugs for sex outside the hospital
and became trapped in his error. When he refused
to continue to provide drugs for her, she followed
through on her threat to report him.
Our categories are for those psychiatric illnesses
that we think served as a cofactor in generating misconduct. They are not for the reactive anxiety and
depression reactions that often occur immediately
after the misconduct and then inevitably with greater
intensity when the misconduct is publicly identified.
Numerous authors use slightly different categories
(Norris, Gutheil, & Strasburger, 2003). We sometimes run into cases that fit more than one of these
categories. Notice that substance abuse is not listed
here. Sexual misconduct associated with substance
abuse tends to be viewed as a symptom of addiction
and is handled separately by most boards.
Brain diseasea mental or brain illness, such as,
schizophrenia, bipolar disorder, steroid psychosis, or Alzheimers disease, may impair the judgment and impulse control of the professional
Depressive Life Processesa loss of an important person or job has created a sense of grief
and despair that has motivated the professional
to inappropriately reach out to a willing patient
Psychopathic Characterusually refers to a narcissistic/psychopathic person with more than
one professional sexual violation, an exploitative life pattern, and strong psychometric
evidence of psychopathy. These people seem
to lack restraint and evidence of struggle with

293

their conscience, and feel entitled to use the

patient for their purposes
Sexual compulsivity with or without paraphiliawhile paraphilic problems are often evident
from puberty, we have seen them arise with a
compulsive intensity in young adulthood. The
pressure of their sexual desires overwhelm their
restraint mechanisms and cause the inappropriate behavior with their patients
Characterological Problemsthe most common diagnosis is mixed character disorder with
a heavy use of externalization of blame. This
perhaps just represents a strongly defensive posture that prevents us from finding out the more
truthful version of the misconduct. Many of
these individuals seem to be dysthymic
Absence of Pathologyone might be tempted
to assume that professional sexual misconduct
never occurs without a significant recognizable
pathological pattern, but our experience does
not support this idea. We suspect that ethical
breaches, even those involving sex (Gartrell
et al., 1992), are more common than has been
realized, and can result from ordinary human
temptation to break the rules to satisfy some
urgently felt personal need

CONCLUSION

The actual extent of professional sexual misconduct

can not be ascertained with certainty for any professional group. When these egregious acts come to
attention, however, the professionals personal and
professional lives are inevitably profoundly altered.
Social institutions such as state medical boards punish these cases severely in an attempt to diminish their
incidence in others. The Program for Professionals
systematically evaluates the accused and finds that
most cases fall into one of five categories but a large
minority of cases show no significant premorbid
psychopathology.
References
American Psychiatric Association. (1993) Principles of
medical ethics with annotations especially applicable to psychiatry. Washington, D.C.: American
Psychiatric Association.
American Psychiatric Asociatios Ethical Principles
Committee. (2005). Principles of ethics and professionalism in psychiatry (pp. 127). Washington,
D.C.: American Psychiatric Association.

294 SPECIAL POPULATIONS

Appelbaum, P. S. & Jorgenson, L. (1991). Psychotherapistpatient sexual contact after termination of treatment: An analysis and a proposal. The American
Journal of Psychiatry, 148, 14661473.
Epstein, R. S., Simon, R. I., & Kay, C. G. (1992).
Assessing boundary violations in psychotherapy:
Survey results with the exploitation index: Bulletin
of Meninger Clinic, 56, 150166.
Erbom, J. A. & Thomas, C. D. (1997). Evaluation of sexual misconduct complaints: The Oregan Board of
Medical Examiners, 19911995. American Journal
of Obstetrics and Gynecology, 176(6), 13401346.
Fones, C. S., Levine, S. B., Althof, S. E., & Risen C. B.
(1999). The sexual struggles of 23 clergymen: A
follow-up study. Journal of Sex & Marital Therapy,
25(3), 183195.
Frick, D. E. (1994). Nonsexual boundary violations
in psychiatric treatment. In J. M. Oldham, &
M. B. Riba (Eds.), Review of psychiatry. Washington,
D.C.: American Psychiatric Press.
Gartrell, N. K., Milliken, N., Goodson, W. H. I.,
Thiemann, S., & Lo, B. (1992). Physician-patient
sexual contact: Prevalence and problems. The
Western Journal of Medicine, 157, 139143.
Herman, J., Gartrell, N., Olarte, S., Feldstein, M., &
Localio, R. (1987). Psychiatrist-patient sexual contact: Results of a national survey of psychiatrists
attitudes. The American Journal of Psychiatry,
144(1), 164169.

Levine, S. B., Risen, C. B., & Althof, S. E. (1994).

Professionals who sexually offend: Evaluation procedures and preliminary findings. Journal of Sex &
Marital Therapy, 20(4), 288302.
Levine, S. B. (2003). What patients mean by love, intimacy, and sexual desire, In Althof, S. E (Ed.), The
handbook of clinical sexuality for mental health
professionals (pp. 2136). New York, NY: Brunner/
Routledge.
Markel, H. (2004). Becoming a physician: I Swear
by ApolloOn taking the Hippocratic oath.
New England Journal of Medicine, 350(20),
20262028.
Martinez, R. (2000). A model for boundary dilemmas:
Ethical decision making in the patient-professional
relationship. Ethical Human Sciences and Services,
3(1), 4361.
Norris, D. M., Gutheil, T. G., & Strasburger, L. H. (2003).
This couldnt happen to me: Boundary problems
and sexual misconduct in the psychotherapy relationship. Psychiatric Services, 54(4), 517522.
Roberts, L. W. & Dyer, R. (2004). Ethics in mental
health. Washington, D.C.: American Psychiatric
Publications, Inc.
Simon, R. I. (1989). Sexual exploitation of patients: How
it begins before it happens. Psychiatric Annals, 19,
104112.
Simon, R. I. (2004) Maintaining treatment boundaries.
Psychiatric Times, 11:1417.

Chapter 21

Stalking
Ronnie B. Harmon

Stalking emerged in the national consciousness in

the United States in the last decade of the twentieth
century as a crime of passion and violence. A series
of homicides, some involving celebrities and aggressive fans, some involving unstable individuals whose
approaches to ordinary people were rejected, raised
the awareness of the California legislature about what
had, up to then, been a relatively overlooked phenomenon in criminal justice. To date, much research
about stalking behavior has focused either on defining the problem, or on predicting which stalkers are
more likely to become dangerous to their targets,
and when such dangerous behavior might manifest
itself. In many stalking cases, the only real guarantee
of victim safety will come with the cessation of the
stalking. Understanding which type of stalker will
persist no matter what interventions are taken, versus
which type of stalker can be encouraged to desist
in their behavior, may facilitate the management of
these difficult cases.

PROBLEMS OF DEFINIT ION

Initial attempts to clarify the nature of this phenomenon focused on the stalker as someone who
was not well known (or not known at all) by the
target of his attention (Dietz, Matthews, Martell,
Stewart, Hrouda, & Warren, 1991a; Dietz et al.,
1991b; Zona, Sharma, & Lane, 1993). By the mid1990s, laws against stalking had evolved across the
United States and around the world. Advocacy for victims of domestic violence had broadened the publics
perception of stalking to include situations in which
individuals who were trying to terminate former intimate relationships were relentlessly pursued by their
former partners (Kurt, 1995; Meloy & Gothard, 1995).
As awareness about stalking increased, the definition
of the phenomenon broadened (Harmon, Rosner, &
Owens, 1995, 1998; Mullen, Path, & Purcell, 2000).
A stalker could be a former lover, an acquaintance, or
a total stranger. The stalking could be done from a

295

296 SPECIAL POPULATIONS

distance (by telephone or mail) or in person (through

following and visiting). It could be accompanied by
threats of violence, or protestations of undying love,
or both.
The process of defining stalking has proceeded
on two tracks: the legislative level and the behavioral
level. Legislators were concerned with fashioning
laws that would give local law enforcement the tools
needed both to protect the public from perceived
dangerous predators, and to prevent stalking behavior from escalating to violence. Behavioral scientists
attempted to clarify the motives behind stalking activities, with the expectation that identifying the causes
of the behavior might lead to an understanding of
how to contain it.

Legislative Definitions
Purcell et al. (2004), in an extensive, international
review of antistalking legislation, concluded that while
there is no consistent, universal legal definition of
stalking, most laws contain some combination of
three elements: conduct requirements, intention, and
the response of the victim.
Conduct requirements define stalking by the
actions of the offender. In contrast to many other
criminal offenses, such as robbery or homicide, with
stalking there may be no single identifiable incident that marks the beginning, middle, or end of
the crime. Stalking consists of a series of incidents
occurring episodically. Some early antistalking legislation listed specific acts (i.e., following, telephoning,
approaching, letter writing). When it became clear
that it would not be feasible to list all actions that
could be taken by a stalker, the legal phrase course
of conduct was integrated into many antistalking
laws. In New York State, judicial references to case
law defining course of conduct date back to the
English common law case of Crepps v. Durden (1777),
in which the Court held that the sale of four loaves of
bread on Sunday in violation of a statute forbidding
such sale constituted one offense, not four. Case law
decisions have resulted in the definition of course
of conduct as an intentional pattern of conduct
encompassing a period of time, no matter how short,
evidencing a continuity of purpose (Rosenbaum,
2000). Generally speaking, a minimum of two specific actions have been considered to constitute a
course of conduct.

Intention can be defined as the motivation behind

the stalking behavior. Early anti-stalking laws required
the perpetrator to have made a threat (Miller, 2003),
and/or to intend to harm or frighten the victim. This
was quickly recognized as being nonproductive in
stalking cases where the pursuit was based on the
desire to create and/or maintain a loving relationship,
in which case the stalker could claim they had no intention of hurting anyone. In many jurisdictions, statutory
requirements were amended so that the stalker only
had to intend to commit the acts of which they were
accused (i.e., making calls, mailing letters, sending
gifts). Deliberate behavior, whether it was intended to
cause fear or not, could be punished as stalking.
The response of the victim is an important element to the offense of stalking. In addition to the
ongoing nature of the crime, the offense of stalking
is also unusual in giving substantial weight to the
impact of the offense on the victim. The stalking victims perceptions, or the perceptions of an impartial
reasonable person, of the stalkers behavior as threatening or frightening, may determine whether a crime
has been committed (U.S. Dept. of Justice, 1998). In
many jurisdictions, if it can be demonstrated that the
stalker knows or should know that his actions are causing fear in his target, then, regardless of his intent, he
can be charged with stalking (Radosevich, 2000).
Behavioral Definitions
Behavioral definitions have focused on the development of classification systems, or typologies, intended
to enable the understanding of stalking behavior and,
through such understanding, to facilitate its management. Such classifications group stalkers according
to such things as motivation, relationship with the
targeted individual, and psychiatric disorder.
The United States National Center for Victims of
Crime has adopted a classification system that divided
stalkers into two major categories, love obsessed and
simple obsessed. This classification was developed by
Dr. Michael Zona, a California-based forensic psychiatrist affiliated with American law enforcements first
organized antistalking unit, the Los Angeles Police
Departments Threat Management Unit (Zona et al.,
1993). Love obsessed stalkers are defined as being fixated on another individual with whom they have no
relationship; simple obsessed stalkers have a history of
a prior relationship with their targets. A third, much
smaller category, erotomanics, is defined clinically

STALKING

in the Diagnostic and Statistical Manual of Mental

Disorders (American Psychiatric Association, 2000).
They constitute a specific subset of love-obsessed
stalkers who believe that the object of their affection also loves them. The stalker believes that their
targeted object is sending them coded, intimate
messages, or, they may feel that the target has been
unable to demonstrate their love because of outside
interference, or shyness. The major problem with the
Zona classification system is its failure to sufficiently
distinguish among the many different types of simple obsessed stalkers who compose a large percentage of their sample population.
Mullen (2003) defined stalking as [A] constellation of behaviors in which one individual persistently
inflicts repeated, unwanted intrusions and communications on another. The typology developed
by Mullen et al. (1999, 2000) under the auspices of
Monash University and the Victorian Institute of
Forensic Mental Health in Australia, incorporated
these items in a multiaxial approach. Motive was
divided into five types: the rejected may have been
trying to reopen a terminated relationship, intimacy
seekers were lonely individuals trying to create a relationship, resentful stalkers felt that they had been
damaged in some way and sought justice, predatory stalkers included sexual predators who targeted
specific victims, and the incompetent stalker also
sought a relationship, but was incapable of using
socially acceptable means to connect with a partner. Relationship categories included prior intimate
partners, professional contacts, work-related contacts,
casual acquaintances and friends, the famous, or
strangers. Psychiatric disorder was classified as either
psychotic or nonpsychotic. The system was intended
for use in the development of predictions about the
nature and course of the stalking, and the management of the behavior by treating mental health and
law enforcement professionals.
Boon and Sheridan (2001) developed a four-part
classification system from a sample of self-referred
victims of serious stalking. Former intimate partners, especially when there was a history of domestic
violence, were found to be at high risk for violence.
Infatuated stalkers were a low-level risk for dangerous
actions toward their targets, and might respond well
to legal action. Stalkers who had a delusional fi xation
about their targets could be somewhat more dangerous; these individuals might have a history of psychiatric problems and/or of previously stalking other

297

victims, and were difficult to dissuade from their pursuits. This category includes individuals who can be
diagnosed with the delusional mental disorder erotomania (American Psychiatric Association, 2000), in
which the object of their affection is generally a person of higher status or reputation. Although they are
strangers, the delusional individual firmly believes
that there is an existing relationship between them.
Because of this unshakable belief, all attempts to
dissuade the stalker are viewed as either unwelcome
interference from others (like security personnel or
family members, who may consequently become at
risk for harm), or as the stalking victims roundabout
means of communicating their love. Finally, sadistic
stalkers (similar to the predatory stalkers discussed
by Mullen et al. (1999, 2000)) see their targets as victims to be intimidated. The motive behind this type
of stalking is the exertion of power and control over
another individual, who is frequently a former intimate partner. This type can be very dangerous and
capable of physical violence, and are considered the
most difficult stalking cases to manage, from the
point of view of law enforcement intervention.
For both legal and behavioral researchers of stalking, the most important objective was the development of a classification system that would serve as
a workable resource for law enforcement officers
attempting to predict the trajectory of stalking behavior and to respond accordingly to protect its victims from physical and emotional harm. Boon and
Sheridan (2001) wanted to serve the needs of law
enforcement professionals by identifying offenders
according to motivational orientation. Spitzberg
(2002, p. 263), in his meta-analysis of studies of stalking behavior, notes that many attempts to define stalking have the objective of managing risk to victim
and society through risk prediction. This objective is
illustrated by the attempt to identify characteristics of
the perpetrator or the victim that distinguish the nature of victimization. Other studies (Palarea, Zona,
Lane, & Langhinrichsen-Rohling, 1999; Roberts,
2002) looked at whether relationship behavior patterns could be used to predict post-breakup stalking,
and also at when behavior can be considered to cross
the line from normal courtship into obsession.
What is clear is that there is no one profile of
a stalker or of stalking behavior. Different types of
stalkers may share a common behavior pattern, but
will react differently to attempts to control stalking
behavior. Some will target one individual for a period

298 SPECIAL POPULATIONS

of time, but will respond to an encounter with the

criminal justice system by discontinuing their stalking behavior. Others will react by repeating the
stalking, but against a different target. Finally, some
will persist in their pursuit of a single victim regardless of all efforts to discourage them.

THE STA LK ING R ECIDI V ISM PROFILE

The following analysis is based on data collected

for the studies of Harmon et al. (1995, 1998), reexamined in studies by Rosenfeld and Harmon (2002)
and Rosenfeld (2003), and presented at national conferences (Ciric & Harmon, 2002; Harmon, 2001;
Harmon, 2005).
Harmon et al. (1995, 1998) reported on a descriptive study of 174 stalkers referred for evaluation to
the Forensic Psychiatry Clinic of the Criminal and
Supreme Courts of New York, New York. The research
resulted in a typology that theorized that stalking
behavior was definable in two major dimensions (see
Table 21.1). For the first dimension, a distinction was
made between stalking which could be considered
sexually motivated (amorous stalking, in which the
focus was on situations in which the stalking behavior was related to a desire to either initiate or maintain an intimate relationship, or to punish the victim
for terminating such a relationship) versus stalking
which was in no way sexually motivated (persecutory,
or vengeful stalking, in which the stalking behavior
was related to a desire for revenge for a financial or
situational wrong the victim was perceived as having
committed against the stalker). Individuals may have
been victimized because of either of these types of
obsessions. The second axis of the typology grouped
stalkers according to the relationship they had with

their victims before the stalking began. The initial

grouping established six types of relationships: personal (including sexual partners and family members), professional (including professional individuals
retained by the stalker), employment (supervisors,
coworkers, and subordinates), media (celebrity stalking), and acquaintance (neighbors, former friends,
casual dating relationships), and none (stranger
stalking). In the 1998 paper of Harmon et al., these
classifications were simplified to form three categories: former intimates included sexual partners
and family members; acquaintances subsumed the
professional, acquaintance, and employment classifications; and no prior relationship, which included
media or celebrity stalking and complete strangers.
One of the goals of the classification system was to
eliminate, as much as possible, overlap among the
groups.
The research found that, for this specific population of criminally charged stalkers with suspected
mental illness, the prestalking relationship between
the parties was more important in predicting risk
of harm than was the motivation behind the stalking. Threats to the target and the stalkers psychiatric diagnosis (particularly personality disorders and
psychoactive substance use disorders) were also significantly more likely to predict aggressive behavior.
For example, the woman whose neighbor stalks her
because he believes she is the love of his life, and he
wants to be united with her is likely to receive a different, less threatening type of attention from him than
she gets from the ex-husband who can not accept the
termination of their relationship. The lawyer whose
former client has become hopelessly infatuated with
him may receive the same level of attention as he
does from the former client who is convinced that he
cheated her out of her inheritance.

Table 21.1 Stalking Relationship Typology

Stalking Motive

Prior Relationship
Intimate/Former
intimate

Acquaintance

None/Stranger

Amorous stalkers

Abusive ex-husband
(domestic violence)

Infatuated employee
(or neighbor, client)

Enamored fan (celebrity

stalking)

Persecutory/vengeful
stalkers

Estranged adult child

seeking financial
support

Disgruntled client
neighbor, or employee

Angry constituent
(victims)

Harmon, 2005.

STALKING

Further analysis of this preliminary data set

(Ciric & Harmon, 2002; Harmon, 2005) was initiated on the basis of the principle that researchers
had been discovering that it was difficult to predict which stalkers might turn to physical violence
in their pursuit patterns, and which stalking situations might remain psychologically stressful for the
victim, but never escalate to dangerousness. If such
prediction was not feasible, it was thought that it
might be more fruitful to direct inquiries to the
question of whether a stalker could be persuaded,
either by legal or psychological means, to desist from
the stalking behavior. A stalker who had abandoned
his pursuit would, by default, no longer pose a risk
to the victim.
The Stalking Recidivism Profile is based on the
following definitions:
Single-incident stalking: A series of activities leading to an arrest either for stalking or for violating an
initial order of protection. For this type of stalker, the
behavior pattern is generally not repeated after the
arrest/legal intervention. For example, a 51-year-old
man was found incompetent to stand trial with a
diagnosis of paranoid schizophrenia, on a charge of
harassing a popular actress. He had sent numerous letters to her over a 5-year period, expressing his love and
demanding money. Since this finding, and his consequent hospitalization in a State psychiatric facility,
he has not returned to the attention of the Forensic
Psychiatry Clinic, and there was no record of a further
arrest at the time of the study data collection.
Persistent stalking: Multiple incidents of stalking
behavior that do not cease subsequent to a legal intervention. This type of stalker does not appear to desist.
All of the incidents of stalking in the arrest record
relate to the same target or group of targeted individuals. For example, X. was a middle-aged white man
charged with second-degree aggravated harassment
on three occasions (August 1995, October 1995, and
July 1996), and criminal contempt on three occasions
(November 1995, March 1996, and July 1997). While
in custody he continued to write letters to the complainant, a former acquaintance whom he had dated.
Although these were the only charges reported in his
New York State file, his Probation file indicated an
arrest record dating back to 1958, in five other states,
and on federal property. These offenses included
weapons possession, drugs, assault, and robbery, and
the sentences ranged from conditional discharge to

299

as much as 4 years incarceration. This man would

not be deterred by the legal system, and his harassing
behavior toward the victim ceased only when he was
killed in a motorcycle accident in 1999.
Serial stalking: Multiple incidents of stalking
behavior in conjunction with legal action (arrest),
where the targets of subsequent or simultaneous stalking are different, unrelated individuals or groups of
individuals. It should be noted that Goldstein (2000)
coined the term serial stalking, which he defined as
the sequential stalking of discrete victims at different times (emphasis in original), but does not consider the simultaneous stalking of multiple unrelated
targets to be serial stalking. Thirteen percent of the
stalkers in the current data set were serial stalkers. One
of the more infamous of these was Ms. Y. Even before
her first referral to the Forensic Psychiatry Clinic
for evaluation, she had been accused of stalking a
well-known local physician. At the time of her first
referral to the Clinic, she had begun to stalk another
physician from the staff of the same hospital facility.
Ms. Y., a well-spoken, attractive woman in her late
30s, originally from a middle class background, believed that this doctor was her boyfriend. She was so
convincing that she nearly persuaded the Court of the
righteousness of her cause, until she began to stalk
the (male) judge and prosecuting attorney assigned
to her case. According to one evaluating psychiatrists
report:
The Probation Department provided information
that twenty individuals have taken out an order of
protection against Ms.[Y., and] that four judges
have taken themselves out of this case because of
harassment or inappropriate behavior on the part
of Ms. . . .
Less dramatic, but still disturbing to the victims,
was a homosexual woman diagnosed as a true erotomanic, who had multiple arrests over more than
10 years for assault, harassment, and violating orders
of protection. She pursued a social worker who had
been her counselor at a rehabilitation facility, and
a second social worker with whom she claimed to
have been sexually involved (the woman denied this).
Another form of concurrent stalking can be related
to celebrity stalking, where authorities have discovered that obsessed fans may stalk more than one star
at a time. Robert Bardo, the stalker whose murder
of actress Rebecca Schaeffer in 1989 made her the

300 SPECIAL POPULATIONS

poster child for stalking in the United States, simultaneously stalked the then-popular singers Tiffany
and Debbie Gibson (Gross, 1998).
The reexamination of the data explored whether
there was any predictive significance for recidivism
from a variety of independent variables, including the
nature of the prior relationship, the categorization of
the case as amorous versus persecutory, various demographic and clinical characteristics of the stalker, and
various aspects of the criminal case (charges, dispositions, criminal history).
Three principal factors were identified that could
assist victims, victim service providers, and law enforcement to determine if stalking might persist or desist.
1. The previous relationship between the victim
and the stalker: Victims who were acquainted with
their stalkers before the beginning of the harassment
were more likely to be subjected to persistent stalking
than victims for whom their stalkers had been strangers. Stalkers who had been intimately acquainted with
their victims were most likely to continue their stalking
behavior, in spite of efforts on all levels to control them.
2. The violation of an order of protection by the
stalker: The violation of an order of protection is also
an indication that the stalker will be persistent in his
or her behavior. This is consistent with the first finding, since it is more likely that an order of protection
can be obtained when the stalking is in the context
of a previous domestic partnership. It is also true by
definition, since the violation of the court order is, in
effect, an additional incident of stalking behavior.
3. Evidence of physical aggression by the stalker:
Stalkers who exhibit signs of physical aggression
toward their victims are also more likely to be persistent
in their approach. This is probably the most unsettling
of the findings, and also the most important finding
for law enforcement.
Another finding, not reaching the level of statistical significance, must be considered limited to this
specific sample of mentally disordered stalkers. It
appeared that the criminal disposition of the stalking
cases in this small group of defendants did not affect
recidivism. Whether a stalker was sentenced to incarceration or probation, or the length of the term of
either sentence, did not have a significant impact on
the recidivism profile. This suggests that some additional form of intervention, in addition to punishment
by the criminal justice system, should be considered
when mental illness is an issue in a stalking case.

It should be noted that the pilot study was based

on a retrospective chart review of a small convenience
sample of criminal offenders who had been referred
for evaluation to a forensic psychiatry clinic in a major
metropolitan area. The Court or the Department
of Probation had some reason for suspecting that
the assessment of psychiatric issues would be helpful for the disposition of these cases, and for most
of the defendants, some psychiatric diagnosis was
established. Because of confidentiality issues, some
information regarding the criminal records of these
defendants, both before and after the incidents, for
which they were referred to the Forensic Psychiatry
Clinic, could not be obtained, therefore, it is possible
that their criminal history included other incidents
of stalking either in New York City or other localities
that could not be documented.

CONCLUSION

There is preliminary evidence that it may be possible

to use the Recidivism Profile of a convicted stalker
to evaluate the potential effectiveness of criminal
justice system intervention on the duration of stalking behavior in mentally disordered stalkers. The
principal factors to include in this profile are the prior
relationship between the stalker and the targeted individual, any incidence of documented physical aggression during the course of the stalking, and whether
the stalker violated an order of protection to obtain
access to the victim. Law enforcement must pay particular attention to stalkers who have acted violently
toward their victims or toward other individuals around their victims. These persons are among the most
likely to persist in their stalking regardless of legal
intervention. In such situations, the best defense
against stalking may be keeping the victim safely separated from the stalker, either through incarceration
or through hospitalization of the stalker, or through
the careful relocation of the victim.
The author hopes that knowing whether a stalker
may respond to the actions of the criminal justice system will provide some guidance in the management
of these difficult cases.
References
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (DSM-IV-TR).
Washington, D.C.: American Psychiatric Publishing.

STALKING

Boon, J. C. W. & Sheridan, L. (2001). Stalker typologies:

A law enforcement perspective. Journal of Threat
Assessment, 1(2), The Haworth Press, Inc.
Ciric, S. & Harmon, R. (2002). Serial stalking. Presentation at the annual meeting of the American
Academy of Forensic Sciences, Atlanta, GA.
Crepps v. Durden [2 Cowp. 640, 98 Eng. Rep. 1283
(K. B. 1777)].
Dietz, P. E., Matthews, D. B., Martell, D. A.,
Stewart, T. M., Hrouda, D. R., & Warren, J. (1991a).
Threatening and otherwise inappropriate letters
to members of the United States Congress. Journal
of Forensic Sciences, 36(5), 14451468.
Dietz, P. E., Matthews, D. B., Van Duyne, C.,
Martell, D. A., Parry, C. D. H., Stewart, T., et al.
(1991b). Threatening and otherwise inappropriate
letters to Hollywood celebrities. Journal of Forensic
Sciences, 36(1), 185209.
Goldstein, R. L. (2000). Serial stalkers: Recent clinical
findings. In L. B. Schlesinger (Ed.), Serial offenders:
Current thought, recent findings (pp. 167185). Boca
Raton, FL: CRC Press.
Gross, L. (1994). Understanding and surviving Americas
stalking epidemic: A special report. La Mesa,
CA: Bear Publishing. http://www.ncjrs.gov/App/
Publications/abstract.aspx?ID=177996.
Harmon, R. B. (2001). Criminal dispositions of mentally disordered stalkers. presented at the annual
meeting of the Academy of Criminal Justice
Sciences. Washington, D.C.
Harmon, R. B. (2005). The development of a typology
of stalking behaviors to facilitate interventions. Presented at the annual meeting of the International
Association of Forensic Mental Health Services.
Melbourne, Australia.
Harmon, R. B., Rosner, R., & Owens, H. (1995). Obsessional harassment and erotomania in a Criminal Court
Population. Journal of Forensic Sciences, 40, 188196.
Harmon, R. B., Rosner, R., & Owens, H., (1998). Sex
and violence in a forensic population of obsessional
harassers. Psychology, Public Policy and Law, 4(1/2),
236249.
Kurt, J. L. (1995). Stalking as a variant of domestic
violence. Bulletin of the American Academy of
Psychiatry and the Law, 23(2), 219230.
Meloy, J. R. & Gothard, S. (1995). Demographic and
clinical comparison of obsessional followers and
offenders with mental disorders. American Journal
of Psychiatry, 152, 25823.
Miller, N. (2003). A law enforcement and prosecution perspective. National Institute of Justice to

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the Institute for Law and Justice (ILJ), grant no.

96-WT-NX-0007.
Mullen, P. E. (2003). Multiple classifications of stalkers and stalking behavior available to clinicians.
Psychiatric Annals, 33(10), 651656.
Mullen, P. E., Path, M., Purcell, R., & Stuart, G. W.
(1999). Study of stalkers. American Journal of
Psychiatry, 156, 124449.
Mullen, P. E., Path, M., & Purcell, R. (2000). Stalkers
and their victims. Cambridge, UK: Cambridge
University Press.
Palarea, R. E., Zona, M. A., Lane, J. C., &
Langhinrichsen-Rohling, J. (1999). The dangerous
nature of intimate relationship stalking: Threats,
violence and associated risk factors. Behavioral
Sciences and the Law, 17, 269283.
Purcell, R., Path, M., & Mullen P. E. (2004). Stalking:
Defining and prosecuting a new category of offending. International Journal of Law and Psychiatry,
27, 157169.
Radosevich, A. C. (2000). Thwarting the stalker: Are
anti-stalking measures keeping pace with todays
stalker? U. Ill. L. Rev. 1371.
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romantic relationships: Characteristics of stalking
former partners. Journal of Forensic Sciences, 47,
10701077.
Rosenbaum, D. J. (2000). What does Course of
Conduct mean in the stalking law? http://www.
correctionhistory.org/northcountry/html/knowlaw/
courseofconduct3.htm, Prepared by the Domestic
Violence Team of Albany County, March.
Rosenfeld, B. (2003). Recidivism in stalking and obsessional harassment. Law & Human Behavior, 27(3),
251265.
Rosenfeld, B. & Harmon, R. (2002). Factors associated
with violence in stalking and obsessional harassment cases. Criminal Justice and Behavior, 29(6),
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stalking victimization and management. Trauma,
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(1998). Stalking and domestic violence: The third
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38(4), 894903.

Chapter 22

Child Pornography and the Internet

L. Alvin Malesky, Jr., Liam Ennis,
and Carmen L. Z. Gress

IN T RODUCT ION

Although the Internet has experienced exponential

growth since its inception, it has only been in existence for a relatively short time. The Internet as we
know it today originated in the late 1960s when the
Advanced Research Projects Agency (ARPA) of the
United States Department of Defense funded the development of a communications system to be used in
the event of an attack on the United States (Casey,
2004). By 1971, computers at 15 locations throughout the United States were connected via this system.
In October of 1972, scientists showcased the ARPA
network at the First International Conference on
Computers and Communication by linking computers at 40 different locations (http://www.let.leidenuniv.nl/history/ivh/frame_theorie.html, accessed
July 5, 2006). During this same year a new communication system that allowed direct person-to-person
transition of electronic message (e-mail) became operational (http://www.let.leidenuniv.nl/history/ivh/

frame_theorie.html, accessed July 5, 2006). Internet

usages increased dramatically during the late 1980s
and 1990s. By 2000, over 40% of U.S. households
were connected to the Internet (U.S. Department of
Commerce [USDOC], 2001). It is also estimated that
over a billion people worldwide are currently using
the Internet (www.cia.gov/ciapublications/factbook/
rankorder2153rank.html accessed June 7, 2006).
Although the Internet has facilitated education
and research, expedited communication and the
flow of information, and assisted in commerce and
business growth, the impact of this technology has
not been entirely positive. Concerns about Internet
usage include cyber addictions, in which individuals spend excessive amounts of time online, often at
the expense of their family, friends, and job (Brody,
2000; Cooper, Delmonico, & Burg, 2000; Putnam &
Maheu, 2000); its use in the advancement of extremist ideologies (Schafer, 2002); and its use in illegal
activities (Casey, 2004; Conly, 1989). The use of the
Internet to acquire and distribute child pornography

302

CHILD PORNOGR APHY AND THE INTERNET

in particular has received considerable attention

from mental health clinicians, law enforcement
personnel and the media (Cooper, 2001; Harrington,
2003; Thompson, 2002).
Irrespective of the increased focus of law enforcement or the extensive media coverage, the actual
prevalence of this online behavior is unclear. A recent
study by Wolak et al. (2005) estimated that there
were approximately 1700 arrests in the United States
for Internet-related child pornography possession in
2000. While this represents only 2.5% of roughly
65,000 arrests for all types of sexual assaults committed against minors during this time, it is uncertain
as to how many individuals engage in this type of
online behavior but do not come to the attention of
law enforcement officers. The number of arrests and
convictions is expected to grow with the increased
use of the Internet coupled with law enforcements
improved knowledge and expertise in handling these
types of cases (Wolak, Finkelhor, & Mitchell, 2005).
However, at this time arrests and convictions for this
online behavior remain relatively low compared to
other types of child sexual exploitation.
Although child pornography on the Internet has
received increased attention, understanding the
complex issues surrounding the acquisition and distribution of online child pornography (e.g., etiology,
treatment, and legal applications) is still in its infancy.
This chapter addresses these issues by providing an
extensive review of the legal and legislative issues
pertaining to child pornography and the Internet in
the United States, Canada, and Europe. The authors
also draw upon developed bodies of research and
established theoretical models from the fields of
sociology, criminology, media psychology, and social
psychology in offering an explanation as to why individuals use the Internet to collect and disseminate
child pornography. Finally, assessment and treatment
of individuals convicted for possession of child pornography is discussed.

DEFINING CHILD POR NOGR A PH Y

The term child pornography is utilized in this chapter

for purposes of consistency; however, it does not fully
convey the nature and extent of abuse and exploitation that often occur with the production of this
material (Wolak et al., 2005). The process associated
with the creation of child pornography goes beyond

303

commercial manufacturing typically associated

with adult pornography and the adult entertainment
industry. Child abuse images is a more appropriate
descriptor of this material in that this phrase conveys
the abuse that often occurs prior, during, and subsequent to the creation of pornographic images, audio,
and video involving minors (Wolak et al., 2005).
Furthermore, this phrase eliminates the commercial
connotation associated with the term pornography
(Lee, 2003). However, as previously stated child pornography will be used in this chapter to be consistent with the research literature as well as due to this
terms widespread use in legal statute.
Legislative bodies that determine definitions,
restrictions, and penalties for possession or distribution of child pornography share a common goal:
the protection of children from sexual exploitation.
However, definitions of what constitutes child pornography vary in accordance with the relevant legislation and legal precedents in each country or legal
jurisdiction. This can provide advantages, such as
the ability for local laws to reflect contemporary cultural and community standards. However, this lack
of consistency also has distinct disadvantages, such as
disagreement among cultures living within the same
jurisdiction, and ambiguity in the law, which could
make policing across jurisdictions difficult. The following section provides an overview of the American,
Canadian, British, and European Unions legal definitions of child pornography.
Legal Definitions
The United States. Crimes involving child pornography are governed by federal or state law, depending on the specifics of the offense. For example, the
federal statute oversees child pornography where
the producer or distributor knows or has reason to
know, that the depiction was or will be transported in
interstate commerce or was created using a camera,
film, or other material that has traveled in interstate
commerce (Astrowsky & Peters, 2002, p. 1). When
commerce does not cross state or national borders, or
if the U.S. postal service was not used to receive and/
or transport material associated with the crime, child
pornography is prosecuted at the state level. Although
guided by federal statute on child pornography, each
state is able to augment or adapt their laws dealing
with child pornography. Federal and state statutes
concerning child pornography, sexual exploitation,

304 SPECIAL POPULATIONS

and child abuse and neglect can be reviewed at http://

www.ndaa.org/apri/programs/ncpca/ncpca_home.
html and http://www.childwelfare.gov respectively.
Currently, U.S. federal law defines child pornography as,
. . . any visual depiction, including any photograph, film, video, picture, or computer or computer-generated image or picture, whether made
or produced by electronic, mechanical, or other
means, of sexually explicit conduct, where
1. the production of such visual depiction
involves the use of a minor engaging in sexually
explicit conduct;
2. such visual depiction is a digital image,
computer image, or computer-generated image
(see discussion in this chapter on Ashcroft v. Free
Speech Coalition and the PROTECT Act) that is,
or is indistinguishable from, that of a minor engaging in sexually explicit conduct; or such visual
depiction has been created, adapted, or modified
to appear that an identifiable minor is engaging in
sexually explicit conduct (18 U.S.C. 2256[8]).
The term sexually explicit is defined by U.S.C.
2256(2) as (1) graphic sexual intercourse, including
genitalgenital, oralgenital, analgenital, or oral
anal, whether between persons of the same or opposite sex, or lascivious simulated sexual intercourse
where the genitals, breast, or pubic area of any person is exhibited; (2) graphic or lascivious simulated
(i) bestiality; (ii) masturbation; (3) sadistic or masochistic abuse; or (4) graphic or simulated lascivious exhibition of the genitals or pubic area of any person.
In relation to child pornography, U.S. federal law
defines a minor as anyone below the age of 18. A
depiction is deemed to be graphic where, a viewer
can observe any part of the genitals or pubic area of
any depicted person or animal during any part of
the time that the sexually explicit conduct is being
depicted (U.S.C. 2256[10]).
Defining lascivious behavior and determining lascivious intent represent an ongoing challenge in
the U.S. courts. These determinations are often
accomplished by comparing the visual depictions in
question to a nonexhaustive list of factors known as
the Dost criteria (Astrowsky & Peters, 2002; United
States v. Dost, 1986). In accordance with the Dost criteria lascivious behavior and intent are determined
on the basis of the following: (1) whether the genitals or pubic area are the focal point of the image;

(2) whether the setting of the image is sexually suggestive (i.e., a location generally associated with sexual activity); (3) whether the child is depicted in an
unnatural pose or inappropriate attire considering her
age; (4) whether the child is fully or partially clothed,
or nude; (5) whether the image suggests sexual coyness or willingness to engage in sexual activity; and
(6) whether the image is intended or designed to elicit
a sexual response in the viewer.
Additionally, with the passing of the aforementioned sections, Congress augmented the definition
of child pornography to include the scope of exhibition of the genitals or pubic area in section 2256(2)
(E), in the definition of sexually explicit conduct
is not limited to nude exhibitions or exhibitions in
which the outlines of those areas were discernible
through clothing. In other words, images that focus
on the genitals and pubic area can be considered lascivious even if the aforementioned areas are clothed,
a precedent set by United States v. Knox (1992).
To understand the current legislation, a review of
a few specific cases is required. In 1982, the Supreme
Court determined, in New York v. Ferber, that child
pornography was exempt from protection by the First
Amendment of the U.S. constitution (i.e., the right
to freedom of expression) because (1) the production
and dissemination of child pornography are related to
the sexual abuse of children, (2) the underlying activity (sexual molestation and exploitation) is illegal, and
(3) the societal and artistic value of child pornography
is de minimus, or insignificant (New York v. Ferber,
1982; as cited in Bower, 2004, p. 239). In 1996, the
Child Pornography Prevention Act (CCPA, P.L.
104208, 110 Stat. 300926) acknowledged the increasing role of technology in the production of child
pornography, including the production of computergenerated images that are virtually indistinguishable
from real depictions of child sexual abuse. This Act
broadened the scope of what may be considered child
pornography to include not only depictions of actual
children, but also visual depictions that appears to
be, of a minor engaging in sexually explicit conduct
(emphasis added, Cohen, 2003). Subsequently, the
CCPA rekindled discussions about the limitations of
protection afforded by the First Amendment (Cohen,
2003).
In the case of Ashcroft v. Free Speech Coalition
(2002), the United States Supreme Court determined criminalization of fictitious or virtual (child)
pornography was unnecessary because (a) virtual

CHILD PORNOGR APHY AND THE INTERNET

child pornography need not involve nor harm a real

child in the production process and (b) virtual child
pornography was not intrinsically related to child
sexual abuse (Ashcroft v. Free Speech Coalition, 2002).
Therefore, unlike real child pornography, the court
granted virtual child pornography first amendment
protection. Bower (2004) noted two important issues
regarding this case: (a) the court did not address computer-modified images, which involves a real child
and (b) the ruling provided an opening to present
evidence that virtual child pornography is intrinsically related to child sexual abuse and exploitation
and should not, therefore, receive First Amendment
protection.
In 2003, the PROTECT Act (Prosecutorial
Remedies and Other Tools to end the Exploitation
of Children Today, the second major update to
the initial Protection of Children Against Sexual
Exploitation Act of 1977) amended the definition
of child pornography to include such visual depiction is a digital image, computer image, or computer
generated image that is, or is indistinguishable from,
that of a minor engaging in sexually explicit conduct
(pp. 10821). This is a significant change because the
inclusion of . . . a digital image, computer image, or
computer generated image that is indistinguishable
may be considered by some as unconstitutional under
the Ashcroft decision (Cohen, 2003). At time of press,
this has not yet been successfully challenged in court.
Indistinguishable means virtually indistinguishable
and does not apply to drawings, cartoons, sculptures,
or paintings (18 U.S.C. 2256[1], as added by the
502(c) of the PROTECT Act).
Canada. Crimes involving child pornography are
governed by federal law in Canada. The Criminal
Code of Canadas definition of child pornography,
last updated in 2005, is
(a) photographic, film, video or other visual representation, whether or not it was made by electronic or mechanical means,
(i) that shows a person who is depicted as
being under the age of eighteen years and
is engaged in or is depicted as engaged in
explicit sexual activity, or
(ii) the dominant characteristic of which is the
depiction, for a sexual purpose, of a sexual
organ or the anal region of a person under
the age of eighteen years;
(b) any written material, visual representation or
audio recording that advocates or counsels sexual

305

activity with a person under the age of eighteen

years that would be an offense under this Act;
(c) any written material whose dominant characteristic is the description, for a sexual purpose,
of sexual activity with a person under the age of
eighteen years that would be an offense under this
Act; or
(d) any audio recording that has as its dominant
characteristic the description, presentation or representation, for a sexual purpose, of sexual activity
with a person under the age of 18 years that would
be an offense under this Act (Criminal Code of
Canada, Section 163.1 [1]).
Regina v. Sharpe (2001, 150 C.C.C. [3d] 321 [S.C.C.])
[Note: Criminal and civil cases taken (or defended)
by a government in a Commonwealth country, such
as Canada, the United Kingdom, and Australia, are
undertaken in the name of the Commonwealth head
of State (British Monarch) or Crown (aka Regina,
Latin for Queen and Rex, Latin for King)] initiated
a rewording of the child pornography legislation
(reflected in the aforementioned definition and
described further subsequently) and served as a legal
precedent, providing two exemptions to the law on
possession of child pornography, and reignited the
defense of artist merit in Canada. In 1995, Robin
Sharpe was charged with two counts of possession
and two counts of distributing child pornography:
the material in question were photographs, drawings, and 17 stories depicting sexual activity with
minors (Grover, 2004). The defense argued that the
charge of possession for the written material was
unconstitutional because section 163.1(6) and (7) of
the Canadian Criminal Code allowed a defense of
artistic merit or an educational, scientific or medical
purpose (Grover, 2004). After the British Columbia
(BC) Supreme Court acquitted Sharpe of the charges
and the BC Court of Appeal upheld the acquittal,
the BC government appealed to the Supreme Court
of Canada. The Supreme Court upheld the existing
law but provided two exceptions: (a) the creator, and
only the creator is a user of the material and (b) it
did not involve minors (Regina v. Sharpe, 2001). As
a result, Bill C-2, the latest in a series of proposals
to amend the law regarding sexual offenders, made
a number of changes significant to the definition of
child pornography (represented in the current definition), including (a) audio as a possible source of child
pornography and (b) a second category of written and
audio material whose dominant characteristic is the

306 SPECIAL POPULATIONS

description, for a sexual purpose, of sexual activity

with a person under the age of eighteen . . . .
A distinct difference between the U.S. and Canadian definitions of child pornography is Canadas
ambiguity of what can be considered an image of
child pornography and its inclusion of written and
audio material. Written and/or audio child pornographic material is not included in the U.S. federal
definition of child pornography and is, therefore,
legal unless the material is deemed obscene by the
court.
The United Kingdom and European Union.
The United Kingdom consists of three separate legal
jurisdictions: England and Wales, Scotland, and
Northern Ireland. In England and Wales, child pornography is defined as an indecent photograph or
pseudo-photography, such as a computer-modified
image, of a child, including film, any form of video
recording, and copies and/or negatives. Similar definitions are used in Northern Ireland and Scotland.
A child, as related to child pornography, is a person
below the age of 18 in all three of these jurisdictions.
Like in the United States, these Acts only address
photographic material. Other potential examples
of child pornography, such as written work or audio
recordings, are subject to general obscenity legislation (Gillespie, 2005). In addition, there are a series
of exceptions as related to photographs of 16- and
17-year-olds, which if applicable, must be brought
forth by the defense, rather than the police or
crown. For example, in Scotland, exceptions include
(1) photographs that are of a person aged 16 or over, or
the accused reasonably believed that to be so; (2) the
accused and the 16- or 17-year old subject of the photograph were either (a) married to or civil partners of
each other or were partners in an established relationship at the time of the offense, or (b) at the time when
the accused obtained the photograph, the subject of
the photograph consented to being photographed,
or (c) for the photograph to be in the possession of
the accused (depending on which offense has been
charged), or the accused reasonably believed this to
be the case, or (d) that distribution was only to the
16- or 17-year-old subject of the photograph.
Indecency is not defined in any of the United
Kingdoms Acts but is determined by a judge or jury
as illustrated by cases such as Regina v. Graham Kerr,
Regina v. Smethurst, and Regina v. Murray (Gillespie,
2005). The courts stated in Regina v. Graham Kerr
(1988) and Regina v. Smethurst (2002) that

the decision as to what is indecent is an objective question for the jury to answer . . . this would
mean, in contested cases, that the jury would be
shown the images and asked to consider whether
they believed they were an indecent image of a
child (Gillespie, 2005, p. 438).
An interesting example of this was Regina v. Murray
(2004). Murray recorded and modified a television
medical documentary about a young male with a
genital defect. His modifications included slowing
the tape speed and focusing the image on the males
genitals. Defense argued that the images in question
were decent because the video was decent and images
were only clips from the video (Gillespie, 2005). The
Court of Appeal rejected this argument stating the
clips were images in their own right and the jury
could decide if an image abstracted from a decent
image was indecent.
In 2000, the EU-Framework Decision on Combating the Sexual Exploitations of Children and Child
Pornography used the U.S. Criminal Code as a model
for defining child pornography (Graupner, 2004).
On the basis of the U.S. Criminal Codes definition
of child pornography, the EU-Framework defines
child pornography to include all visual depictions of
explicit sexual conduct with a person below the age
of 18 including fictitious depictions such as comic
strips, drawings, paintings, and virtual imagery
(Graupner, 2004). Consistent with the U.S. definition, the visual depictions need not be nude, nor does
the EU-Framework require the establishment of the
minors true age.

USING THE IN T ER NET TO ACQUIR E

A ND DIST R IBU T E CHILD
POR NOGR A PH Y

Although there has been significant legislative activity, both in the United States and abroad, in crafting
and/or revising laws dealing with child pornography
fundamental questions still exist regarding the nature
and function of the Internet in the dissemination
and acquisition of these images. Specifically, (1) why
is the Internet an attractive vehicle for engaging in
this type of activity? (2) who is using the Internet for
these purposes? (3) what effect, if any, do these online
sexual behaviors have on the individuals who engage
in them?

CHILD PORNOGR APHY AND THE INTERNET

Why Do Individuals Use the Internet

to Disseminate and Acquire Child
Pornography?
Although child pornography predates the Internet,
recent advances in technology have made digital
cameras, home computers, and the Internet affordable and effective vehicles for the production, storage,
dissemination, and acquisition of these images.
Cooper (1998) suggested that the accessibility,
affordability, and perceived anonymity of the Internet
make it an attractive tool for individuals interested in
engaging in sexual activity. Cooper (1998) dubbed the
accessibility, affordability, and anonymity provided
by the Internet as the Triple A Engine. Although
Cooper did not introduce the Triple A framework
to explain sexually exploitative online behavior specifically, his theory serves as a useful foundation in
understanding why this technology is used for these
purposes.
The Internet is extremely accessible. Millions
of Americans have Internet access in their homes
(USDOC, 2001). The Internet can also be accessed
from public places such as libraries, coffee shops, and
airports. In addition, cellular telephone users can
now access the Internet, allowing one to get online
from virtually anywhere at anytime.
Before the Internet, individuals interested in child
pornography had to go to considerable lengths to
indulge their interests. The Internet has created an
omnipresent avenue by which people can access a limitless array of sexual preoccupations and interests. The
National Center for Missing and Exploited Children
(NCMEC) reported a 39% increase in reports of
child pornography from 2003 to 2004. This was the
seventh consecutive year that dramatic increases in
reports of child pornography had been observed. This
number has also increased in the United Kingdom.
According to a National Childrens Homes report,
the number of individuals proceeded against by the
police increased 1500% from 1988 to 2001 (Carr,
2004). Thus, not only is the Internet readily accessible but online child pornography is also accessible for
the motivated and savvy Internet user.
In addition to being available, Internet access is
relatively inexpensive. One can obtain a high-speed
DSL or cable connection for approximately $40 a
month and slower dial-up connections are even less
expensive. One can also access the Internet from public places such as coffee shops or universities utilizing

307

Wi-Fi or wireless technology for free. Once online,

Internet users have access to an unlimited supply of
sexually explicit material. Although pornography is a
multibillion-dollar industry, tremendous amounts of
sexually explicit material are available for minimal or
no charge. Many adult websites offer free samples
with the intention of enticing consumers to pay for
access to a wider range of images and full-length movies. Furthermore, shareware websites facilitate the free
exchange of pornographic images and video clips.
Although the online adult pornography industry
generates billions of dollars in revenue each year, distribution of child pornography does not often appear
to be a profit-driven venture (Taylor, 1999). In fact,
some individuals distribute their collection of
child pornography free of charge with the hope that
others will reciprocate in the future (OConnell &
Taylor, 1998). Furthermore, individuals may disseminate images as a way to increase their social status
and credibility in virtual pedophile communities
(OConnell & Taylor, 1998). The ease of copying and
electrically sending these images also contributes to
the affordability of acquiring, maintaining, and
even distributing ones collection of child pornography. In summary, Internet access is inexpensive if not
free. Once online, motivated individuals can acquire,
reproduce, and disseminate child pornography at
minimal expense.
Individuals typically keep their online sexual behaviors private (Cooper, Boies, Maheu, & Greenfield,
1999; Leiblum, 1997), particularly when the behavior is aberrant or illegal (Lanning, 1992). McKenna
and Bargh (1998) stated, In virtual groups, where
people can be anonymous and do not deal in faceto-face interactions, individuals can admit to having marginalized, or nonmainstream, proclivities
that they hid from the rest of the world (p. 682).
McGrath and Casey (2002) likened the Internet to
a mask that conceals more than just the face (p. 85).
The Internet affords one the ability to create e-mail
addresses, screen names, and persona that not only
prevent others online from knowing who they are,
but also contribute to a sense of escapism and depersonalization. It has been argued that, by reducing
social disincentives, the Internet blurs the boundaries
between fantasy and reality, allowing the individual
to explore and indulge their fantasies (McGrath &
Casey, 2002).
In addition to the inherent anonymity of the
Internet, extra precautions can be taken to further

308 SPECIAL POPULATIONS

conceal the users identity. Computer programs

strip information from e-mails (remailers) that make
it extremely difficult to detect who actually sent an
e-mail. Encryption software and passwords can also
be employed to conceal information transmitted electronically. Some online communities that advocate
for adult/minor relationships actually post links to
websites that offer free encryption and remailer software (Malesky, 2005), as well as discourage its members from using their actual names while posting on
the groups bulletin board.
Although some individuals recognize the advantages of increased online security (i.e., encryption
software) in avoiding detection by law enforcement it
is clear that this realization is not universally shared
(Malesky, 2005; Wolak et al., 2005). For example,
Malesky (2002) found that only 17% of the incarcerated offenders in his study, who admitted using the
Internet for sexually deviant and illegal purposes used
encryption software or remailers to conceal sexual
images of children. Wolak et al. (2005) found similar
results with their study. One must be cautious, however,
generalizing the results of these studies to all individuals exchanging child pornography over the Internet.
The subjects in the research by Malesky (2002) and
Wolak et al. (2005) comprised exclusively of individuals who were apprehended for sexual offenses, which,
by definition, indicate that they were unsuccessful in
their efforts to remain anonymous. It is possible that
individuals who take greater precautions to maintain their anonymity in the course of their Internet
activities are consequently more successful in avoiding detection, and are therefore underrepresented in
correctional or forensic samples. Notably, when more
than 100 members of an international network of child
pornography collectors and distributors were arrested
in 1998, hundreds of other members of this same network began to utilize encryption software and other
tactics to conceal their identities, rather than discontinue their illegal online behavior (McGrath & Casey,
2002; Shannon, 1998). In summary, the Internet is
readily available, affordable if not completely free, and
relatively anonymous. This makes it an ideal vehicle
for individuals interested in acquiring and disseminating child pornography.
In addition to Coopers Triple A framework,
media psychology can also be used to elucidate why
individuals use the Internet to collect and distribute
child pornography. Researchers in this field (Song,
LaRose, Eastin, & Lin, 2004; Swanson, 1992) have

identified two general motivations for using mass

communication. The first content-oriented motivation refers to behavior that is engaged in for the purpose of acquiring information that can subsequently
be used to obtain desired outcomes. With regard to
the Internet, this could include learning where and
how to access online child pornography and to avoid
detection in doing so. Process-oriented motivations
on the other hand, are actions that result in a pleasurable experience that is realized in the moment, while
the media is being accessed (e.g., masturbation to
online pornography). Cooper et al. (2004) found that
men with online sexual behavior problems (broadly
defined as the use of the Internet for any activity that
involves sexuality and causes problems in off-line
functioning) identified two motivational domains
related to engagement in online sexual behaviors.
The first reason men engaged in online sexual behavior was to advance their off-line sex lives, which is
consistent with the content-oriented motivations
identified in the media psychology research. The second reason men engaged in online sexual activities
was as an alternative to off-line sexual relationships.
This motivation appears to overlap with the concept
of process-oriented media usage.
Although individuals manufacture, collect, and
disseminate child pornography over the Internet for
a variety of reasons, sexual interest appears to be the
primary reason for engaging in these activities. A
recent study using phallometric assessment of sexual
arousal found that collecting child pornography was a
stronger diagnostic indicator of pedophilia than actually sexually offending against a child (Seto, Cantor, &
Blanchard, 2006). These authors stated, people are
likely to choose the kind of pornography that corresponds to their sexual interests, so relatively few
nonpedophilic men would choose illegal child pornography given the abundance of legal pornography
that depicts adults.
It should be noted that, although sexual gratification is likely the primary reason most individuals
collect child pornography via the Internet, it may not
be the sole motivation for engaging in this behavior
(OConnell & Taylor, 1998; Quayle & Taylor, 2002).
Online pornographic images are often part of a
larger collection or series. Some of these series have
their own name (i.e., Amy or Kevin), supposedly
named after the victim in the pictures (Lee, 2003).
Individuals may collect images to complete a certain
set or series much like an individual would collect

CHILD PORNOGR APHY AND THE INTERNET

baseball cards to complete a set. Individuals may

exchange electronic images of child pornography as
a way to increase their social status and credibility in
online pedophile communities (OConnell & Taylor,
1998). Some of these individuals report collecting
images they do not personally find sexually arousing
with the intent of trading them with other collectors for more preferred images (OConnell & Taylor,
1998). Wolak et al. (2005) also suggested that individuals may download child pornography because they
are inquisitive about this type of sexual material and
view these images to satisfy their curiosity. Finally,
some individuals may also use these images as a way
to groom potential victims by attempting to demonstrate, via these images, that there is nothing aberrant
about adult/minors sexual contact. However, as previously stated sexual gratification is likely the primary
reason most individuals collect child pornography.
Who Is Using the Internet to Collect
and Disseminate Images of
Child Sexual Abuse?
Before the advent of the Internet, the distribution and
acquisition of child pornography required that the
interested individual access a clandestine network of
suppliers under significant risk of detection and arrest.
It is logical to assume that these individuals had strong
pedophilic interest as evidenced by their willingness
to expend considerable effort and take substantial risks
to acquire preferred pornographic materials (Taylor &
Quayle, 2003; Quayle & Taylor, 2003). However, the
Internet has removed many of the obstacles that previously would have deterred all but the highly motivated
from procuring child pornography. Thus, it is likely
that individuals convicted of Internet child pornography offenses represent a more heterogeneous group
than samples that have historically been used in studies of child pornography possessors. The best descriptive information about child pornography offenders
comes from the National Juvenile Online Victimiation
Study (Wolak, Finkelhor, & Mitchel, 2005). Based on
nearly 2000 arrests for Internet-related child pornography possession, Wolak et al. (2005) found that the vast
majority of individuals arrested for possession of child
pornography are male, Caucasian, over the age of
26 years, and have at least a high-school education.
Most (62%) were unmarried, although many (42%) had
biological children, and many (34%) were living with
children at the time of the crime. Nearly half (46%)

309

had access to minors either as the result of their living arrangements or through work or organized youth
activity. A significant minority in Wolak et als sample
had known substance abuse problems (18%) but few
had been diagnosed with mental (5%) or sexual (3%)
disorders. Twenty-two percent had prior nonsexual
criminal histories, and prevalence of past violent and
sexual offending was 11% and 22%, respectively. In
a much smaller sample, Seto and Eke (2005) found
higher rates of past offending, with 56% of their sample of 201 child pornography offenders having prior
nonsexual criminal records, 24% and having prior
sexual contact offenses. Fifteen percent of Seto and
Ekes sample had prior charges for child pornography
offenses.
The question of whether Internet child pornography offenders differ from contact sex offenders in
terms of individual characteristics and behavioral
motivations is an important one. At present, there
has been little research comparing Internet child
pornography offenders to individuals who have
committed contact sex offences against children.
On recent study that did compare child pornography
offenders with child molesters (Webb, Craissati, &
Keen, 2007) found more similarities than differences. Relatively high levels of self-reported psychopathology were evident in both groups, with 40% of
the sample reporting serious and diffuse personality
disorder. Both Internet offenders and child molesters
were characterized by schizoid, avoidant, and dependent traits, suggesting a disordered attachment orientation that inclines them to fear rejection, withdraw
from potentially threatening social situations and
relationships, or an excessive reliance on others for
assistance with coping. Internet offenders and child
molesters were both characterized by problems with
intimate relationships and general self-regulation,
but Internet offenders were distinguished by greater
problems with sexual self-regulation (i.e., sexual preoccupation, sex as coping, deviant sexual interests).
In contrast, child molesters were rated as more psychopathic, had more problems with offence supportive attitudes, and greater problems with supervision
noncompliance.
Although only minimal attention has been paid to
comparing and contrasting the two groups, preliminary evidence suggests that Internet offenders generally resemble child molesters. The existing evidence,
however, suggests that degree of nonsexual antisociality appears to be a factor that may have utility for

310 SPECIAL POPULATIONS

distinguishing between those offenders who indulge

their sexual proclivities through Internet pornography
from those who directly victimize actual children for
the same purpose. Ultimately, additional empirical
attention needs to be paid to investigating similarities
and differences between these groups, and to distinguishing between child pornography offenders who
are content to indulge their sexual interests online
and those for whom child pornography use is accompanied by hands-on offending.
Causes and Consequences of Collecting
and Disseminating Child Pornography
over the Internet
The question of whether viewing online child pornography contributes to the development of sexually
exploitative tendencies or whether they simply reflect
preexisting traits and interests has yet to be answered
empirically. Research focusing on problematic Internet usage or Internet addiction suggests that the
influence Internet use has on subjective well-being
is dependent on the characteristics of the individual. For people who are more introverted, increased
Internet usage has been linked with decreased wellbeing and self-esteem, and increased loneliness and
negative affect. The opposite effects have been found
for extroverts (Kraut, Kiesler, Boneva, Cummings,
Helgeson, & Crawford, 2002). Davis (2001) proposed
a cognitive behavioral model of Pathological Internet
Use (PIU) that emphasized the etiological role of
maladaptive cognitions that intensify or maintain
the behavior. Cognitions associated with self-doubt,
low self-efficacy and negative self-appraisal such as,
I can only get along with others in cyberspace, or
people treat me badly off-line facilitate further use
of the Internet to postpone or avoid anxiety provoking experiences. Avoidant behaviors, in turn, create
significant problems with daily functioning and limit
opportunities for corrective experiences.
Middleton et al. (2006) suggest that, the focus of
research on the effects of pornography should concentrate on the context and meaning of pornography
for each individual user in meeting their sexual needs
(p. 3). Fisher and Barak (2001) proposed a model for
understanding the antecedents and consequences of
accessing sexually explicit materials on the Internet
that, although developed to explain behavior around
the acquisition of sexually explicit materials in general, is equally applicable to child pornography. In

Fisher and Baraks (2001) model, erotic stimuli evoke

cognitive responses that in turn interact with arousal
and affective responses to initiate preparatory sexual
behaviors. In the case of child pornography on the
Internet, preparatory behaviors might include locking ones bedroom door, disrobing, and directing
ones web browser to a favorite online source of child
pornography. Successful engagement in preparatory
behaviors increases the likelihood that overt sexual
behaviors will occur. Sexual behaviors will result
in outcomes that will be subjectively appraised as
either positive or negative, and these outcomes feed
back into the system to increase or decrease the likelihood that similar sexual behaviors will be repeated
in the future. Which sexual behaviors an individual
engages in is heavily influenced by three types of cognitive responses to sexually arousing stimuli: (1) informational responses (i.e., beliefs about sexual activity),
(2) expectative responses (i.e., subjective probability
estimates concerning outcomes of sexual activity),
and (3) imaginative responses (i.e., scripts of sexual
episodes that may be used to safely and privately experience behaviors that the individual would be reluctant to actually engage in).
Marshall & Barbaree, (1991) formulated an etiological theory of sexual abuse that provides a useful
lens through which to view Internet based offending. Rooted in attachment theory (Bowlby, 1982),
Marshall and Barbarees (1991) theory describes the
process by which children who fail to develop secure
attachments with caregivers in early life subsequently
fail to develop the emotional or behavioral capacity to successfully engage in intimate relationships.
Moreover, they fear rejection and are afraid to look to
others for assistance in meeting their needs. As these
children approach and enter adolescence, the authors
suggest that they are likely to resort to sexual selfstimulation to combat chronic feelings of emotional
loneliness, and subsequently, the physical act of sex
becomes associated with intimacy. Furthermore,
because male self-esteem is at least partially based
on the males subjective sense of sexual competence
(Schimel, 1974, as cited in Marshall, Hudson, &
Hodkinson, 1993) insecurely attached young males
will be attracted to cognitive sexual scripts that depict
them as powerful, potent, and in control. Substantial
increases in testosterone levels during pubescence
likely make this a sensitive period during which adolescent males may be particularly responsive to whatever form of sexual imagery or fantasy they choose

CHILD PORNOGR APHY AND THE INTERNET

to indulge in (Smallbone, 2006). Through masturbatory conditioning, these coercive sexual scripts may
develop in to engrained sexual preferences (Abel &
Blanchard, 1974; Marshall & Eccles, 1993; Marshall
et al., 1991).
It is most likely that the type of sexual material
that individuals seek and find stimulating is related
to preexisting vulnerabilities and other dispositional
differences (Fisher & Barak, 2001; Morahan-Martin,
2005; Seto, Maric, & Barbaree, 2001; Seto et al.,
2006). Marshall and colleagues (1993) surmised the
appeal that coercive sexual fantasy and behavior has
for emotionally isolated young males, noting that,
having sex with a child requires none of the social
skills that these boys have failed to acquire; it provides a rare opportunity in the lives of these young
males to experience power and control, and to be
relatively unconcerned with rejection; and it satisfies those needs that have become focused on
physical gratification (p. 176).
The Internet provides a venue in which the insecurely attached youth in Marshalls model can seek
sexual stimuli that reinforce the association between
sex and intimacy, and fuel and shape sexual fantasies, and nurture the development of coercive sexual
scripts. Engaging in online sexual behaviors may, in
turn, serve to reinforce or shape the sexual and personal dispositions that motivated the individual to
engage in online sexual behaviors in the first place
(Fisher & Barak, 2001). Fisher and Barak (2001)
noted that Internet users bring with them, a lifelong
learning history including beliefs about sexuality,
expectations about sexual outcomes, and emotional
correlates of sexual arousal. Although online sexual
behavior may interact with the individual factors
to reinforce deviant sexual preferences or facilitate
hands-on offending for some Internet users, most
individuals with typical developmental learning
experiences and nondeviant sexual preferences are
inclined to avoid violent and pedophilic sexual stimuli (Bogaert, 2001; Fisher & Barak, 2001; Seto, Maric,
& Barbaree, 2001). Thus, the evidence suggests that
a reciprocal relationship exists in which self-motivated participation in online sexual behaviors reinforces and influences sexual attitudes and behaviors
(Fisher & Barak, 2001; Malamuth, Addison, & Koss,
2001; Malamuth & Impett, 2001; Padgett, BrislenSlutz, & Neal, 1989; Seto et al., 2001). Ultimately,

311

pornography use cannot be seen as a necessary or

sole cause of contact sexual abuse, because many
perpetrators have had little or no exposure to pornography, and many pornography users have not
committed sexual offenses.

CHILD POR NOGR A PH Y, SE X UA L

CON TACT OFFENDING,
A ND R ECIDI V ISM

An important question is whether downloading child

pornography is associated with risk for future offending, and if so, is risk restricted to further downloading
of illegal pornography, or is there also increased likelihood of committing contact offenses. The available
data suggest that a significant proportion of individuals arrested for possessing child pornography have
committed hands-on sexual offences in the past.
Data from the NCMEC (2005) indicated that 40%
of men arrested for possession of child pornography
had also sexually victimized children, and an additional 15% of offenders were dual offenders who
tried to victimize children by soliciting undercover
investigators who posed as minors online. Hernandez
(2000) found that offenders convicted of possession
of child pornography or crossing state lines to have
sex with a minor reported having committed more
contact sexual offenses than individuals arrested for
contact sex offenses. Twenty-four percent of the
201 men in Seto and Ekes (2005) sample had a
prior history of contact sexual offending at the time
of their arrest for child porn possession. Thus, for
many child pornography offenders, there is already
a behaviorally demonstrated precedent for committing actual, as opposed to virtual, sexual abuse of a
child.
There are few data to inform the issue of risk for
future offending, be it in the form of accessing illegal
pornography or the commission of contact offenses.
Seto and Eke (2006) examined recidivism among
198 child pornography offenders over an average
follow-up period of 3.6 years. Of the child pornography offenders, 13 (6.6%) committed a contact sexual offense during the follow-up period, whereas 14
(7.1%) committed another child pornography offense.
The violent (including contact sexual offense) offense
rate was 9%, and the overall rate for a new offense of
any kind was 22%. Violent and sexual contact reoffending were predicted by variables related to violent

312 SPECIAL POPULATIONS

offense history, and no significant predictors of child

pornography recidivism were found. Seto and Eke
(2006) recommended that variables associated with
general antisocial tendencies, especially measures of
psychopathy, appear to be useful tools for assessing
and understanding recidivism among child pornography offenders.
Webb et al. (2007) compared Internet child pornography offenders and child molesters on measures
of criminal recidivism and treatment compliance
over a relatively short, 18 month follow up period.
Overall findings indicated that child molesters were
more likely than child pornography offenders to reoffend generally (8% vs. 1%), violently (3% vs. 0%), and
to breach the conditions of community supervision
(17% vs. 0%). Rates of sexual recidivism were similar for both groups, with 3% of child pornography
offenders and 2% of child molesters incurring a new
conviction for a sexual offence (Internet or contact).
Child molesters were significantly more likely to be
noncompliant with supervision, and were more likely
to drop out of treatment (18%) compared to child pornography offenders (4%).
The available research suggests that at least a significant minority of child pornography offenders
have committed hands-on sex offences in the past,
and those rates would likely increase if undetected
offending could be accounted for. However, little is
known about the potential for child pornography
use to escalate to actual, rather than virtual, sexual
abuse of a child for offenders who have no prior history of contact offending. Calder (2004) suggested
that accessing child pornography implies a desire for
sexual contact with children, and others (Quayle &
Taylor, 2002; Sullivan & Beech, 2003) have suggested
that downloading illegal pornography can facilitate
the commission of a contact offence through the pairing of sexual images, fantasy, masturbation, and cognitive distortions. Sullivan and Beech (2003) proposed
a motivational typology based on variable degrees of
pedophilic interest that implies corresponding variations in risk for committing a contact offence. Sullivan
and Beech distinguish between individuals who
access child pornography as part of a larger pattern of sexual offending (Type 1) from those who
do so to nurture a developing sexual interest in children (Type 2), and those who are merely curious but
not fixated (Type 3). Ultimately, links between downloading child pornography and the commission

of hands-on sex offences are largely intuitive and

theoretical at present.

R ISK ASSESSMEN T A ND M A NAGEMEN T

An informed, comprehensive assessment of risk for

reoffense is essential for the effective management of
sex offenders. A good risk assessment should be both
prescriptive and preventative; it should identify dispositional factors that made the offender vulnerable
to committing the offense, and prioritize treatment
interventions that serve to mitigate an offenders risk
for sexual reoffense. The focus of risk assessment
evaluations in these cases should be on understanding what the offender was trying to accomplish as a
function of his or her Internet-related behavior. The
evaluators task is to formulate an opinion about how
and why the offender chose to engage in the sexual
behaviors that led to his charges, and to determine
whether the factors that led to those behaviors might
lead the offender to engage in similar behaviors in the
future (Hart, Laws, & Kropp, 2003).
There have been considerable advances in the
field of sex offender risk assessment over the past
decade. These advances have led to the development of numerous scales and protocols for appraising recidivism risk (Epperson et al., 1998; Hanson,
1997; Quinsey, Harris, Rice, & Cormier, 1998).
Unfortunately, these instruments were not developed
with specific consideration of offenders who exploit
children via the Internet. Thus, Internet offenders,
including possessors of child pornography, are not
specifically identified in the normative samples and
the predictive utility of variables related to Internet
usage was not investigated. Middleton et al. (2006)
observed that, it may be the case that current psychometric assessments, which have been developed
and normed for use with contact sex offenders, are
possibly not effective in highlighting the psychological vulnerabilities of this population (p. 13). In lieu
of data supporting the predictive validity of actuarial
assessment instruments for cases involving Internetrelated offending, the use of established norm-based
estimates of sexual reoffense appears to be inappropriate, at least in cases where possession of child
pornography is the sole sexual offense of record.
Furthermore, these instruments observe the behavior of a whole population of test subjects. The utility

CHILD PORNOGR APHY AND THE INTERNET

concerning a specific individual is therefore limited

to assessing how the individuals characteristics compare to members of a relevant sample population and
how recidivism rates are distributed in a roughly similar population.
In addition to the aforementioned limitations,
a more general limitation for most established sex
offender risk assessment schemes is that they tend
to be based exclusively on historical risk factors that
are, by definition, not amenable to change (Hanson,
Morton, & Harris, 2003; Ward & Beech, 2004).
Consequently, these instruments are of limited utility for informing treatment planning and supervisory contingencies. In response to these limitations,
recent approaches to risk assessment have increasingly
emphasized a risk-need approach that focuses on the
identification of dynamic or alterable risk factors in
addition to static risk factors assessment (Bonta, 2002;
Douglas & Skeem, 2005).
Dynamic Risk Assessment
Barbaree (2003) argued that static factors tell us
which offenders are more likely to reoffend, whereas
dynamic factors tell us when an offender is more
likely to reoffend. To ensure public safety sex offenders must receive the appropriate level of service and
supervision, and those decisions require the accurate
identification and management of dynamic risk factors. Dynamic risk factors represent criminogenic
needs that serve as treatment targets, and that, if
successfully addressed correspond with changes in
risk for reoffense (Andrews & Bonta, 2003; Andrews,
Zinger, Hoge, Bonta, Gendreau, & Cullen, 1990;
Bonta, 2002; Ward & Stewart, 2003). Dynamic risk
factors can be divided into stable and acute factors
(Hanson & Harris, 2000). Stable dynamic factors are
those that are theoretically alterable but entrenched
and slow to change (e.g., alcohol dependence). In
contrast, acute dynamic factors are states that are
subject to rapid fluctuations that may occur over
periods of weeks, days, or even minutes (e.g., alcohol
intoxication).
The authors have elected to discuss assessment
and treatment within a risk-need framework, with a
focus on stable dynamic factors for several reasons.
First, as previously discussed, the predictive validity of
established risk assessment instruments has not been
established for Internet sex offenders, including those

313

who download child pornography. Second, Ward and

Beech (2004) proposed that stable dynamic factors
represent individual vulnerabilities that have a causative relationship with sexual abusive behavior. Thus,
discussion of stable dynamic factors affords the opportunity to discuss both evaluation and treatment considerations within a common model. Although there
is growing empirical support for the consideration of
dynamic risk factors in the assessment of sex offense
risk (Hanson & Harris, 2000, 2001), the extent to
which the established literature on sex offenders may
be generalized to collectors of child pornography is
not yet known. Moreover, there have been very few
empirical studies of recidivism among offenders
arrested for Internet-related sex crimes. Thus, the
dynamic risk factors discussed in this chapter are
presented not for their established predictive validity,
but rather, for their theoretical and heuristic value,
and for the purpose of generating discussion in the
burgeoning area of Internet-related sexual abuse. The
factors discussed in the remainder of this chapter
are not mutually exclusive, and in fact it is likely that
all five factors contribute to each occurrence of sexually exploitative behavior in varying degrees (Ward &
Beech, 2004).
There are five stable dynamic risk factors of particular relevance for individuals who utilize the
Internet to acquire or distribute images of child sexual abuse. Ward and Beech (2004) developed an etiological model of sex offense risk that incorporated
four stable dynamic risk domains based on the work
of Hanson and Harris (2001) and Thornton (2002).
Those stable dynamic factors included (1) sexual selfregulation, (2) general self-regulation, (3) intimacy
deficits/interpersonal functioning, and (4) offense
supportive cognitions. The current authors also considered a fifth stable dynamic factor, negative social
influences, on the basis of its established predictive utility in the nonsexual offender literature, its
inclusion in current dynamic assessment schemes
(Hanson & Harris, 2001), and its theoretical relevance for individuals who download images of child
sexual abuse from the Internet.
Sexual Interests/Sexual Self-Regulation
This risk domain includes sexual preoccupation, use
of sex for coping, affect regulation, and deviant sexual preferences. Quayle et al. (2006) likened sexual

314 SPECIAL POPULATIONS

stimulation to a form of self-medication for some

individuals; a tactic utilized to alleviate feelings of
anxiety, loneliness, and depression. Contemporary
theories of sexual deviance describe how, during
childhood, some offenders become prematurely and
inappropriately sexualized and develop a tendency
to use sex as a mechanism for coping and affect regulation (Marshall & Barbaree, 1991; Marshall &
Marshall, 2002; Ward, Hudson, Marshall, & Siegert,
1995; Ward & Sorbello, 2003). Masturbation is a
reliable and pleasurable form of avoidant coping
and therefore is a highly reinforcing and easily generalized behavior. Studies have shown that sexual
offenders tend to utilize ineffective coping strategies in general, and are more likely to indulge in
both coercive and consensual sexual fantasies when
under stress (Cortoni & Marshall, 2001; Marshall,
Serran, & Cortoni, 2000). These findings suggest
that although the content of sexual fantasy may be
a salient consideration for many sex offenders, the
broader tendency to utilize sexual means of regulating ones affective state may be a more defining
and etiologically significant characteristic for many
offenders.
Quayle et al. (2006) described the Internet as a
perfect vehicle for avoiding or altering negative
mood states through sexual stimulation because it
is readily available, immediate, and controllable.
Cooper et al. (2004) found that over 80% of men
identified as having noncriminal online sexual
behavior problems engaged in online sexual activities as a form of distraction from their daily lives. An
additional 56% of this same sample reported engaging in online sexual activities as a form of stress relief.
Middleton et al. (2006) examined 43 men convicted
of Internet-related sex offenses and found that 33%
of them were characterized by the inability to identify and modulate mood states, and the tendency to
self-soothe through sexual means. Quayle and Taylor
(2002) stated,
Through the Internet the unsatisfactory elements
of life that were difficult to address or change could,
for periods of time, be avoided and substituted for
a world that was more controllable. Sexual satisfaction could be sought and gained, allowing the
respondent to have perfect control (p. 349).
Recent data suggests that possession of images of
child pornography may be a more valid indicator of

pedophilia than actual history of contact offenses

against children. Seto et al. (2006) found that men
who had been convicted of possessing child pornography were three times more likely to be to be
identified as pedophilic on the basis of results from
phallometric testing than child molesters without
charges related to child pornography. Although individuals who collect and/or disseminate these images
likely do so as a result of preexisting traits and sexual interests, it has been argued that online sexual
behaviors allow for the exploration, indulgence, and
crystalization of sexual fantasies that otherwise would
have self- extinguished (Cooper, Scherer, Boies, &
Gordon, 1999). Empirical data and clinical intuition
suggest that downloading child pornography is most
frequently accompanied by sexual fantasizing and
self-stimulation, and that users download specific
images of child pornography on the basis of how well
those images correspond with preexisting sexual
fantasies (Quayle & Taylor, 2002; Seto et al., 2006).
Moreover, Quayle and Taylor (2002) interviewed
13 men convicted of downloading child pornography and observed a pattern of escalating sensation
seeking as individuals seek out increasingly extreme
(e.g., depictions of younger children) sexually explicit
materials. The authors opined that this pattern of
escalation may be due to the rapidity with which
individuals habituate to sexual stimuli delivered via
the Internet, and their subsequent efforts acquire
novel, provocative images.
Ward and Stewart (2003) suggested that the
presence of deviant sexual interests signifies the
absence or distortion of internal and external factors necessary for healthy, egalitarian relationships.
Thus, a primary goal of therapy is the acquisition of
additional skills to manage stress in life and to nurture healthy relationships. For offenders who have
demonstrated a pattern of using masturbation or
sexual fantasizing to regulate affect or distract from
stressors, learning to effectively self-manage negative emotional states is a primary treatment goal.
Interventions that contribute to the development
of adaptive coping strategies, such as relaxation
training and mindfulness exercises (see Linehan,
Dimeff, & Koerner, 2007 for review of applicable
cognitive behavioral techniques), aim to improve anxiety tolerance and encourage the use of more direct,
effective strategies for coping and problem solving. By providing instruction in the use of adaptive
coping skills early in treatment, offenders acquire

CHILD PORNOGR APHY AND THE INTERNET

functional skills that may serve in the stead of the

maladaptive behaviors targeted by treatment. Daily
diaries cataloguing the occurrence of emotionally
provocative events, subjective ratings of emotional
intensity, and ratings of the individuals confidence
in his ability to tolerate the emotional experience,
may serve as useful tools for treatment. Over the
course of treatment offenders practice utilizing
developing skills to manage anxiety that may be
experienced before, during, and following therapy
sessions, and therapy time is devoted to the discussion of successful and failed attempts to utilize new
skills outside of treatment. By deconstructing his
own offense process, each individual offender can
learn to identify circumstances that are likely to
elicit a strong emotional response, and to develop
a plan to use alternative affect regulation strategies
under such conditions. Treatment may also need to
address off-line problems, such as family conflict
or unemployment that the offender is attempting
to avoid through sexual self-gratification. Some
offenders, particularly those with avoidant attachment orientations, may experience difficulties in
recognizing, labeling, and tolerating negative emotional states, and subsequently, interventions aimed
at improving emotional self-awareness may be warranted early in the therapeutic process. Finally,
although not universally effective for all offenders,
behavioral procedures aimed at modifying deviant
sexual arousal patterns may be beneficial for those
with deviant preferences.
General Self-Regulation Problems
General self-regulation refers to the ability to plan,
problem-solve, and regulate impulses to achieve longterm goals (Thornton, 2002). Problematic self-regulation
as evidenced by lifestyle impulsivity and poor emotional control, is well correlated with general and
violent offending (Lynam, Caspi, Moffitt, Raine,
Loeber, & Stouthamer-Loeber, 2005; Pulkkinen,
Virtanen, Klinteberg, & Magnusson, 2000; Seager,
2005; Zuckerman, 2002). Problems with behavioral
self-regulation have also been associated with risk
for sexual reoffending (Firestone, Bradford, McCoy,
Greenberg, Larose, & Curry, 1999; Hanson &
Bussiere, 1998; Prentky & Knight, 1991; Rice & Harris,
1997). Hanson and Harris (2001) found that, of all the
items of the Sex Offender Need Assessment Rating
(SONAR), general problems with self-regulation

315

demonstrated the strongest effect for discriminating

between recidivists and nonrecidivists.
Impulsivity has been discussed in the literature as
the inability to wait for delayed rewards and/or a tendency toward risk taking (Green & Myerson, 2004).
Relapse prevention models of substance abuse and
sexual offending have utilized the term Problems of
Immediate Gratification (PIG) in reference to the
principle that small, immediate rewards have greater
subjective value than large, delayed rewards (Marlatt,
1989; Laws, Hudson, & Ward, 2000). Laws (2003)
argued that the devaluation of delayed rewards is
almost certainly the behavioral mechanism by which
certain precursors lead to impulsive sexual behaviors (p. 77).
The Triple A Engine of the Internet has created
the opportunity for near immediate gratification for
anyone with an interest in child pornography. Sexual
self-gratification may serve as a reliable, immediately
available alternative to more prosocial behaviors
and outcomes that are both uncertain and considerably delayed. Moreover, individuals may devalue
the rewards of participating in appropriate egalitarian relationships or trying alternative coping strategies because they have no history of success in
these realms and subsequently expect that future
successes are improbable. For these individuals,
masturbation fueled by sexually explicit images of
children may represent the proverbial bird in hand
that is preferred over the two in the bush represented by more adaptive, but less probabilistic behaviors. Temporal and probabilistic factors may also
influence the appraisal of negative outcomes (e.g.,
criminal charges, public embarrassment, and loss
of employment) that might otherwise serve as deterrents. Offenders may rightly believe that detection is
improbable, and any negative consequences that are
incurred will not be realized for weeks, months, or
even years, contributing to the devaluation of longterm deterrents.
A fundamental aim of cognitive behavioral sex
offender treatment is the enhancement of the offenders self-management skills to maintain therapeutic
gains achieved through treatment. Behavioral selfregulation is also relevant to the offenders willingness/ability to abide by supervisory restrictions, and
to implement treatment recommendations in the
community. Quayle et al. (2006) suggested that preference for immediate gratification interferes with
the individuals ability to realize his personal goals

316 SPECIAL POPULATIONS

and values. They further suggest that by getting the

offender to examine and explicitly state their values, the treatment provider can assist the offender
in examining how immediate gratification in general, and downloading child pornography in particular, may inhibit their ability to fulfill those values.
Structured approaches to cost-benefit analyses, where
values assigned to different behavioral outcomes are
explored rationally, may be useful for this purpose.
Additionally, Laws (2003) emphasized importance
of demonstrating the rewards of alternative behaviors early in treatment. Marlatt et al. (1997) stated,
Benefits from current treatment are far from certain,
but if they were better defined, more probable, and
occurred sooner, their value would be discounted
less and treatment would be engaged in more (p. 71).
Consequently, behavioral goals should be clearly
operationalized, systems of measurement should be
instituted, and the offender should receive feedback,
early and often, that highlights observable treatment
gains. By formulating a functional analysis of the
individuals interest in, and use of child pornography,
the treatment provider can identify the purpose that
downloading child pornography serves for the individual, as well as the contexts within which this behavior is likely to occur. It is important to recognize that
offenders are being asked to relinquish behaviors that
have reliably served a valuable purpose. Behavioral
change is unlikely to occur or be maintained if the
offender is not provided with alternative means by
which to achieve the goals that were previously met
through the target behavior. Thus, lack of behavioral
control may be addressed by framing problems of
immediate gratification as barriers to the achievement of personal goals, through participation in costbenefit analyses, and by structuring treatment such
that the individual will experience tangible benefits
early in the treatment process.
Intimacy Deficits
Deficit models of sexual offending, whereby perpetrators choose inappropriate partners as a result of
emotional loneliness and failed attempts to achieve
intimacy with more suitable partners, have a long history in the sex offending literature (Marshall, 1993;
Marshall, Hudson, & Hodkinson, 1993; Ward &
Siegert, 2002). Research has shown that adult sexual
offenders tend to feel inadequate and emotionally
lonely in intimate relationships (Fisher & Howells,

1970; Marshall, 1989; Marshall, Payne, Barbaree, &

Eccles, 1991; Pacht & Cowden, 1974), and anticipate
that they will be rejected by intimate partners (Panton,
1978). Quinn and Forsyth (2005) commented that
the Internet has transformed vicarious sex into an
increasingly viable and attractive substitute for interpersonal forms of sexual fulfillment (p. 197).
The relationships that child pornography offenders experience online, including actual communications with other child pornography offenders as
well as fantasy relationships the offender creates with
children depicted in the pornographic images, may
serve to compensate for unsatisfactory interpersonal
relationships in the offenders off-line life. Middleton
et al. (2006) examined the psychological profiles of
43 men convicted of Internet-related offenses within
the context of pathways model by Ward and Siegert
(2002) of sexual offending and found that 35% of
the sample fell within the Intimacy Deficit pathway.
Other authors have found that a disproportionate
number of men arrested for possession or distribution
of child pornography (33% to 80%) were not, and in
many cases had never been, involved in an intimate
romantic relationship (Frei, Erenay, Dittmann, &
Graf, 2005; McLaughlin, 2006; Middleton, Elliott,
Mandeville-Norden, & Beech, 2006). It should be
noted, however, that Wolak and colleagues (2005)
found that 37% of the child pornography offenders
in their study were married or were living with a partner and 27% were separated, divorced, or widowed
(indicating that they had at least been in a relationship at some point in time). Caplan (2002) observed
that noncriminal problem Internet users demonstrate
a preference for online, rather than in-person, interactions. Young (1997, as cited in Song et al., 2004)
suggested that the anonymity of the Internet permits
individuals to adopt new identities which may compensate for personal deficits that limit the individuals social comfort and success in their off-line lives.
As noted by Middleton et al. (2006) many Internet
offenders may find that, images depicting children
are less fearful and the child a more accepting partner, and they may use the Internet as a maladaptive
strategy to avoid their perceived likelihood of failure
in adult relationships (p. 11).
Intimacy problems are frequently attributed to
insecure attachment and subsequent difficulties in
establishing satisfactory interpersonal relationships
(Marshall, 1989; Ward, Hudson, & Marshall, 1996;
Ward & Siegert, 2002). Attachment theory is based

CHILD PORNOGR APHY AND THE INTERNET

on the belief that early interpersonal experiences set

the stage for predictable cognitive, affective, and relational behavior processes that guide personality and
social behavior throughout the lifespan (Bowlby,
1982; Shaver & Mikulincer, 2002). Intimacy deficits
can then be viewed as enduring traits that are unlikely
to exhibit rapid therapeutic change. Because of the
interpersonal nature of intimacy problems, the therapeutic process and quality of relationships between
the offender and the therapist and/or therapy group
are of particular importance (Serran, Fernandez,
Marshall, & Mann, 2003). Individuals who substitute children for adult sexual partners will likely also
present with distorted cognitions that frame sexual
relationships with children in romantic, adult-like
terms (Ward & Beech, 2004; Ward et al., 1996).
Thus, from a treatment perspective relationship,
communication, and intimacy skill deficits need to be
addressed. Couple counseling would also be appropriate for individuals who are already in relationships.
Although the Internet is becoming an increasingly
sociable acceptable mode of meeting potential dating
and sexual partners via websites such as match.com
and yahoo personals, for individuals with a history of
using the Internet to engage in illegal behavior, this
medium is not recommend to seek out potential relationships. This behavior might prove too tempting for
some individuals in the early stages of treatment to
fall back on maladaptive interaction patterns given
the anonymity, accessibility, and affordability of the
Internet.
Offense Supportive Cognitions
The concept of cognitive distortions has figured
prominently in theories of sex offending etiology and
treatment. Cognitive distortions are beliefs about
sexuality and sexual behavior that individuals use
to justify and disinhibit sexually abusive behaviors.
Marshall et al. (1999) suggested that cognitive distortions may initially represent conscious efforts by the
offender to overcome internal inhibitions deterring
him from committing preferred sexual acts, and with
repeated offending may become deeply engrained.
Exposure to child pornography may serve to reinforce the individuals self-justification for indulging their deviant sexual interests (Marshall, 2000).
The very fact that these images are available on the
Internet provides evidence for the downloader that
others are engaged in similar or more egregious

317

behaviors. This in turn may have a normalizing function for the individual. By focusing on the end product (i.e., child pornography) rather than the actual
events that led to its production (i.e., sexual abuse
of a child) the Internet user is able to create distance
between his own behavior and the actual abuse of
a child and may even start to view his behavior as a
victimless crime thereby differentiating himself
from those who have direct involvement in child
sexual exploitation. Furthermore, child pornography
that portrays children as compliant, willing, and even
enthusiastic participants in sexual activities serves to
reinforce the distortion that children can consent to
engage in such behaviors, and that those behaviors
are not harmful to the victim. Some child pornography offenders will justify their sexual behavior on
the Internet by framing it as an outlet for sexual urges
that allows them to refrain from committing contact
offenses (Quayle & Taylor, 2002). There are no data
to support or refute the contention that downloading
these type images serves as an effective harm reduction strategy. At best, collecting and masturbating to
child pornography appears to be a suboptimal tactic
for managing inappropriate sexual urges. At worst, it
perpetuates the abuse of children by creating a market for new images, reinforces cognitive distortions
regarding the abuse of children, and may actually
move the individuals closer to committing contact
offenses against a child.
Bandura (1977) stated that so long as individuals
disregard the detrimental effects of their conduct,
there is little likelihood that self-censuring reactions
will be activated (p. 157). Because cognitive distortions impede motivation and behavior change, they
need to be identified and challenged early, and remain
an ongoing treatment focus throughout therapy. Many
offenders will embrace the notion that downloading child pornography is a victimless crime, or minimize severity of harm relative to more violent contact
offenses. In these cases, the treating clinician will wish
to explore and emphasize the experience of the child
victim that led to the creation of pornographic images,
and emphasize the permanence with which images of
that abuse will persist in cyberspace.

NEGAT I V E SOCI A L INFLUENCES

Association with people who have antisocial values and criminal tendencies has been identified as

318 SPECIAL POPULATIONS

a robust predictor of nonsexual recidivism among

juvenile and adult nonsexual offenders (Andrews &
Bonta, 2003; Gendreau, Little, & Goggin, 1996). The
role of social influences on the sex offending process
has not, however, received much empirical attention,
perhaps because sexual offenses are most frequently
perpetrated by a lone offender.
The Internet provides a social forum for people to
meet with others and exchange information (Quayle
et al., 2006). McKenna and Bargh (1998) suggested
that the Internet provides a venue where people
who are socially isolated and/or have socially devalued traits can reap the benefits of joining a group
of similar others: feeling less isolated and different,
disclosing a long secret part of oneself, sharing ones
own experiences and learning from those of others,
and gaining emotional and motivational support
(p. 682). Although McKenna and Barghs (1998)
comments were made in reference to the Internet
as a positive influence on identity development, the
Internet may also serve to plug isolated sexually
deviant individuals into virtual social systems that
promote deviant values and encourage enactment of
sexually deviant or illegal inclinations.
Turkle (1995) argued that the Internet allows individuals to experiment with different personae under
favorable conditions where the individual will not
be punished or censured for expressing unpopular
attitudes and behaviors. Research by McKenna and
Bargh (1998) investigated the effects of Internet newsgroup membership on identity development for individuals with concealable marginalized identities
(e.g., homosexuality; fetishism). The authors found
that newsgroup involvement led to increased importance of the group identity, and that users begin to
feel that this aspect of themselves is more socially
acceptable than they had thought. This reduces the
inner conflict between the marginalized self aspect
and cultural standards (p. 692).
Ward and Hudson (2002) suggested that pedophilic offenders tend to gravitate toward individuals
who share similar attitudes, beliefs, and preferences.
Malesky and Ennis (2004) echoed this sentiment
and speculated that individuals with pedophilic sexual preferences will be inclined to seek validation for
their sexual proclivities from like-minded peers in
virtual communities. An observational study of activity on a propedophilia Internet newsgroup found that
although a substantial number of newsgroup postings included statements supportive of pedophilic

behaviors, and/or erotic images of young boys, the

majority of newsgroup communications were unrelated to either sexuality or children (Malesky & Ennis,
2004). The majority of inter-user communications
were conversational dialogues about current events,
arts and entertainment, and other nondeviant topics. Malesky and Ennis (2004) proposed that through
virtual communities,
offenders and potential offenders may find a sense
of membership and community that they lack in
other aspects of their lives. The fact that the user
is in contact with individuals who not only share
their pedophilic interests, but also listen to similar
music, read the same books, and have the same
hobbies, may have a normalizing effect on ones
perception of their deviant interests (p. 98).
In addition to providing a venue for social interactions, some online communities may serve as virtual
market places where the acquisition and distribution of child pornography can be conducted freely,
and where users can share information regarding
where to find additional images, how to effectively
conceal ones identity online, and disseminate information that would otherwise be difficult to access
(e.g., membership information for propedophile organizations), and arrange in person meetings with other
sex offenders (Durkin, 1996; Malesky, 2005). Durkin
(1996) found that nearly one quarter of postings on
a pedophilic Internet newsgroup represented efforts
to orchestrate off-line contacts with other newsgroup
users. Moreover, although illegal pornography can
be accessed for free, many of the most content rich
websites featuring child pornography are covert, and
require knowledge (e.g., web address, passwords) that
would only be available through word of mouth,
and virtual communities represent the most direct
route by which to access this information.
Individuals who have been active traders of child
pornography will likely have established communication networks with other traders. These traders
may attempt to solicit further exchanges of pornography, regardless of whether the offender in treatment
initiates contact. Furthermore, involvement in virtual
communities that endorse sexually exploitative values and behaviors may serve to undermine treatment
efforts aimed at creating dissonance between the
offenders personal values and their sexually exploitative behavior.

CHILD PORNOGR APHY AND THE INTERNET

Although some computer programs restrict adult

material (pornographic websites) from being accessed
over the Internet as well as monitor the users online
activity it is unrealistic to assume that these precautions (although helpful in some cases) would prevent
all individuals from accessing online child pornography. Thus, other precautions can to be taken to
reduce risk of reoffense. In extreme cases, Internet
offenders employed in the fields of computer/Internet
might need to pursue employment where they are
not required to work on the Internet (especially if
their work is largely unsupervised). In addition, highrisk Internet offenders should not be allowed to have
computers in their homes. If this suggestion is unrealistic because of the presence of family members
or roommates, then the offender should be closely
monitored to ensure that he or she does not misuse
the computer or the Internet. Finally, probation and
parole officers working with this population should
receive specialized training focusing on the strengths
and weaknesses of filtering programs used to screen
access to sexual material as well as on ways computer
programs can be used to monitor ones online activity. Although these suggestions are not a panacea to
prevent offenders from accessing child pornography
over the Internet, they do make it more difficult for
offenders to engage in illegal or sexually inappropriate
online behavior. In addition to aforementioned suggestions, provisions prohibiting contact with potential
trading partners or propedophilic online communities should be included in community supervision
orders and treatment contracts. Furthermore, where
polygraph examination represents a routine element
of community management, examiner should question the examinee about his online communications
and activities.

CONCLUSION

In summary, the Internet is ideally suited for individuals with sexual interests in children and has
dramatically altered the behavioral economics that
govern the acquisition of sexual goods, resulting in
opportunities for near immediate gratification that
were previously unavailable. However, technology
is not solely responsible for changing the behavior
of individuals who use it (McGrath & Casey, 2002).
The Polaroid camera did not cause camera owners to
develop an interest in creating pornographic images

319

in their homes. Rather, it simply provided an avenue

by which those with an interest in photographically
documenting their sexual activities could create their
own pornography in the home. Similarly, the Internet
is primarily a catalyzing agent that allows individuals with particular psychological vulnerabilities to
explore their sexual interests, indulge and operationalize their fantasy life, and avoid detection (McGrath
& Casey, 2002).
Regardless of whether the offenders index offense
involves use of the Internet, evaluators and treatment
providers will be wise to determine whether Internet
usage issues, be they indulgence in child pornography
or an excessive involvement in online relationships at
the expense of off-line relationships, play a role in the
development or maintenance of the sexually abusive
behavior. The evaluator should not only investigate
the nature of the offenders Internet-related behaviors
but also determine the function that online behaviors
may serve for the offender. As suggested by Middleton
(2004), At the very least the treatment (of sex offenders) needs to be based on a specific assessment of the
individual including the context in which the behavior was developed and sustained (pp. 110).
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Chapter 23

Sexual Abuse by Clergy

Graham Glancy and Michael Saini

Sexual abuse by clergy receives a great deal of media

attention and generates immense public outcry toward
the perpetrators (Saradjian & Nobus, 2003). Plante
and Daniels (2004) suggest there are several factors
that account for this attention. First, the Roman
Catholic Church is an intriguing organization with
perceived secrecies and inner workings, which make
the incidents of clergy abuse fascinating and of great
interest to the media and general population (Wills,
2000). Clergy are often placed on a spiritual, moral,
and ethical pinnacle, which leads to an expectation of
the highest level of behavior: When they error, sin,
and fall from grace, it is a much bigger drop for them
(Plante & Daniels, 2004). As well, Catholic clergy
take a vow of celibacy prohibiting sexual contact of
any kind, thereby creating an expectation of complete
abstinence from their sexual behaviors. Plante (1996)
further suggests that much of the media has cast the
Roman Catholic Church as being unable or unwilling to deal with clergy abuse within the Church.

Given the American media attention to clergy

abuse, it is not surprising that most literature found
in this area is focused on clergy of the Roman Catholic
Church in the United States. Perpetrators of child
sexual abuse, however, can be found among clergy
of various denominations and in various countries
(Saradjian & Nobus, 2003). Furthermore, based on
the review by Wolfe et al. (2003), allegations of child
sexual abuse have been made in almost every type
of community institution serving children, including
schools, nursery schools, sports, and voluntary organizations. This has led to revelations and inquiries into
the issue of childhood abuse in various institutions
(Law Commission of Canada, 2000).
Although child abuse by family members has
received considerable scientific and professional attention, we know less about the etiologies, typologies,
and treatment options for members of community
organizations and institutions who abuse children
(Wolfe et al. 2003). Plante (1996), for example, notes

324

SEXUAL ABUSE BY CLERGY

the plethora of commentary on clergy abuse but the

dearth of empirical information on those who are
accused of committing these acts. Songy (2003) highlights that several scholars have suggested examining
the etiology and treatment of sex offenders within a
broader comprehensive model of offending. However,
others like Marshall (1997) and Songy (2003) argue
that developing a general framework for sex offenders oversimplifies the complexity of sexual abuse in
various settings and circumstances. Consistent with
this view, Songy states, Given the complexities of
etiology, it is essential that a treatment program thoroughly evaluate all possible factors leading to the sexual offenses of a particular client. In other words,
special attention is needed to examine the available
empirical information of clergy abuse in order to
screen, prevent, and treat those clergy who sexually
abuse children.
The current limited empirical evidence of clergy
abuse is partly due to the lack of access to priests and
a general lack of data on them (Connors, 1992). Much
of the literature consists of either anecdotal descriptions or impassioned arguments detailing the characterization of the Churchs response to clergy abuse
(Terry & Terry, 2005). In reviewing the modest sample
of empirical literature on clergy abuse, it should further be noted that many of these studies suffer from
methodological flaws, including small sample sizes,
lack of comparison groups, and the employment of
study designs that lack scientific rigor. Keeping these
limitations in mind, we reviewed the existing compilation of empirical studies on clergy abuse toward
children to begin developing a framework to improve
our understanding of this phenomenon.
In this chapter, we focus on etiological factors comprising of intrapersonal, interpersonal, and systemic
levels of analysis and present current clergy offender
typologies that have attained general acceptance
within the scientific community. In the anticipation of understanding the etiological factors of these
offenders, we have initiated a scholarly discourse of
their characteristics within the context of their institutions. In the review of literature concerning sexual
abuse by clergy, we will go on to make some suggestions regarding prevention, training, and treatment.
At the outset of this chapter, it is important to
emphasize that we are not seeking to excuse this
behavior, but rather, to understand it better to be
able to make some suggestions for preventing the

325

repetition of a scandal that has caused so much public discontent, as well as private pain and suffering.
Although some statements may be considered controversial, it is important to present all of the empirical
data to ensure that the review remains comprehensive
and scientifically objective in its presentation.
Much of the inquiry in this field relates to the
Catholic Church. However, we have broadened our
field of inquiry to include other religious denominations when the data is available.

BACKGROU ND

According to Doyle (2003), sexual abuse by clergy

is not a new issue for the Church. It has existed
throughout the history of the Roman Catholic
Church, as well as other religious groups. He amasses
evidence to suggest that the abuse of minors was
considered a heinous crime worthy of significant
punishment over the course of some centuries. The
1917 Code of Canon Law, for example, specifically
articulated sexual contact with a minor by a cleric as
being an ecclesiastical crime. Doyle further argues
that, contrary to the suggestion of many authors, the
Church has officially acknowledged sexual abuse as
a problem for centuries.
Doyle notes that at the end of the Second Vatican
Council in 1965, the Church underwent significant changes, including a demythologizing of the
Church, its rituals, and clergy. Although a decline in
clergy reverence has occurred, Doyle suggests that
the Church has not diminished the feelings of elitism among its clergy. Furthermore, the hierarchical
system of the Church remains largely intact. Doyle
also points to the power of clericalism within the
Church as being a contributing factor to clergy abuse.
He describes clericalism as the Churchs policy of
maintaining or increasing the power of the Church,
thereby creating power imbalance between individual
clerics and their parishioners. Doyle suggests that this
unequal distribution of power fosters an atmosphere
that facilitates sexual abuse by the clergy against the
more vulnerable parishioners.
When sexual abuse by clergy occurs, research indicates that the survivors can experience a significant
array of harm including depression, self-harm, suicide,
self-blame, posttraumatic responses, and major life
derailments (Bera, 1996; Fortune, 1989; Harris, 1990).

326 SPECIAL POPULATIONS

Qualitative accounts from survivors suggest that children who are sexually abused by clergy can typically
be divided into two groups: those whose families are
deeply involved in the Church community, therefore
have deep faith in both clergy and religion, and those
from troubled families (Bera, 1996).
On the basis of a large number of media articles
reporting cases of sexual abuse by clergy across the
United States, Canada, and Europe, Doyle (2003)
suggests that incidents of sexual abuse by clergy have
certain common facets:
The victims are generally from families closely
involved in the life of the Church.
Abuse takes place many times over a prolonged
period of time.
Disclosures are initially met with disbelief by
parents and others.
Church leaders first try to silence the victims to
avoid a scandal.
Disclosures are often not made until the victim
reaches adulthood.
Many victims experience trauma and dysfunction following the abuse.
Notwithstanding the long history of sexual abuse
within the Church context and the known negative
consequences for children who fall victim of clerical
abuse, less is known about the characteristics of clergy
who abuse these children.

PR EVA LENCE

Very few systematic, well-controlled studies have

been conducted to determine actual prevalence of
clergy abuse (see Kelly, 1998; Saradjian & Nobus,
2003). McGlone (2001) notes the unreliability of any
estimated figures due to the inherent problems of
relying on victim disclosure or perpetrators reports.
It is noteworthy that he did not have an easy task
when attempting to simply find actual numbers of
Roman Catholic brothers and priests in the United
States. This bespeaks the uncertain and complicated structure of the Church. McGlone estimates
that there are 53,000 Roman Catholic brothers and
priests in the United States. On reviewing the professional and lay media, he estimates that between
0.2% and an upper limit of 4% of Roman Catholic
brothers and priests have committed sexual abuse.
This suggests that there are between 100 and 2,000

priest perpetrators in the United States. Loftus

and Camargo note that among 1,322 male Roman
Catholic clerics who had been treated at a treatment center for troubled clerics, 2.7% of these were
pedophiles, 8.4% were viewed as hebephiles, and
27.8% incidentally were sexually active. Out of the
111 priests who were perpetrators of sexual misconduct with children, 98 had perpetrated against boys
(Loftus & Camargo 1993). Goodstein (2003) further
estimates a prevalence rate of 1.8% based on stories
in the American national press.
In reviewing the various studies, Plante (2003)
concludes that approximately 2% of Roman Catholic
priests have sexually exploited minors. He asserts that
sexual abuse by clergy is found among male clergy
members at about the same percentage in most faiths.
He also makes the point that men who work in a variety of occupations, which bring them into close contact with children, such as Boy Scout leaders, sports
coaches, school bus drivers, and teachers have the
same proportion of sexual perpetrators as the clergy.
He concludes that the Catholic priests are not more
likely to sexually abuse children than clergy in other
faiths, people whose jobs bring them into close contact with children, or adult males in the general
population.
Plante also goes on to note that the vast majority of
priests who sexually abuse children choose adolescent
boys rather than latencyaged children or young
girls. A further study by McGlone (2001) compared
a group of pedophile clergy offenders to hebephiles
and found that 68% were male-to-male abusers, 20%
male-to-female abusers and 12% abused both men
and women.

ET IOLOGICA L FACTOR S

Songy (2003) argues that few scholars have offered

enough information to describe clearly the nature
and etiological factors of sexual abuse by clergy. In
response, we have searched the professional literature for empirical investigations of clergy abuse and
have summarized the etiological factors leading to
the sexual offense against children. In our review, we
have uncovered three levels of analysis in the study
of clergy abuse: intrapersonal, interpersonal, and systemic. Each level will be presented, followed by our
proposed model to connect the levels into a working
model of sexual abuse by clergy.

SEXUAL ABUSE BY CLERGY

Intrapersonal Factors
Langevin and Watson (1996) reviewed the general etiologic factors that predispose individuals to sexually
offend. They highlight sexual deviance as the primary
factor and note that the majority of sex offenders are
motivated by the presence of a sexual disorder. This
is often accompanied by a number of disinhibiting
factors such as substance abuse, antisocial personality disorders, psychotic mental illness, criminality,
neuropsychological impairment, and endocrine disorders. Of these disinhibiting factors, alcohol intoxication and alcohol abuse are found to be significant
contributors to sexual offenses. For example, 52% of
sex offenders in Langevin and Watsons study were
alcoholics and 52% of all sex offenses were carried out
under the influence of alcohol. Drug abuse, in contrast, is found in only 3% of sex offences (Langevin,
Curnoe, & Bain, 2000).
Researchers have claimed that clergy offenders
are unique in comparison to other offenders within
the general population (Terry & Terry, 2005). To
examine these potential differences, Langevin et al.
(2000) compared 24 male clerics accused of sexual
offenses with 24 sex offender controls and matched
them by offense type, age, education, and marital status and then compared to a control sample of 2125
sex offenders matched only according to offense type.
They found that clerics in the study were, as a group,
statistically older, more educated, and predominantly
single as compared to the groups. They found that all
groups suffered from sexual disorders and most disorders were predominantly homosexual pedophilia.
In Langevin and Watsons (1996) in-depth study of
clerics, they found that 70% reacted most strongly to
male children physiologically, representing a lifelong
preference to male minors over adults.
Not surprisingly, Langevin et al. (2000) found that
clerics reported a prosocial history, mental stability,
and the absence of antisocial personality disorders
in contrast with the general population of sexual
offenders. However, clerics also reported more endocrine disorders. These disorders, such as diabetes
and thyroid disorders may mimic the symptoms of
major mental disorders and are associated with mood
swings, depression, aggressiveness, and cognitive dysfunction. Also noteworthy, a third of all groups were
alcoholics. These observations are similar to results
found by Loftus and Camargo (1993) (Table 23.1)
In one of the most scientific studies, Loftus and

327

table 23.1 Etiological FactorsIndividual

Paraphilic
Neuropsychological impairment
Endocrine abnormalities
Alcohol abuse
Personal history of having been sexually abused
Immaturity/intrapsychic problems

Camargo (1993) examined 158 clerical clergy priests

in a treatment center using a control group of nonoffending priests by employing the Millon Multiaxial
Personality Inventory (MMPI)-III and the Rorschach
inkblot method. Loftus and Camargo found high levels of dependency and schizoid features in pedophile
priests. Surprisingly, they did not find higher levels of
narcissism or differences in sexual knowledge compared with national norms for men. Gerard Jobs,
Cimbolic, Ritzbbler, and Montana (2003) noted pathological responses in a variety of Rorschach Scales in
a group of cleric sex offenders who were hebephilic.
In another study using the Rorschach Scales, hebephile Catholic priests were found to demonstrate significant pathological responses.
In a retrospective study of 1322 male clergy in a
residential treatment centre, Camargo (1997) found
that molesters of youth had distinctly unique neuropsychological variables compared to other sexually
active clergy. This is consistent with the findings of
Langevin et al. (1987) on pedophiles in the general
population and Langevin and Watsons (1996) study
on clerics who commit sexual offences, as well as on
sexually offending physicians (Langevin, Graham
Glancy, Curnoe, & Bain, 1999). Studies have revealed
that substance abuse, endocrine disorders, and neuropsychological factors may be disinhibiting factors in
those whose sexual preference is deviant, resulting in
the acting out of fantasies (Langevin et al., 1999).
Haywood et al. (1996) suggest that cleric child
molesters are more likely to have been sexually abused
in childhood. They conclude that being sexually
abused in childhood is associated with child molestation in adulthood but is no different when comparing
clerics and nonclerics. In general, their rates of child
abuse among child molesters were significantly higher
than in most other reports (see Marshall & Barbaree,
1990). Bryant (1999) found that 66% of his small
cohort of clergy who had sexually abused had been
sexually abused themselves. However, Langevin et al.

328 SPECIAL POPULATIONS

(1999) dismiss this as an etiological factor. Similarly,

Ruzicjka (1997) found no incidences of sexual assault
in 10 convicted clergy.
While acknowledging the complexity of sexual
offending, Lothstein (1999) cites increasing evidence
of the association between frontotemporal pathology and clergy sex abuse. This is construed by electroencephalogram (EEG) abnormalities supported
by neuropsychological testing. Lothstein argues,
however, that these studies suffer from methodological flaws, which preclude generalizing a causal link
between brain dysfunction and child sexual abuse by
clergy. He also notes that the possible link is further
complicated by the presence and unknown effects
of substance abuse by clergy who offend. Lothstein
recommends that when assessing clergy for brain
abnormalities, those who have a history of hard neurological signs, such as head trauma and seizures,
should be considered to be at high risk for sexual disinhibition and those with a history of soft neurological signs, such as impulsivity, should be considered to
be at lower risk, but still in need of a comprehensive
evaluation to determine actual risk.
Rossetti and Anthony (1996) compared 100 samesex priests who had abused adolescents with the purpose of constructing and validating an MMPI-II scale.
Rossetti constructed a 23-item scale and was able
to statistically differentiate the same-sex hebephiles
from controlled groups who were being evaluated for
nonsexual psychiatric disorders as well as a normative
sample. Plante (1996) could also differentiate priests
who sexually abuse minors from nonabusing controls
on the overcontrolled hostility scale of the MMPI
and by using verbal intelligence quotient (IQ), which
approached statistical significance.
Falkenhain (1998) examined the MMPI-II profiles
of 97 Roman Catholic priests and compared them to
a population of secular childhood sexual abusers.
By using a method to delineate clusters, Falkenhain
found a sexually and emotionally underdeveloped
cluster, a significantly psychiatrically disturbed cluster,
a defended characterological cluster, and an undefended characterological cluster.
The findings noted used sensitive phallometric
testing administered by an experienced expert and/or
standardized measurements for data collection, but
it is interesting to note the self-reported sexual preferences of priests. For instance, a study often cited
(Staff, 1999) notes that 83% of priests consider themselves heterosexual and 17% consider themselves

homosexual. McGlone (2001), in a study of 80 priest

volunteers, notes that 60% considered themselves
homosexual, 31% heterosexual, and 9% bisexual.
According to Scheper-Hugues and Devine (2003),
the majority of priests who assault young boys are not
homosexual in orientation or preference, but rather,
they are more likely sexual immature, regressed, or
sexually adolescent males (p. 27). Although this article is filled with polemic and invective, the authors
fail to provide real scientific information to back
claims being offered.
Interpersonal Factors
Plante and Daniels (2004) report that there is no evidence to suggest that Catholic priests are more likely
to sexually offend against children than clergy from
other religious traditions or men in general. Based
on these findings, they argue that allowing clergy
to marry or engage in sexual relationships with consenting adults would not significantly reduce clergy
abuse. Fones et al. (1999), however, studied the sexual struggles of 19 clergy and found that these men
wanted to be known by others beyond their role of
clergy and that they felt isolated from others and had
feelings of loneliness (Table 23.2).
Scholars have also reported that a combination of
loneliness and social isolation were common complaints among the clerics in their studies (Cowan
2002; Langevin et al. 1999). This data, supported
by empirical research conducted on sex offenders
within the general population, finds sex offenders
scoring lower on measures of intimacy and higher on
measures of loneliness than nonoffending males in
community comparison groups (Garlick, Marshall, &
Thornton, 1996; Seidman, William, & Stephen,
1994). Markham and Mikail (2004) suggest that
these empirical results match their clinical experiences as they find that the majority of clergy child sex
offenders have a high prevalence of loneliness, lack
table 23.2 Etiological FactorsInterpersonal
Wish to be known beyond their role to others
Few friends of their own age
Loneliness
Relationships with youth
Power-over in relationships
Lack of boundaries in relationships

SEXUAL ABUSE BY CLERGY

rewarding close adult relationships, and often have an

overidentification with the clerical role.
In Kennedys (1992) study, 57% of clergy were
considered to be emotionally underdeveloped. From
an attachment perspective, when strong emotional
bonds are not established, individuals experiencing
some loss or emotional distress are more likely to act
out as a result of loneliness and isolation (Markham &
Mikail, 2004). Cowan, for example, notes that in
a study of three Protestant male clergy who had
offended against adult females, these men reported
maternal and paternal abandonment and a lack of
childhood play (Cowan, 2002).
Extensive empirical research has demonstrated
that child sex offenders exhibit a compromised capacity to form intimate relationships (Markham & Mikail,
2004). Marshall (1989), for example, found that men
who abuse children often have not developed the
social skills and self-confidence necessary for them
to form effective intimate relationships with peers.
Kennedy (1992) reports that clergy in the sample were
more comfortable with relationships with teenagers,
had fewer friends their own age, and used intellectualization as a coping device in relationships. Based
on a qualitative analysis, Bryant (1999) found that the
majority of clergy sex offenders in the study claimed
they were heterosexual rather than homosexual in
orientation and that these clergy cited a variety of circumstances to explain choosing male victims, including access to teen boys, discomfort with women, and
fear of pregnancy. Bumby and Hansen (1997) also
found that child sex offenders expressed higher levels
of fear of intimacy than other sex offenders.
Systemic Factors
Lack of openness in Church: McGlone (2003)
reports on the many writers who have chronicled
sexual abuse by clergy within the Church and has
noted a history of unintentional and intentional neglect and ignorance on the part of the Church leaders
to confront the problem of sexual abuse (Table 23.3).
Jenkins (1996) states that the problem of sexual abuse
has been obscured by the divergent political agendas
of the Church leaders who want to bury the problem
instead of taking proactive steps in trying to screen,
prevent, and deal with cases of abuse. Plante and
Daniels (2004) further note that the Catholic Church
has had a history of acting in a highly defensive manner regarding sexual abuse by clergy. They note that

329

table 23.3 Etiological FactorsSystemic

Lack of openness in Church
Clericalism
Seminary training
Insularity
Lack of training in boundaries and sexuality
Lack of clear ethical codes
Lack of supervision
Celibacy

the Catholic Church has not always treated victims

and their families with understanding and compassion. In addition, the Catholic Church has been unwilling or unable to sponsor and lead genuine research
in the area of sexual abuse (Loftus, 1999; Plante,
1999). Sipe (1999) argues that the Churchs history of
secrecy concerning sexual matters is intertwined with
the Churchs lack of information about sexual abuse
against children. He contends that this combination
of missing information and secrecy has contributed
to the Churchs failed attempts to manage sexual
abuse by using methods that were counterproductive to healing, which included (1) the reassignment
of priests; (2) sending them on a retreat to repent for
their sins; or (3) sending them to a psychiatric institution run by the Church (Table 23.3).
Clericalism: Doyle (2003) explains that clericalism represents a policy of maintaining or increasing the power of the Church. This policy has
contributed to a power imbalance between individual
clerics and their parishioners. When these hierarchical relationships exist, whether perceived or real,
the potential for abuse of power is present (Robison,
2004). The notion of clericalism is especially important to the study of sexual abuse by clergy, given that
clergy lack ethical codes or guidelines that guide
behaviors protecting against abuses caused by power
differentiations.
Seminary training: Carnes and Delmonico (1994)
notes the inadequacy of the seminary model of training in critical areas of sexuality, which then heightens
the possibility of future sexual misconduct. Irons and
Laaser (1994), for example, studied 25 clergy who had
been referred for sexual misconduct and found that
they had little insight into the areas of abuse, did not
appreciate how their own history of trauma might
affect their professional life and had a lack of training
in the issue of transference and countertransference.

330 SPECIAL POPULATIONS

They further found that clergy had little training

or education regarding sexual abuse, domestic violence, addictive diseases, and healthy professional
boundaries.
Norris (2003) discusses the role of forensic psychiatrists in developing preventative training programs
and consulting with the Church, which is consistent
with Plantes (1996) plea that mental health professionals become involved in this issue. It is important
for any program therefore, to include training on
boundaries, healthy sexuality, and learning about
individual coping mechanisms as well as spirituality. These programs should address primary prevention of clergy sexual abuse if delivered to receptive
vessels. Receptivity of the seminary students can be
increased with greater accuracy by careful screening
of applicants.
Lack of clear ethical codes: Sipe (1999) notes
the absence of clear ethical codes for the clergy.
Although he acknowledges that the Canon Code is
quite explicit, this has never been translated into a
clear ethical code that could become a guiding document and then taught and discussed in seminary
training. Robison (2004) also highlights the lack of
written rules to govern clergy conduct and behaviors
and suggests that this lack of codes has been a contributing factor in the misuse of power in religious
institutions. Robison observes that the role of clergy
within the Church is set up for dual relationships
between clergy and parishioners. For example, clergy
must ensure professional distance while also being
expected to participate and engage in social activities with the parishioners. Given the lack of clear
relationship definitions and the feelings of loneliness
expressed by many clergy, they are particularly vulnerable to boundary violations when seeking emotional support from their parishioners. Calling for the
need of clearly defined ethical codes, Lebacqz and
Barton (1991) note that notions of mutuality are missing in the clergyparishioner relationship given that
parishioners share deeply personal information with
the clergy but this sharing is not reciprocal, thereby
creating power imbalances.
Lack of supervision: Sexual addiction has been
linked to high demanding jobs with little structure or supervision (Carnes, Delmonico, Griffin, &
Moriarty, 2001). According to Saradjian and Nobus
(2003), the most pervasive systemic problem of
sexual abuse within the Church is reflected in the
Catholic Churchs inadequate response in dealing

with the clergy who abuse children and in the lack

of supervision of the clergy to prevent abuse. They
report of clergy simply being moved from a parish
when accused of sex abuse, thereby exacerbating the
problem by providing them with further opportunities to offend against more unsuspecting victims and
their families. They report that the Catholic Church
in the Unites States, Canada, and Europe has since
acknowledged these problems.
To demonstrate the impact of this systemic problem, Saradjian and Nobus (2003) used a grounded
theory approach to investigate cognitive distortions
in self-report statements of 14 clergy who had sexually abused children and found that the Churchs
inadequate dealings of the accused clergy offenders
(Plante, 1996) contributed to the offenders perception of an approval of higher allegiances (Thomson,
Joseph, & David, 1998). Saradjian and Nobus (2003)
found that offenders attributions related to not getting caught, which only served to increase the likelihood of subsequent offenses and to provide the
clergy with accessto more unsuspecting children.
Plante and Daniels (2004) emphasize that not all
church jurisdictions have dealt with clergy abuse in
the same manner, but these experiences have been
true for many.
Vow of Celibacy: Gregoire (2003) argues that it
is not the task of therapists to debate the relevance of
clergy celibacy, but rather to increase the therapists
sensitivity to the culture of celibacy so as to implement better informed treatment strategies for celibates when dealing with issues of sexuality. Adams
(2003) suggests that mental health professionals have
historically failed to address issues of celibacy in treatment with clergy because of its connection with the
Church. He argues that celibacy should be explored
on an individual level to determine whether its potential implications for abuse and whether celibacy itself
has causative or aggravating factors related to the
offense. Adam further suggests that the issue of celibacy is a critical point of treatment for clergy given
their internal struggles between coming to consciousness regarding their sexual feelings and behaviors and
the violation of their vows of celibacy by exploring
healthy forms of sexual expressions.
Gregoire (2003) gives a readable explanation
regarding the history and meaning of celibacy and
points out that celibacy is practiced by different religious and nonreligious groups. In the religious context, celibacy is believed to help in the advancement

SEXUAL ABUSE BY CLERGY

toward spiritual enlightenment and salvation.

However, the definition of celibacy is imprecise.
Some regard celibacy as a commitment to remain
unmarried and others regard celibacy as a voluntary
renunciation of genital sex. Sipe (1995) argues that it
is this imprecision that leads to ambiguity, a lack of a
clear definition of clergy abuse and subjective interpretations of what it means to be celibate.
For many clergy, vows of celibacy are no easier
to keep than vows of faithfulness and loyalty among
the married (Rossetti & Lothstein 1990; Thoburn &
Balswick 1994; Young, Eric, Al, OMara, & Buchanan,
2000). Sipe (1999), for example, found that only 2%
of his cohorts of about 1300 Catholic clergy were
genuinely celibate, another 20% desperately tried to
maintain celibacy, and about 80% of the clergy in the
sample were not celibate. Gregoire (2003) also notes
that 50% of vowed celibates are involved in long- or
short-term relationships.
Relating the issue of celibacy and sexual abuse
by clergy, Adams (2003) poses a bipartheid question.
Firstly, Do individuals with vulnerable sexual problems choose the priesthood as a refuge? The second
question is Does celibacy lead to sexual abuse?
He argues that the answer is yes to both questions. He believes that young men chose priesthood
before conscious acceptance of their own sexuality.
Sexuality is not integrated into a priests identity. As
such, the expression of sexuality is disassociated from
the value system of the moral governing self. Sexual
feelings generate feelings of loss and result in resentment and entitlement. Lothstein (1999) reports on
the belief system of a number of priests who did not
view sex with men or boys as violating their vow of
celibacy.
Langevin et al. (1999) suggest that many offending clergy have a sexual preference for minors, which
is presumed to have started in adolescence. This supports the theory that is borne out of personal experiences where many priests enter the clergy to seek a
refuge from anomalous sexual urges. They believe
that celibacy has a magical way of protecting them
from acting out their fantasies. However, when certain disinhibiting factors such as neuropsychological damage, endocrine disorders, or substance abuse
collide with loose boundaries and opportunity, the
stage is set for sexual abuse. In some individuals,
however, celibacy may contribute to offending and
it is perhaps timely for the Church to examine this
issue.

331

Toward an Etiology Model of Clergy Abuse

The literature review has demonstrated that the path
that leads clergy to sexually offend against children
can vary considerably and the propensity of clergy
abuse can be explained by the interrelationships
between intrapersonal, interpersonal, and systemic
factors. As stated previously, empirical research is
limited and many of the studies suffer from methodological flaws. Therefore, it would be premature to
speculate whether certain factors have more predictive value than others in determining the likelihood
of clergy committing abuse. More scientific studies
are needed before such claims can be made. Within
the current state of empirical knowledge, we propose
an overarching etiology model that focuses on the
intersection of intrapersonal, interpersonal, and systemic for the assessment and analysis of clergy abuse.
Within this multilevel framework, each level encompasses major variables located within the available
empirical research.
The model (Figure 23.1) subscribes to the
notion that clergy abuse is caused by a full complexity of factors. Arrows in the model move from both
directions to indicate that it is both the individual
characteristics and the clergys experiences with environmental factors that will determine whether abuse
is more likely to occur. All factors are considered to
interact with the others and the model provides an
etiological factor analysis that addresses the complexities in the field. No single individual factor alone can
determine the likelihood of clergy committing a sexual offense against a child and there remains considerable debate in the field about the potential impact on
many of the factors. For example, much debate continues on whether being a previous victim of sexual
abuse increases the risk of clergy abuse. Some studies found no association between previous abuse and
clergy abuse (Langevin et al., 1999; Ruzicjka, 1997)
while others have found an association between the
two (Bryant, 1999). In this proposed model, we suggest noting past sexual abuse as a possible factor, but
only in combination with other factors at all three levels. Therefore, we put forth this model as a guidepost
approach to help practitioners and researchers consider the full complexity of the intersection between
these etiological factors. We further propose that prevention, screening, and treatment are best achieved by
considering the combination of variables impacting
clergy abuse.

332 SPECIAL POPULATIONS

Systemic
Culture of
denial

Vow of
celibacy

Clericalism

Interpersonal

Power
over in
relationships

Few friends
own age

Intrapersonal

Absence of
ethical codes

Substance
Psychotic
Endocrine
abuse
disorders mental illness
Sexual
deviance

Access to
youth
Lack of
education

History of
Intrapsychic
abuse
problems
Neuropsychological
impairment

Isolation

Rigidity in relationship roles

Lack of
supervision

Inadequate
screening

Church secrecy/
Lack of openness

figure 23.1 An etiological model of clergy abuse: Intersections of intrapersonal, interpersonal, and systemic
factors.
Within this framework, we propose that improvements to the intrapersonal level of functioning (e.g.,
substance abuse treatment, counseling for past abuse,
treatment for personality problems, etc.) will have a
stronger effect if these changes are complimented
with changes to both the interpersonal level (e.g.,
improved social supports, increased flexibility in relationships, etc.) and the systemic level (e.g., ongoing
supervision, increased educational opportunities, a
move toward more openness within the Church culture, etc.). These targeted areas for prevention and
treatment will be examined in further detail within
the chapter.
Typology
Gonsiorek (1999) proposes a typology based on the
observations at a walk-in counseling center in Minneapolis for cases of various types of sexual misconduct.
Gonsiorek points out that within the first group
of nave offenders, clergy are inadequately trained
regarding ethics, professional conduct, and sexual

information, which sets the stage for poor negotiation

of gray areas in boundary management. By the nature
of the work, clergy are often thrown into positions
where these areas may be difficult. At-risk situations
often occur when the clergy is involved in activities
with adolescent parishioners. These activities often
take place outside of Church and may involve volunteer work, attending peoples houses, or recreational
activities such as camping and trips. One of the particular pitfalls we have seen in our practice is when
clergy begin to form a relationship with an adolescent
male to introduce him to priesthood with the hope
that he will enter priesthood. This type of behavior
may involve dinners at the subjects house and then
weekend or camping trips. These boundary crossings
set the stage for the slippery slope that sometimes
leads to a more serious boundary violation, such as
sexual misconduct (Table 23.4). In the second group
of the normal to mildly neurotic, the clergyman is
often at a crisis in his own life and feels depressed
and isolated. Lacking proper social support, he uses
the parishioner to satisfy his own needs as a person

SEXUAL ABUSE BY CLERGY

table 23.4 A Typology of Sexual Misconduct

Naive
Normal and/or mildly neurotic
Severely neurotic and/or socially isolated
Impulsive character disorders
Sociopathic or narcissistic character disorders
Psychotics
Classic sex offenders
Medically disabled
Masochistic/self-defeating

who listens and helps him. This can proceed to a

romantic relationship. Gabbard (2001) uses the term
love sick when describing physicians in this role. This
appears to be one of the commonest groups of sexually exploitative clergy and generally the prognosis for
rehabilitation is said to be good.
The third group, the severely neurotic, has
chronic moral problems of low self-esteem, personal
inadequacy, and social isolation. Often, they are particularly involved in their work since they have little
else in their lives. Gonsiorek (1999) states that this
behavior tends to be repeated every decade or so, as
their basic character structure is chronically impaired.
Like other professionals who are involved in sexual
misconduct, they are often known as particularly
hardworking, well-liked professionals, known for their
stellar work, dedication, and open-door policies. It is
a regretful paradox that often these most dedicated
professionals, in their zeal to help, allow boundary
crossings to become boundary violations and end up
damaging parishioners instead of helping them.
In the next group, the impulsive character disorders, clergymen generally have legal or interpersonal difficulties in their histories. This group is
rare since it is unusual for a person with this type
of character to complete the training and dedication needed to become a clergyman. However, some
scrape through and once they do, their behavior may
be out of control in a number of contexts. They are
differentiated from the next group, the sociopathic
or narcissistic character disorders, in that the latter
groups behavior tends to be more deliberated and
planned. The sociopathic character disorders are
described as calculating and lacking in empathy.
They may select parishioners who are the most vulnerable and therefore less likely to complain and be
believed.

333

Another rare group is the psychotic group. They

suffer from a serious mental disorder. Once treated,
they generally demonstrate an understanding and
feel remorse. Their prognosis is dependent on the
treatment of the underlying condition.
Another group is the classic sex offender group,
in other words, those suffering from a paraphilia. A
study by Langevin et al. (1999) suggests that paraphilias, mainly, homosexual pedophilia, or hebephilia
is common among clergy who sexually abuse their
parishioners. As part of any reasonable relapse prevention plan, they should only be allowed back into
the profession if they are not allowed access to their
preferred object, most commonly, adolescent boys.
Therefore, they should only be allowed to work
in administration or other positions. Supervision
should be built in for a long period of time, as it is not
uncommon for them to slip back into frontline positions if they are not supervized.
The final group is the masochistic/self-defeating
group. These are people who are unable to resist the
demands of a small group of parishioners and, therefore, their boundaries are eroded. Not uncommonly,
they attempt counseling with parishioners who have
severe personality disorders, which occasionally leads
to romantic and sexual contact with resulting mayhem. They often display other types of self-defeating
behavior such as not collecting their salary and not
taking care of themselves in other areas in their life.
This group represents a high proportion of sexual
offenders.

PR EV EN T ION A ND SCR EENING

Davis (1998) notes two factors that need to be

addressed in what he refers to as clergy sexual addiction. These are the environment in which the clergy
are required to work and the demands made on them
as individuals.
Regarding the environment, he stresses the clergys unclear boundaries that are repeatedly alluded to
in this chapter. This results in role confusion. The
clergy have little structure and supervision, yet the
expectations placed upon them are unrealistically
high. First of all, they act as caregivers, a fact that
makes it difficult for them to ask for or receive care.
Secondly, they are expected to be both perfect and
godly and live their lives effectively in a goldfish bowl
scrutinized by the whole community. Davis asserts

334 SPECIAL POPULATIONS

that as a result, they cannot be truly themselves. They

become personally and professionally isolated and
cannot deal with their inner shame. He advocates that
early boundary violations should not be swept under
the carpet but should be addressed in the climate
of openness. Priests should be educated at an early
stage, presumably in the seminary, to explore sexual
issues and connection with others, thereby breaking
their feelings of shame and humiliation.
Once in practice, their emotional and physical isolation should not be allowed to fester. Davis advocates
for support groups after graduation, which encourages
openness and accountability. Likewise, Delmonico
(2003) calls for openness within the Church, formal training on professional and sexual boundaries,
and avenues for help, guidance, and self-care for the
clergy.
In a chapter on the prevention of clergy sexual
abuse, Sipe (1999) complains of the lack of methods in screening out possible sex offenders from
candidates to the priesthood. Glancy and Langevin
(2002) in a proposal that was eventually put before
the Canadian Conference of Bishops argue that
there are well-established tests that can be used for
screening, and would be no more expensive than
methods used thus far. Evidence suggests that the
MMPI can not only be used to identify a significant
number of those that sexually abuse but is also useful for identifying serious psychopathology and personality disorders and for screening those who are
likely not ideally suited for such a responsible profession. In addition, the Wechsler Adult Intelligence
Scale (WAIS) would point to neuropsychological
factors that in association with other pathology
might raise some red flags (Camargo, 1997). Most
particularly, we advocate the use of the Abel Screen
(Johnson & Listiak, 1999). This is a computer-based
test that measures reaction time to a variety of stimuli. It has been demonstrated to have acceptable
psychometric properties and due to the fact that no
sexually explicit images are used, it is something
that does not cause any moral dilemmas. We would
also advocate the use of a questionnaire that looks
at the presence of sexual deviation and sexual functioning such as the Sexual History Questionnaire
(Paitich, Langevin, Freeman, Mann, & Handy,
1977) as well as screening for substance abuse. This
screening would be associated with criminal background checks, reference checks, and a personal
interview. A further safeguard would be to ensure

close supervision and support for all new clergy

admitted to the seminary.
Davis (1998) argues for an in-depth examination
of professional ethics. Sipe (1999) decries the lack
of professional ethical standards available to priests.
Many professional bodies (Law Commission of
Canada, 2000) have set out clear ethical standards
and procedures for their professions that delineate
clear boundaries, openness, and accountability. We
would argue that the Church needs to parallel such
developments even at the expense of limiting the
type of work the clergy are able to do and the circumstances in which they can complete their work.
Traditionally, priests have been expected to enter into
the community and practice in all sorts of settings.
This may not be appropriate, given the crisis in which
the Church finds itself.

T R E AT MEN T PROGR A MS

Marshall (1999) advocates the establishment of treatment centers for offending clergy. His model incorporates a standard relapse prevention model with some
of the components noted that are specific to clergy.
He also discusses the importance of ongoing supervision and follow-up of clergy offenders. It is our experience that clergy can respond to a relapse prevention
approach similar to that used in other sexual offenders.
This is the only method of treatment that is evidence
based (Marshall, 1999) for offenders and is widely used
across the world. These programs are based on cognitive behavioral therapies and are generally delivered as
part of a multimodal problem. Cognitive behavioral
programs lend themselves to adjunctive treatment
such as the use of sex drivereducing medications
(Bradford, 2000). In addition, empathy training is
generally included as a type of victim sensitization
(Regehr & Glancy, 2001) (Table 23.5).
table 23.5 Ongoing Training
1. Ongoing supervision and training in
boundaries
2. Ongoing dialogue regarding healthy
general and individual sexuality
3. Ongoing availability of support regarding
intrapsychic issues
4. Ongoing supervision and dialogue
regarding spirituality

SEXUAL ABUSE BY CLERGY

Bryant (1999) describes a program called Victim

Sensitive Offender Therapy that comprises many of the
elements in a multimodal relapse prevention program.
He emphasizes the perpetrator accepting responsibility for his actions and the harm that it caused to his
victims. Following victim sensitization, the offender
learns to understand his offence cycle and prepares
a relapse prevention plan. Echoing many others in
the field, Bryant advocates the long-term execution
of such a program to reflect the chronic nature of a
paraphilia.
Another facet of the program works on addressing
cognitive distortions, which is common in thinking
about sex offenders in general and clergy in particular (Sheldon & Parent, 2002). These disturbances
may be a function of a lack of sexual knowledge,
social knowledge, or education and discussion of
sexual matters.
Laaser (Laaser & Gregoire, 2003) advocates a
similar model to any sexually addictive client involving inpatient or intensive outpatient treatment as well
as individual and family therapy. He quotes Carnes
model of recovery, which contains educational,
behavioral, and psychodynamic components as the
most effective form of treatment. He discusses the
issue of whether the group should be homogeneous
for clergy or a mixed group (Laaser, 1991).
Nunez (2003) takes homogeneity a step further in
describing an outpatient group, based on a 12-step
recovery program, comprising of clergy hebephiles
only. Laaser and Gregoire (2003) discusses countertransference issues that can sabotage therapy unless
addressed. He also stresses vocational guidance
since many offenders will be voluntarily or involuntarily leaving the clergy and venturing into the
secular world. Like others before him (Hudson,
1997), he stresses spiritual direction and counseling. He also notes the emotional abandonment felt
by many of these people, urging maximal long-term
support in conjunction with ongoing monitoring and
surveillance.
Adams (2003) suggests that one facet of treatment
should be to increase awareness of issues within the
perpetrators background so that they can understand their own individual personality and sexual
problems. He also advocates exploring the role of
celibacy within their lives as well as the meaning
of this concept. Alvarez (2003), in discussing clergy
who have had problems with what he describes as
sexual addiction, not necessarily sexual molestation

335

of minors, urges addressing issues of theology and

values when working with clergy who are at a stage
where they are yet to assault anybody. In this way,
he suggests that an understanding of healthy sexuality, as discussed in his article, will help clergy resolve
many of their early sexual issues (Alvarez, 2003). It
is possible that if this is affected either in training or
early in a career, this can prevent future and more
serious sexual misconduct.
Gregoire (2003) makes the extremely important
point that early indicators or anomalous sexual preference should lead to the decision to remove the
clergyman from the ministry and moved into a more
appropriate career that does not involve any contact with or power over minors. This is particularly
important, as we have discussed earlier, in that some
clergy believe that a celibate life will miraculously
solve their sexual problems or alter their sexual orientation. The Charter for the Protection of Children
and Young People by the United States Conference
of Catholic Bishops (2005), mandate that the goals
of treatment when dealing with Catholic priests can
no longer include a return to the ministry. Therefore,
Songy (2003) urges the consideration of alternative
goals, presumably together with vocational guidance.
He urges treatment programs to consider reclaiming
the sacrament of priesthood. He argues that as priests
reclaim their pastoral sensitivity they will devote more
of their prayer to the mental and spiritual health of
their victims and the healing of the Church. However,
it is argued that relapse prevention programs should
address the particular sexual misconduct and this can
be affected in conjunction with other therapists who
address spiritual issues.
Irons and Laaser (1994), based on a large clinical experience, assert that restoration is possible.
They advocate 2 to 3 years of treatment plus ongoing
monitoring. However, they do not state that a career
change may be necessary. It would be our opinion,
that, based on the principles of relapse prevention,
it is likely not possible for a clergyman to be restored
to his previous position wherein he has power and
control over minors. He should be moved to a clerical position. It should be noted, however, that there
have been instances in our experience where this
has led to slippage, whereby the priest starts doing
occasional work with the community that exposes
minors to him and, therefore, puts the community at
risk. Repeated monitoring should carefully safeguard
against this.

336 SPECIAL POPULATIONS

F U T UR E DIR ECT IONS

Plante (1999) and colleagues suggest eight directions,

which have been outlined by Plante and Daniels
(2004). We present these eight directions and add
our own emphasis to better address sexual abuse by
clergy.
1. Accept and understand the facts. Plante (1999)
and colleagues state that we must deal with
clergy abuse guided by reason and compassion
rather than bias and hysteria. We must collect
all of the available data and let the facts inform
our thinking in order to deal more effectively
with the prevention and treatment of sexual
abuse by clergy.
2. Treat offending clergy. We have reviewed presented existing treatment available for clergy
who sexually abuse. It is important that clergy
are given the opportunity to attend treatment
and that they are supported through this
process.
3. Collaborate between mental health and church
professionals. We have alluded to this earlier.
Mental health and church professionals should
come together with a clear mandate to protect
and prevent future clergy abuse by ensuring
that all clergy receive adequate training and
support. Furthermore, offenders or those who
are at high risk of offending should be effectively diagnosed and treated.
4. Treat victims. Victims and their families need
both validation and treatment. Victims should
be offered counseling and support.
5. Share Data. Data obtained by the Church and
treatment facilities should be made available
to each other and to researchers to develop a
more comprehensive understanding of clergy
abuse. Plante and Daniels (2004) point out that
far too many researchers have been unable to
study these problems because of a general lack
of cooperation from the Church.
6. Develop clear policies for intervention. Sipe
(1999) notes the absence of clear ethical codes
that could form guiding policies. Plante and
Daniels (2004) suggest that national and international standards could be developed and
issued by the Church in collaboration with appropriate mental health and legal professionals.
7. Train and support clergy. Delmonico (2003)
notes the inadequacy of the seminary model
of training in critical areas, which prepares the
ground for sexual misconduct. Clergy need
training and supervision to ensure health;
personal and professional boundaries are both

understood and maintained. Clergy also need

ongoing support regarding issues related to sexuality, sexual expression, and celibacy.
8. Practice what you teach. Plante and Daniels
(2004) call for common sense and compassion
instead of the recent hysteria and demonization
of the clergy in the media.

CONCLUSION

We believe that further empirical studies are needed

to address current gaps in the knowledge base of sexual abuse by clergy. We agree with McGlone (2003)
that the collection of both preliminary and descriptive data is essential to advance our basic understanding of clergy abuse. We have also proposed a model
that includes etiological factors found within existing scholarly work. Future research should test the
proposed model by conducting multivariate analysis
to determine whether a hierarchy of variables can
be used to better screen and assess the risk of clergy
abuse.
We agree with the pleas from Plante and Daniels
(2004) that mental health professionals should
become more involved with the prevention, screening, and treatment of clergy who sexually abuse. As
they point out, many of the experts of sexual offences
toward minors are psychologists and other mental
health professionals (Daw, 2002; Rossetti, 1996).
Therefore, psychologists and counselors have the
interest and skill to help consult and manage these
issues working closely with Church officials, offending clergy, the media, child protective services, law
enforcement, abuse victims and victim groups and
the Catholic laity (Plante & Daniels, 2004).
We also suggest that scholarly clinical researchers
are required to become more involved in the study
of clergy abuse and should take on a more predominant role in these research activities. Future research
to advance current knowledge on the etiological factors, preventions, and treatments of sexual abuses by
clergy should utilize generally accepted scientific
procedures and standardized methodologies to eliminate potential bias. Although important in all fields
of study, researchers need to be aware of the political, religious, and social implications of their work
and should guard against these forces to ensure that
future work remains uncontaminated.
Given the current crisis in the Roman Catholic
Church and other denominations, Church leaders

SEXUAL ABUSE BY CLERGY

ought to inspire themselves and others to become

active participants in the process of scientific discovery to ensure the cultivation of reliable information
to help and treat the clergy who abuse. Religious
leaders could facilitate a culture of openness, thereby
breaking down current barriers for sample recruitment strategies, as an example. Becoming more
open to scientific research has many benefits for the
Church and its clergy. First, a move toward openness
would demonstrate a genuine eagerness to address
the Churchs current crisis. Second, by participating
in research, validity and reliability of data collection
would be improved because the data would become
more representative of the clergy population. Third,
empirical results can demystify current inaccurate
portrayals of clergy in the general public, such as all
clergy are pedophilic priest (Jenkins, 1996). Lastly,
by increasing openness and involvement, Church
leaders position themselves as active players in the
search of effective solutions to prevent abuse and
develop evidence-based interventions to treat those
clergy who commit sexual abuse against children.
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Chapter 24

Manifestations of Sexual Sadism:

Sexual Homicide, Sadistic Rape,
and Necrophilia
Stephen J. Hucker

This chapter reviews a very wide range of sexually

anomalous behavior that has been subsumed under
the term sexual sadism. At the one end are individuals
who engage in unusual but consensual sexual activities in private and commit no crime. Typically they
do not regard themselves as either sexually deviant
or criminal in any way. At the other end of the spectrum are behaviors that are criminally proscribed and
viewed with revulsion by all but most of the offenders
themselves.
The issue of where normal ends and the pathological begins is always contentious in the area of
sexual anomalies or paraphilias and no more so than
in the topics of sadism and masochism, known in
some circles as S & M bondage and domination
and similar terms. No position is taken here on that
issue but rather they are treated as phenomena for
observation and study. The extreme forms however
justify medical or other professional concern and
intervention and these are outlined.

HISTORY OF THE CONCEP T

History records possible examples of notorious criminals, whose crimes may have represented sexually
sadistic behavior, including Gilles de Rais in the
fifteenth century, who raped and murdered innumerable children, and Elizabeth Bathory, in the seventeenth century, who tortured young girls and drank
their blood.
Richard von Krafft-Ebing is usually credited with
the introduction of the term sadism from the name of
the French nobleman, the Marquis de Sade, whose
erotic novels clearly depict humiliation of women and
cruelty towards them. Psychopathia Sexualis (KrafftEbing, 1886) contains descriptions of all manner of
sexually sadistic behavior and has remained a classic
account of the phenomenon. Before Krafft-Ebings
time, sexual behavior that would today be considered
anomalous, was not considered within the purview
of medicine but rather a matter of moral or criminal

340

MANIFESTATIONS OF SEXUAL SADISM

concern. As one of the leading psychiatrists of his day

and, one who took part in the development of forensic
psychiatry in Europe and testified regularly in court,
he thus came to influence the perception of abnormal sexual behavior, including homosexuality, in a
more humane way that could potentially benefit from
medical understanding and intervention (Oosterhuis,
2000).
For Krafft-Ebing the cardinal feature sadism was,
the experience of sexual, pleasurable sensations
(including orgasm) produced by acts of cruelty,
bodily punishment afflicted on ones person or
when witnessed by others, be they animals or
human beings. It may also consist of an innate
desire to humiliate, hurt, wound or even destroy
others on order, thereby, to create sexual pleasure
in oneself (Oosterhuis, 2000, p. 109).
The emphasis on infliction of pain was also central to the concept of algolagnia (literally paincraving) introduced by Schrenck-Notzing (1895)
and which he subdivided into active (sadism) and passive (masochism) forms. Eulenberg (1911) included
psychological pain in the form of humiliation in his
conceptualization, as did Krafft-Ebing.
Further expansion of the concept occurred under
the influence of psychodynamically oriented writers.
Thus, Karpmann (1954, p. 10) observed that in the
sadist, the will to power is sexually accentuated . . . he
revels in the fear, anger and the humiliation. Pain is
not as important in itself but because it symbolizes
power and control over the victim. Expanding on this
idea, Fromm (1973) suggested that the
core of sadism . . . is the passion to have absolute and
unrestricted control over living beings . . . whether
an animal, child, a man or a woman. To force
someone to endure pain or humiliation without
being able to defend himself is one of the manifestations of absolute control, but it is by no means
the only one. The person who has complete control over another living being makes this being
into his thing, his property, while he becomes the
other beings god (pp. 383384).
This eroticization of feelings of power and control
has also been emphasized by other writers (Brittain,
1970; MacCulloch, 1983; Myers, Burgess, Burgess, &
Douglas, 1999).

341

The current official classification systems adopt

a more limited view. Thus, ICD-10 (World Health
Organization, 1992) defines sadism as the preference
for sexual activity that involves bondage or infliction of
pain or humiliation and the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; American
Psychiatric Association) requires, inter alia, psychological or physical suffering including humiliation of
the victim to cause sexual excitement in the sadist.
As will be discussed subsequently, however, experience has shown that these definitions have proven
very difficult to apply in practice with the result that
even experienced clinicians appear to employ criteria,
whether official or idiosyncratic, quite inconsistently.

PR EVA LENCE

Given the problems of diagnostic consistency to be

discussed presently, the data that have been offered in
the literature on the frequency of sexual sadism have
to be viewed with considerable skepticism, a point
emphasized by Marshall with respect to offender
populations (Marshall & Kennedy, 2002). KrafftEbing (1886) suggested that sadistic acts were more
common among men and argued that subjugation of
women was a natural propensity of men. It is therefore paradoxical that, in modern times, commercially
produced sadomasochistic pornography commonly
portrays women as the dominatrix (Weinberg, 1987)
although typically these women are prostitutes catering to masochistic men (Breslow, Evans, & Langley,
1985, 303317).
In their now classic study, Kinsey et al. (1953)
reported that between 3% and 12% of women and
10% to 20% of men admitted to responding sexually
to sadomasochistic narratives. Crepault and Couture (1980) found that 14.9% of men in a sample from
the general population reported fantasies of humiliating a woman and 10.7% of beating up a woman.
While Arndt et al. (1985) also found that about a
third of women and about 50% of men had sexual fantasies of tying up their partner, it does not seem likely
that this represented their preferred sexual outlet but
rather was simply part of their sexual repertoire.
Similarly, a survey of the covers of pornographic
magazines (Dietz & Evans, 1982) noted that 10%
to 20% of them illustrated bondage and discipline
themes.

342

SPECIAL POPULATIONS
SA DISM, M ASOCHISM, A ND OTHER
PA R A PHILI AS

Stekels (1929) further elaborations of the concepts of

sadism and masochism and their clinical features led
to their increasingly wide acceptance of these terms
among clinicians. However, as already noted, the varied definitions of the terms make it sometimes difficult
to determine whether a case described by one author as
a sadist would necessarily be accepted by another as
qualifying for that term. Such problems aside, sadism
and masochism have been regarded as complementary
anomalies or separate poles of the same disorder (e.g.,
Karpmann, 1954). Supporting this idea is the finding
that individuals who report masochistic fantasies are
also likely to report sadistic fantasies as well (Arndt
et al., 1985) and the survey by Spengler (1977) of selfidentified sadomasochists found that 29% alternated
between the two roles. Hucker and Blanchard (1992)
noted also an association between asphyxiophilia
(an expression of extreme masochism) and sadistic
murder (Smith & Braun, 1978).
It is now well-recognized that paraphilic diagnoses
tend to overlap in the same individual, with an average of two or three diagnoses being present. In one
study, 18% of sadists were also masochistic, 46% had
raped, 21% had exposed, 25% engaged in voyeurism
and frottage, and a third in pedophilia (Abel, Becker,
Cunningham-Rathner, Mittelman, & Rouleau,
1988). Similarly, other authors have noted particularly
an overlap between sadism, masochism, fetishism,
and transvestism (Gosselin & Wilson, 1980) in selfidentified sadomasochists and among serious sadistic
offenders, transvestism and fetishism is also strongly
represented (Dietz et al., 1990; Prentky, Cohen, &
Seghorn, 1985).

SA DIST IC PER SONA LIT Y DISOR DER

Not all those who engage in cruelty, torture, and

similar behavior are sexually aroused by the activity
(Dietz et al., 1990). The type of person who deliberately behaves in this way but who derives no apparent
sexual pleasure from it had received some attention
in the psychiatric literature, notably from psychoanalytic writers (Kernberg, 1970; Schad-Somers, 1982),
who delineated the central features of a sadistic
personality disorder that became incorporated into
DSM-III-R.

Berner et al. (2003) found a much greater number

of individuals with the diagnosis of sadistic personality disorder in their forensic settings than in the general population. Also, using DSM-III criteria with a
sample of 70 incarcerated sex offenders Berner et al.
found that the diagnosis of sadistic personality disorder was made in 68% of sadists and 32% of nonsadists, those groups also being identified using strictly
applied DSM-III criteria. They suggested a dimensional model for the diagnosis of sexual sadism may
also be more appropriate.
However, it has been found that there is considerable overlap between sadistic personality disorder and
with the narcissistic and antisocial personality disorders, in particular, and it did not appear in DSM-IV
as a separate diagnostic category.
Types of Sexual Sadism
Krafft-Ebing himself described no less than eight subtypes of sexually sadistic behavior including lust murder (in which sexual arousal is intimately linked to the
act of killing), necrophilia, injury of women by stabbing or flagellation, defilement of women, other types
of assaults on women causing indirect harm (such as
cutting off their hair), whipping of boys, sadism toward
animals, and sadistic fantasies without any actual
acts. Later, Hirschfeld (1956) made a simple distinction between major (including lust murder, necrophilia, and stabbing) and minor sadism (the rest of
Krafft-Ebings categories, as well as humiliation of a
consenting partner using bondage, mild flagellation,
submission, or degrading acts). Individuals who participate in voluntary, consenting acts of minor sadism,
either as recipients or perpetrators, often refer to the
activity as bondage and discipline, dominance
and submission, or sadomasochism (Gosselin,
1987; Weinberg, 1987). The dominant partner places
the submissive partner in a situation of helplessness
and applies some form of discipline or punishment,
typically accompanied by verbal degradation. Pain,
humiliation, bondage are administered and there may
also be whips, or fist insertion into the anus or vagina.
Roles of masterslave, governesspupil, and so on are
used to ensure a tone of humiliation and debasement,
along with cross-dressing, treating the submissive like
an animal, sometimes urinating (water sports) or
defecating on his or her body. Further humiliation
may be added by forcing the person to wear diapers or
to lick the dominants boots. Flagellation or flogging

MANIFESTATIONS OF SEXUAL SADISM

is applied typically to the buttocks while bindings,

including gags or blindfolds, to render the submissive
helpless and unable to move, are also frequently used.
Enemas may be administered so that the submissive
loses control of their bodily functions and their discomfort may be aggravated by forcing them to retain
the enema for prolonged periods.
Although most large cities have networks of individuals with interests such as those just described,
and there are specialized subcultures within homosexual communities catering to sadomasochistic
partnerships, it is difficult to know how many such
individuals progress to more serious major or dangerous sadistic activities though Freund suggested
that this did occur (Freund, Seto, & Kuban, 1985).
Certainly, early detection of major sadism can be difficult, though an obvious priority from the criminal
justice perspective.
An early precursor of later rapists may include
apparently nonsexual offenses, such as break and
enters, during which a rape may occur (Revitch,
1978) and later manifest more obvious major sadistic
behavior. In other cases, of course, the major sadism
may have been present from the beginning but simply not disclosed or detected.
Major sadistic behavior includes piqeurism
where the attacker stabs a female victim, usually in
the buttocks or breast and then runs off (De River,
1958). The rare phenomenon of vampirism involves
the letting of blood by cutting or biting, sometimes
drinking it, accompanied by sexual arousal (Jaffe &
DiCataldo, 1994). Some individuals will take their
own blood for this purpose but, more importantly in
the present context, vampirism is closely related to
necrophilia and lust murder.
Necrophilia and Sadism
Although the term necrophilia appears to describe a
fairly clear-cut sexual anomaly, like the term sexual
sadism itself it has been used in a number of different
ways by different authors including, some cases where
there has been no contact with corpses at all, including neurotic equivalents of necrophilia based on
material derived from psychoanalytic explorations of
conscious and unconscious fantasy material (Calef &
Weinshel, 1972).
Krafft-Ebing (1886) regarded necrophilia as a
manifestation of sadism though Moll (1912) and
Ellis (1936) observed that infliction of pain is not

343

necessarily a feature. Krafft-Ebing was well aware of

this and observed that, in some cases,
When no other act of crueltycutting into pieces,
etc.,is practiced on the cadaver, it is probable
that the lifeless condition itself, forms the stimulus
for the perverse individual . . . the object of desire is
seen to be capable of absolute subjugation, without possibility of resistance.
A strong fetishistic element is obvious in these cases
(Ellis, 1936). Krafft-Ebing cited, from the original
French literature, Bertrand, the Vampire of Paris, and
Ardisson, the Vampire of Muy, as examples of these
kinds of cases.
Like Krafft-Ebing, Hirschfeld (1956) divided
necrophiliacs into those who violated a person who
was already dead and those who sexually abused a
person they had themselves murdered, to possess
and destroy her beyond death (p. 425).
In an extensive review of previously reported and
unreported cases Rosman and Resnick (1989) discriminated between genuine necrophilia, which fulfilled
DSM-III-R criteria, from pseudonecrophilia. True to
the formulae of the manual, they defined the former
cases as those where during the preceding 6 months
the individual reported recurrent, intense urges and
sexually arousing fantasies involving corpses, which
were either acted on or were markedly distressing.
Conversely, pseudonecrophilia included incidental cases in which the subject had sex with the body
without having had any preexisting fantasies of doing
so, necrophilic homicide in which the murderer
killed to obtain a body with which to engage in sexual activity, and necrophilic fantasy of activity with
corpses without any actual activity with them.
Necrophilic behavior can vary from simply being
in the presence of a corpse to kissing, fondling, performing sexual intercourse, or cunnilingus on the
body (Hucker, 1990). In other cases, the behavior is
even more grotesque and involves mutilation (KrafftEbing, 1886) or drinking the corpses blood or urine
(De River, 1958). Pseudo-necrophiles engage in
mutilation and necrophagia (eating body parts) less
commonly than genuine necrophiles (Rosman &
Resnick, 1989).
Of particular concern are those who kill in order to
obtain a body for subsequent violation and for whom
the act of murder generates sexual frenzy (Brittain,
1970; Burgess, Hartman, Ressler, Douglas, &

344

SPECIAL POPULATIONS

McCormack, 1986). In an interesting anecdotal

report (Smith & Braun, 1978, pp. 25968) the subject
needed to have complete control over his sexual partners and had them either simulate death or unconsciousness or strangled them himself. In the total
sample collected by Rosman and Resnick (1989), 42%
had committed homicide though these authors also
note that sadism is not an intrinsic characteristic of
true necrophilia.
Lust Murder and Sadistic Murder
Homicides in which the killer derives sexual pleasure from the act of killing are termed lust murders
(Bartholomew, Milte, & Galbally, 1975, pp. 15263)
and sexual sadism generally appears to underlie the
phenomenon (Brittain, 1970; Dietz et al., 1990;
Ressler, Burgess, & Douglas, 1988). The killing itself
may replace all other sexual activity (Podolsky, 1965).
Many authors have referred to Brittains (1970)
profile of the sadistic murderer though his observations have not been consistently supported (Langevin,
Ben-Aron, Wright, Marchese, Handy, 1998). Brittain
described the typical lust murderer as an overcontrolled, introverted, timid, and socially aloof individual
who appeared to others as prudish and sanctimonious.
Sexually inexperienced, though deeply deviant with
vivid and violent sadistic fantasies, he is described
as vain and egocentric but having a low self-esteem
and his crimes enhance his feeling of superiority and
power that he cannot otherwise attain. Grubin (1994)
reported on 21 men who killed during a sexual attack
and compared them with 121 rapists who did not kill
their victims. Lifelong difficulties with heterosexual
relationships and social isolation were typical of the
sexual killers but Brittains (1970) sadistic murderer
profile was not more common among them.
MacCulloch and his colleagues (1983) also emphasized the importance of fantasy as a precursor to these
offenses as have other workers (Burgess et al., 1986;
Ressler et al., 1986; Prentky et al., 1985; Proulx, Blais,
& Beauregard, 2005). Some offenders reveal their fantasies upon direct questioning whereas others reveal
them indirectly in their drawings, writings, videotape
collections, and libraries. It needs to be remembered
that the kinds of imagery that appeals to sadists is
not necessarily obviously pornographic to others. It
has been noted that detective magazines, Soldier of
Fortune, and similar publications may be preferred
(Dietz, Harry, & Hazelwood, 1986, pp. 197211).

The U.S. Federal Bureau of Investigations

Behavioral Science Unit has provided the material
for some of the most detailed work on sexual sadists
published so far, on the basis of their extensive, worldwide consultations (Dietz et al., 1990). Their 30 cases
were all males, most were white, and almost half were
married at the time of their crimes. Forty three percent had a history of homosexual experience, 20%
crossdressed, and 20% had a history of other sexually
anomalous behavior. Approximately half had parents
with a history of marital infidelity or divorce. Twenty
three percent reported they had been physically
abused, and 205 reported that they had been sexually
abused, as children. Half had had no previous criminal record and a number of them had a reputation
in their communities as solid citizens. Half tended
to drive excessively with no clear goal and 30% were
police buffs who collected police-related paraphernalia or modified their vehicles to resemble police
cars. Most had carefully planned their offenses.
Commonly they abducted their victims and held
them captive for more than 24 hours, binding them
up, blindfolding them, and gagging them. The typical activities were sexual bondage, rape, and forced
fellatio though vaginal intercourse and insertion of
foreign objects also occurred. All the victims were tortured and this characteristic was necessary for inclusion in the study and helped all subjects clearly fulfill
DSM criteria. Seventy three percent of the victims
were ultimately murdered. The subjects recorded
their crimes in more than half the cases in diaries,
audio- and videotapes, photographs, and drawings,
and 40% kept mementoes of the victim. Dietz et al.
(1990) also found that 50% had a history of drug abuse
other than alcohol, and the group of Langevin et al.
(1988) found that 75% abused nonmedical drugs and
50% were heavy drinkers.
Proulx et al. (2005) found that sadists were more
likely than nonsadistic sexual offenders to have had a
specific conflict with a woman during the 48 hours
before the offense and to have had conflicts with
women in general. They were also far angrier and
sexually excited, and reported deviant sexual fantasies prior to their offenses. The sadists reported more
often having planned their offense and deliberately
selecting their victim than the nonsadistic offender
controls.
Disturbed parentchild relationships and poor
socialization are commonly noted (Dietz et al., 1990;
Langevin, Ben-Aron, Wright, Marchese, & Handy,

MANIFESTATIONS OF SEXUAL SADISM

1988) and 40% had antisocial personalities with a

strong narcissistic element with a penchant for selfaggrandizement and media hunger (Brittain, 1970).
Dietz et al. (1990) also highlighted the highly narcissistic personalities of these offenders. Proulx et al.
(2005) also described personality features of their
sexual sadists who, in comparison with a matched
group of nonsadistic sexual offenders, showed more
schizoid, schizotypal, histrionic, and avoidant personality features. Brittain (1970) observed an effeminate
tinge in some sadistic murderers and Langevin et al.
(1988) noted their strong tendency to crossdress and
to experience gender dysphoria.
Dietz et al. (1990) reported that more than a third
of their cases had an accomplice in their crimes.
These partners are an interesting group as they illustrate the dominance of one individual over another.
Hazelwood et al. (1993) reported on seven women
who became involved with sexual sadists and who
typically became subjected to a subtle process of
seduction and transformation involving psychological, physical, and sexual abuse until they became
compliant appendages of the sadistic man. In some
cases the degree of compliance and time over which
control was exerted were extraordinary. However,
the extent of their apparent willingness to become
involved in their partners sadistic behavior has sometimes reflected on their own credibility during subsequent testimony against their former partners (e.g.,
Hill, 1995).
In a paper comparing the results of the FBI study
with 29 sadistic and 28 nonsadistic sex offenders
from their own facility, Gratzer and Bradford (1995)
found a number of differences suggesting that the
FBI-identified cases may not be representative of
sexual sadists as a whole and constitute an extreme
group. Indeed, as Marshall & Hucker (in press)
point out comparison of several studies, including these and others done by Marshall in Canada
(Marshall & Kennedy, 2003) show quite striking differences in certain respects suggesting, once again,
that there are sometimes considerable differences in
diagnostic practice that make comparison between
studies somewhat confusing and perhaps less than
meaningful.
There is some evidence of an occasional link
between sexual murder and asphyxiophilia. Two men
who practiced autoerotic asphyxia had also committed sexual murders or had fantasized committing a
murder (Brittain, 1970; Hucker & Blanchard, 1992).

345

Sadistic Rape
It seems clear that rape is a multidetermined phenomenon and rapists do not constitute a homogeneous group (Marshall & Barbaree, 1990). It has been
found that the degree of deviant sexual arousal, as
determined by penile plethysmography, appears to be
associated with the frequency and degree of violence
in sexual assault (Abel, Barlow, Blanchard, & Guild,
1977; Becker, Blanchard, & Djenderedjian, 1978),
suggesting that deviant arousal characterizes the
most violent and habitual rapists. Moreover, as such
people show a strong preference for sexually aggressive stimuli, it seems likely that they prefer such types
of interaction that are sometimes referred to as the
preferential rape pattern (Freund, Scher, & Hucker,
1983, 1984), paraphilic coercive disorder (Abel,
1989), or biastophilia (Money, 1990). These men
are sexually aroused by fantasies and urges of forcing
themselves sexually on their victims.
While the preferential rapist is believed to not
use greater force than is necessary to gain the victims compliance, in contrast, the sexual sadist is
aroused by the use of gratuitous violence (Abel, 1989),
though the offenders estimate of how much force
was required may, of course, be of dubious value.
Preferential rape proneness may involve coercing the
victim into fellatio or submitting to anal intercourse,
behaviors typical of sexual sadists (Dietz et al., 1990).
Also, targeting strangers occurs with both sadists and
preferential rapists. That there may be an overlap
between courtship disorders and sexual sadism is
supported by the observation that, 9 out of 17 serial
sexual murderers also showed evidence of voyeurism, telephone scatologia, or exhibitionism (Warren,
Hazelwood & Dietz, 1996). However, voyeurism
by such offenders may consist of prowling around in
search of a victim to assault and, moreover, the simple
dichotomy between sadistic and nonsadistic rape has
not been supported by the researches of Knight and
Prentky (1990, 1994).
Most researchers report that only 5% to 10% of their
samples of rapists fulfill DSM criteria for sexual sadism
(e.g., Abel et al., 1988) although some have reported figures much higher (Fedora, Reddon, Morrison, Fedora,
Pascoe, & Yeudall, 1992; Hucker et al., 1988). It seems
likely that these discrepancies reflect the fact that
the subjects derived from very different populations,
namely mental health versus correctional, although
it is also likely that different researchers have used

346

SPECIAL POPULATIONS

varying conceptualizations of sexual sadism despite

apparent adherence to official criteria (see subsequent text for further discussion of this issue).
As a group, rapists show greater arousal to nonsexual violence than nonrapists (Barbaree, Marshall, &
Lanthier, 1979; Quinsey, Lalumiere, & Seto, 1994;
Seto & Kuban, 1996), and violent rapists tend to
respond more strongly to depictions of sexual violence
than do comparatively less violent rapists (Quinsey
et al., 1994). However, the absolute value of these
responses is, however, quite small. Moreover, rapists
do not respond significantly more to nonviolence perpetrated by men against other men. These differential
responses with respect to nonsexual violence between
men and women appear to be due to implied sexual
elements in the act, as opposed to an intrinsic response
to aggression (Quinsey, Chaplin, & Upfold, 1984).
Complicating the matter further is the fact that
30% of normal, noncriminal men admit to sexual
fantasies of raping or tying up a woman (Crepault &
Couture, 1980). In one study, 16% to 20% of those who
did indicated they were highly aroused by sadomasochistic narratives (Malamuth, Haber, & Feshbach,
1980) and by those in which the victim is in pain
(Malamuth & Check, 1983). Also, most young males
appear to be aroused by depictions of women bound
and in distress than by smiling, cooperative women
(Heilbrun & Leif, 1988).
In another study, 45% of male college students
stated that they would rape a woman if they would
not be caught and 32% of women would enjoy being
raped if no one were to know (Malamuth et al., 1980).
Similar kinds of figures have been reported in a number of other studies (Malamuth & Malamuth, 1983;
Malamuth, 1981; Koss, Gidycz, & Wisniewski, 1987).
It appears that a degree of coercion in sexual relationships can lead to arousal and enjoyment in both sexes
and plays a role in traditional courtship (Ellis, 1936).
However, common though such themes may be in
fantasy, such studies do not provide information on
how frequently truly sadistic fantasies are acted upon
or, more centrally, whether these themes represent
the preferred method of sexual expression.

CUR R EN T ISSUES IN THE DI AGNOSIS

OF SE X UA L SA DISM

In a landmark review of studies of sexual sadism in

sexual offenders Marshall and Kennedy (2003) found

that although authors frequently indicated they had

followed the criteria outlined in a relevant edition of
the American Psychiatric Associations Diagnostic
and Statistical Manual of Mental Disorders (DSM),
the criteria that were actually used to identify the
samples did not in fact correspond with DSM criteria. Several researchers (e.g., Brittain, 1970; Dietz,
Hazelwood & Warren, 1990; Fromm, 1973; Gratzer &
Bradford, 1995; Langevin, Ben-Aron, Wright,
Marchese, & Handy, 1988; MacCulloch, Snowden,
Wood, & Mills, 1983) regard the core feature of sexual
sadism as the exercise of power and control over the
victim, while other features (such as torture, humiliation, other forms of aggression) are seen as the means
by which this end is achieved. Marshall and Kennedy
also noted that some of these authors (e.g., Ressler,
Burgess, & Douglas, 1988) also describe the expression
of violence or aggression as the central feature of sexual
sadism, as do Seto and Kuban, (1996), but, whatever
characteristics are seen as diagnostic, sexual arousal by
this feature is viewed as the necessary element.
The DSM-IV-TR (American Psychiatric Association, 2000) definition of sexual sadism requires the
presence of recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real,
not simulated) in which the psychological or physical
suffering (including humiliation) of the victim is sexually exciting to the person (p. 574). Thus, the DSM
requires that the psychological and physical suffering
of the victim must be sexualized for the offender to
meet criteria for sexual sadism. Unfortunately, this
is a subjective feature that can only be confirmed by
the offender. As few sexual offenders provide accurate self-reports, the clinician typically must infer this
essential detail from other information such as details
of the crime scene, reports by victims, the offenders
life history, and the history of history. The DSM-III
(American Psychiatric Association, 1980) acknowledged that the poor interdiagnostician reliability of
earlier versions of DSM was the result of requiring diagnosticians to make inferences about a patients motivations from unobservable processes. Consequently in
DSM-III and subsequent editions, for almost all diagnoses except, regrettably, the paraphilias, it has been
necessary to attempt to specify observable criteria.
Both from the point of view of research into the
nature of sexual sadism and its characteristics, and in
order to treat or manage the problems presented by
sexually sadistic offenders, it is necessary to have a
clear consensus definition of what constitutes sexual

MANIFESTATIONS OF SEXUAL SADISM

sadism. However, the DSM is intended to be the

consensus document for researchers and clinicians
attempting to study sexual sadism, as already noted.
Marshall and Kennedy (2003) found that although
almost all authors who claimed to adhere to DSM
criteria, appeared not to do so in practice. Marshall
and his colleagues then followed up their review of
the literature with two studies to evaluate the reliability of the diagnosis of sexual sadism. Marshall et al.
(2002) extracted from files in three Canadian federal
prisons the psychiatric reports in which psychiatrists
had conducted risk assessments of various types of sex
offenders over a 10-year period. All of these sex offenders had previously identified as high risk to reoffend
sexually using at least one actuarial risk assessment
instrument. Fifty-nine evaluations were identified
involving 41 cases where the offender was diagnosed
as a sexual sadist ; the remaining 18 cases were given
various other diagnoses. The 14 evaluators were all
experienced forensic psychiatrists who reported using
DSM-III-R or DSM-IV criteria. The offenders who
were given a diagnosis of sexual sadism were compared with those who were not given this diagnosis
on 20 offense characteristics extracted from extensive
police and victim reports and from court records on
the files, 10 sets of self-reported information, and 7
data sets derived from phallometric assessments of
sexual interests. All this information was available
to the psychiatrists performing the evaluations. It
transpired that offenders who were not diagnosed as
sexual sadists were significantly more likely to have
beaten or tortured their victims than were those diagnosed as sexual sadists. Moreover, nonsadists showed
greater sexual arousal to nonsexual violence and
sadists displayed greater arousal to consenting sexual
scenes. A composite sadism score was calculated from
offense details but once again the nonsadists who
scored higher than sadists. The only characteristic
that predicted the psychiatrists diagnosis was a prior
psychiatric report giving that same diagnosis; none of
the information provided by the researchers appeared
to have any influence even when contradictory.
A subsequent study clearly showed that the findings of the earlier study cannot simply be dismissed
as based on the idiosyncrasies of a small group of psychiatrists who were singled out by Marshall and his
colleagues. Marshall et al. (2002) carefully extracted
information from the files of 12 of the offenders in
their first study, six of whom had been identified as
being a sexual sadist while the other six had been

347

given another diagnosis such as pedophilia or antisocial personality disorder. The information contained
details of the offenders life history, crime scene
details and other details of his offense(s), psychological and phallometric test results, and self-reported
sexual interests and activities provided by the offenders themselves. All this information on each of the 12
offenders was provided to 15 internationally renowned
forensic psychiatrists with experience, working with
sexually sadistic offenders. These authorities were
asked to complete several tasks, the most important
of which was that they decide whether each offender
was or was not a sexual sadist. Not only was the percent agreement among the experts quite low (75%
agreement where chance agreement would be 53.3%),
the kappa statistic revealed completely unsatisfactory
interdiagnostician agreement (kappa = 0.14).
The two studies by Marshall et al. are not the
only evidence of poor agreement between clinicians
on the diagnosis of sexual sadism. Levenson (2004)
assessed sex offenders for the application of a civil
commitment as a Sexually Violent Predator (SVP)
in Florida and compared the diagnoses identified by
each of the two independent assessors. The resultant
kappa coefficient for sexual sadism was only 0.3, again
suggesting that clinicians cannot reach an acceptable
standard of agreement on this diagnosis.
Despite this poor showing, most clinicians would
argue that the studies indicate, as did the early studies of diagnostic disagreement over schizophrenia, a
need to tighten up the criteria and exercise greater
care in applying them. Also, the problem may lie in
the DSMs requirement that the sadist must be sexually aroused by the suffering and humiliation of the
victim. Since only the offender can know whether
they were or were not so aroused, and their self-report
is typically unreliable, the diagnosis requires the clinician to infer sexual motivation in the infliction of
cruelty, torture, or degradation, thereby reducing
diagnostic reliability.
Some authors have suggested that phallometric
assessment can assist in increasing diagnostic reliability (Hollin, 1997; Hucker, 1997). However, a satisfactory stimulus set specifically for sadists has not
yet been developed although several researchers have
adapted available stimulus material for men who sexually assault adult females. Thus, Seto and Kuban
(1996), used arousal to a description of a brutal rape
as an index of sexual sadism. However, they found
no differences between rapists they defined as sadists

348

SPECIAL POPULATIONS

and rapists whom they determined were not sadists,

a finding that replicated previous studies (Barbaree,
Seto, Serin, Amos, & Preston, 1994; Langevin et al.,
1985; Rice, Chaplin, Harris, & Coutts, 1994). Proulx,
Blais, & Beauregard (in press) used a modification of
their standard phallometric stimuli to include sets
describing rapes that involved either extreme physical violence or had additional elements involving the
humiliation of the victim. These stimulus sets are
closer to the DSM criteria for sexual sadism than are
any others currently available. Proulx et al. found that
the sadistic rapists showed significantly greater arousal
to both the physically violent and humiliating scenes
than their nonsadistic rapists. These data suggest that
specifically designed sadistic stimuli may reliably distinguish sadistic from nonsadistic sexual offenders.
However, paradoxically, the sadists and nonsadists
were differentiated as either sadistic or nonsadistic
prior to the testing and yet the phallometric test was
used to confirm or refute that diagnosis.

A PROPOSED SOLU T ION

As an alternative to current diagnostic practices,

Marshall & Hucker (in press) suggest that sexually
sadistic behaviors may still usefully provide a basis
for more accurately and more reliably identifying
these problematic offenders. In the study by Marshall
et al. (2002) where international experts were asked
to identify sexual offenders as sadists or not, these
experts were also asked to rate the importance for the
diagnosis of sexual sadism of a variety of features of an
offenders behavior. While the experts were not able
to agree on the diagnosis, they nevertheless generally
agreed on the features that are important in making
the diagnosis.
Marshall & Hucker (submitted for publication)
have developed a rating scale (see Table 24.1) derived
from this study and based on the features weighted
according to the values assigned by the experts in the
Marshall et al. (2002) study. Inter-rater reliability studies are being conducted in several locations worldwide. It is hoped that this dimensional approach will
prove more helpful than the categorical diagnosis has
been and it is worth noting here that there have been
other calls for the DSM to move to a more dimensional approach across all diagnoses (Widiger &
Coker, 2003).

Treatment of sexual sadism is generally regarded

as one of the most ominous paraphilias in terms of
risk to potential victims. Consequently it is typically
necessary to combine both psychological approaches
and pharmacological treatments in order to minimize
the possibility of a repeat offense.
Psychological approaches have been employed
over the years with all types of sex offenders but met
with little success until the advent of cognitive behavioral techniques. These have been demonstrated to
have considerable effectiveness and form the mainstay of psychological treatments for sex offenders at
the present time (Marshall, Anderson, & Fernandez,
1999). Much has been written on this topic and the
specifics of the methodology are discussed elsewhere
in this volume (see Chapter 9).
At this point in time, most medical specialists
involved with treating sexual sadists, as well as other
types of sex offenders, use a small range of pharmacological agents to suppress sexual drive as part of an
overall treatment or management strategy in combination with cognitive therapy. These agents can be
broadly grouped into hormonal agents and serotonergic drugs. Several authors have developed protocols for the use of these treatments (Reilly, Delva,
& Hudson, 2000; Bradford, 2000). Bradford (2001),
Briken, Nika, & Berner (2001), and Briken, Hill, &
Berner (2003) have outlined algorithms to assist in
the selection of the most appropriate medication
based upon levels of severity of potential offenses.
The use of serotonin reuptake inhibitors is recommended for the milder cases of sex offender or those
with obsessive-compulsive features. Clearly, when
sexual sadism is involved, the more potent hormonal
agents such as leuprolide acetate, an LHRH agonist,
will be required. Again this topic justifies extended
coverage and is explored in more detail elsewhere in
this book (see Chapters 9 and 14).

CONCLUSION

To this time, no research has demonstrated the effectiveness of treatment with sexual sadists although, as
we have seen, there is evidence of their effectiveness
with other sexual offenders. It will be difficult to evaluate treatment for these individuals because (fortunately) they constitute a small proportion of sexual
offenders and thus there are rarely enough available to

MANIFESTATIONS OF SEXUAL SADISM

349

Table 24.1 Rating Scale for Sexual Sadism

Clearly
Absent
1

Possibly
Present
2

Present to
Some Extent
3

Clearly
Present
4

Clearly
Dominant Feature
5

1. Offender is sexually aroused by sadistic acts

2. Offender exercises power/control/domination over victim
3. Offender humiliates or degrades the victim
4. Offender tortures victim or engages in acts
of cruelty on victim
5. Offender mutilates sexual parts of victims
body
6. Offender has history of choking consensual
partners during sex
7. Offender engages in gratuitous violence
toward victim
8. Offender has history of cruelty to other
persons or animals
9. Offender gratuitously wounds victim
10. Offender attempts to, or succeeds
in, strangling, choking, or otherwise
asphyxiating victim
11. Offender keeps trophies (e.g., hair,
underwear, ID) of victim
12. Offender keeps records (other than trophies)
of offense
13. Offender carefully preplans offense
14. Offender mutilates nonsexual parts of
victims body
15. Offender engages in bondage with
consensual partners during sex
16. Victim is abducted or confined
17. Evidence of ritualism in offense
From Marshall & Hucker, submitted.

justify an outcome study. In addition, quite a number

of sexual sadists are incarcerated indefinitely, further
reducing the number available for an outcome study.
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Chapter 25

Persons with Intellectual Disabilities

Who Sexually Offend
Dorothy Griffiths and J. Paul Fedoroff

Persons with intellectual disabilities present many

similar and some unique features that can contribute
to the development of sexually offending behavior.
This chapter will review: the history of sexuality of
persons with intellectual disabilities, the prevalence
of sexually offending behavior, methods of comprehensive assessment strategies to identify risk factors,
vulnerabilities and central processing challenges,
and methods to develop an integrated model of
intervention.
While cognitive impairment can be caused by
dementia, this chapter will deal only with global
intellectual impairment secondary to intellectual
disabilities present at birth or with pervasive developmental delay. Neither the criteria for sexual offense
under the criminal code nor the diagnostic criteria
for paraphilic sexual disorders currently explicitly
include provisions for individuals with intellectual
disabilities. Yet this group poses special challenges
not only to the judicial system but also to those with
the responsibility of providing for their care. There
353

are several reasons for this that will be expanded

subsequently.
First, the criminal justice system requires that the
accused understand the charges, the trial process,
the consequences of being found guilty and that the
accused be able to assist counsel in their own defense.
By definition, accused with intellectual disabilities as
a group are less likely to meet criteria for fitness to
stand trial. However, intellectual disability by itself
does not necessarily mean that a specific individual
is unfit to stand trial.
Second, individuals with intellectual disability
often live with less than normal degrees of privacy.
They may have been raised and reside in group
homes or even institutions. As a result, unconventional
sexual behaviors are more likely to be detected.
Third, intellectual disability can manifest not
only in academic deficiency but also, particularly
in developmental delay syndromes like Aspergers
disorder, in profound social skills impairment.
Impairment in the development of normal social

354 SPECIAL POPULATIONS

relations makes the expression of abnormal social

relations more likely.
Intellectual disability, whatever its cause, often
alters the presentation of comorbid medical and psychiatric disorders. Similarly, the presence of sexual
problems often clouds the ability of care providers to
evaluate complete differential diagnoses and treatment plans. The presence of an intellectual disability
enlarges the differential diagnosis. The same is true
for individuals who display unconventional sexual
interests. Unfortunately, once a person has been diagnosed with intellectual disability or a sexual disorder,
there is a tendency to attribute the cause of all problems to the intellectual disability or sexual disorder.
Embryologists often comment that ontogeny recapitulates phylogeny. By analogy, the perils and pitfalls
faced by care providers of sex offenders with intellectual disabilities can be best understood by reviewing
the perils and pitfalls that these men and women have
historically faced themselves.

SOME HISTOR ICA L CON T E X T FOR

U NDER STA NDING SE X UA LIT Y OF
PER SONS W ITH IN T ELLECT UA L
DISA BILIT IES

The sexuality of persons with intellectual disabilities

largely led the direction of the field in the early part
of the last century. Beliefs regarding the increased
risk of sexual interest, promiscuity, impulsivity, and
risk to children among the population of persons with
disabilities fueled public policy. Early in the last century people with intellectual disabilities were considered to be sexually dangerous to society (Simmons,
1982). The agenda to control the sexuality of persons
with disabilities was not promulgated solely on the
concern to protect innocent individuals from sexual
indiscretion or for moral reasons, but to control the
potential sexual by-products. The reproduction of a
second generation of persons with genetic deficits was
seen as a drain on societys resources. This social policy movement, known as Eugenics, resulted in largescale identification, isolation, and segregation of
persons with intellectual disabilities within Western
society. Institutions were constructed to allow social
control over the threat of future generations of persons
with disabilities. Gender segregation, punishment of
sexually active participants, and mass involuntary
sterilization was enforced within institutions. These

practices, subsumed under the rubric of eugenics were so well established in North America that
they were studied and emulated by Hitler and the
infamous Nazi regime. Although mass forced sterilization was discontinued in the 1970s, many of the
premises of the eugenics movement continue to influence policy today. Although many individuals with
disabilities now live in community care, they are still
often denied routine sex education and their access to
appropriate, loving relationships is often discouraged,
restricted and even punished in both institutional
and community settings.
Although sexual aggression by all persons, including those with developmental disabilities, is a significant concern in our society, it is erroneous to consider
sexual aggression by persons with developmental
disabilities as a direct product of the disability. The
relationship between sexual aggression and persons
with developmental disabilities has historically been
grounded in myth. One of the most prevalent myths
is the eternal child myth that states that mental age
is a predictor of all aspects of the persons life rather
than a description of functioning on a test of cognitive
abilities. This results in people with disabilities being
seen as children (Simmons, 1982) and as such their
sexuality is ignored. A second yet contradictory myth
is founded on the dangerousness theory of persons
with disabilities and their sexuality. The dangerousness myth stems back to a very flawed study done at
the beginning of the last century by Goddard (1912)
who claimed to demonstrate that persons with intellectual disabilities were genetically linked to criminality, degeneracy, mental illness, and future generations
of socially undesired offspring.
In fact, most people with intellectual disabilities,
with the exception of those with certain genetic or
endocrine abnormalities, develop secondary sexual
characteristics at about the same rate as nondisabled
people and the majority of disabling conditions are
not genetic (Griffiths, 2003). For the most part they
experience sexual feelings and respond sexually to
the same stimuli as nondisabled persons do. They
have the same variability in sex drive as others.
Like nondisabled people, persons with intellectual disabilities require normalized environments in
which to be educated and experience social learning
regarding personal, moral, social, and legal responsibility regarding sexuality. Individuals with disabilities also benefit from formal sociosexual education
to gain sociosexual knowledge (Watson, Griffiths,

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

Richards, & Dykstra, 2003) and guidance necessary

to learn responsibility about sexuality. It is also vital
to learn appropriate sexual expression, and to reduce
the vulnerability to abuse or be abused (Hard, 1986 as
cited in Roeher Institute, 1988).
Moreover, there is no conclusive evidence that
people with intellectual disabilities develop sexually
inappropriate behavior more frequently than the general population if they have normal opportunities
to learn about their sexuality. In fact, it may be less
common than among people who are nondisabled
(Day, 1994). As with nondisabled individuals, the
development of sexually inappropriate behavior in
persons with intellectual disabilities can be affected
by many factors including lack of sexual education,
deprivation of peer group interactions, family restrictions on activities, lack of social exposure, and even
lack of motor coordination. The offenses committed
by people with developmental disabilities are often
less serious than offenses committed by nondisabled
people (e.g., public exposure, masturbating in public,
inappropriate touch).

PR EVA LENCE OF SE X UA LLY

OFFENDING BEH AV IOR
A MONG THIS POPUL AT ION

One other potentially misleading set of research

regarding this population is based on prison statistics
regarding sex offenders. Sex offenders with identified intellectual disabilities appear overrepresented
in the charged and imprisoned population of sexual
offenders. There is a great disparity in the reported
incidence of sexually offending behavior of persons
with intellectual disabilities; statistics range from
15% to 33% (Shapiro, 1986; Steiner, 1984). Day (1994)
cautions that the prevalence rate may actually be
higher because it does not account for those persons
with intellectual disabilities who were not charged
but diverted to residential care facilities. These rates
appear alarming in relation to the 3% incidence of
intellectual disability that exists in the general population until it is realized that the data were largely
gathered from arrest and conviction rates.
There are two hypotheses that put perspective
on the aforementioned statistics. First, overrepresentation of persons with disabilities within the
offender population may not indicate a greater
incidence of offense but an increased vulnerability

355

when persons with intellectual disabilities are

within the judicial system. Second, because of the
learning and environmental conditions posed to
most persons with intellectual disabilities regarding
their sexual life, many individuals may be deemed
sexually inappropriate by virtue of their label or
because of a lack of appropriate sociosexual conditions. Day (1997) argues that the high rates of sexual offense behavior committed by persons with
developmental disabilities may be a reflection of the
generally repressive and restrictive attitudes toward
the sexuality of persons with disabilities (Day, 1997).
Each of these hypotheses will be elaborated in the
following sections.
Persons with intellectual disabilities and the
judicial system: Griffiths et al. (2002) note that
from arrest to trial, offenders who have cognitive
disabilities are more likely to be disadvantaged.
They are more likely to be arrested or waive their
rights due to impaired understanding of caution and
legal rights. To gain approval of authority fi gures
they may false confessions or provide incriminating evidence, and fail to plea-bargain. They are also
more likely to be jailed pretrial because of failure to
meet bail or personal recognizance; offenders held
pretrial are generally more likely to be convicted
(Toberg, 1992). They are less likely to be able to
afford or mount a solid legal defense and are more
likely to be declared unfit to stand trial (ValentiHeins & Schwartz, 1993) or convicted. In general
their prison terms are longer than similar offenders
without disabilities (Laski, 1992). However, if found
unable to stand trial they are virtually denied due
process in court, and typically institutionalized,
presumably for rehabilitation or habilitation. The
unfortunate outcome, however, is that often such
services are not available and the individual ends
up being confined for an indefinite period of time,
without a process of redress (Fedoroff, Griffiths,
Richards, & Marini, 2000).
Prevalence of sexually deviant versus inappropriate behavior caused by social conditions and
learning: The full range of deviant sexual behavior (i.e., fetishes to pedophilia) similar to that of the
nondisabled population have been noted in the
population of persons with intellectual disabilities
(Griffiths et al., 2007). The profile presented by
this offender group is similar to that of nondisabled
offenders (Day, 1997), with some exceptions. In general, sexual offenders with intellectual disabilities

356 SPECIAL POPULATIONS

commit the same range of crime, including

those of a sexual nature, as nondisabled persons (Luckasson, 1992). However, they are more
likely to be the victims of sexual crime rather
than victimizers (Griffiths, 2003);
commit less serious assault offenses, but more
inappropriate behaviors such as public masturbation, exhibitionism, and voyeurism (Gilby,
Wolf, & Goldberg, 1989);
have far fewer victims (Griffiths, Quinsey, &
Hingsburger, 1989);
have larger proportion of male victims, than
the nondisabled population. The research varies as to whether the majority of their victims
are female (Brown & Stein, 1997; Gilby et al.,
1989; Murrey, Briggs, & Davis, 1992) or equivalent against males and females (Brown & Stein,
1997; Day, 1994; Griffiths, Hingsburger, &
Christian, 1985; Griffiths et al., 1989);
display more social skill deficits, are more
sexually naive, lack interpersonal skills; and
demonstrate increased difficulty interacting with
the opposite sex (Tudiver, Broekstra, Josselyn, &
Barbaree, 1997).
Day (1994) has proposed that there are two types
of sexual offenders with intellectual disabilities. The
first group commits only sexual offenses; this is a
lower risk group that fits the aforementioned profile
more closely. The second group presents with greater
risk for violence and assault and commits not only
sexual offenses but also a range of nonsexual offensive behaviors. This distinction represents a critical
feature in this population.
The sexual offenders with intellectual disabilities
who commit only sexual offenses present with a different profile and the nature of their offenses are typically less serious or persistent (Day, 1994). It may be
argued that this group represents those described in
the Diagnostic and statistic manual of mental disorders (4th Edition) (DSM-IV-TR) as those showing
challenges in judgment, social skills, or impulse
control that might result in sexual behavior that
may be unusual but is diagnostically different than
paraphilia (American Psychiatric Association [APA],
2000). Langevin & Curnoe (2003) suggest that sexual offense committed by persons with intellectual
disabilities may not be a matter of paraphilia but of
loneliness, lack of social skills, or even curiosity.
Among persons with intellectual disabilities there is
a higher experience of abuse (Griffiths et al., 1989;
Gilby et al., 1989), poor self-esteem (Lackey & Knopp,

1989), lack of sociosexual knowledge and experience

(Hingsburger, 1987), and poor social problem-solving
skills (Hingsburger, 1987). All of the above may contribute to a false or counterfeit diagnosis of paraphilia.
The latter, often referred to as counterfeit deviance,
can be differentiated from paraphilia as these acts do
not represent a persons preferred and recurring sexual behavior (APA, 2000).
Counterfeit deviance was illustrated in a series
of case examples by Hingsburger et al. (1991), in
which the sexually offensive behavior of persons with
intellectual disabilities was the product of experiential, environmental, or medical factors, rather than
a paraphilia. They demonstrated how lack of privacy
(structural), modeling, inappropriate partner selection or courtship, lack of sexual knowledge or moral
training, or a maladaptive learning history or medical
or medication effects could present as paraphilia in
this population (Hingsburger, Griffiths, & Quinsey,
1991).
The subgroup of offenders described previously
differs significantly in profile from the subgroup of
sexual offenders with intellectually disabled, who
are at high risk of violence and reoffense. The latter
group more closely resembles the nondisabled sexual
offender. Day (1994) profiled this group as having a
high incidence of sociopathic personality disorder,
brain damage, family dysfunction, and who also
engage in other nonsexual inappropriate behaviors.
Day further found they had lengthy histories of antisocial behavior, were undersocialized, demonstrated
poor impulse control, and were likely to commit serious sexual offenses. These high-risk sex offenders
who are intellectually disabled have also been found
to become more persistent sex offenders, and the
nature of their crimes are more serious (Day, 1994).
Day (1994) noted that the younger the age at first sexual offense and at first conviction, the more likely the
individual would fall into this more serious group of
offenders who are less sexually nave and more specific and persistent in their sexual offenses.
Comprehensive clinical evaluation of the complex
factors that could be influencing sexual aggression in
persons with intellectual disabilities is required to
distinguish paraphilia from sexually inappropriate
behavior that may topographically look like paraphilia
but lack the pathognomonic recurring and pathological use of sexual fantasies, urges or behavior. A careful differential diagnosis, based on evaluation of the
individuals environment, socio-sexual knowledge

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

and attitudes, learning experiences, partner selection, courtship skills, and biomedical influences is
required to differentiate paraphilia from counterfeit
deviance (Griffiths et al. 2007). The diagnostic distinction is important as it determines the nature of
intervention.

CH A LLENGES TO CLINICA L
ASSESSMEN T A ND IN T ERV EN T ION
(R ISK FACTOR S, V ULNER A BILIT IES,
A ND CEN T R A L PROCESSING
CH A LLENGES)

Griffiths (2002) summarized research from both the

field of disability and the field of sex offender to illustrate the potential relationship between known risk
factors for development of sexual offending behavior
and the life experiences that have afforded most people with intellectual disabilities by virtue of nature or
nurture.
Sex offender research shows an increased risk for
sexual offense associated with certain neurological/
biomedical abnormalities, mental illness, lack of
attachment bonds, childhood sexual trauma, and a
lack of empathy, skills and prosocial inhibition. These
biomedical, psychological, and social risk factors or
vulnerabilities are described in Table 25.1 with special reference to the increased vulnerabilities of persons with intellectual disabilities.

COMPR EHENSI V E ASSESSMEN T

Guidelines for the assessment and treatment of sex

offenders generally have been developed by two
organizations, the Association for the Treatment
of Sexual Abusers (ATSA) and the International
Association for the Treatment of Sexual Offenders
(IATSO, Coleman et al., 1995). Neither organization has specifically addressed the issue of assessment and treatment of sexual offenders who are
intellectually disabled (Langevin & Curnoe, 2002).
While these guidelines are applicable to this population, there are some additional considerations. A
careful differential diagnosis is based on evaluation
of the relevant history, mental status examination,
the context of the behavior, sociosexual knowledge
and attitudes, partner preference and selection, and
general risk.

357

Concern for Consent

There are two relevant areas of consent for consideration. Consent relative to assessing and determining
consent issues involved in the events that prompted
the assessment. Although these will be discussed
briefly subsequently for expansion on these topics
refer to Fedoroff et al. (2002) and Sheehan (2002)
respectively.
First, the clinician needs to determine before
proceeding to conduct an assessment if informed
consent has been obtained to proceed, to gather background information, to speak with other parties, and
in some cases to perform assessments such as phallometry or risk evaluations. There are some guiding
questions that can aid the clinician in determining
consent issues.
What is the benefit of the assessment for the person? If the assessment is to direct intervention or support, then the benefit for the individual appears clear.
However, sometimes the assessment is requested for
legal purposes, where the assessment may not only
be not beneficial but damaging to the individual.
Additionally the limits to confidentiality must be
clearly discussed (Fedoroff et al., 2002).
Determining if the consent is informed differs
depending on whether the person with intellectual disabilities is capable/competent to provide his/
her own consent, or if substitute consent is required
because of age or competency. Individuals with intellectual disabilities may feel undue pressure to agree
to the assessment and to be reluctant to disappoint
or anger staff or the clinician by refusing to participate. Persons with intellectual disabilities have been
found to agree to persons in authority beyond the
point where nondisabled persons would have begun
resistance (Flynn, Reeves, Whelan, & Speake, 1985).
Their history may have included formal or informal
compliance training to authority figures that predispose concerns regarding compliance versus consent.
Additionally, the learning challenges of persons with
intellectual disabilities cause concern as to whether
the consent is truly informed. However, persons
with intellectual disabilities are not ipso facto incompetent to make their own decisions or to provide
informed consent for various treatments, activities, or
personal/financial events. Legal incompetence based
on intelligence is not absolute; a person may be legally
incompetent to manage their finances but totally
competent to make decisions within other areas.

Table 25.1 Biopsychosocial Risk Factors and Vulnerabilities Associated with Paraphilia Specific to Persons
with Intellectual Disabilities
Risk
Factors And
Vulnerabilities

Association With Paraphilia

Risk Factors Specific To Persons With

Intellectual Disabilities

Neurological/
Biomedical
Abnormality

40% of sex offenders demonstrate neurological

impairments (Hucker, Langevin, Wortzman,
Bain, Handy, Cambers, & Wright, 1986; Hucker,
Langevin & Bain, 1988); the nature of the sexual
offense may correlate to the type of brain abnormality or endocrine disorder (Langevin, 1992). (i.e.,
sexually offensive behavior is frequently associated
with temporal lobe abnormalities (Cummings,
1985; Hucker, Langevin, Dickey, Hardy, Chambers
& Wright, 1986), with pedophiles and rapists being
more likely to have left temporal dilation, whereas
sadistic offenses are correlated with right temporal
dilation (Langevin, Wortzman, Wright, & Hardy,
1988). The correlations although statistically
significant are not perfect.
In addition, endocrine disorders were apparent in
10% of sexual assault cases (Langevin, 1992), and
most evident in cases involving pedophilia.
Gaffney and Berlin (1984) demonstrated that
pedophiles show hypersecretion of luteinizing
hormone.

There is an overrepresentation of learning

disability among persons who engage in
exhibitionism and a greater likelihood
of language-related problems, aphasia,
and object identification problems in the
pedophilia subgroup of offenders (Langevin,
1992). Among the offender group,
pedophiles show the greatest cognitive
challenge.

Mental Illness

Langevin (1992) has observed that one in ten cases

of sexual offense involved a major mental illness.
The DSM-IV-TR indicates that unusual sexual
behavior may result from a manic episode,
schizophrenia, or dementia (APA, 2000).

Twenty percent to thirty five percent of persons

with intellectual disabilities will have a
coexisting mental health problem (Nezu,
Nezu, & Gill-Weiss, 1992), and among
developmentally handicapped offenders this
could be as high as 3047% (Steiner, 1984;
White & Wood, 1988).

Lack of
Attachment
Bonds

Marshall et al. (1993) demonstrated a relationship

between attachment bonds and paraphilia
(conditioned link between the roles of
domination and sexual satisfaction).

Persons with disabling conditions have been

shown to have increased avoidance and
disorganization in their attachment patterns
(Goldberg, 1995).

Childhood
Sexual
Trauma
(Traumagenic
Experiences)

The relationship between childhood sexual or

physical trauma and paraphilia has received
much clinical attention (e.g., Money & Lamacz,
1989). Forty percent of child molesters and 25%
of rapists had been abused as children. Between
20% and 75% of sex offenders grew up in families
where violence was a way of life or where parents
were alcoholic (Langevin, 1992). According
to the traumagenic model, there is a correlation between the age of onset of fantasy-driven
sexual aggression and the age of their own abuse,
the duration of their abuse, and the level of
invasiveness of the abuse (Pithers, 1993).

Sexual and physical abuse of persons with

intellectual disabilities is extremely prevalent
in our society. Eighty eight percent of persons
with intellectual disabilities have been
sexually exploited (Hill, 1987). Hard (1986,
as cited in Roeher Institute, 1988), reported
that 68% of females and 30% of males in his
study of persons with intellectual disabilities
were sexually abused before the age of 18
years. Although exact prevalence is difficult to
determine due to differences in methodology
used, Doucette (1986) suggested that persons
with intellectual disabilities are at least one
and one half times more at risk for sexual
abuse than other members of society.
Clinical reports of offenders have noted a
high rate of abuse among individuals with
disabilities who commit sexual offending
behavior (Griffiths as cited in Roeher
Institute, 1988; Hingsburger, 1987).
(continued)

358

Table 25.1 (Continued)

Risk
Factors And
Vulnerabilities

Association With Paraphilia

Risk Factors Specific To Persons With

Intellectual Disabilities

Deficits in
Skills of
Empathy

Empathy is capacity to cognitively perceive

anothers perspective, to recognize affective
arousal within oneself, and to base compassionate
behavioral responses on the motivation induced
by these precepts. Barbaree and Serin (1993)
suggest that the inhibition to sexual assault is a
prosocial process, which is enhanced by positive
attitudes toward others and sensitivity to anothers
pain and suffering. Some researchers have
offered an inhibition hypothesis to explain
sexual aggression (Barbaree, Marshal & Lanthier,
1979; Marshall & Barbaree, 1984).

Empathy requires an integration of cognition,

affect, and behavior (Pithers, 1993). This
difficulty in compassionate understanding
may interfere with the individuals ability to
take the perspective of their potential victim
or of those who may influence the individual
negatively in the commission of an offense
(Pithers, 1993).
Individuals with cognitive disabilities have
increased difficulty in understanding
the perspectives, feelings or thoughts of
others. This perspective taking also has
been identified as one of the underlying
vulnerabilities of sex offenders (Pithers, 1993).

Skill Deficits

Sexual offenders may lack the necessary social

skills, or sexual knowledge and experience
to develop appropriate relationships (Abel,
Rouleau, & Cunningham-Rathner, 1984).
In addition, a sexual dysfunction, such as
premature ejaculation, might be present which
interferes with the aggressors ability to engage in
sexual activity that is socially accepted.

For persons with intellectual disabilities,

thinking is very concrete and rooted in
the here and now and more rigid and
perseverative (MeGee & Menolascino,
1992), leading to difficulty in interpreting
relationships or contextual cues, such
as private vs. public, and appropriate vs.
inappropriate unless training is provided.
Persons with intellectual disabilities often
have difficulty acquiring social skills and in
spontaneous generalization of skills outside
the training environments unless training
specifically focuses on developing these
skills (Griffiths, Feldman & Tough, 1997).
Most persons with intellectual disabilities are
deficient in their knowledge of biological
and social aspects of sexuality (Murphy,
Coleman, & Haynes, 1983b), however are
able to develop sexual knowledge if afforded
the opportunity of education (i.e., Lindsay,
Bellshaw, Culross, Staines & Michie, 1999).

Lack of
prosocial
inhibition

Sexual offenders justify their behaviors by

distorting their belief system regarding the
offending behavior; cognitive distortions are
self- statements made by offenders that allow
them to deny, minimize, justify, and rationalize
their behavior (Murphy, 1990, p.332). This
allows them to reduce the cognitive dissonance
that might otherwise inhibit their behavior
(Abel, 1984).
Anger, alcohol, and intoxication can also act as to
reduce prosocial inhibition and can contribute to
sexually inappropriate behavior (MacDonald &
Pithers, 1989; Pithers, Beal, Armstrong & Petty,
1989).

These distortions have been reported among

offenders with intellectual disabilities
(Murphy et al., 1983b). Additionally persons
with intellectual disabilities have grown up
in some cases in cultures where the typical
social values were not present and the typical
prosocial inhibitions were not developed
(Griffiths et al., 1989).
Tudiver et al. (1997) surveyed offenders who
were developmentally disabled and found that
although one-fifth of the group used alcohol
and approximately 5% used other drugs, the
consumption of alcohol and drugs played a
role in only 3.5% of the sexual incidents.

The table indicates that individuals with intellectual disabilities may be at greater risk to develop sexually inappropriate sexual expressions
not by virtue of their disability but because of the interplay of their learning challenges and the lack of appropriate sociosexual learning
experiences typically afforded this population.
Adapted from Griffiths, 2002.

359

360 SPECIAL POPULATIONS

For an individual who is capable of making their

own life decisions, informed consent may be and
is likely possible. But it requires a rigorous procedure to ensure that it is truly informed and free of
duress. Some ways to ensure this are to determine
if the purpose and procedure for the assessment has
been clearly explained and read to the individual to
a point of understanding. For example, can the individual describe in his/her own words, what they will
be asked to do, do they know who to talk to if they
have questions, and do they clearly understand it is
ok with everyone if they say they do not want to do
this or continue? Probing questions can be helpful to
ascertain this.
How can the clinician validate that the consent
is informed and free of duress? The presence of an
advocate of ones choosing or from an advocating
agency, who knows the individual well, could cosign
the consent to say they observed the process and
believe the person to understand what was agreed to
and the conditions of consent and their right to withdraw consent. It is often advisable to discern if the
person has a history of overcompliance. Third party
participants will know the compliance of the individual, however when in doubt the clinician could probe
by asking some silly question to which the obvious
answer would be no. When the person is not able
to consent, then third party or legal substitute consent is required for consent to be valid. Particularly in
the case of forensic evaluations, consideration should
be given to producing an independent record of the
assessment by recording the assessment with audio or
(preferably) videotape. This will not only provide a
record of the assessment but also minimize the number of assessments the accused must undergo.
The consent or assent issues regarding the offending situation also need to be examined. The parties
involved in the sexual act may have been in mutual
agreement to the action that may indicate assent.
However, legal consent requires a much more rigid
criterion. Sheehan (2002) suggests legal consent
should be based on evaluation of whether the individual has knowledge and understanding of (i) basic
anatomy and physiology, such as that sex involves
more than just penetration but the issues of pleasure
(ii) privacy, (iii) of the risk of disease or pregnancy
and that these can be prevented through safe sex
measures, (iv) inappropriate partners, such as animals, children, immediate relatives or where money
is exchanged, and that (v) consent can be withdrawn

even if a person has consented before. She also suggests that the individual should be aware that some
people believe that sex is only appropriate in a loving,
respectful monogamous relationship.
The need to protect vulnerable individuals while
still respecting their right to autonomy and right to
make choices about their intimate lives makes generalizations difficult. DuVal (2002) recommends that
determinations of capacity must be made within the
context of a particular choice, rather than globally.
Restrictions on choices must be reasonable and the
least onerous, aimed at achieving specific protective
purposes. DuVal summarizes the twin responsibilities, While caregivers and families have an important obligation to advocate for and assist persons with
developmental disabilities, they must be wary of
infantilizing them or creating dependence in doing
so (p. 447). Although in some cases an individual
may not be able to meet strict criteria for informed
consent, the lack of informed consent should not be
concluded to be sexual assault, but rather a lack of
capacity to give legal consent. The other party may
have assented to the action even though the strict
legal definition was not met. Although the act is still
nonconsenting and as such training is required to
assist the person if possible to be able to learn what
is required to give informed consent or teach the
alleged offender about consent, the determination of
assenting but nonconsenting action directs treatment in an entirely different way then if the action
represented sexual assault.
Relevant History
The life experiences of the offender with intellectual disabilities can often reveal many clinically
important facts. As with nondisabled offenders,
the history of offense or offenses provides valuable
information regarding the nature of the offense, the
preferred target for the offense, and the conditions
under which the offense occurred. Individuals with
intellectual disabilities will often deny memory of
the events to avoid punishment or ridicule, however
many are also very poor historians of past events and
as such may provide answers to questions they do not
fully recall in an attempt to comply with the interviewer. The challenge in gaining the history from
the individual with a disability is to attempt to differentiate issues of motivation to conceal from challenges in memory.

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

In the section that follows, Marinos and Griffiths

(2006) provide generalized guidelines for interviewing offenders who are intellectually disabled. There
are however 750 known genetic causes of intellectual
disability and as such the reader should be aware that
there may be great variation within the population
and as such implement the generalizations with caution to individual differences.
Persons with intellectual disabilities are able to
provide descriptions of past events but they will give
less detail. In an interview, the person with an intellectual disability may need more time and support to
provide adequate answers. The person may appear
unresponsive to questioning; however it may actually be that the individual needs more time to process and respond. In some cases responses may come
some time later in the conversation. When describing
past events, persons with intellectual disabilities generally demonstrate difficulty recalling temporal order
or duration because of challenges with time and date,
for example a person may say they committed an
offense last week but it was actually 2 years earlier.
Research has shown that individuals with intellectual disabilities are unable to recall events if subjected to unstructured questioning. They may also
fabricate more on misleading short-answer questions
and are more prone to errors on false leading specific
and statement questions due to the demands of the
situation and the desire to conform to the authority figure. If given a list of options the person with
an intellectual disability is likely to choose the last
one provided. They are also less able to correct information if given misleading recall questions or false
leading specific and statement questions. They may
be less accurate and less confident in recall if highly
anxious; stress can create disassociation and suggestibility, especially when questions are posed to try to
trip the person up.
Unfortunately, a secondary source of gathering
data, client records, is similarly flawed.
Let us examine some examples:
Jon was identified as a high-risk offender based
upon records from the institution. The records
referred to several sexual assaults that he had committed before placement at the institution. He was
denied community-access for many years until an
interview with a family member revealed that the
sexual assaults never happened. Jon had said that he
wanted to be sexual with a girl and his concerned
parents responded by placing him in the institution

361

stating reason that he was in danger because of his

interest in girls. This was misinterpreted to mean
that he was a sexual predator.
Roger was similarly labeled as a pedophile and
was restricted from all activities where there were
children. By going back into original sources, it was
found that this 20-year restriction was on the basis of a
report in his records that said that Roger had touched
a 10-year-old girl on her genital area. What the report
failed to indicate was that Roger was 11 at the time.
Now 31 years of age, he had lived most of his life
mislabeled as a pedophile.
Often the events surrounding a sexual misbehavior are not recorded accurately at the time or based
on supposition rather than observations as in the
situations described previously. However, at other
times, events are recorded inaccurately. More often,
events are not recorded because of concern regarding
wrongful labeling. When events are recorded they
are often written with bias or innuendo, for example
Paul should not be around children or John
becomes bothered by children. Thus, although it is
important to review the records for life history and
sexual offense history, the records should be examined for inconsistencies and data should be verified
where possible with interviews with family and longtime care providers.
The history of the individual can provide valuable information regarding the sociosexual learning
experiences of the individual. A high percentage of
individuals with intellectual disabilities have been
sexually abused; the abuse is typically perpetrated by
a caregiver, generally repetitive, and typically goes
unidentified, unprosecuted, and without treatment
for the victim (Sobsey, 1994; Sobsey & Doe, 1991;
Sobsey & Varnhagen, 1991). Although some sex
offenders within the general population may replay
their own victimization in their subsequent offenses,
the role of the victimization may be more currently
salient for persons with intellectual disabilities
because of a lack of opportunity for prosocial sociosexual education and experiences to replace the
sexual abuse experiences. The abuse may have been
their first or only sexual encounter before the event
in question. If the individual has never experienced
consenting sexual relationships, nor afforded education regarding these issues, then it may be that the
behavior is motivated more out of ignorance than
intent to violate. Lack of sex education has been demonstrated in some cases as a pivotal piece in nave

362 SPECIAL POPULATIONS

offenders, however, it should not be assumed that all

persons with intellectual disabilities lack knowledge
about sex. Often the most dangerous offenders in this
population are very knowledgeable.
Mental Status
Tests of intelligence: One of the common assessments conducted with persons with intellectual disabilities when they commit a sexual offense, is a test
of intelligence. Unfortunately these test results are
often misinterpreted as predictive of all aspects of the
persons functioning rather then their ability to perform on a test that was designed to predict academic
success. An evaluation of a cognitive ability is more
than just an IQ score. An IQ score and the associated Mental Age (MA) are indicative of the persons
performance at that point in time on a test of intelligence. However the IQ is not just a number but a continuum of skills that represent not only quantitative
but qualitative differences in abilities, which results
in a different developmental pattern, in both timing
and degree (McGee & Menolascino, 1992). An individual with a developmental disability may be able
to function fairly independently in society and may
appear socially competent.
Marinos and Griffiths (2006) caution regarding
the common use and misuse of the concept of MA
in these cases. The MA refers to the number of questions a person can answer on the test compared to others of a certain age; it does not account in any way for
the persons life experience or understanding of other
aspects of life. For example, although an adult male
may have an IQ that is described in terms of a MA of a
child it does not mean that his thoughts, experiences,
and general knowledge are that similar to a child.
This man has lived an adult lifespan of experiences
and physical maturation. Moreover because the predictive validity of most tests is less than accepted levels, caution must be used in applying the outcome of
psychological tests to predict behavior (Aiken, 1994).
Intellectual disability refers to a permanent condition occurring before the 18th year that results in
significantly below average intellectual functioning
as measured on an individually administered test
of test of intelligence (IQ less than 75) plus significant deficits in adaptive functioning (APA, 2000). An
IQ measure may provide understanding about the
method of central processing strategies the person
uses and challenges to learning and as such may be of

some benefit when designing a habilitative approach

to teach alternative skills.
The American Association of Mental Retardation
(AAMR) (1993) proposed additional criterion to the
IQ measure that includes identification of the persons strengths and weaknesses, as well as the supports needed by the person to enhance functioning.
A more accurate assessment of mental status therefore
involves examining the adaptive functioning of the
individual, including functional strengths as well as
challenges.
Adaptive functioning: Assessment of adaptive
functioning provides the clinician with information
regarding issues such as personal strengths and habilitative needs that could be part of a package for building resiliency. This assessment might include lifestyle
planning (such as domestic or vocational goals), basic
functioning skills (such as communication), and also
social goals (self-management strategies such as social
skills, social problem solving, and anger management). The example of Bruce illustrates the value of
understanding the persons functioning.
Bruce is an individual labeled with low moderate abilities. He can independently access his community; however, Bruce has difficulty with emotional
regulation and communication. Bruce was accused
of touching a child in the groin. He was arrested and
charged. When the situation was reviewed, it became
clear that Bruce did indeed point to the childs groin
area and perhaps did touch it, but the motivation was
not sexual but to point to the insignia that was on the
childs pants in the groin area. Bruce had limited communication skills and typically communicated his
thoughts to others by touching what interested him.
The charges of sexual assault were dropped because
the assessor was able to demonstrate that this behavior, although inappropriate communication, was
nothing more then his attempt to communicate.
Mental health: Persons with intellectual disabilities are more likely than the general population
to experience a coexisting mental health problem
(Nezu, Nezu, & Gill-Weiss, 1992). Although Langevin
(1992) noted that one in ten sex offenders have a coexisting mental illness, among offenders who have intellectual disabilities this could be as high as 30% to 47%
(Steiner, 1984; White & Wood, 1988). In some cases
the mental illness can be a cause or contributing condition to the sexual offense. For example, Jason has
begun to touch individuals in a sexual manner at his
school. He grabs at the private parts of young girls and

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

the teacher. His behavior was considered purposefully sexual until the psychologist noted that along
with this new behavior, Jason was constantly moving, displaying very pressured speech patterns and
had rapid flights of ideas. She investigated with his
mother about his sleep patterns and found that he had
not been sleeping. A referral to a psychiatrist resulted
in a diagnosis of mania, which when treated resulted
in the elimination of all symptoms including sexual
touching.
Etiology of the disability: Some syndromes commonly related to persons with intellectual disabilities (i.e., fetal alcohol syndrome, Tourettes disorder,
and Aspergers disorder) have been associated with
sexually inappropriate behavior (Griffiths, Richards,
Fedoroff, & Watson, 2002). The expression of the
inappropriate behavior therefore may be associated
with the behavioral phenotype of the syndromes,
respectively impulse control, tics, and social skill deficits. It should however be noted that Aspergers disorder and Tourettes disorder do not necessarily imply
intellectual disability, and indeed may present with
normal or genius level intelligence. Nonetheless,
these behavioral or central processing challenges
present a risk that the individual may respond to
arousing situations inappropriately. The offense to
the victim remains unchanged; however, knowledge
of the vulnerabilities that led up to the assault will
alter treatment strategies.
It appears that certain types of brain damage may
relate to how individuals centrally process information and may contribute, in some way, to the sexual
offenses of persons with and without intellectual disabilities (i.e., impulse control) (see Langevin, 1992).
Although direct application of this research to practice
is still emerging, it has implications for neuropsychological retraining and psychotherapy intervention.
Context
As stated earlier, appropriate sexual, sociosexual
behavior was traditionally not taught to, made available to, or permitted in social service agencies that
support persons with intellectual disabilities. The
learning environment of persons with intellectual disabilities can affect their sexual behavior in two ways.
First, where sexual behavior has been so suppressed,
controlled, or punished, individuals may develop
erotophobia, which may manifest itself as a negative
reaction to anything sexual and denial, anger or self-

363

punishment regarding ones sexuality (Hingsburger,

1992).
Second, the socioenvironmental context that is
typically repressive and punishing may inadvertently promote sociosexual behavior whose function is driven primarily to gain sexual satisfaction
while avoiding punishment and ridicule, rather then
the engagement of sexual satisfaction in appropriate, consenting, and relationship driven contexts
(Griffiths, 2003). The systems in which people with
intellectual disabilities live can promote a Catch
22 regarding the development of sexually appropriate behavior. Although persons with intellectual disabilities do not tend to demonstrate any more sexually
inappropriate behavior than nondisabled persons if
they are provided a normative learning experiences
(Edgerton, 1973), the nature of the generally repressive and restrictive attitudes or conditions provided
for persons with intellectual disabilities promotes a
higher incidence of sexually inappropriate behavior
(Day, 1997).
There are several contextual considerations to
evaluating the sexual offense of a person with an
intellectual disability:
First, if the person were not intellectually disabled
would this be considered an offense?
The sexual behavior of an individual with an
intellectual disability may be considered inappropriate because policy and procedure in the supporting
agency dictate it to be so.
Second, the context in which the person lives
may provide a basis for understanding if the sexually
repressive or punitive nature of the environment is
contributing to the expression of sexual behavior in
an inappropriate manner.
Let us take a few examples:
John and Sean live in a group home where intimacy, especially between the same sex is prohibited.
After many reprisals in their group home for attempts
at intimacy, they opt to seek privacy in the bushes in
the park. Although the behavior resulted in the couple being arrested for engaging in a public indecent
act, the function of the behavior was not exhibitionism but the desire for intimacy in a world that provides them no respect for privacy. Thus knowledge of
the supporting family attitudes or agency policy and
procedures about sexual behavior may be an important consideration in the evaluation of the event.
Similarly, Peter masturbates openly in the living
room of his group home. He is continually sent to

364 SPECIAL POPULATIONS

his room, but comes out to the common area in just

a few minutes and begins again. The staff members
believe that his exposure is a paraphilia and believe
that he may be at risk to display this behavior in the
community. However, the assessment revealed that
Peter engages in this behavior only in the presence
of a few individuals, whom it appears he finds attractive. The initial impression was that he is engaging in
this behavior to either shock or interest the women.
However an alternative hypothesis is that the presence of an attractive woman is necessary for him to
get an arousal and his home does not allow him any
erotica for use in his bedroom. He was taken to a
poster shop and helped to purchase of a poster of his
choosing for his wall; he chose an attractive woman
in bathing suit. He was then given a few instructions
on privacy and private places to be sexual. From that
moment on he stayed in his room to masturbate. This
simple solution resolved the situation and allowed the
clinician to evaluate that the apparent paraphilia was
probably a by-product of the contextual restrictions
combined with his disability. He was unable to use
mental imagery of an attractive woman unless the
stimuli was present, but because he had no access to
arousing stimuli, because of policy and practice of the
agency, and because he had not been taught the difference between public and private, he resorted to the
public use of arousing stimuli (i.e., the presence of
attractive women in the living room).
Sociosexual Knowledge and Attitudes
Sociosexual knowledge and attitudes are an important element in the assessment process for individuals with intellectual disabilities who sexually
offend. Attitudes regarding sexual behavior are typically conducted with sexual offenders regarding
attitudes toward women and cognitive distortions.
However, in addition, a sociosexual knowledge
and attitude assessment is recommended (Griffiths
et al., 2007).
Attitudes and cognitive distortions: The Abel
and Becker Cognition Scale (ABCS, Abel, Becker, &
Cunningham-Rathner, 1984) was a measure designed
for sexual offenders without disabilities. This was
revised by Kolton et al. (2001) for use with persons
with intellectual disabilities, however it does not have
demonstrated validity for this population. The nature
of the items may lead to individuals with intellectual
disabilities giving responses that may be misleading

because the individual is responding to please the

examiner.
Sociosexual knowledge and attitudes: Although
not typical in a sexual evaluation for nondisabled persons, assessment of the sociosexual knowledge and
attitudes of sexual offenders with intellectual disabilities provides valuable information in making a differential diagnosis of paraphilia. Adults with intellectual
disabilities generally know less about their sexuality
and sexual abuse than teenagers without disabilities (Murphy, 2003); sex education can make a significant difference in understanding and knowledge.
Hingsburger et al. (1991) presented case examples of
persons with intellectual disabilities for whom the
treatment, for certain inappropriate sexual behaviors, was sex education alone. Other cases however
represent more clinically complex intervention where
sex education is often a critical vulnerability for the
development of the inappropriate sexual expression
and one of the main components of effective intervention (Griffiths, Quinsey, & Hingsburger, 1989;
Griffiths, 2002).
The SocioSexual Knowledge and Attitudes Tool
(SSKAAT-R) (Griffiths & Lunsky, 2003) and the
Sexual Knowledge, Experience, Feelings and Needs
Scale (SexKen-ID) (McCabe, 1994) represent two of
the evaluative tools available that measure change in
both knowledge and attitude. These measures provide an individually administered evaluation using a
picture book, to which participants answer minimally
verbally demanding questions. Although there are
less complicated measures available (i.e., Timmers,
Du Charne, & Jacob, 1981), the psychometric evaluation of the simpler measures is lacking (McCabe,
Cummins, & Deeks, 1999).
The SSKAAT-R has been field-tested across North
America and has excellent psychometric properties,
including internal consistency, test-retest reliability,
and content validity. This measure is particularly
appropriate to identify the base of knowledge and attitudes that the individual has with regard to a range
of sociosexual behaviors and as an aid in differential
diagnosis of counterfeit deviance related to a lack of
awareness of boundary issues. This measure includes
the additional dimension of evaluating age and gender discrimination.
The Sex Ken-ID reports high levels of internal
consistency for all subscales with the exception of the
needs and feeling subscales (McCabe et al., 1999).
Testretest reliability data and validity data were less

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

convincing. Whitehouse and McCabe (1997) state

that future programmes need to consider the use of
checklists and transcript analysis to cover both the
more accurate but more limited assessment of sexual facts as well as the more complex analysis of feelings and attitudes. The Sex Ken-ID differs from the
SSKAAT-R because it also requests information about
experiences and as such would serve as a valuable tool
in exploring experiences and feelings that may relate
to sexual dysfunction.

PH A LLOMET RY (PA RT NER SELECT ION

A ND PR EFER ENCE)

Diagnosis of paraphilia using sexual assessment procedures for this population should be undertaken
cautiously. Typical sexual preference interviewing
and testing procedures require adaptation and careful interpretation when used with this population.
Individuals with intellectual disabilities may have
difficulty providing self-report information; more
concrete interview questions might be preferable
(Murphy, Coleman, & Abel, 1983a). Although phallometric measures with this population have been
reported to be accurate in determining sexual preference on both age and gender and useful for those
who have committed a sexual offense (Murphy et al.,
1983a), some individuals with intellectual disabilities may present with physical, communication, and
behavioral challenges that can interfere with the
evaluation and may not demonstrate the expected
response to the testing situation. Murphy et al.,
(1983a) noted that common medications in this population can interfere with testing results. They further
noted that some individuals were cognitively unable
to focus on the visual test stimuli or had greater difficulty discriminating situations that were deviant.
Griffiths et al. (1989) noted that some individuals had
difficulty with age discrimination and suggested the
use of a card sort test to assess if individuals could
determine who is like me? and who is it ok to have
sex with?
Phallometric testing is described in more detail
elsewhere in this book (Fedoroff, Kuban & Bradford,
2006). Concerning phallometric testing of individuals with intellectual disabilities, it is most important
to be aware that phallometric testing is not designed
to determine guilt or innocence of an alleged crime.
Its purpose is to objectively measure sexual arousal

365

patterns in a controlled laboratory setting. Results of

this testing can aid in the design of a comprehensive
treatment plan but should never be relied upon in
isolation.
Unfortunately, phallometric testing is underutilized in men with intellectual disabilities. This is
due to a lack of suitably equipped facilities that are
comfortable and experienced in dealing with this
population. In addition, some care providers and
agencies have a reluctance to agree to the testing due
to an unproven belief that phallometric testing may
somehow unleash deviant sexual interests. Likely
this represents another manifestation of the eternal
child myth described earlier in this chapter.
While there is no reason to consider the prescription of phallometric testing contraindicated in
men with intellectual disability, special caution is
needed. This is because abnormal test results can
easily be misused by third party agencies to deny or
delay appropriate treatment, housing, or enrollment
in social and educational programs. Caution also
needs to be exercised to ensure that collateral information from phallometric testing is not misused.
For example, phallometric testing designed to investigate to presence or absence of sexual interest in
children (pedophilia) will also reveal information
about the subjects sexual orientation concerning
adults. Regrettably, some care providers and agencies
(officially or unofficially) treat homosexual clients
differently than their heterosexual ones.

R ISK ASSESSMEN T

The research on differential evaluation procedures

is largely unavailable for this population. Moreover,
direct application of some testing procedures to
this population may have potential challenges. For
example, risk assessment in the general population
of sex offenders is best evaluated using instruments
like the Sex Offender Risk Appraisal Guide (SORAG)
(Quinsey, Harris, Rice, & Cormier, 1998). However,
persons with intellectual disabilities may score uniformly higher on various measures of the score by virtue of the experiences afforded them in life because
of the disability label (Griffiths, Richards, & Fedoroff,
2002).
Researchers have now completed three studies
that are relevant to this proposal. In the first study
18 male sex offenders with intellectual disability

366 SPECIAL POPULATIONS

were case-matched on the basis of age and number of known victims to 18 male sex offenders
with no intellectual disability (Fedoroff, Selhi,
Smolewska, & Ng. 2001). They were scored on modified versions of the VRAG and SORAG in which
Child and Adolescent Taxon (CAT) (Quinsey et al.,
1998) scores were substituted for Hare Psychopathy
Checklist scores. The data were analyzed retrospectively. The men with intellectual disability were
scored significantly higher on both the VRAG and
SORAG (VRAG mean scores: 0.11 vs. 5.5; p = 0.01
respectively) (SORAG mean scores: 0.11 vs. 5.3;
p = 0.04 respectively). These results were interpreted as supportive of the hypothesis that some
items on the VRAG and SORAG have different
significance in men with intellectual disability. For
example, the item lived with both biological parents until age 16 was scored positively in significantly more men with intellectual disability than
in the control group (p = 0.0002). Our group has
speculated that the reasons that men without intellectual disability fail to live with their parents are
different than those of men with intellectual disability. Since VRAG and SORAG scores are currently
used to make treatment and disposition decisions in
men with intellectual disability, it is vitally important
that their validity be demonstrated in this group.
In a second study using a completely independent
group of men, 38 men with chart diagnoses of intellectual disability who were accused of sexually offending against children were matched with 38 male child
molesters without intellectual disability on the basis
of age at the time of their index offense, and number
and gender of their victims (Fedoroff, Curry, &
Madrigrano, 2006). In this study VRAG and SORAG
scores were based on scores that included Hare
Psychopathy checklist scores but the item Elementary school maladjustment was scored as zero for all
men since this information was not scored reliably
in the database used. Again, this study involved retrospective analysis. In this study, although there were
no significant differences between the two groups
in VRAG or SORAG scores, the intellectually disabled group scored significantly lower than the nonintellectually disabled group on the Hare Psychopathy
checklist (Hare, 1991)(16.38 vs. 20.80 respectively;
p < 0.05). In addition, both groups had higher average VRAG and SORAG scores than in the previous
study (mean VRAG score = 1.79; mean SORAG score
= 2.41). Again, there were significant differences

on several individual items on both the VRAG

and SORAG instruments (not all of which corresponded to the items identified in the first study).
These findings support the hypothesis that individual
items on the VRAG and SORAG have different significance in sex offenders with and without intellectual disability and raise the possibility that there may
be other mediating factors. For example, it may be
that VRAG and SORAG scores are falsely elevated
in men with developmental delay who have low psychopathy scores but this difference may diminish in
the sub-group of developmentally delayed sex offenders who have high levels of psychopathy. A study to
investigate this possibility is currently under-way.
In a third study (Quinsey, personal communication) 58 men from institutions designed to house
individuals with intellectual disabilities and serious
histories of antisocial and aggressive behaviors were
prospectively followed for an average of 16 months
after discharge from their home institute. Items from
two scales used to assess dynamic risk factors (the
Problem Identification Checklist and Proximal Risk
Factor scale (Quinsey, Coleman, Jones, & Altrows,
1997)) were subsequently selected if they exhibited a significant linear trend across previous, prior,
and index months in which problematic incidents
had occurred. The resulting instrument, the Short
Dynamic Risk Scale was found to show significant
linear trends for both nonviolent and violent incidents
even when VRAG scores were statistically controlled.
These results suggest that improved assessment
instruments specifically designed for individuals with
intellectual disability not only can but need to be
developed and validated in this population.

IN T EGR AT ED MODELS
OF IN T ERV EN T ION

In the 1980s the first specialized treatment programs were developed for persons with intellectual disabilities who demonstrate sexually offensive
behavior (i.e., Coleman & Murphy, 1980, Griffiths
et al., 1989). Before the 1980s, persons with intellectual disabilities who engaged in sexual assault were
managed by segregation and institutionalization
(Griffiths et al., 1989), chemical arousal reduction
(i.e., hormone therapy) or behavioral suppression
(Foxx, Bittle, Bechel, & Livesay, 1986). It was common belief at that time that persons with intellectual

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

disabilities would not benefit from traditional therapy

or counselling. As a result it was uncommon for therapeutic interventions to be considered. However, in
the 1980s, treatment programs began to emerge that
promoted a therapeutic approach including training skills in sexual responsibility, sociosexual knowledge, coping skills, and control of deviant arousal
through relapse prevention strategies (Griffiths et al.,
1989; Haaven, Little & Petre-Miller, 1990; Lindsay,
Marshall, Neilson, Quinn, & Smith, 1998; Nezu,
Nezu, & Dudeck, 1998; Ward et al.,1992).
Habilitative Mental Health
Model of Intervention
Griffiths et al. (1989) and Tudiver et al. (1997) recommend that treatment methods for developmentally
delayed offenders be grounded on the same treatment
approaches used for nondelayed offenders, but tailored to address the learning needs, and special issues
of offenders with intellectual disabilities. The components identified by Griffiths et al. (1989) include
social skills, sex education, responsibility training,
relationship training, coping skills, and the control of
deviance.
However, the general sexual offender treatment
model is largely rehabilitative; rehabilitation implying
the person receives treatment to return their sexual
expression to a state of dignity. Persons with intellectual disabilities by virtue of their disability and life
experiences have generally not been afforded the life
experience or training to understand and experience
their sexuality as normative. While this argument
may be valid for some nondisabled sex offenders, sexual offenders with intellectual disabilities require an
increased emphasis on habilitation. Habilitation
involves an active education and training component
within a strong habilitatively supportive environment
to set up the conditions by which the individual can
assume, perhaps for the first time a sense of dignity
and responsibility with regard to ones sexuality.
As noted in Table 25.1, multiple and co-occurring
risk factors may increase the likelihood that persons
with disabilities may experience challenges regarding their sexuality. The accumulation of risks or
adversity over a lifespan can predispose an individual
to act in a certain way. For example a lack of communication, social skills, or positive sex education,
or the experience of victimization may alter how a
person understands or responds to their sexuality.

367

Persons with intellectual disabilities are particularly

disadvantaged in their life opportunities to develop
adaptive and resilient lives that would allow them to
respond positively to mental health challenges and
risk factors. Resiliency is the developmental process
that enables a person to adapt to adverse situations
(Masten, 2001) in the absence of psychopathology
or high-risk behavior related to a persons situation
(Miller, 2002).
Multicomponent treatment is considered best practice in the field for persons with intellectual disabilities who commit a sexual offense (i.e., Griffiths et al.,
1989 or Haaven et al., 1990; Nolley, Muccigrosso, &
Zigman, 1996). Intervention typically includes development of a range of habilitative skills through
individual and group therapy (such as sociosexual
education, coping and anger management skills, and
social communication and assertiveness skills).
However, habilitative intervention places strong
emphasis on the role of the environment and coordination of a support network. Habilitation is based
therefore on two primary and interacting intervention elements: development of habilitative strengths
within the individual and exposure to the habilitatively appropriate environment by which the acquired habilitative strengths can become appropriated
by the individual. Research would indicate that
knowledge and skill is difficult to achieve with this
population (Feldman, 1994) and dependent upon
training in the natural environment or in settings
that closely simulate real-life situations, using sufficient and relevant exemplars, and that is naturally
trapped into the reinforcement conditions of the
environment (Griffiths et al., 1997; Horner & Albin,
1988; Miltenberger et al., 1999; Neef, Lensbower,
Hockersmith, & DePalma, 1990).
Habilitative Education
The critical difference in teaching persons with intellectual disabilities from teaching those who do not
have disabilities is that they may not have ever developed the understanding or skills regarding normative
sexual behavior. Granted some may argue, correctly,
that the same could apply to some nondisabled offenders and conversely that some offenders with intellectual disabilities are all too knowledgeable about what is
normative, but elect to act in a manner that is illegal and inappropriate (i.e., children and aggression).
Both rival arguments are correct for some individuals.

368 SPECIAL POPULATIONS

However at the risk of overgeneralizing, most

offenders with intellectual disabilities require training in appropriate sociosexual interactions and in the
range of compensatory self-management skills necessary to provide prosocial responses in the presence of
arousing events and the avoidance of same events.
Proactive strategies for managing sexually
inappropriate responses: Knowledge of the instigating conditions for the behavior can suggest education
approaches to (a) remove or reduce the contributing instigating conditions, (b) introduce instigating
stimulus conditions to compete with the offensive
behaviors, or (c) alter the individuals reaction to the
instigating events.
This approach is based on education. For example a pedophile would be taught to (a) avoid situations
that are considered high risk for repeated offense (i.e.,
babysitting, public parks, school yards, fairs) and/or (b)
introduce instigating stimulus conditions that would
compete with the possible offense such as the presence of others who will monitor the situation, and/
or (c) alter the individuals reaction to the contributing conditions by teaching the individual new ways
of coping with these events (i.e., walking away from a
high risk situation where there is a child present). The
latter is of course the most difficult proactive strategy.
Proactive strategies depend on solid behavioral
analysis of the antecedents and setting events that
precipitated previous events and that are related to the
individuals arousal patterns as well as those antecedent conditions that tend to inhibit the presence of the
offending behavior.
Teaching new skills: In addition to the proactive
strategies, it is important to provide opportunity for
the individual to learn new skills in dealing with these
events. Skills in prosocial behavior such as sociosexual interactions and self-management/impulse control and anger management training packages for
this population are available. Preset training packages however can fail to address the specific triggering conditions for an individual, and as such although
an individual may have been deemed a graduate of
anger management or sociosexual education programs, the training may be ineffective because it
failed to address the specific anger or sociosexual factors that contribute or trigger the challenges for that
individual. Thus although they represent an excellent starting point for habilitative skill development,
these packages should be individualized to ensure
they are meeting the needs of the individual.

Additionally, once skills are taught their use in the

natural environment will depend on the value they
have in the environment, as such the program should
build in systematic recognition for the individual
when the new skills are being effectively applied in
previously challenging situations. However, sociosexual skills are complicated and as such ensuring their
success in the real world can not always be predicted.
The person may learn appropriate sociosexual interactions, choose an age appropriate partner but be
rejected for reasons unknown. As a result, part of the
educational process is that sexual attraction is unpredictable and that potential rejection is an expected
behavior. Too often, persons with intellectual disabilities are taught the appropriate behaviors without being taught that the partner may or may not
respond as scripted. Thus it is critical to review the
contingencies and prepare alternative responses to
the alternatives.
Developing a Supportive, Positive
and Reinforcing Environment
for the Treatment of Offenders
Many authors have described how the environment can influence the development of challenging
behaviors in persons with intellectual disabilities
(i.e., Gardner, 1996; Martens & Witt, 1988) and the
role of the environment in treatment (i.e., Griffiths,
Gardner, & Nugent, 1998), however few have discussed the nature of that environment for offenders
with intellectual disabilities (i.e., Haaven et al., 1990;
Griffiths et al., 1989).
Griffiths et al. (1998) suggest that the habilitatively
appropriate environment should be as normalized as
possible; normalized implies that it promotes learning and use of those skills and behaviors that result
in an enriched lifespace for the individual (p.100).
Unfortunately persons with intellectual disabilities
who present with challenging behavior, such as sexual aggression, are typically provided physical conditions that are not normative, offered limited if any
habilitatively appropriate programming, and given
very limited, controlled, and sterile social conditions.
Griffiths et al. (1998) suggest that such conditions
combine with the preexisting challenges in coping,
social, and related skills produce increased vulnerability to future challenges. The presence or absence
of certain environmental events (i.e., availability
of reinforcing experiences and associations, daily

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

activities, material possessions, and valued relationships) as well as adaptations in the environment have
been shown to influence the motivation and presentation of behavior (Gardner, Cole, Davidson, & Karan,
1986). Other environmental issues include clustering, size and space, and opportunity to access normative environments and interactions that can promote
culturally appropriate expectations and learning and
generalization opportunities (Griffiths et al., 1998).
The possibility of reoffense within programs is a
particular concern that needs to be addressed in the
treatment environment. Clear socially constructed
expectations and standards of conduct function as
guides for appropriate actions for both the individual
and the care providers. Often individuals with disabilities have received inconsistent or poorly defined
expectations; these conditions do not establish conditions for the development of prosocial inhibitions to
impulses or stimulation present at the moment. As a
result the individual does not learn to be concerned
over the immediate or long-term consequences that
may result.
Care providers also need guidance in how to provide respectful and consistent interactions with the
individuals they support. Consistency among care
providers shifts the emphasis in interactions from
testing the limits of each staff to more developing
constructive interactions. The respect element in the
interactions allows for the promotion of increased
social motivation, decreased aversive elements, and
begins to provide, within the confine of the known
expectations, the development of choice and prosocial problem-solving.
The role of the social environment is to ensure
that the individual has the opportunity to develop,
perhaps for the first time, the value of positive relationships with a variety of people, who become part
of a persons life by mutual choice and maintain
relationships because of mutual enjoyment. Another
element to social habilitation is to develop a range of
sustaining or stable relationships that provide potential opportunity for personal or, where appropriate,
intimate relationships to develop.
A key factor in the long-term success and generalization of intervention may be the development
of habilitatively appropriate social environments.
Ultimately the outcome of the environment is to
allow the person to experience success in social interactions and daily life, so that the person emerges with
enhanced self-esteem awareness and control. The

369

new identity or new me, as Haaven et al. (1990)

describe it, is now based on these positive experience
and the new strengths that have been developed. The
person should emerge from the intervention with
clear expectations for a new and improved quality of
life within a life-space based upon an ongoing contingency plan, for both prosocial and inappropriate
sexual expressions within the natural environment.
According to Renwick et al. (1994), quality of life is
determined by three elements: first, a sense of meaning and physical/psychological health and wellbeing,
second a sense of belonging in the community and
with important others, and third a sense of engagement and growth in everyday life and of a future. The
emphasis on building an improved quality of life for
offenders is to shift the focus from hopelessness and a
lack of control to a focus on hope and resiliency.
Factors such as trusting relationships, encouragement, personal strength and self-esteem, social
and interpersonal skills, communication skills, as
examples, are pivotal factors in building resilience
(Masten, 2001). Additionally, certain qualities of the
environment or the individual can compensate for or
protect the individual in the face of risk. Applying a
resiliency model of intervention to sex offenders with
intellectually disabled offenders would suggest that
recidivism could be enhanced by building a supportive, positive and reinforcing environment and the
competencies to respond to risk factors.
Intervention OutcomeWhat Do
We Want Them to Measure?
Sex offenders with intellectual disabilities, particularly those individuals who are labeled as mildly or
moderately disabled, have been surprisingly responsive to treatment (Lackey & Knopp, 1989). Although
the claims of success have generally not been followed up with strong empirical research; many studies lack pretreatment assessment or reliable direct
observations in the generalizability of outcomes to
the natural environment where the triggering events
are naturally present and unrestricted.
In a proactive model of intervention, outcome
evaluation goes beyond measuring the rate of
offending behavior (recidivism). It includes evaluation of (a) the development and transfer of proactive
skills to replace the sexually inappropriate behavior
within the natural environment, (b) the ongoing system of support for the individual to ensure that the

370 SPECIAL POPULATIONS

contingencies of reinforcement for prosocial behavior or for the inhibition of inappropriate behavior are
maintained, and (c) evaluation of the outcome of an
improved quality of life for the individual to ensure
that resiliency has been developed.
Recidivism as an outcome measure: Commonly,
recidivism is the only outcome measure employed.
However, recidivism data relies on the person being
caught and on reconviction rates, rather then actual
offense rates. In reviewing five studies that reported
recidivism as their treatment outcome data, rates
ranged from 2% to 40% with follow up from 2 to
10 years post treatment (Demetral as cited in Nolley
et al., 1996); Day, 1997; Lund, 1992; Haaven et al.,
1990; Swanson & Garwick, 1990). The rate of recidivism reported was not related to the length of the
follow up. In fact one of the largest rates of recidivism
was reported in a study that had a 2.5-year follow-up
(Swanson & Garwick, 1990). However, recidivism
data may relate to treatment location (Nolley et al.,
1996). For example, Demetral (as cited in Nolley
et al., 1996) reported a recidivism rate of less than 2%
within a community program; Haaven et al. (1990)
indicated a rate of recidivism of 23% for their population of institutionalized offenders. Nolley et al.
(1996) cautioned that these research findings may be
interpreted in two ways. First one could assume that
the populations differ or that the data from the community was less accurate.
However, Nolley and associates suggested that the
better outcome data from the community programs
were the result of highly qualified facilitators who
provided increased social opportunities for persons
with developmental disabilities, enlisted natural support systems, and ensured greater opportunity for
learning about culturally acceptable ways of sexual
expression. The aforementioned thesis, although still
speculative, is consistent with the empirical understanding of generalization principles for teaching
persons with intellectual disabilities (Griffiths et al.,
1997) and with the clinical findings of Griffiths et al.
(1989).
Direct observation as an outcome measure: The
use of direct observation across individuals and settings
in the natural environment provide increased levels
of confidence in treatment effectiveness. Treatment
outcomes are often measured in this population by
use of the Casper technique. This approach is used
when the individual has demonstrated that they can
meet set standards of competency in learning self-

control and relapse skills in a safe environment.

Once criteria within the safe environment are met,
the individual is then given graduated opportunities
to gain degrees of freedom to reduce supervision in
the natural environment where previous triggering
events may be present. For example the person may
move from a direct escort on a low risk activity (e.g.,
walk to the corner store and back, or going on the
bus to work, if those are deemed to be low-risk situations for the individual), to being allowed independent access but within a restricted time-frame (i.e.,
15 minutes) and along a particular path (i.e., avoiding the school yard). Initially, however the degrees of
freedom are provided with the persons knowledge
that someone may be watching. A staff member that
the individual does not know will be either shadowing the individual from a distance and recording
if the individual employed his prosocial skills and
showed inhibition of inappropriate behavior if the presence of potential triggers presented themselves (i.e.,
a child). The staff is therefore available to intervene
should the individual not show the appropriate skills.
Initially a staff member would be watching each
trip until a measure of confidence is gained that the
individual is able to use the skills in different situations, with different people and in the proximity of
potential relapse targets. This strategy provides three
advantages. It begins to generalize the individuals
learned skills from the safe environment to the natural community with graduated levels of supervision.
Second, it provides an opportunity for the program
to provide direct monitoring and evaluation of outcomes. Third, it enables the program to introduce
generalization probes in a controlled manner that
affords minimum risk to the community. Reduction
of the supervision is carefully orchestrated to ensure
changes reflect evidence that is based upon the outcome data and the individually determined degree of
risk for various situations.
The Casper stage of intervention is developed
in conjunction with the individual and explained as
a way in which the person can gain confidence that
their new skills are useful in allowing them to gain
community opportunities in a manner that is safe for
them to keep out of trouble. The cooperation and
agreement of the participant is important; the motivation of the individual to ensure self and other safety
is part of the process of change. The Casper technique has been used in many settings and appears to
have both clinical and research applications.

SEXUAL OFFENDERS WITH INTELLECTUAL DISABILITIES

BACK U P CON T INGENCIES: IF
PROACT I V E A PPROACHES
A R E NOT EFFECT I V E

When proactive approaches are not effective, things

can go wrong even in ideal practice environments.
Usually it takes the form of a frantic telephone call
saying: there has been an incident. These calls
often come from a front-line worker who is not the
usual caretaker of the person in question. Typically,
the usual frontline worker has gone on vacation, been
transferred, or called in sick. This is because people
with intellectual disability are upset by change in routine. A new worker can mean new problems.
The first response is to ascertain if anyone is hurt
(physically or psychologically). If a sexual assault
involving penetration is suspected the victim should
be assessed by a rape crisis team at a medical facility
as soon as possible.
Often the incident raises the question of whether
the police need to be called. Almost always, the
answer is yes. Care providers and agencies are not
detectives and it is vitally important that any investigations be done by a third party agency with experience in such matters. The police are the experts in
deciding if a criminal charge is warranted.
Ideally, the agency involved will already have a
working independent relationship with the hospital
and the police. Assessment of victims with intellectual disability is a topic beyond the scope of this
chapter. Similarly, the special procedures advised for
police departments charged with the responsibility
of investigating alleged sexual offenses committed
by people with intellectual disabilities have been
described in detail elsewhere (Richards, Watson, &
Bleich, 2000).
If the accused is arrested and taken into custody,
agency workers should be reminded that they have
an obligation to respect the confidentiality rights of
their clients. They should consult with their professional college if they are unsure of their obligations.
In the event that they are requested to give statements to the investigating police, they should be
clear about whether they are acting as a fact witness
or as a professional.
If the accused is taken into custody, the agency
and care providers normally suspend their treatment since this is now the obligation of the custodial
facility. It is not uncommon however for the custodial facility to seek advice about how to manage the

371

individual. There is no ethical problem in providing

assistance to the accused provided the assistance
does not devolve into an investigation of the alleged
offense.
Once the individual is returned to the community either on bail or having been acquitted or found
guilty, a full reassessment is required and appropriate
treatment should be undertaken. These issues have
been described in detail elsewhere (Fedoroff et al.,
2002; Langevin & Curnoe, 2002). They can be summarized as follows:
1. Establish a comprehensive differential diagnosis.
2. Do not rely on the diagnosis of intellectual
disability or a paraphilic disorder to explain
everything. Is there a comorbid condition or
environmental factors?
3. Treat the comorbid conditions.
4. Simultaneously treat the sexual problem(s).
5. For sexual problems, assess the severity/seriousness of the problem.
6. Present the treatment options including risks
and benefits of not accepting treatment to the
individual and/or substitute decision-maker.
7. Consider any treatment agreed upon as a trial
that will be reevaluated regularly.
CONCLUSION

The history of persons with intellectual disabilities has been fraught with human rights violations,
often because of concern regarding their sexuality. It
is therefore not surprising that inappropriate sexual
behavior was not addressed proactively or therapeutically until recently. In the past few decades, the
forensic and disability fields have both begun to
address treatment for this population.
Literature and research has begun to emerge
that provides an increasing understanding of the
similarity and differences in the etiology and treatment for sexual offense behavior in persons with
intellectual disabilities compared to the nondisabled offender. This understanding will hopefully
lead to improved assessment and intervention for
those persons who are intellectually disabled and
who offend sexually.
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(2003). Sex education. In D. Griffiths, D. Richards,
P. Fedoroff, & S. Watson (Eds.), Ethical dilemmas: Sexuality and developmental disabilities
(pp. 387416). Kingston, NY: NADD Press.
White, D. L. & Wood, H. (1988). Lancaster Counter
MRO Program, In J. A. Stark, F. J. Menolascino,
M. H. Albarelli, & C. C. Gray (Eds.), Mental
retardation/mental health: Classification, diagnosis, treatment, services. New York, NY: SpringerVerlag.
Whitehouse, M. A. & McCabe, M. P. (1997). Sex education programs for people with Intellectual disability: How effective are they? Education and Training
in Mental Retardation and Intellectual Disabilities,
32, 229240.

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Part VII

Forensics

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Chapter 26

Forensic Considerations
Rusty Reeves and Richard Rosner

As described throughout this book, the identification,

evaluation, and treatment of a sex offender requires
specialized knowledge within the broader areas of
forensic psychiatry and psychology. On the other
hand, the forensic evaluation of a sex offender follows
a principle common to all forensic evaluations. That
is, all forensic psychiatric and psychological evaluations require the rational organization and analysis of
data. A four-step method devised by Richard Rosner
(2003) allows such rational organization and analysis. The four steps are issue, legal criteria, data, and
reasoning.
Issue: What is the specific psychiatricor psychologicallegal issue?
Legal criteria: What are the legal criteria that will be
used to resolve theissue?
Data: What are the data relevant to the legal criteria
that will be used to resolve the issue?

Reasoning: How may the data be applied to the legal

criteria to establish a rational psychiatric or psychological opinion?
ISSUE

In any given forensic evaluation, whether a sex

offender evaluation or not, numerous psychiatricor
psychologicallegal issues may arise. The first step
an evaluator takes is the identification of the specific
legal issue or issues that the referring party wishes
the evaluator to address. A judge, attorney, or mental
health agency often will ask for a psychiatric evaluation of a defendantand leave it at that. The evaluator is then left to identify the legal issue involved. Do
not guess. The evaluator should instead contact the
referring person and determine the precise legal issue
or issues the referrer wishes the evaluator to address.
If the evaluator fails to identify the correct issue or

379

380 FORENSICS

issues, the evaluators report might address irrelevant

issues, and thus prove not only useless to the legal
system but also inimical to the evaluators forensic
career. Such mistakes are more common than one
might think.
In a sex offender evaluation, for example, a judge
might ask for just thata sex offender evaluation.
The evaluator should clarify the issue or issues
involved. The judge might want to know treatment
options for an identified sex offender. Alternatively or
in addition, the judge might want to know the nature
of a sex offenders psychopathology, if any, and the
risk of recidivism the offender poses. The issues
might be more generic: competence to stand trial,
legal insanity, and termination of parental rights
are all issues that could arise in an evaluation of a
sex offender. In jurisdictions with Sexually Violent
Predator (SVP) statutes, the judge might wish to know
whether a known sex offender is civilly committable
under one of these statutes. In a typical forensic evaluation of a sex offender, several issues are involved.
Each issue requires a separate evaluation according
to the relevant legal criteria in the particular jurisdiction (see Criteria subsequently).

CR IT ER I A

There are numerous legal arenas in which a given

forensic issue is relevant. Most legal systems are
arranged hierarchically. For example, the United
States has its federal, military, and 50 state jurisdictions plus the District of Columbia. A separate set of
statutes (laws created by a legislature), case law (rulings made by judges), and administrative code (policies created by bureaucracies) govern each of these
jurisdictions. Statutes, case law, and administrative
code offer the legal criteria which define an issue.
Thus, for the purposes of a forensic evaluation, statutes, case law, and administrative code all function
as law.
Numerous and diverse jurisdictions and their
subdivisions ensure that the legal criteria defining
an issue are themselves numerous and diverse. The
forensic evaluator must be certain of the jurisdiction
in which the evaluator is working, and then be certain of the legal criteria applicable to an issue within
that jurisdiction. Such knowledge requires familiarity with the arrangement of the legal system within
ones country. An evaluator also requires a means to

access the relevant criteria. Asking the referring attorney for the criteria is the most simple and most common means. The attorney should provide a written
statement of the criteria. An oral report is unreliable.
The attorney may be uncertain of the precise criteria. This circumstance is not uncommon, especially
in SVP practice in which the law is evolving and is
subject to constant challenge. The evaluator should
either insist that the criteria be made available, or be
independently certain of the criteria. If the criteria
one uses in an evaluation are incorrect, ones opinion
is logically unsupported. Subscriptions to legal publications (e.g., Westlaw) are an independent means for
an evaluator to access the legal criteria. The Internet
is tempting, tedious, and disappointing. Searches are
slow, and the free information that is available (when
it is available) is almost always incomplete.
Simply finding the criteria is insufficient. The criteria may be vague, and thus open to interpretation.
For example, SVP statutes require, as a criterion for
commitment, that an examinee exhibit a personality disorder or mental abnormality that makes one
likely to commit acts of sexual violence. This ostensible single criterion actually contains within it terms
that are themselves criteria (i.e., mental abnormality, personality disorder, likely, and acts of sexual violence). An evaluator should not presume an
understanding of these several criteria. For example,
what does likely mean? Does it mean, as might
seem intuitively obvious, 51% probability of recidivism? If so, over what period? Or does likely mean
something else entirely?
In New Jersey, for example, likely to engage in acts
of sexual violence is statutorily defined (NJSA [a]) to
mean the propensity of a person to commit acts of
sexual violence is of such a degree as to pose a threat
to the health or safety of others. If that definition is
no less vague than the term it defines, New Jersey case
law is equally unhelpful. The New Jersey Supreme
Court construed the legislatures definition as requiring that a sex offender have serious difficulty controlling his or her harmful sexual behavior such that it
is highly likely that the person will not control his or
her sexually violent behavior and will reoffend (In re
Commitment of W.Z). Thus we are back to likely,
again, but no further enlightened. One must peruse
the courts dicta in the aforementioned case to learn
that the court rejects the requirement that likely
means a quantifiable standard, such as 51% chance
of recidivism. In other words, likely, in New Jersey

FORENSIC CONSIDER ATIONS

means whatever amount and type of risk the judge

considers unacceptable for the community to bear.
Although the term likely may be a definitional
quagmire, not all criteria in SVP law are so troublesome. Acts of sexual violence are explicitly defined
in the various SVP statutes, and typically include contact offenses (e.g., sexual assault) as opposed to noncontact offenses. (e.g., exhibitionism) However, even
with this criterion there are wrinkles. In New Jersey, a
sexual contact offense includes a perpetrators sexual
contact with himself (NJSA [b]). Therefore masturbation in the presence of a victim would be a sexually violent offense under New Jersey SVP law. Such
peculiarities are common in other states as well, and
demand close attention by the evaluator.
Then there are the terms mental abnormality
and personality disorder. These terms are so broad
and ill-defined that an experienced practitioner in
this area could be tempted to make an argument for
a mental abnormality or a personality disorder in
just about any sex offender. For example, antisocial
personality disorder has been established in case law
as a qualifying personality disorder under SVP statutes. Persons with antisocial personality disorder are at
greater risk that those without the disorder to commit
crimes of all sorts, including sex offenses. However,
there is nothing about the generic antisocial personality disorder (at least as it is defined in the Diagnostic
and Statistical Manual of Mental DisordersFourth
Edition, Text Revision [DSM-IV-TR] [2000a]) that
predisposes a person to commit sex offenses in particular. Yet courts accept this diagnosis with its limited
albeit real association with sex offenses. An evaluator might also write that an offenders particular
manifestation of his antisocial personality disorder
includes sex offenses. Courts accept this argument
also. However, this argument could be criticized for
associating an offenders sex offenses too closely with
the offenders antisocial personality disorder when
perhaps it is some other mental conditionsome as
yet unidentified and unnamed mental statethat
could better account for an offenders commission of
sex offenses.
The situation is even more fraught with potential
error when the qualifying diagnosis is Personality
Disorder NOS (Not otherwise specified) or
Paraphilia NOS (Not otherwise specified). In this
situation, the evaluator is not constrained by established DSM-IV-TR personality disorder or paraphilic
diagnoses and their criteria, but instead mixes and

381

matches criteria from various personality disorder

and paraphilic diagnoses, or creates diagnostic criteria de novo. One must be careful in this situation not
to create a specious diagnosis simply to account for an
offense. A common example of this situation is when
an adult is attracted to, and engages in mutually voluntary sexual activity with postpubescent adolescents
who are statutorily unable to provide consent (typically 14- and 15-year-olds.) Does this offender have
a paraphilia? Is it a version of Pedophilia which is
defined in DSM-IV-TR [2000b] as attraction to prepubescent children? Or is it something else? Does
this person have any diagnosable mental disorder?
That the offender broke the law is insufficient evidence, by itself, for the establishment of a psychiatric
diagnosis. According to DSM-IV-TR (2000c), the key
to whether such an offender exhibits a paraphilia is
whether the offenders victims were able to give consent to the sexual activity. Simply because the law
says an individual is unable to give consent, does not
make it so within a psychiatric evaluation. Evidence
suggests that many 14-year-olds have developed the
decision-making capacities of adults (see summary
of sources in Melton, Lyons, & Spaulding, 1998). If
the offenders victims were able to give consent, the
authors argue that such an offender does not have
a paraphilia even if that offender commits socially
objectionable acts.
On the other hand, under particular circumstances, the establishment of a qualifying diagnosis
whose only evidence is the offenses themselves is
entirely legitimate, and represents neither a tautology nor a capitulation to the prosecution. For example, an adult male who is convicted on four separate
occasions of having sex with 8- to 10-year-old boys is
a pedophilewhether that person admits to committing the acts or to experiencing pedophilic desires.
Establishing a psychiatric diagnosis by behavior,
including criminal behavior, is the nature of psychiatric and psychological practice. That is, we infer mental conditions from behavior, as we take as axiomatic
a determinism in which all behavior arises from brain
activity.
Although one can easily criticize the ambiguities
in SVP law, the situation is not a free-for-all. The
law does establish the rough boundaries of the issue.
Even within the ambiguity of SVP law, an evaluator
is unlikely to recommend, for example, commitment
of a one-time incest offender with no diagnosis of
Pedophilia and no other criminal history. Such an

382 FORENSICS

offender lacks a qualifying psychiatric diagnosis and

(using actuarial instruments) most likely also represents a low risk for recidivism.
The foregoing paragraphs illustrate an essential
problem in SVP law. That is, sexual recidivism in
SVP statutes is keyed to psychiatric diagnoses when,
as explained elsewhere in this book, recidivism is better predicted by things such as age of the offender,
number of past offenses, and characteristics of the
victims, rather than with psychiatric diagnoses. An
evaluator performing SVP evaluations should keep
this dilemma in mind, if only to clarify for oneself
this messy mixing of psychiatry and law.

DATA

After the evaluator identifies the legal issue and the

criteria defining the issue, the evaluator then gathers the data relevant to the criteria defining the issue.
An old admonition bears repeating: forensic assessments are not confidential in the way that medical
and therapeutic records are. The judges, attorneys,
parole and probation officers, and other agencies
requesting these evaluations use the same to render
legal or administrative decisions that might benefit or
hurt the examinee. Before a forensic evaluator conducts an evaluation, the evaluator must warn the subject about the purpose of the assessment, the lack of
confidentiality, that the evaluator is not functioning
as a therapist, and that the subject may choose not to
participate (although the evaluator will complete the
evaluation with or without the subjects participation.)
Such a warning is required by the ethical guidelines
of professional psychiatric and psychological societies
(Weinstock, Leong, & Silva, 2003).
The consequences of sex offender evaluations are
serious. Outcomes may involve a persons liberty, a
persons reputation, and the stigma that will likely
follow a person for the rest of the persons days. The
subject of a sex offender evaluation has ample motivation to dissemble. Furthermore, many sex offenders
are ambivalent about their offenses, and are defended
against acknowledging both to themselves and to others the nature and extent of their crimes and passions.
Such persons may require many years of confrontation and treatment before they even begin to acknowledge their thoughts and deeds. They may have been
arrested many a time for sex offenses, and yet continue to offer superficially plausible and convincing

excuses for how they were framed by a jealous lover,

mistakenly identified, caught in a sweep, and so on
the excuses are endless in their number and variety.
Only when one steps back and regards, for example,
the implausibility of three unjustified arrests for
rape does one realize the skill with which offenders
lie. Therefore, the forensic evaluator remains skeptical of any unsupported claim made by an examinee.
A useful dialectic is, Listen carefully, and never
believe a word they say.
Pay close attention to the examinees statements
for contradictions, distortions, minimizations, and
evasions. The examiner should persist in pursuing
ostensibly closed lines of inquiry. These apparent
dead ends may actually be the examinees attempts to
block disclosure through vagueness, circumlocution,
distraction, and denial. The examiner compares the
statements, behavior, and mental state of the examinee to what the examiner knows about genuine sex
offender psychopathology and general psychopathology. A good evaluator is a good diagnostician. The
evaluator should therefore maintain at least a parttime clinical practice.
Of equal or greater importance than the interview
is the review of collateral information. Such a review is
more useful than the interview itself when the issue
is recidivismas recidivism is currently predicted
best by static factors such as number and type of sex
offenses, age of the examinee, and type of victims.
An evaluator does not require an interview to ascertain this historical information. Indeed the interview
may actually prove counterproductive when assessing
risk of recidivism. The examinees statements about
himself and his crimes may be wildly inaccurate. The
evaluator might also be fooled by the examinees intellectual understanding of his psychopathology and his
apparent sincerity in avoiding reoffense.
Collateral information also allows the evaluator to investigate the truthfulness of the examinees
statements. An examinees statements gain credibility if independent documentation supports the
statementsand vice versa. Typical sources of historical information in a sex offender evaluation
include criminal history, criminal complaints, police
reports, records of institutional adjustment, actuarial
assessments, general psychiatric records, statements
from clinicians, and, of course, previous forensic
evaluations.
At the same time that an evaluator is skeptical of
an examinees statements, the evaluator should also be

FORENSIC CONSIDER ATIONS

skeptical of oral and written reports provided by the

prosecution. Prosecutors are overworked. Their oral
recounting of an offenders crimes may be inaccurate.
Prosecutors are also, unsurprisingly, pro-prosecution.
Their bias is toward conviction and incarceration. An
evaluator does well to rely upon written reports rather
than oral reports. However, even written reports
contain errors. This is particularly true over time.
Compared with original written reports, subsequent
written reports referring to earlier reports invariably
lose information, and sometimes even change information. The losses and changes may work for or
against the examinee. Therefore, an evaluator should
seek the earliest available documents.
If, in conducting an evaluation, the evaluator
thinks that something is missing, then it is missing.
The evaluator should seek the missing information.
Such searches may involve securing a judges order
for release of information, and making numerous,
unhelpful phone calls before one reaches the person who can actually answer the evaluators question. These delays and hassles are a routine aspect of
forensic work. The result, however, is a more accurate report. The evaluator also spares himself or herself the embarrassment of having a sedulous judge or
attorney point out the missing information.
Normative tests and physiological arousal tests
are additional diagnostic tools in sex offender evaluations. These tools are growing in number, diversity,
and accuracy, and are slowly replacing unsupported
and untested individual clinical opinion. A normative test is a test in which the distribution of results
is known within a population. Such a test offers an
established reliability and validity. A particular type of
normative test, the actuarial assessment (discussed in
Chapter 6), is now the standard of practice in assessing risk of sexual recidivism. Although an actuarial
assessment is intended to remove clinical judgment
from the evaluation, most actuarial assessments do
require a modicum of professional judgment. More
importantly, actuarial assessments require assiduous adherence to the coding rules of each particular
instrument. The rules may seem intuitive, but they
often are not. Conducting these assessments under
time pressure, as deceptively simple as the assessment may seem, will result in errors that could have
profound consequences. Furthermore, a given actuarial assessment may be inappropriate if the individual being evaluated differs from the members
of population on which the test was developed. For

383

example, the Minnesota Sex Offender Screening

ToolRevised is explicitly contraindicated for incest
offenders (Epperson et al. 1998).
Penile plethysmography is a useful independent
measure of the object of a test-takers sexual arousal.
Sexual arousal to illicit objects (e.g., children) is, in
turn, one of the strongest general predictors of sexual recidivism (Hanson & Morton-Bourgon, 2004.)
Penile plethysmography is, unfortunately, and for
various reasons described elsewhere in this book
(Chapter 7), an underutilized diagnostic tool.
The support of normative testing and physiological arousal testing does not place ones final opinion
beyond dispute, but does make ones opinion unlikely
to be dismissed altogether as being unreliable, invalid, and obscure or idiosyncratic in its reasoning.

R E ASONING

After the evaluator gathers the data relevant to the

legal criteria, the evaluator proceeds with what is
arguably the most difficult part of the evaluation: the
application of the data to the criteria to establish a
rational opinion. The reasoning process requires not
only logical thinking, but also logical thinking articulated on paper. The structure of a forensic opinion
should follow the three steps of a syllogism. The first
step is the assertion of a premise: All cheeses are curd
separated from whey. The second step is the assertion of a minor premise or fact: Stilton is a cheese.
The third step is a deductive inference or conclusion
which follows from the premise and fact: Stilton is
curd separated from whey.
In a forensic opinion, the premise is the legal criteria. The fact is the data relevant to the criteria. The
conclusion is the final opinion. Take the generic SVP
law, for example. A SVP is a person convicted of a
sexually violent offense who suffers from a mental
abnormality or a personality disorder that makes the
person likely to engage in acts of sexual violence if
not confined (the premise.) Mr. Smith is convicted
of a sexually violent offense, suffers from Pedophilia,
and has committed multiple pedophilic offenses even
after numerous apprehensions (the fact). Therefore,
Mr. Smith is an SVP (the conclusion).
Each step in a forensic opinion may be incorrect,
and thus is open to refutation. The legal criteria may
be incorrectin a SVP evaluation, in a given jurisdiction, an evaluator might incorrectly assume that

384 FORENSICS

likely to commit acts of sexual violence means a

51% probability of recidivism over a lifetime. The
data may not relate to the criteria: a mental status
examination in the absence of a discussion of a persons sexual history neither supports nor refutes the
question of whether an offender exhibits a mental
abnormality or personality disorder associated with
sexual offenses. The final opinion may have little or
no relation to the criteria and data: a conclusion that
a person requires antiandrogen treatment to reduce
his risk of recidivism does not answer the question
posed by an SVP evaluation of whether the person
exhibits a mental abnormality or personality disorder that makes one likely to commit acts of sexual
violence.
The forensic evaluator should assume that an
intelligent and skeptical layperson will be reading the report. Jargon should be avoided unless it
is subsequently explained. The evaluator should
take time to explain clinical phenomena which the
evaluators experience has made obvious. Givens
in therapeutic practice should be critically evaluated and supported with references in the scientific
literature. Various contingent recommendations
should be offered in anticipation of various judicial
outcomes. Uncertaintiesand uncertainties are the
norm in this businessshould be acknowledged.
Such explanations are often more difficult to articulate than they might seem. In addition, the evaluator will routinely find that clinical assumptions
the evaluator makes have little basis in the scientific
literature.
For example, practitioners in sexual disorders
know as a commonplace that incest offenders are, on
average, at lower risk of recidivism than are extrafamilial offenders. However, a referring judge or agency
may be entirely ignorant of this crucial distinction.
An evaluator should make this distinction explicit,
and should support the distinction with references
to recidivism studies. On the other hand, the reason
why incest offenders have a lower rate of recidivism
is open to speculation. It might be that incest offenders exhibit better overall self-control than nonincest
offenders. Or it might be that, with an exclusive incest
offender, it is easy to remove and thus protect a single victim. Other explanations are also possible. The
evaluator should explicitly state these limits of knowledge. Acknowledgement of uncertainty is not a reflection upon ones skill as a forensic evaluator. Rather,
acknowledgement of uncertainty is a reflection of

the primitiveness and difficulty of the science of prediction of human behavior. Normative data are simply unavailable to contribute to many assessments.
Acknowledgement of uncertainty also adds to ones
credibility as it reflects honesty. Finally, acknowledgment of uncertainty allows the trier of fact to place
an opinion in perspective, and weight the opinion
accordingly.
A forensic evaluation culminates in a written
report. Courtroom testimony represents but a small
fraction of forensic work. A well-written report may
even render testimony superfluous. Thus the ability to
write logically, comprehensively, and relevantly is an
essential skill for the forensic practitioner. Although
various formats for reports exist (Silva, Weinstock, &
Leong, 2003), the following format is useful for most
forensic reports, including sex offender evaluations:

I. Identifying Datathe name and date of birth

of the examinee, the date of the evaluation,
the date of the report, and the name of the
evaluator
II. Reason for referralthe person or agency
requesting the referral, the legal issue, and the
legal criteria defining the issue
III. Opinionfollowing the convention of judicial
opinion, the forensic evaluators opinion should
sit near the beginning of the report. The opinion should be stated in language meeting the
legal standard for the issue at hand
IV. Sources of informationpersons interviewed,
dates of interviews, documents reviewed, and
dates the documents were created
V. Warning of lack of confidentialitya statement
warning the examinee of the purpose of the
evaluation and who will see the report, and an
estimate of the examinees comprehension of
the warning
VI. Relevant historythe offense or incident that
led to the referral with reports of the examinee
and others, criminal history, psychiatric history,
medical history, family history, and social and
developmental history
VII. Mental status examinationappearance, attitude, movements, orientation, attention, memory, fund of knowledge, intelligence, speech,
mood, range of emotional expression, perception, thought process, thought content, and
insight into ones mental illness and/or circumstance precipitating the evaluation
VIII. Test Resultsthe results of normative testing
(e.g., actuarial assessments)

FORENSIC CONSIDER ATIONS

IX. Diagnostic Formulationan organization of

the aforementioned data supporting a diagnosis, if any, including an acknowledgment of the
diagnostic system and criteria that are used
X. Forensic Formulationan organization of the
aforementioned data which applies the data to
the legal criteria and issue, and identifies the
reasoning used to reach ones conclusion.

CONCLUSION

Rational organization and analysis in a forensic

psychiatric or psychological report allows one to
manage large amounts of complex data. Because
forensic mental health issues rarely reach the level
of scientific certainty that other areas of scientific
inquiry do (e.g., as in DNA analysis), a common
conceptual framework allows areas of uncertainty
or disagreement to be highlighted and explained. A
common framework also allows efficient communication among colleagues. Finally, rational organization and analysis is likely to make ones presentation
more effective.
References
Diagnostic and statistical manual of mental disordersfourth edition, text revision (p. 706).
(2000a). Washington, D.C.: American Psychiatric
Association.
Diagnostic and statistical manual of mental disorders
fourth edition, text revision (p. 572). (2000b).
Washington, D.C.: American Psychiatric Association.

385

Diagnostic and statistical manual of mental disordersfourth edition, text revision (p. 566).
(2000c). Washington, D.C.: American Psychiatric
Association.
Epperson, D. L., Kaul, J. D., & Hesselton, D. (1998). Final
report on the development of the Minnesota Sex
Offender Screening ToolRevised (MnSOST-R).
Paper presented at the 17th Annual Conference
of the Association for the Treatment of Sexual
Abusers. Vancouver, Canada.
Hanson, R. K. & Morton-Bourgon, K. (2004). Predictors
of sexual recidivism: An updated meta-analysis
200402, Public Works and Government Services
Canada, available at www.psepc-sppcc.gc.ca/publications/corrections/pdf/200402_e.pdf.
In re Commitment of W.Z., 339 N.J. Super. 549, 773
A.2d 97 [A.D. 2001], certification granted 169 N.J.
611, 782 A. 2d 428, affirmed as modified 173 N.J.
109, 801 A. 2d 205.
Melton, G., Lyons, P., & Spaulding, W. (1998). No place
to gothe civil commitment of minors (p. 128).
Lincoln, NE: University of Nebraska Press.
New Jersey Statutes Annotated (a) 30:427, et. seq.,
2008.
New Jersey Statutes Annotated (b) 2C:141d., 2008.
Rosner, R. (2003) A conceptual framework for forensic
psychiatry. In R. Rosner (Ed.), Principles and practice of forensic psychiatry, 2nd edition (pp. 36).
London: Arnold.
Silva, J. A., Weinstock, R., & Leong, G. B. (2003).
Forensic psychiatric report writing. In R. Rosner
(Ed.), Principles and practice of forensic psychiatry,
2nd edition (pp. 3136). London: Arnold.
Weinstock, R., Leong, G. B., & Silva, J. A. (2003).
Defining forensic psychiatry: Roles and responsibilities. In R. Rosner (Ed.), Principles and practice of forensic psychiatry, 2nd edition (pp. 713).
London: Arnold.

Chapter 27

Sexual Predator Laws

and their History
Albert J. Grudzinskas, Jr., Daniel J. Brodsky,
Matt Zaitchik, J. Paul Fedoroff,
Frank DiCataldo, and Jonathan C. Clayfield

For centuries, the criminal justice system has struggled to define the methodology of and the justifications for social control of sexual behavior that does
not conform to community mores. This chapter will
compare and contrast the historical and contemporary attempts in the United States and Canada to
address the risk created by individuals who engage in
behaviors broadly characterized as sexually deviant.
It will consider the rationale for sentencing, and the
earliest attempts to bring treatment into the criminal dispositional formula for sex offense based prosecution. It will also consider the impact that the choice
of societal response has on risk assessment and evaluation in the two systems, including the assessment
and commitment of juvenile offenders (for a more
comprehensive discussion of risk assessment, see
Chapter 5). The current United States practice of civil
commitment for a person deemed to be a sexually violent predator (SVP) will be discussed beginning with
the U.S. Supreme Court decision in Kansas versus
Hendricks. This practice will then be compared and

contrasted with the Canadian approach of designating an offender as a dangerous offender (DO) or a
long-term offender (LTO) under the criminal law.
This chapter is intended as an overview of the law,
as it exists, and not as a defense or a critique of any
specific model.

COMMON L AW OR IGINS FOR CA NA DA

A ND THE UNIT ED STAT ES

Under English Common Law those offenses not

specifically punishable at common law that involved
matters of morality and family were assumed under
the jurisdiction of the ecclesiastic courts. In 1558,
the Court of High Commission was established by
the English upper social classes. For a period until the
middle of seventeenth century, crimes against morality (such as adultery, bigamy, incest, assault with
intent to ravish, and blasphemy) were addressed by
concurrent jurisdiction of the ecclesiastic courts and

386

SEXUAL PREDATOR LAWS AND THEIR HISTORY

the Court of High Commission. An offenders economic and social rank often determined the venue.
Penalties in the Court of High Commission actually
proved to be more severe than those meted out by
the ecclesiastic courts. Sanctions from both bodies
however ignored the sentencing concept of proportionality and lacked connection to the prevalence of
the acts or to the harmfulness of the offense. Although
the ecclesiastic courts enjoyed a brief resurgence
after the return of the monarchy in 1660, the common law eventually took control of matters of sexual
aberration (Group for the Advancement of Psychiatry, GAP,1 1977).
The historical origin of the system, Parliament,
enacted for protecting the public from mentally disordered individuals who pose a threat to the safety
of others is also ancient and still evolving2. In fact,
the present day legislative schemes in both Canada
and the United States can be traced back through
the writings of Sir Matthew Hale in the seventeenth
century on the special verdict of acquittal and
enlargement, Sir Edward Coke in the sixteenth century and Brackton in the thirteenth century, and with
rudimentary beginnings even earlier to Aristotles
fourth century bipartite division of knowing and acting. Before the invention of medicine, psychiatry, or
psychology it was commonly believed that the only
way to protect society was to keep mentally disordered offenders from places where they could cause
harm.3 Efforts to come to grips with the problem
included the enactment of civil statutes such as the
Vagrancy Act of 1744, but their use was informal and
irregular. Undercommon law there was little difference
if insanity was raised before the trial or as a defense
because it was the question of dangerousness itself
that informed detention status of the prisoner, as well
as readiness for release even if the cause of the risk was
unknown. There was no criminal sanction available
to restrain insane acquittees and some considered it
to be a problem that accused would go at large after
a verdict (Keeton, 1961; MacDonald et al. v. Vapour
Canada, 1977; R. v. LePage, 1994; Starnaman v.
MHC-P, 1995; Walker, 1968; Winko v. British Columbia
[Forensic Psychiatric Institute], 1999).
Early U.S. History
In the early colonial history of the United States,
English common law principles prevailed in most
jurisdictions. Sin and crime were often equated, and

387

treatment was tied to bodily punishment such as

public flogging to prevent the recurrence of individual sexual transgressors (GAP, 1977, p. 847) and to
serve as a deterrent to others. Enforcement of morals
and religious values was seen as the purpose of the
law. In fact the language of the Old Testament was
incorporated into the language of statutes enacted
by the colonies. In Massachusetts for example, since
at least 1697, Sodomy and Buggery were defined as
abominable and detestable crimes against nature,
either with mankind or with a beast (Mass. Gen.
Law, c. 272, 34 as quoted in GAP, 1977, 848849).
The definition remains the same in the 2007 edition
of the statutes. The punishment, originally death in
some jurisdictions, has been reduced to imprisonment in the state prison for not more than twenty
years.
The concept supporting punishment of the crime
of rape has also evolved over time. Originally, rape
of a propertied virgin, was punishable by death and
dismemberment, and included the severing of the
tails of the offenders horse and dog (Bracton, 1968 as
quoted in GAP, 1977, p. 850). As the colonies evolved
into states, the common law evolved into criminal
codes. Defenses made available for other criminal
acts became available for sex crimes. Some offenders were found incompetent to stand trial, others
occasionally pled insanity when some major offense
involving sexual violence occurred, and still others
were handled civilly as being mentally ill and a final
disposition was postponed indefinitely (GAP, 1977,
p. 851852).
Early History in Canada
The contemporary Canadian model of preventative detention for noninsane offenders can be traced
back to the Gladstone Committee Report in England
(Gladstone Report, 1895) at the junction of two
comparatively recent trends in modern British and
American criminology: the expanding influence of
the psychiatric interpretation of crime as symptomatic of mental disorder4 and increasing confidence
in the scientific method and empirical analysis to
understand human behavior.5 In 1895 the Report of
the Departmental Committee on Prisons urged law
reformers to exercise restraint when legal innovation
in the name of science is based upon deduction or
hypothesis, rather than empirical proof or proven
guilt for acts committed,

388 FORENSICS

it is not unreasonable to acquiesce in the theory

that criminality is a disease, and the result of
physical imperfection . . . [and] . . . the time has
come when the main principles and methods
adopted by the Prison Acts should be seriously
tested by the light of acquired experience and scientific research . . . (Gladstone Report, 1895, p. 5,8,
and 34).

PR ISON R EFOR M, OSCA R W ILDE , A ND

THE GL A DSTONE COMMIT T EE

We punish and have always punished for many reasons including the accomemphatic demand by an
alarmed public for severe reprisal or denunciation.
By the late 1800s, a belief in punishment as the only
object of sentencing and confidence in the prison
system as a desirable and effective means of dealing
with prisoners came increasingly into question (Hart,
1962). In 1841, Dorothea Dix exposed the terrible
conditions under which Massachusetts housed inmates with mental illness at the East Cambridge jail.
She began a crusade for prison reform and national
legislation to provide for persons with mental illness who found themselves incarcerated. In January
1894, the London Daily Chronicle published a critical expose on London prisons that called into question the treatment of mentally disordered offenders.
It also called into question the supposition that an
insanity defense would always be sought if it were
available; the assumption being that, trial counsel
would recognize the issue and proceed accordingly.
Other journals such as Truth, Pall Mall Gazette, and
the Weekly Dispatch followed suit. The Liberal government considered it a sweeping indictment by
the media against the whole of the prison administration including the principles of prison treatment
as prescribed by the Prison Acts. Home Secretary
Herbert Asquith acted on June 5, 1894 by setting up
a prison committee under Herbert John Gladstone
to inquire to and report on the administration of
prisons in England and the treatment of offenders,
including juveniles, detained in them (Gladstone
Report, 1895).
The Gladstone Committees terms of reference
were expanded on January 16, 1895 to include the
prison treatment of habitual criminals and the
classification of prisoners generally. The Prison
Committee cited unchallenged evidence that, as a

criminal passes into the habitual class, prison life,

subject to the sentences now given, loses its terrors
and as familiarity with it increases.
The Committee was surprised to discover that
previous inquires have almost altogether overlooked
this all important matter. The habitual criminals . . .
In examining the overlooked group of prisoners,
the Committee noted that,
(i) Punishment for the particular offense in which
the habitual offender was detected was almost
useless because the real offense, it was thought,
was the wilful persistence in the deliberately
acquired habit of crime.
(ii) Habitual criminals were members of an undeterrable class because the prison regimen had
little or no deterrent effect unless the offender
was subjected to long periods of imprisonment and penal servitude.
(iii) While, the class of habitual offenders was
generally orderly and easy to manage, they are
seen as a most undesirable element in a mixed
prison population. Therefore, it was proposed
that habitual offenders should be kept segregated from other prisoners.
(iv) Most habitual criminals are not of the
desperate order who run the risk of comparatively short sentences with comparative
indifference.
The Committee would propose that a new form
of sentence should be placed at the disposal of the
judges involving long-term segregation, but they were
not to be treated with the severity of first class hard
labor or penal servitude and their forced work should
be under less onerous conditions (Gladstone Report,
1895, p. a1a2, 5, 7, 1112, and 31).
After 2 months, one of the most infamous chapters in British legal history occurred and brought
immense pressure on the uniquely situated Gladstone
Investigative Committee.
On March 1, 1895, libel suit charging the Marques
of Queensberry with publicly maligning Oscar
Wilde as a sodomite brought the problem to the
attention of the public. Oscar Wilde was enormously
successful as a playwright, novelist, poet, short story
writer, and beloved critic of literature and of society
(Abrams, 1979; Hyde, 1948). Wilde was a 38-year-old
married man when he met and established a homosexual relationship with the 22-year-old poet, Lord
Alfred Douglas or Boisie as the young Lord was

SEXUAL PREDATOR LAWS AND THEIR HISTORY

known. Boisies father, the Marquis of Queensberry,

did not approve of the relationship and he was persistent in a campaign to break up the relationship.
Queensbury went to the Albermarle Club and told
the porter to hand a card to Wilde. The Marquis card
read Oscar Wilde posing as a Sodomite. Believing
that the Marquis had gone too far and needed to
be restrained, Wilde initiated a libel action. The
trial proceeded before Collins J. at the Old Bailey.
Queensberry argued; isnt any father justified in
endeavouring by all means possible to rescue a son
from evil companionship? So well-executed was the
defence that Wilde elected to retire from the prosecution and the judge directed the jury to find that while
the libel was in fact true, it was published for the protection of the community (Hyde, 1948, p. ivv, 1415,
17, 5458, 102104, 107108, 173176).
The evidence proffered during the aborted libel
hearing lead to Wildes arrest and charge with gross
indecency. Wilde pleaded not guilty on April 26,
1895. The first trial proceeded before Charles J. at the
Old Bailey and ended with a hung jury. The second
trial proceeded before Wills J. but this time the jury
returned a guilty verdict. Immediately thereafter, a
sentence of 2 years at hard labor was imposed and he
was taken to Wandsworth Prison and later to Reading
Gaol. The Court would not permit Wilde to say anything on his own behalf before he was handed the
maximum penalty permitted under English law.
Wills J. had for many years presided over countless
rape and murder trials declared Wildes case to be
the worst he had ever tried and that the defendant
was deserving of the severest punishment. Justice
Wills stated In my judgment it [the sentence] is
totally inadequate for a case such as this. (Hyde,
1948, p. 5960, 63, 67, 93, 179189, 265266, 272,
336339).
The iniquitous relationship with Queensberrys
son sparked a massive public debate that informed
the Gladstone Committee and propelled penal reform
in England and abroad. The vexing questions included the following: Did Oscar Wilde show a failure to
control his sexual impulses? Could he be cured? If
he were at liberty, was Lord Alfred Douglas at risk?
Was he likely to engage in homosexual acts with others thereby putting the public at risk? Was he insane
or in danger of becoming insane? What could be
done to convince him that his conduct was morally
wrong? Should the sentence be indeterminate? If
not, indeterminate, then what should the interval be

389

and under what conditions? If so, was treatment possible? How should the treatment be prescribed and
monitored? (Hyde, 1948, p. iiv, 365366, 371372).
Throughout the eighteenth century, Sodomy/
Buggery was punishable by death5. The lesser offense
of gross indecency was punishable pursuant to the
Criminal Law Amendment Act 1885 by a term of
imprisonment not exceeding 2 years, with or without
hard labor. The observations of U.S. Supreme Court
Chief Justice Warren Berger in the case of Bowers v.
Hardwick are apposite:
the proscriptions against sodomy have very
ancient roots. Decisions of individuals relating
to homosexual conduct have been subject to state
intervention throughout the history of Western
civilization. Condemnation of those practices
is firmly rooted in Judeao-Christian moral and
ethical standards. Homosexual sodomy was a
capital crime under Roman law. See Code Theod.
9.7.6, Code Just. 9.9.31, (Bailey, 1975).
During the English Reformation when powers of the
ecclesiastical courts were transferred to the Kings
Courts, the first English statute criminalizing sodomy was passed. 25 Hen. VIII, ch. 6. Blackstone described the infamous crime against nature as an
offense of deeper malignity than rape, a heinous
act the very mention of which is a disgrace to human
nature, and a crime not fit to be named. (Tucker,
Tucker, & Blackstone, 1996). The common law of
England, including its prohibition of sodomy, became
the received law of Georgia and the other Colonies.
The Gladstone Committee report was released
on April 10, 1895, just 1 month before Oscar Wilde
was committed to prison for 2 years of hard labor.
Of course, the issues of Wildes failed prosecution,
arrest, incarceration, and presumptive risk informed
the report and are inexorably entwined. The Prison
Committee was highly critical of the administrative
principles underpinning British prison life and it
emphasized the pressing need for treatment in prison
to take place alongside deterrence for the protection of the public (Gladstone Report, 1895, p. 5, 89,
4547; Hyde, 1948, p. 103).
Oscar Wilde did not fare well in prison. In the
first plea for clemency on July 2, 1896, Wilde argued
that he was rightly found guilty of indecency, but
forcefully argued that he should not be punished
as a criminal, but treated as an unfortunate victim
of sexual madness (erotomania) which displayed

390 FORENSICS

itself in loathsome monstrous sexual perversions that

could consume his entire nature and intellect. After 6
months, a second petition was filed, this time asking
the Home Office implement the Gladstone Committees recommendations to prevent his mental decompensation. Wildes brilliance was self-defeating
(Radzinowicz, & Hood, 1986). This time the petition
was denied because it was expressed in too lucid,
orderly polished style to cause apprehension (Hyde,
1948).
The Gladstone Committees recommendations
did result in legislative change. Indeed, before the
Committees recommendations were acted upon
dangerous people were sentenced in England and
Canada like all other offenders. Then in 1908 with
the Prevention of Crime Act, 1908, the sentence of
preventative detention and the double-track system
became a part of the laws of England.7 This new
statute was enacted to put the Gladstone Committees recommendations in play and thereby extend
the reach of preventative detention to a group of incipient and persistent dangerous criminals engaged in
the more serious forms of crime.8 The statute was
new, but the concept was familiar. Many years before
the Inquisition would sometimes impose a sentence
for such time as seems expedient to the Church.
The underlying concept was not even a uniquely
British concept. For example, in 1787 Dr. Rush was
invited to Benjamin Franklins home in the United
States where he read a pamphlet proposing that all
criminals ought to be sentenced indeterminately and
returned to the community with dispatch only after
they have been rehabilitated. The new English
law provided the authority for a court to impose
a new form of sentencean indefinite term of
postsentence detention as relapse prevention. The
beneficiary was to receive two sentences: the first
punishment was fixed taking into account conventional sentencing principles including the moral
culpability of the offender and the seriousness of the
offense; the second was a special individuated measure. For offenders with three prior convictions, a sentence of preventive detention of not less than 5 years
and not more than 10 years could be attached to the
ordinary sentence (Hart, 1962; Morris, 1951; Pratt &
Dickson, 1997; Radzinowicz, & Hood, 1986).
The minimum term was limited by the sentence
imposed. The extended detention or second track was
to be served under conditions less rigorous than penal
servitude with enhanced opportunities for detainees

to avail themselves of treatment. The offender would

be unsure of how much time they would have to
server, but s/he would be provided an opportunity to
cut short the indeterminate sentence. Of course, this
presupposed that criminal characteristics could be
identified and modified through treatment. However,
the sentence would be much longer for the high
needs prisoner than s/he would get from a judge
applying traditional sentencing principles including
proportionality. For the treatment-resistant prisoner
who managed to stay alive until the date of his or her
release and suffered all the joy and fear of leaving
the penitentiary, the news that the system claimed
more years of detention must have been devastating. Herbert Lionel Hart, an eminent British legal
philosopher, recognized that the offenders perspective might be somewhat at odds with this bifurcated
sentence:
Certainly the prisoner who after serving a threeyear sentence is told that his punishment is over
but that a seven year period of preventive detention awaits him and that this is a measure of
social protection, not a punishment, might think
he was being tormented by a barren piece of conceptualistm though he might not express himself
in that way (Hart, 1962).
The animating objective was to lay hold of two defined
groups of lawbreakers and subject them to strong
restraint and training where it was deemed expedient for reformation and the prevention of crime. The
Committee found the following:
(i) As a consequence of social conditions of the
general population . . . Lads grow up predisposed to crime, and eventually fall into it.
and
(ii) Most habitual criminals are made between
the ages of 1621
Consequently, to dam the headspring of recidivism,
young offenders were prescribed indeterminate
detention in juvenile reformatories with an emphasis on individual treatment and special arrangements
for after care.9 For, habitual offenders a new sentence
was introduced to enable a deterrent sentence to be
imposed that was longer than fixed principles would
stand for to permit individual treatment during the
custodial part and special arrangements for postsentence community after care (Fox, 1934; Gladstone

SEXUAL PREDATOR LAWS AND THEIR HISTORY

Report, 1895, p. 1113, 31 & 34; Radzinowicz, &

Hood, 1986, p. 465489; Strange, 1996).

SE X UA L PSYCHOPATH L AWS IN THE

U NI T ED STAT ES

Among the first to actually demonstrate a relationship

between the law and psychiatry in terms of effect on
social control efforts, Penrose (1939) described the
hydraulic model of social control. He identified
European countries where low numbers of persons
committed to the mental health system corresponded
to high numbers of persons committed to the prison
system and vice versa (Penrose, 1939). Briefly, this
theory suggests that the size of a jurisdictions correctional and psychiatric institutional populations
vary inversely, such that when the rate at which one of
these social control agents is used declines, the utilization of the other will increase, thereby maintaining
a kind of social control homeostasis.
Sutherland (1950) observed (p. 147) that For a
century or more two rival policies have been used in
criminal justice. One is the punitive policy; the other
is the treatment policy. Generally, the trend toward
one and away from the other is based on cultural
change in the society. Brakel and Cavanaugh (2000)
considering changes in sex offender laws, observed
that, It is old news that the field of law known as
mental health law is especially susceptible to these
pendulum-like swings. The interdisciplinary character, the vagaries of science . . . whose theories are
not always easy to grasp by outsiders and whose relevance to legal methods and objectives is not always
clear, may, according to Brakel (p. 7071), lead to a
tendency to lurch from one positional extreme to
the other. (See also: Grudzinskas, Clayfield, Fisher,
Roy-Bujnowski, & Richardson Clayfield, 2005)
Considering the spreading of so-called sexual
psychopath laws in the United States Sutherland
observed (p. 147) that, Treatment tends to be organized on the assumption that the criminal is a socially
sick person. If a person is ill and that illness leads to
or forms the basis for a behavior, then within acceptable bounds of public safety, we can feel justified in
excusing the conduct. The concept of relief from
responsibility for criminal conduct is premised on the
idea that not only does a treatable psychiatric disorder exist, but that the disorder is directly related to the
particular type of criminal behavior. Social control

391

turns to the medical model when we come to believe

that advances in treatment will provide a reduction in
crime. The growth of sexually violent person commitment laws seems premised on the idea that forcing a
connection between the individual defendant and the
treatment facility and then supervising that connection for a reasonable time period, the court can promote treatment. This treatment engagement is then
expected to reduce criminal behaviors (Wolff, 2003).
In the United States, dangerous sexual offenders
were dealt with by incarceration and punishment
like all other offenders until the late 1930s when the
first of two waves of civil legislation for the commitment of sexual offenders was initiated. Beginning in
the 1930s, a handful of American States responded to
anxiety in relation to sexual crimes, particularly those
involving children, by passing laws with therapeutic
intent targeting sexual psychopaths.10 These statutes provided something of a moving target though
because it was not consistently clear who the sexual
psychopath was.11 The varied and subjective thinking
that is engendered by the term sexual psychopath is
such that its application constituted a constantly shifting terrain for those accused and for counsel confronting it. Accordingly, there was no true recourse against
the allegation that a person was a sexual psychopath
other than by the accused indicating that in their
own opinion they were not. The lack of a clear, objective and ascertainable standard in the legislation was
caused by the false assumption that the target group
was a consistent or homogeneous offender class and
the fact that,
Sexual psychopathy is not a psychiatric diagnosis. It is a term used with a variety of confusing
meanings and applications but with no precise
clinical meaning. Also, since sex psychopaths are
defined in statutes, the term is therefore an established legal concept. Definitions of statutes of sex
psychopaths which arose in the 1930s were taken
from a confluence of sources. Legislative bodies
drew on an amalgam of psychiatric and social concepts to encompass a heterogeneous group of individuals seen as dangerous with respect to control
over their sexual behaviour but not seen as legally
insane. (Brakel, & Rock, 1971, p. 341359; Brakel,
Parry, & Weiner, 1985; GAP, 1977, p. 840841,
853, 861867)
The idea was to identify as best as possible the group of
habitual offenders at the time of sentence completion

392 FORENSICS

to send them to places of safekeeping until recovery

was established. What informed this legislative initiative was an understanding that the habitual offender,
would fail to control their sexual behavior or idiosyncrasies and that they could consequently be
identified and segregated. In this sense, the grouping was analogous to that of individuals classified
as possessing a certain propensity, such as drug
addiction or alcoholism. They were to be dealt
with even though they were not at present violating any law . . . They were viewed as alternatives
to straight imprisonment for handling people who
either had behaved sexually in a manner that got
them into difficulties with the criminal law or who
were seen as having the potential to do so. The sex
statutes were meant to be harbingers of a future
in which all criminals would be treated under
similar provisions . . . Although the history of the
sex statutes emphasizes dual goalscommunity
safety and treatments-their origin appears more
closely tied to desires of legislators to protect their
constituents. The preservation of community
safety is encompassed within the police power of
the state, while any treatment measures are carried
out under the parens patriae duty of the state to
rehabilitate its wayward citizens (Brakel & Rock,
1971, p. 341359).
Brakel and Rock (1971) identified 31 states as having sexual psychopath or sex offender statutes by
1971. The first rush to enact laws began in Michigan
in 1937. This was followed in rapid succession by
Illinois, California, and Minnesota by 1939. Vermont,
Ohio, Massachusetts, Washington, Wisconsin, the
District of Columbia, Indiana, New Hampshire,
and New Jersey followed suit over the next 10 years
(Sutherland, 1950). The pattern of enactment that
he identified was eerily similar to the pattern in
effect in recent years with the reemergence of sexually violent offender commitment laws in the United
States. A states fears are first aroused by a serious,
often violent sex crime, frequently involving a child
victim. A protracted manhunt for the offender adds
to the fear. The fear is seldom related to the statistical evidence supporting risk of further offenses (see
for example Chapters 1, 5, 16). This leads to the next
step in the process, the agitation of community activity and the call for protective legislation. The third
step is the appointment of a study group or task force
to draft such legislation (the results of the group study
are often ignoredin Massachusetts in 1948 the

study group recommended repeal of the law that had

been passed before its study was complete, in favor of
keeping sex criminals within the general correctional
population [Massachusetts, 1948]). The final step is
the presentation of the law as the most scientific and
enlightened method of protecting society from dangerous sex criminals (Sutherland, 1950).

CA NA DA A ND PR EV EN T I V E
DET EN T ION

In 1936, the government of Canada announced

the creation of a Royal Commission to Investigate
the Penal System. Appointed as chairman of the
Commission was Mr. Justice Joseph Archambault
who considered it fundamental to the discharge of
the Commissions mandate to examine local penal
policy and the legislative changes that were taking
place in England and the United States.
In January 1938 the Archambault Commission
tabled its recommendations. While the Commission
was impressed with various aspects of the English
model, it thought improvements were possible. The
Archambault Commission acknowledged the initial
purpose of the British legislation as the reformation of
professional or persistently dangerous criminals, but
observed that this did not occur in the British practice. It noted however that,
Notwithstanding the best methods of punishment and reformation that may be adopted, there
will always remain a residue of the criminal class
which is of incurable criminal tendencies and
which will be unaffected by reformative efforts.
These become hardened criminals for whom
iron bars and prison walls have no terrors, and in
whom no hope or desire for reformation, if it ever
existed, remains (Report of the Royal Commission,
Archambault, 1938).
Recognizing that the nature of a prisoners confinement to a behavior modification unit is for treatment,
the Commission recommended that legislation be
enacted to mark this residual class of offenders and
to provide for their indeterminate detention in a
special prison(s) because they with few exceptions,
[they] should never be set at liberty. However, preventative detention should be less rigorous than penal
servitude and modeled after the approach taken in
New York State in a special prison that is neither

SEXUAL PREDATOR LAWS AND THEIR HISTORY

punitive nor reformative but primarily segregation

from society (Brakel & Rock, 1971, p. 358359; R vs.
Lyons, 1987, p. 1623).
By March 1939 a new Penitentiary Act had been
drafted. However, with the outbreak of war in Europe
and with Canada entering the war on September 10,
1939, attention to issues of domestic crime and punishment were diverted.
August 15, 1945 marked the end of the World
War II and just 4 months later, in December 1945,
Parliament finally enacted the Penitentiary Act that
had been drafted years earlier. In 1947, Canada
enacted its first preventative detention legislation.
Speaking in the House of Commons on July 3, 1947
John Diefenbaker urged the Canadian Parliament to
move quickly on criminal law reform because,
psychological and penological advances have
been made which in considerable measure necessitate an early alternation in the law with respect
to insanity and also with respect to the principles
applicable to responsibility.12
It was not a particularly infamous offender or shocking crime that brought the problem of violent recidivism to the forefront of public attention again to spur
legislative action. The postwar world just seemed to
be a more dangerous place as the troops returned
home and increasingly attention was redirected to
issues of public safety on the home front.
This postwar trepidation led to a backlash in the
spring of 1947 that began the Canadian Dangerous
Offender provisions of the Criminal Code. Canadas
first Commissioner of Penitentiaries, General Ralph
Burgess Gibson, who appointed by the Minister of
Justice pursuant to the terms of reference contained
in s. 4(a) of the 1945 Penitentiary Act to Consider
and report on the several recommendations made
by the Archambault Committee before the war. On
February 5, 1947, General Gibson reported to the
Minister of Justice that it would be advisable if most of
the prewar Archambault Commission recommendations were acted upon. He took no position on habitual
offender legislation or indeterminate sentences (Act
to amend the Criminal Code S.C. 1947, c. 55, s.18;
House of Commons Debates, 1947, p. 4685, 50295031,
5065; Pratt, & Dickson, 1997, p. 371; Report of the
Royal Commission, Archambault, 1938; Report of the
Special Commissioner, Gibson, 1947, p. 1; Sutherland,
1950, p. 142143, p. 1011, 218219. 224).

393

It was against this backdrop on June 26, 1947 that

the Minister of Justice, James Ilsley, introduced legislation proposed by the Conference of Commissioners
on Uniformity of Legislation in Canada (now called
the Uniform Law Conference of Canada) to give recognition to the habitual offender as a distinct criminal class to be indeterminately segregated and
flagged for intensive treatment. It was thought, especially for young offenders, that rehabilitation would
be ever so much easier this way. The habitual offender statute to incapacitate the risk posed by the
new criminal class was enacted on July 3, 1947. The
new law also purported to give judges the power to
order convicts admitted to specially designed treatment facilities that could really offer tailor made
treatments that held out the best prospect of rehabilitation. (The term of imprisonment was not indefinite; rather, it was indeterminate and the term
commonly referred to as The Bitch and the designation as the feet first only exit designation.) One
MP, Frank Jaenicke, underscored the relationship
between the new class of offender and the not criminally responsible,
I would consider an incurable criminal on par
with a mentally incompetent person. Criminals
who persist in committing crimes, in spite of
their previous punishments are, in my opinion,
mentally defective as compared with ordinary law
abiding citizens who accept our moral code, which
is reflected in our criminal law as reasonable and
necessary . . . the state of mind of a habitual criminal is somewhat equal to a defective mind (House
of Commons Debates, 1947, p. 50305035).
The Canadian habitual offender law only superficially emulated British law introduced in 1908,13
but it was far more onerous because, among other
things, it
(i) conferred discretionary jurisdiction on judges
to impose either determinate or indeterminate sentences;
(ii) made the legislation apply to young persons
18 years of age or more;
(iii) took away the right to state funded counsel.
(Act to amend the Criminal Code S.C. 1947, c. 55,
s.18; Brakel, Parry, & Weiner, 1985, p. 739; House of
Commons Debates, 1947, p. 4685, 50295031, 5037,
5065; Pratt, & Dickson, 1997, p. 371; Report of the

394 FORENSICS

Royal Commission, Archambault, 1938, p. 1011,

218219, 224).
The prerequisite for habitual offender designation
was that the offender had been convicted of three or
more indictable offenses and could be shown to be
persistently leading a criminal life.
Canada expanded its definition to include
Criminal Sexual Psychopaths on June 14, 1948 in a
move to bring the law more in line with the American
habitual offender classification.
John Diefenbaker: Legislation similar to this
exists in eight states of the American Union . . .
Where does the minister get the definition of
criminal sexual psychopath?
James Iseley:

From Massachusetts.12

The amendment gave discretion to the court in determining whether an accused should be found to be a
criminal sexual psychopath in section 1054A which
read in part the court, before passing sentence, may
hear evidence as to whether the offender is a criminal sexual psychopath and such other evidence as it
may deem necessary in addition to the mandated evidence of at least two psychiatrists. The power was not
only a discretionary one but could also be exercised
by the Court on its own motion without application
by counsel for the prosecution or for the prisoner, and
the exercise of the power did not depend in any way
upon the consent of counsel.14 In R. v. Carey, Laidlaw J.
pointed out (p. 29) that
during the argument of the appeal, attention was
directed to s. 1054A of the Cr. Code, enacted
by 1948, c. 39, s. 43. That section empowers the
Court before passing sentence to hear evidence
as to whether the offender is a criminal sexual
psychopath. The power so given to the Court is
a discretionary one. It may be exercised by the
Court on its own motion without application by
counsel for the prosecution or for the prisoner, and
the exercise of the power does not depend in any
way upon the consent of counsel (Act to amend
the Criminal Code S.C. 1948, c. 39, s. 43; House
of Commons Debates, 1948, p. 51955199, 5203).
In December 1953, a Department of Justice committee to inquire into the principles and procedures
followed by the Remission Service was established
and Mr. Justice Gerald Fauteux was appointed chairman of the Commission. Its report was released in the
spring of 1956 (Fauteux Committee, 1956).

In 1954, the Criminal Code was revised after some

27 years. The preventive detention provisions were
now all contained in Part XXI of the Criminal Code
and had new section numbers. Section 660 dealt with
the application to find an offender a habitual criminal and section 661 dealt with the application to find
an offender a criminal sexual psychopath. Under
section 661 the court was now given a discretion
upon application to hear evidence as to whether the
accused was a criminal sexual psychopath and to hear
any evidence it considers necessary as to whether
the accused was a sexual psychopath (Act to amend
the Criminal Code S.C. 1954, c. 51).
The legislation remained unchanged until amendments were made in 1961 which changed the terminology from criminal sexual psychopath to dangerous
sexual offender, the timing of the application and the
language associated with the courts mandate to hear
that type of application. With respect to the new designation of dangerous sexual offenders the court was
now mandated to hear any relevant evidence upon
application being made (S.C. 196061, c. 43, s. 34).
Section 660 continued to relate to habitual criminals
and section 661 now related to dangerous sexual offenders. Dangerous Sexual Offender would now replace the
older term, Criminal Sexual Psychopath (Act to amend
the Criminal Code S.C. 19601961, c. 43, s. 32).
Accordingly sentences of preventive detention
could be imposed if an offender was found to either
be a habitual criminal, criminal sexual psychopath or
a dangerous sexual offender (DSO):
(i) Habitual Criminals
Individuals who, since attaining the age of 18 years,
had, on at least three separate occasions, been convicted of an indictable offense for which s/he was liable
to imprisonment for 5 years or more and was leading a
persistently criminal life (repealed October 15, 1977).
Legislation at this time allowed the following
options:
convicted, not sentenced and then found to
be a habitual criminal for which an indeterminate sentence would be imposed; or,
convicted, sentenced and then found to be a
habitual criminal with the indeterminate sentence replacing the original sentence imposed.
(ii) Criminal Sexual Psychopaths
Persons who, by a course of misconduct in sexual
matters, have shown a lack of power to control their
sexual impulses and who, as a result, are likely to

SEXUAL PREDATOR LAWS AND THEIR HISTORY

attack or otherwise inflict injury, pain, or other evil

on any person (repealed 19601961 and replaced with
dangerous sexual offender provisions).
(iii) Dangerous Sex Offenders (DSO)
Persons who, by their conduct in any sexual matter,
have shown a failure to control their sexual impulses
and, who are likely to cause injury, pain, or other evil
to any person, through failure in the future to control
their sexual impulses (repealed October 15, 1977).

K A NSA S V ER SUS HENDR ICK S A ND

MODER N SE X UA L PR EDATOR L AWS

At the time of this writing, the United States has 21

jurisdictions with post-criminal sentence civil commitment laws for sexually violent predators. This
new wave began in the state of Washington with the
1990 enactment of the Community Protection Act.
Following the pattern identified by Sutherland, the
law came about after considerable public outcry when
a 7-year-old boy was abducted, raped, mutilated, and
left for dead (he survived) by a recidivist sex offender
who had been released from prison some 2 years earlier. Washington first formed a commission (The
Task Force on Community Protection). The Task
Force issued its report, and called for a scheme of
proportional sentences for sex crimes. Rather than
alter the mental health commitment law, the Task
Force recommended a narrowly drawn sex offender
commitment statute. The Washington Legislature
enacted the recommendations (Wash. Rev. Code
Ann., 2008b). The statute served as the nearly identical model for the Kansas statute that served as the
basis for the United States Supreme Court decision
that redefined the field.
In 1994, the Kansas Legislature facing issues
similar to those in Washington, borrowed on the
Washington experience and enacted its own sexually violent predator law. In the Acts preamble, the
Legislature found that the treatment need of this
population are very long term and the treatment
modalities for this population are very different that
the traditional treatment modalities for people appropriate for commitment under the general involuntary
civil commitment statute (Kan. Stat. Ann., 1995).
Leroy Hendricks had served 10 years of his sentence for a conviction for taking indecent liberties
with two 13-year-old boys. The Kansas Act went into
effect shortly before his release. The state moved to

395

commit Hendricks. At his commitment hearing he

testified that when he get[s] stressed out, he cannot
control the urge to molest children. The state also
presented testimony from a licensed clinical social
worker that Hendricks had a diagnosis of personality trait disturbance, passive-aggressive personality,
and pedophilia. The chief psychologist at the facility
holding him after his release from a halfway house
testified that Hendricks suffered from pedophilia and
that he would likely commit offenses against children
if not confined. He further opined that pedophilia
met the statutory definition of mental abnormality.
Hendricks defense offered testimony from a forensic
psychiatrist that it was not possible to predict future
dangerousness with any degree of accuracy. The
jury found beyond a reasonable doubt that he was
a sexually violent predator. The Court committed
him to the custody of the Kansas Secretary of Social
and Rehabilitation Services. Hendricks appealed.
The Kansas Supreme Court found that to commit
a person, a state is required by substantive due process to prove by clear and convincing evidence that
a person is both mentally ill and dangerous to himself or others. (In re Hendricks, 1996) The United
States Supreme Court reversed the Kansas Court
(Kansas v. Hendricks, 1997). The Constitutional legal
arguments raised are not relevant to this discussion
(see Grudzinskas, & Henry, 1997). The issues that are
relevant relate to the underlying justification for commitment. The Court noted that some additional factor
beyond dangerousness, such as mental illness, must
be coupled with the dangerousness. Justice Thomas
writing for the majority explained that the Court had
upheld Kentuckys commitment of mentally ill or
mentally retarded individuals. (Citing Heller v. Doe,
1993) The Court had also upheld Minnesotas commitment of persons with a psychopathic personality
(Citing Minnesota ex rel. Pearsonv. Probate Court of
Ramsey Cty. 1940). According to the decision, the
term mental illness does not carry any talismanic
significance (Kansas v. Hendricks, 1997, p. 359).
Justice Thomas noted that the definition of terms of a
medical nature that have legal significance has traditionally been left to legislators. He concluded that,
. . . it would be of little value to require treatment as
a precondition for civil confinement of the dangerously insane when no acceptable treatment existed.
To conclude otherwise would obligate a State to
release certain confined individuals who were both
mentally ill and dangerous simply because they

396 FORENSICS

could not be successfully treated for their afflictions. Cf. Greenwood v. United States, (1956).
The fact that at present there may be little likelihood
of recovery does not defeat federal power to make this
initial commitment of the petitioner OConnor v.
Donaldson, 422 U.S. 563, 584 (1975) Burger, C. J.,
concurring; It remains a stubborn fact that there are
many forms of mental illness which are not understood, some which are untreatable in the sense that
no effective therapy has yet been discovered for them,
and that rates of cure are generally low Kansas v.
Hendricks, 1997, p. 366).
Once the Supreme Court approved the process, a
flood of state statutes followed. At this writing, Arizona,
California (2006) (Greenwood v. United States, 1956),
Florida (1998), Illinois (2008), Iowa (2008), Kansas,
Massachusetts (2007, 2008), Minnesota, Missouri,
Nebraska (2007), New Hampshire (2008), New Jersey
(2008), New York (2008), North Dakota (2008),
Pennsylvania (2003), South Carolina (2007), Texas
(2007), Virginia (2008), Washington (2008a, 2008b),
Wisconsin (2007), and the District of Columbia
(2008) all have civil commitment statutes to commit
sex offenders (nytimes.com, 2007).
The early Sexual Psychopath laws in the United
States have generally become known as sexually dangerous person (SDP) laws and survive today in some
states alongside the new SVP laws. Essentially the key
difference between a SDP and a SVP civil commitment proceeding is the matter of timing. Generally,
the prosecution had the ability to invoke the old law
even if the dangerous person was not in prison at the
time. The new law may only be invoked if the violent
predator is imprisoned but nearing sentence completion. Treatment potential is relevant only to the issue
of whether a SDP or SVP can be discharged, it is not
relevant in determining whether a person does or
does not meet the statutory criteria.
What marks the SVP acts as distinctive legislation
are the following central features: (1) their stated
purpose is to detain, in fact, to continue to detain,
sex offenders who are already in custody and who
are likely to reoffend if set free; and (2) their continued detention objective is accomplished via
civil commitment to a treatment facility. The acts
are different from the old sex offender (psychopath) laws to the extent that the latter prescribed
treatment instead of incarceration . . . the population targeted for its treatment mandates is, by

most conventional standards, neither mentally ill

nor treatable (Kansas v. Hendricks, 1997, p. 361.
See also Brakel & Cavanaugh, 2000, p. 7778,
8287; Minnesota ex rel. Pearson v. Probate Court
of Ramsey Cty., 1940, p. 271272).
Although the organizational structure and facility
operations in each state vary, the key fundamentals
of SVP laws are similar and have survived court challenges. This system to segregate convicted criminal offenders (in this case pursuant to Washington
Revised Code 7 1.09.020(1) deemed likely to reoffend
was approved by the Supreme Court in Kansas v.
Hendricks, but the Court underscored that civil commitment on a finding of dangerousness standing
alone is generally not a sufficient ground upon which
to justify indefinite involuntary commitment. Proof
of more than a predisposition to violence is necessary and past acts of sexual violence that resulted in
convictions must be reasonably linked to a diagnosed
mental disorder that predisposes the person to commit criminal sexual acts and a likelihood of the past
repeating itself. The Supreme Court clarified that
the SVP Accused must have a history of criminal
sexual behavior, and must meet two other criteria for
SVP commitment: a mental disorder or personality
disorder predisposing the individual to sexual violence as a result of the abnormality and a likelihood
of future sexually violent behavior without appropriate treatment and custody. The Court explained that
civil commitment statutes are lawful because,
they have coupled proof of dangerousness with the
proof of some additional factor, such as a mental
illness or mental abnormality . . . These added statutory requirements serve to limit involuntary civil
confinement to those who suffer from a volitional
impairment rendering them dangerous beyond
their control (Addington vs. Texas, 441 U.S. 418,
43233, 1979; Baxstrom vs. Herold, 383 U.S. 107,
1966; Kansas vs. Hendricks, 521 U.S. 346, 1997 at
357358, 369; Seling vs. Young 531 U.S. 250, 2001).
In clarifying the volitional impairment qualification,
the Supreme Court ruled in Kansas v. Crane (2002), 534
US 407 (2002) that while the inability to control sexual
behavior need not be absolute when viewed in light of
such features of the case as the nature of the psychiatric diagnosis and the severity of the mental abnormality itself. The loss of volitional control must however be
sufficient to distinguish the dangerous sexual offender

SEXUAL PREDATOR LAWS AND THEIR HISTORY

whose serious mental illness, abnormality, or disorder

subjected the offender to civil commitment, from the
dangerous but typical sexual recidivist convicted in an
ordinary criminal case (pp. 409413).

CA NA DAS PR EV EN T I V E DET EN T ION

SCHEME A F T ER AUGUST 1, 1997

The DO legislation was amended again on August

1, 1997, limiting the judges discretion to sentence
by requiring that a sentence of detention in a penitentiary for an indeterminate period be imposed
upon finding an offender to be a dangerous offender.
Although the new law applied to all offenders, in
practice most people so designated are under custody
for sexual offenses.
Effective August 1, 1997, Part XXIV of the Code
was substantially amended.15 First, section 753.1
was added to the Code thereby creating long-term
offender designation:
753.1(1) The court may, on application made
under this Part following the filing of an assessment report under subsection 752.1(2), find an
offender to be a long-term offender if it is satisfied that
(a) it would be appropriate to impose a sentence of imprisonment of 2 years or more
for the offense for which the offender has
been convicted;
(b) there is a substantial risk that the offender
will reoffend; and
(c) there is a reasonable possibility of eventual
control of the risk in the community.
(2) The court shall be satisfied that there is a substantial risk that the offender will reoffend if
(a) the offender has been convicted of an
offense under section 151 (sexual interference), 152 (invitation to sexual touching) or
153 (sexual exploitation), subsection 173(2)
(exposure) or section 271 (sexual assault),
272 (sexual assault with a weapon) or 273
(aggravated sexual assault), or has engaged
in serious conduct of a sexual nature in the
commission of another offense of which the
offender has been convicted; and
(b) the offender
(i) has shown a pattern of repetitive behavior, of which the offense for which he
or she has been convicted forms a part,
that shows a likelihood of the offenders

397

causing death or injury to other persons

or inflicting severe psychological damage on other persons,16 or
(ii) by conduct in any sexual matter including that involved in the commission of
the offense for which the offender has
been convicted, has shown a likelihood
of causing injury, pain or other evil to
other persons in the future through similar offenses.17
(3) Subject to subsections (3.1), (4) and (5), if
the court finds an offender to be a long-term
offender, it shall
(a) impose a sentence for the offense for which
the offender has been convicted, which sentence must be a minimum punishment of
imprisonment for a term of 2 years; and
(b) order the offender to be supervised in
the community, for a period not exceeding 10 years, in accordance with section
753.2 and the Corrections and Conditional
Release Act.
Second, the dangerous offender provisions were
amended to take away the trial judges discretion to
grant a determinate sentence to those who are found
to be dangerous offenders. Under the new provisions,
the Court was required to impose an indeterminate
sentence following a dangerous offender designation.
Finally, subsection 753(5) was added to the Code
which provides as follows:
753(5) If the court does not find an offender to be
a dangerous offender,
(a) the court may treat the application as an application to find the offender to be a long-term
offender, section 753.1 applies to the application
and the court may either find that the offender
is a long-term offender or hold another hearing
for that purpose; or
(b) the court may impose sentence for the offense
for which the offender has been convicted.
A 1995 report on high-risk offenders described the
purpose of the long-term offender legislation:
Currently in Canada community supervision generally is imposed by means of probation or it may
be the eventual result of a custodial sentence and
the grant of parole or the operation of Statutory
Release . . . The current probation scheme would
not be generally adequate for the purpose of long
term supervision because . . .

398 FORENSICS

the maximum duration of a probation order, 3 years,

is not sufficient for those offenders who can be
managed in the community but who require an
extended period of supervision and treatment to
be stabilized,
probation cannot be attached to sentences of 2 years
or more, leaving lacunae in two ways:
more serious offenders, that is, those who receive
penitentiary length sentences, cannot receive
the support of extended community supervision other than through parole as a result of
the imposition of a long custodial sentence
on dangerous offender applications, the court
currently has only the alternative of indefinite
detention at one extreme, and a definite sentence at the other.
Long-term supervision (LTS) should have as its
objective the enhanced safety of the public through
targeting those offenders who could be effectively
controlled in the community, based on the best scientific and clinical expertise available. Such control may
be the most effective approach in helping to reduce
violent criminal acts, fostering and maintaining
prosocial behavior, and reducing the adverse impact
of incarceration. Supervision under such a scheme
should be designed to avoid long-term or indefinite
incarceration: the focus should be, instead, to exert
all possible effort, short of incarceration, to stabilizing the offender in the community, with particular
attention to any precursors to reoffending that may be
identified. LTS is based on the assumption that there
are identifiable classes of offenders for whom the risk
of reoffending may be managed in the community
with appropriate, focused supervision and intervention, including treatment.
A sentencing option providing for long-term supervision would be aimed at cases where an established
offense cycle with observable cues is present, and
where a long term relapse prevention approach may
be indicated (Victoria, 1995, pp. 1819).
At the same time the Criminal Code was amended
to create the long-term offender provisions, the
Corrections and Conditional Release Act was also
amended. Under s. 134.1 of the CCRA, individuals
released on a long-term supervision order are subject
to the same conditions as attach to any parole order as
well as any condition that the Parole Board considers
reasonable and necessary to protect society and to
facilitate the successful reintegration into society of
the offender. (Corrections and Conditional Release

Act, s. 134.1; Corrections and Conditional Release

Regulations, s. 161).
The new legislation was introduced to replace legislation dealing with habitual offenders. The dangerous offender provisions in s. 753 of the Code allow
courts to remove so-called dangerous offenders from
society on the basis of a future prediction (not punishment for a past crime) and impose an indeterminate sentence of preventive detention18. Pursuant to s.
753.1 of the Criminal Code, if a high-risk/high-needs
offender is found to be a long-term offender, the court
is required to impose a sentence of not less than 2
years for the offense committed plus an order that the
offender be supervised in the community for a period
not exceeding 10 years. Many NCR Accused, DO
and LTOs are habitual criminals (R vs. P.H., 2005 in
para. 2124).
After the implementation of Bill C-55 on August
1, 1997, an accused designated a dangerous offender
automatically receives an indeterminate penitentiary sentence and no statutory release date is set
(Corrections and Conditional Release Act, s. 127,
134.1, s. 134.1). The parole eligibility date (PED) was
increased to seven (7) years from the date of arrest relative to the offense for which the offender received the
indeterminate sentence to bring this parallel with the
eligibility restrictions for offenders serving sentencs
of life imprisonment An Act to amend the Criminal
Code (high risk offenders), S.C. 1997, c. 5 Department
of the Solicitor General Act, S.C. 1997, c. 17, s. 48.
The day parole eligibility date (DPED) received a
coincident increase to three (3) years before the PED
as pursuant to s. 761(1) of the Code.
The legislative objectives serve both punitive and
preventive purposes and resemble the case-law criteria for imposing a life sentences that are primarily
imposed for the same purposes (Victoria, 1995). In
R. v. Hill, Jessup J. noted that,
When an accused has been convicted of a serious
crime in itself calling for a substantial sentence
and when he suffers from some mental or personality disorder rendering him a danger to the community but not subjecting him to confinement in a
mental institution and when it is uncertain when,
if ever, the accused will be cured of his affliction,
in my opinion the appropriate sentence is one
of life. Such a sentence, in such circumstances,
amounts to an indefinite sentence under which
the parole board can release him to the community when it is satisfied, upon adequate psychiatric

SEXUAL PREDATOR LAWS AND THEIR HISTORY

examination, it is in the interests of the accused

and of the community for him to return to society.
(R. v. Hill, 1974, pp. 147148; R. v. Kempton, 1980,
p. 191192).
Chief Justice McLachlin in delivering the judgment
of The Supreme Court of Canada in the Charkaoui
case highlighted the punitive component of preventative indeterminate detention (PID):
It is thus clear that while the IRPA in principle
imposes detention only pending deportation, it
may in fact permit lengthy and indeterminate
detention or lengthy periods subject to onerous
release conditions. The next question is whether
this violates s. 7 or s. 12 based on the applicable
legal principles.
This Court has previously considered the possibility of indefinite detention in the criminal context.
In Lyons, a majority of the Court held that dangerous offender legislation allowing for indefinite
detention did not constitute cruel and unusual treatment or punishment within the meaning of s. 12 of
the Charter because the statutory scheme includes
a parole process that ensures that incarceration is
imposed for only as long as the circumstances of the
individual case require (in p. 341, per La Forest J.). It
is true that a judge can impose the dangerous offender
designation only on a person who has been convicted
of a serious personal injury offense; this Court indicated that a sentence of indeterminate detention,
applied with respect to a future crime or a crime that
had already been punished, would violate s. 7 of the
Charter (in pp. 32728, per La Forest J.). But the use
in criminal law of indeterminate detention as a tool
of sentencingserving both a punitive and a preventive functiondoes not establish the constitutionality
of preventive detention measures in the immigration
context.
The principles underlying Lyons must be adapted
in the case at bar to the immigration context, which
requires a period of time for review of the named persons right to remain in Canada. Drawing on them,
I conclude that the s. 7 principles of fundamental justice and the s. 12 guarantee of freedom from cruel
and unusual treatment require that, where a person is
detained or is subject to onerous conditions of release
for an extended period under immigration law, the
detention or the conditions must be accompanied by
a meaningful process of ongoing review that takes

399

into account the context and circumstances of the

individual case. Such persons must have meaningful
opportunities to challenge their continued detention
or the conditions of their release.
The type of process required has been explored
in cases involving analogous situations. In Sahin,
Rothstein J. had occasion to examine a situation of
ongoing detention (for reasons unrelated to national
security) under the Immigration Act. He concluded
that what amounts to an indefinite detention for a
lengthy period of time may, in an appropriate case,
constitute a deprivation of liberty that is not in accordance with the principles of fundamental justice
(p. 229) (Charkaoui v. Canada (Citizenship and
Immigration), 2007, p. 105110).
For a DO in Canada the chances of the National
Parole Board granting parole are remote. However, if
parole is granted monitoring of the DO in the community will be for the rest of his or her life. The
DPED will be the longer of
parole eligibility date, as determined in accordance with section 761(1), less 3 years.
In other words DPED = [PED of 7 years3
years]; and,
parole eligibility date, as determined in accordance with subsection 120.2(2) of the Corrections and Conditional Release (CCRA), less
3 years. However,
in the case of a combination of life and indeterminate sentences, the sentence which produces
the longest parole eligibility date will govern
what the parole eligibility date will be; and,
if an offender is in custody when s/he commits
an offense for which another indeterminate
sentence is imposed, the date of arrest in these
circumstances is considered to be the date the
offender was charged with the new offense.
Should an offender receive additional determinate
sentences any time while lawfully or unlawfully does
not count as part of the parole ineligibility period and
the date of each sentence will determine the eligibility
rules to be followed (An Act to amend the Criminal
Code (high risk offenders), S.C. 1997, c. 5).
Of course, once a dangerous offender designation is made under the new provisions, the trial judge
must impose an indeterminate sentence. Despite the
enactment of the amendment to Part XXIV of the
Criminal Code, many dangerous offender hearings
still proceeded on the basis of the old provisions and

400 FORENSICS

little seemed to change after August 1, 1997. If both

the old and new provisions were available sentencing
alternatives, the prevailing view was that, because of
the mandatory indeterminate sentence provisions,
the new provisions did not create a lesser penalty
for purposes of the Charter (R. v. Gibbon, 1998).
The creation of the long-term offender designation
did raise a new issue of whether judges were vested
with a residual discretion to consider the long-term
offender provisions in section 753.1 on applications
under section 753 and if so, under what circumstances.
As set out previously, s. 753(5), which was added to
the Code in the 1997 amendments stated that if the
Court does not find an offender to be dangerous, the
Court may treat the application as an application to
have the offender designated as a long-term offender.
The plain language of s. 753(5) of the Code seemed
to suggest that the long-term offender provisions were
only available at a dangerous offender hearing if the
dangerous offender criteria were not met.
Prior to the touchstone decision of the Supreme
Court of Canada in R. v. Johnson in September 2003
(R. v. Johnson, 2003) there were few guiding cases on
the relationship between long-term offender and dangerous offender laws.
For example, in R. v. C.M.M., dated November 7,
1997, the Court held that the application of the longterm offender provisions only arose if the offender
was found not to be a dangerous offender. In that
case, the Court found that the Crown had met the
burden in section 753(b) beyond a reasonable doubt.
The judge therefore declined to consider the longterm offender provisions (R. v. C.M.M., 1997, in para.
14, 61, 64, 66).
Similarly, in R. v. Gibbon, a British Columbia
judge held that the amendments did not apply retroactively. Indeed, the trial judge observed that section
753.1 is only available where the accused is not found
to be a dangerous offender:
I might be attracted to the defence argument if
I were to find that the accused is not a dangerous
offender. However, the evidence is overwhelming
that he is a dangerous offender. Under the new s.
753(5), the Court can treat the Crowns dangerous
offender application as a long-term offender application under s. 753.1, only if it does not find the
accused to be a dangerous offender. Since I find
the accused to be a dangerous offender, the option
of finding him a long-term offender does not arise.
(R. v. Gibbon, 1998 at para. 814).

Several questions remained. For example, could a

trial judge consider and apply the long-term offender
provisions during a hearing commenced under the
dangerous offender provisions? Could a trial judge
consider the prospect of positive therapeutic intervention when determining whether the offender met
the test under s. 753 of the Criminal Code? These
issues remained unresolved until the Supreme Court
decided the Johnson case (R. v. Johnson, 2003).
Courts in Canada were slow to address the issue
whether, and under what conditions, a long-term
offender designation could be imposed in the
course of deciding a dangerous offender application. In R. v. Turley the accused was convicted of a
number of sexual offenses. Mr. Turley was found
to be dangerous offender under the pre-1997 provisions and given a determinate sentence of 10 years.
He appealed the dangerous offender designation
and the prosecution appealed the determinate
sentence. In granting the appeal and substituting a long-term offender designation the British
Columbia Court of Appeal observed thatSince the
conclusion of the dangerous offender proceedings
and the imposition of the previously noted sentence, there have been significant Code amendments concerning dangerous offenders. The
dangerous offender category remains and the
new amended provisions now make mandatory
an indeterminate sentence [i]f the court finds an
offender to be a dangerous offender (s. 753(4)).
The other major change, aside from some evidentiary provisions, is that a new class or category has
been created, namely, the designation of longterm offender. As I see it, the long-term offender
category might be analogized to finding of a lesser
included offence on a dangerous offender application (R. vs. Turley, 1999).
The state of the law in this regard remained unsettled (R. vs. F.W.M., 2001 in paras. 7475) while the
Johnson case worked its way through the courts.19
On October 16, 1998, Jeremiah Johnson was
found to be a dangerous offender and given an indeterminate period of incarceration. In his reasons for
judgment, the trial judge made no reference at all
to the long-term offender provisions. (R. v. Johnson,
1998 per Tysoe J.)
Mr. Johnson appealed and argued that the trial
judge erred in failing to consider the application of
the long-term offender provisions during his dangerous offender hearing. Mr. Johnson was granted a new

SEXUAL PREDATOR LAWS AND THEIR HISTORY

hearing at which he was entitled to call evidence and

make submissions on whether he ought to be designated a long-term offender rather than a dangerous
offender and on September 26, 2003, the Supreme
Court of Canada released its decision which clarified
many of the unsettled issues surrounding the 1997
amendments to the dangerous offender regime (R. v.
Johnson, 2001 in para. 80, 98 and 104; R. v. Johnson,
2003).
First, the Court confirmed that the sentencing
judge retains the discretion not to impose a dangerous offender designation even if the accused meets all
the statutory requirements:
[N]either the purpose of the dangerous offenders
regime, nor the principle of sentencing, nor the
principles of statutory interpretation suggest that
a sentencing judge must designate an offender
dangerous if the statutory criteria in s. 753(1)(a) or
(b) have been met. On the contrary, each of these
factors indicates that a sentencing judge retains
the discretion not to declare an offender dangerous even if the statutory criteria are met. This is
particularly true now that it is clear that offenders
declared dangerous must be given an indeterminate sentence.
The Court went on to explain the rationale for maintaining this discretion:
The proposition that a court is under a duty to
declare an offender dangerous in each circumstance in which the statutory criteria are satisfied
is in direct conflict with the underlying principle
that the sentence must be appropriate in the circumstance of the individual case.20 A rigid rule
that each offender who satisfies the statutory criteria in s. 753(1) must be declared dangerous and
sentenced to an indeterminate period of detention undermines a sentencing judges capacity
to fashion a sentence that fits the individual circumstances of a given case (R. v. Johnson, 2003 at
para. 18, 25).
Second, the Court held that sentencing judges must
consider treatment and management prospects
independently and reject both before imposing a
dangerous offender designation. This is especially
important since treatment may prove to be more
promised than delivered (R. v. Johnson, 2003, in para.
3536; Webster, Dickens, & Addario, 1985, p. 4748,
144145).

401

Finally, the Supreme Court finally ruled on the

relationship between the dangerous offender and the
long-term offender provisions:
In those instances where both the dangerous and
long-term offender provisions are satisfied, it may
be that the sentencing sanctions available under
the long-term offender provisions are capable of
reducing the threat to the life, safety or physical or
mental well-being of other persons to an acceptable level . . . If the public threat can be reduced
to an acceptable level through either a determinate period of detention or a determinate period
of detention followed by a long-term supervision
order, a sentencing judge cannot properly declare
an offender dangerous and sentence him or her to
an indeterminate period of detention.
Later in the judgment, the Court summarized its
decision as follows:
As we have discussed, a sentencing judge should
declare the offender dangerous and impose
an indeterminate period of detention if, and
only if, an indeterminate sentence is the least
restrictive means by which to reduce the public
threat posed by the offender to an acceptable level
(R. v. Johnson, 2003, in para. 32, 37, 44).
The Johnson decision resolved several issues that had
arisen since the 1997 amendment to the Criminal
Code. Principally, that an individual who meet the
criteria for designation as both a dangerous and a
long-term offender has the right pursuant to s. 11(i) of
the Charter of Rights and Freedoms to be designated a
long-term offender and given a determinate sentence
followed by a long-term supervision order:
[A] sentencing judge should declare the offender
dangerous and impose an indeterminate period
of detention if, and only if, an indeterminate sentence is the least restrictive means by which to
reduce the public threat posed by the offender to
an acceptable level. The introduction of the longterm offender provisions expands the range of sentencing options available to a sentencing judge
who is satisfied that the dangerous offender criteria have been met. Under the current regime, a
sentencing judge is no longer faced with the stark
choice between an indeterminate and a determinate sentence. Rather, a sentencing judge may
consider the additional possibility that a determinate sentence followed by a period of supervision

402 FORENSICS

in the community might adequately protect the

public. The result is that some offender who may
have been declared dangerous under the former
provisions could benefit from the long-term
offender designation available under the current
provisions (R. v. Johnson (2003), 177 C.C.C. (3d)
97 (S.C.C.), at 119120).

R ISK ASSESSMEN T A PPROACHES

IN THE UNIT ED STAT ES

There is no uniform standard in the United States

regarding SDP cases. However, for an individual to
be committed as a sexually violent/dangerous person,
the majority of states require that the offender be convicted of (or incompetent to stand trial for) a sexual
offense and that they have a mental disorder, mental abnormality, or behavioral disorder that leads
to dyscontrol of sexual urges and behaviors. Forensic
evaluations of sexual predators, therefore, focus on
an understanding of the offenders psychopathology (broadly defined) as well as factors that lead to
increased risk of sexual reoffense.
Mental Abnormality/Disorder
The terms mental abnormality or disorder are
legal constructs in the context of SDP laws, not necessarily clinical diagnoses. Ultimately, whether the
condition in question meets commitment standards
is decided by the trier of fact. Many mental health
professionals, however, refer to personality disorders or paraphilias listed in the DSM-IV (American
Psychiatric Association, 2000) in reaching their opinion, and leave it to the Court to determine if the legal
threshold of mental abnormality is reached.
The most common disorders found in sex offenders are substance abuse disorders, paraphilias, and
personality disorders (Conroy, 2003). These diagnoses
are determined primarily by behaviors that are overt
and measurable. It has been argued that many such
disorders are not mental illnesses but, rather, determined solely by patterns of behavior (Harris, Rice, &
Quinsey, 1998) and that these disorders (especially
personality disorders) are not amenable to treatment.
The Kansas statute, challenged in Kansas v. Hendricks
(1997) acknowledges that most SDPs meet diagnostic criteria for antisocial personality disorder (APD),
that APD is not a mental illness, and that such individuals are not amenable to treatment (Conroy, 2003;

Cornwell, 1998). Hendricks argued that without legitimate treatment for his disorder, civil commitment
would, amount(s) to little more than disguised punishment, but the Supreme Court disagreed.
Clinicians, then, are faced with a dilemma. They
are required to give an opinion about the presence or
absence of a statutorily defined disorder for which
treatment may not exist; yet, they are also required
to provide an opinion as to whether commitment to a
treatment facility is appropriate. In his seminal monograph on risk assessment, John Monahan (1981) posed
the following question to clinicians asked to complete
an evaluation of violence risk: Are any issues of personal or professional ethics involved in this case?
(p. 103). This question is relevant regarding risk
assessments of sexual dangerousness. Clinicians must
address the question in deciding whether to proceed
with an evaluation. They must be comfortable with
presenting the court with legally-relevant data regarding the offenders pathology and letting the trier of
fact determine whether the legal standard is met.
In addressing the issue of mental disorder the
clinician should proceed, as in all forensic evaluations, by collecting data from multiple sources
including collateral document review, interview, and
psychological testing. Particular attention should
be paid to historical patterns that suggest repetitive
and compulsive criminal/antisocial behaviors, lifelong maladaptive personality characteristics, lack of
stable adult relationships, and a pattern of impulsivity. Interview characteristics of note include failure to take responsibility for offending behavior or
antisocial acts, antisocial attitudes, lack of empathy,
and lack of remorse. Psychological tests, such as the
Millon Clinical Multiaxial Inventory-III (MCMI-III;
Millon, 1994), which assess personality style, the presence of specific symptoms, and the presence of major
metal illnesses, may also be useful. The MMCI-III
validity scales also evaluate the attitude with which
the offender answered the test questions (Heilbrun,
Marczyk, & DeMatteo, 2002). Some clinicians focus
on the offenders impulsivity as an index of dyscontrol. The Barratt Impulsivity Scale (BIS; Barratt,
1985; Stanford & Barratt, 1995) may be a test that is
considered for this purpose.
Risk Assessment
Assessments of future risk of violence are difficult and controversial. Assessments of future risk of

SEXUAL PREDATOR LAWS AND THEIR HISTORY

sexual violence are even more so, yet dangerousness

is . . . the unambiguous justification for the civil commitment of sex offenders (Prentky, Janus, Barbaree,
Schwartz, & Kafka, 2006, p. 371). Historically, dangerousness assessments were based on clinical judgments unguided by empirical data or empirically
validated risk assessment instruments. Such clinical
assessments are particularly prone to false-positive
predictions, even when general criminal recidivism
or violence are to be predicted (Cocozza & Steadman,
1978; Monahan, 1981). Clinical assessments refer
to relatively unstructured evaluations in which clinicians rely on their own experience and clinical
expertise. They, therefore, tend to be idiosyncratic
and unreliable and may include clinical interview,
a review of records, observation of the subject, and
the use of psychological tests that are not specifically
designed for the assessment of sex offenders. These
assessments ultimately rest upon the arbitrary judgment of the clinician and they lack explicit parameters
that define what factors are relevant and what relative
weight they are given (Conroy, 2003; Prentky et al.,
2006; Witt & Schneider, 2005). The advantage of the
clinical approach to risk assessment is that, because
it is unstructured, it allows for broader, individualized assessment of the subject as opposed to seeking
specific nomothetic factors and applying them to
the individual. Due to problems with reliability and
validity, however, purely clinical assessments are not
recommended. Nonetheless, courts have continued
to allow testimony from mental health professionals
based solely on clinical judgment (Conroy, 2003). As
the limitations of clinical assessment became more
apparent to the scientific community, research began
to identify actuarial predictors of recidivism.
As individual risk factors were identified, instruments were developed to predict recidivism with
the goal of removing evaluator bias. Risk variables
can be divided into static (historical, unchanging)
and dynamic (variable, amenable to intervention).
Actuarial assessment instruments initially focused on
static, historical risk factors predictive of sexual recidivism. Monahan had noted that If there is one finding
that overshadows all others in the area of prediction;
it is that the probability of future crime increases with
each prior criminal act (1981, p. 71). The static risk
factors found to be predictive of sexual recidivism
were not identical to those predictive of general criminal recidivism (Conroy, 2003; Hanson & Bussiere,
1998). Measures such as the RRASOR (Rapid Risk

403

Assessment for Sex Offense Recidivism) (Hanson,

1997) and the Static-99 (Hanson, & Thornton, 1999)
focused on risk factors such as history of antisocial
behavior, history of sexual offending, characteristics
of the victims (e.g., gender; relationship to perpetrator), and age of first offense. Static risk factors are
gathered from archival data, such as court, educational and psychological treatment documents and a
clinical interview is not required. In general, scholars
have concluded that actuarial assessment is superior to clinical assessment of risk (Monahan et al.,
2001; Prentky et al., 2006). Yet, actuarial assessment
also has its limitations. None of the current actuarial instruments, for example, accounts sufficiently
for dynamic risk factors of reoffense (Hanson, 1998).
Also, instruments developed for one group of sexual
offenders are, typically, inappropriate for use with
another group. For example, an instrument developed for use with adult male offenders may not be
appropriate for use with female offenders or adolescent offenders (Prentky et al., 2006). Since the
underlying justification for commitment, identified
in the Hendricks decision is treatment (even if it is
currently ineffective), assessments that fail to consider change over time do not measure the variable
the legislatures and courts are requesting the evaluator to consider. There is no purpose to a reevaluation
if the result will always be the same.
Some scholars suggest that pure actuarial assessment should always be used in evaluating risk of
sexual recidivism (e.g., Quinsey, Harris, Rice, &
Cormier, 1998). Others, noting the limitations of
pure actuarial methods, have suggested some combination of clinical judgment and empirically-derived
actuarial risk assessment. Hanson (1998) noted that
actuarial instruments lack comprehensiveness. Not
only do they fail to address dynamic risk factors, they
also cannot even claim to address all relevant static
risk factors (p. 65). Hanson suggested an adjusted
actuarial approach that begins with actuarial predictions and then adjusts these assessments on the basis
of other compelling evidence (p. 65). Others have
suggested a guided clinical approach or structured
professional judgment approach (Douglas, & Kropp,
2002; Hanson, 1998). In this approach relevant clinical data are collected from multiple sources, including clinical interview, and then this information is
informed by empirically-identified risk factors. This
approach allows for flexibility in weighing risk factors guided by idiographic information. The guided

404 FORENSICS

clinical approach allows for professional judgment

and discretion (Chapter 5). As Hanson (1998) pointed
out, however, [a]n inherent problem with the guided
clinical approach is that there is no explicit method
of translating combinations of individual risk factors
into overall recidivism probabilities (p. 62).
Each approach to sex offender risk assessment has
its limitations. Recently, however, researchers have
focused on the importance of dynamic risk factors in
assessment (e.g., Hanson, 2000; Hanson, & Harris,
2000; Witt, & Schneider, 2005). Areas of interest
include: antisocial lifestyle and attitudes, poor social
supports, substance abuse, age, participation in psychotherapy, and sexual deviance. Because of the
importance of dynamic risk factors, many mental
health professionals in the U.S. utilize a guided clinical approach or adjusted actuarial approach to risk
assessment. This is especially true in reassessments of
risk, when a civilly committed sex offenders ongoing
risk must be reviewed.
Although there is substantial research on static risk
factors and these factors have been shown to be useful for identifying long-term risk of sexual reoffending, these factors provide no information concerning
when offenders are likely to reoffend or how to intervene to reduce the potential for recidivism (Hanson,
2000, p. 108). Of particular concern is that relatively
little is known about dynamic risk factors, especially
the effects of psychotherapy on mitigating recidivism
risk. Hanson (2002) found that participation in treatment was associated with lower rates of sexual recidivism, and recent studies have addressed the effects
of psychotherapy, community supervision, age, and
self-regulation on recidivism (Barbaree, Blanchard,
& Langton, 2003; Doren, 2006; Langton, Barbaree,
& Harkins, 2006; Witt, & Schneider, 2005), but considerably more research is needed to fully understand
dynamic risk factors.

THE CI V IL COMMIT MEN T OF

JU V ENILES AS SE X UA LLY DA NGEROUS
OR V IOLEN T PER SONS IN THE
U NI T ED STAT ES

It seems unlikely that juvenile sex offenders were primarily on the minds of state legislatures when they
enacted their respective civil commitment laws for
sexual violent persons and predators. They more than

likely were thinking of the Leroy Hendricks of the

world, adult repetitive pedophiles, and adult repetitive violent rapists when they passed these legislative
schemes. This has not prevented juvenile sex offenders or, more likely, adults whose only sex offense
occurred when they were juveniles from being captured within these civil commitment proceedings
(For a comparative Canadian case see R. vs. Lyons
[1987] 2 S.C.R. 309). There is no systematic national
data maintained about how many adolescents are
subjected to civil commitment procedures as SDPs.
Likewise, there is no national data available about
how many of the total population of individuals civilly committed as SDPs committed their only known
sexual offense or offenses as adolescents, never having sexually offended as adults. Moreover, there has
been little empirical research generally regarding
the application of SDP and SVP laws to juvenile sex
offenders or about the criminal or clinical characteristics of involuntarily committed juvenile sex offenders or adults whose only known sex offense occurred
when they were adolescents.
In the state of Washingtonthe only state that
has made available data about the civil commitment of juvenile sexual offendersthe SVP statute
allows for the commitment of adults and juveniles.
Since the enactment of the law in 1990 to the end
of 2003, a total of 35 referrals (31 individuals) for
juveniles aging out of the juvenile justice system
were identified as likely meeting the statutory criteria for involuntary civil commitment, representing only approximately 1% of the total juvenile sex
offenders paroled during this 13 year period (Milloy,
2006). The state declined to file a petition on 23
(a total of 21 individuals) or approximately two-thirds
of these referrals. In the case of the other 12 referrals,
a petition was filed resulting in six commitments, two
dismissals and four were still awaiting an outcome.
Follow-up data through December 2005 on the 21
juveniles for whom a petition was not filed revealed
that 15% or 71% were convicted of a new offense
and eight or approximately a third were convicted of a
new felony or misdemeanor sex offense.
A necessary condition for the application of any
of the civil commitment procedure for sexual offenders is the prior conviction for a sexual offense. Those
without a prior conviction are not subject to its reach
and scope. Conviction as the outcome of a criminal
trial or hearing is not a term historically in use in
juvenile court proceedings, however. The juvenile

SEXUAL PREDATOR LAWS AND THEIR HISTORY

court, on the basis of its foundation in rehabilitation

and treatment as opposed to retribution and punishment, has eschewed many of the traditional terms and
phrases of the criminal court. In an attempt to avoid
the potential negative effects associated with the
application of terms and labels used for adult felons,
the juvenile court has developed its own lexicon for
juvenile offenders. Instead of criminal convictions
it has substituted delinquency adjudications.
Many state legislatures in their SDP laws circumvent the problem posed by the requirement of a
prior conviction for a sexual offense by specifically
declaring that delinquency adjudications for a sexual
offense constitutes a conviction for the purpose of
civil commitment proceedings as sexual dangerous
persons. For example, Arizona defines a conviction to
include any finding of guilt at any time for a sexually
violent offense or an order of the juvenile court adjudicating the person delinquent for any sexually violent offense. (Ariz. Rev. Stat. 363701). This elastic
use of delinquency adjudications to serve as the functional equivalent of criminal convictions raises very
important procedural questions, however, such as
whether juveniles have been properly informed about
the potential collateral use of their delinquency adjudications, many of which are undoubtedly delinquent
pleas without the benefit of trial.
The presence of some requisite mental condition,
defined within most states as a mental abnormality
and some other personality disorder is a second necessary criteria for civil commitment. The presence of
a mental disorder or abnormality is especially critical according to the majority in Hendricks because
these laws can only be credibly considered civil in
nature if they are applied to a distinct subpopulation
of sexual offenders who are defined as being dangerous because of a mental disorder or abnormality. If
they are being preventively detained merely because
they are dangerous and nothing more, then the procedure is revealed as starkly retributional and thereby
unconstitutional. If, however, the state moves against
the liberty of the individual because they are sexually dangerous by means of some underlying abnormal mental condition, then the process can be neatly
folded into the long standing precedent of depriving
the liberty rights of the mentally ill who have some
impaired control over their dangerous behavior.
The two mental conditions that are typically diagnosed among civilly committed sexual offenders are
the Paraphilias and APD (Doren, 2002). A problem

405

immediately emerges, however, when the application of the paraphilias and the personality disorders
are considered in the case of juveniles facing possible
civil commitment as sexual offenders. It is unclear to
what extent juveniles, particularly early aged ones, are
eligible for such qualifying diagnoses.
According to DSM-IV, to be diagnosed with
Pedophilia, adolescents must be at least 16 years old
and must be at least 5 years older than the child or
children victims. This requirement is in addition to
the presence of Criterion A: Over the course of at
least 6 months, recurrent, intense sexually arousing
fantasies, sexual urges or sexual behaviors involving
sexual activity with a prepubescent child or children
(generally 13 years or younger). (DSM-IV-TR, 2000,
p. 572). The DSM-IV additionally rules out the case
of a late adolescent involved in an ongoing relationship with a 12- or 13-year-old. Using DSM-IV criteria
as a strict guide to the diagnosis of pedophilia, a juvenile adjudicated delinquent at age 15, for instance,
for the sexual abuse of a 9-year-old and 10-year-old
female victim separated in time by less than 6 months
could not be diagnosed with pedophilia absent any
further evidence of continued deviant urges, fantasies
or desires for similar aged victims when he is age 16
or beyond. This evidence may be hard to come by if
the juvenile has been confined in a secure treatment
program without access to younger female children.
The problem with the use of such diagnostic
categories as Antisocial Personality Disorder and
Conduct Disorder in juveniles facing civil commitment as sexual offenders is whether such categories, which describe general patterns of problematic
behavior, can be used to identify specific problems
of sexual deviance and volitional impairments. According to In re to the Care and Treatment of Michael T.
Crane (2000), to satisfy the volitional impairment
criterion a total or complete lack of control is not
necessary but only serious difficulty controlling ones
deviant sexual urges. What is not settled in either
Hendricks or Crane, however, is how these standards
or objectives are to be applied to adolescents. What
is the meaning of the terms mental abnormality and
personality disorder for a juvenile? Are these manifested in a similar manner for adolescents as they
are for adults? Do adolescents have similar volitional
capacities as adults when it comes to controlling their
sexual urges? Do we hold adolescents to the same
standard of serious difficulty controlling sexual urges
as adults? Or does their immature status require that

406 FORENSICS

we think about these capacities differently? What is

the predictive value of a sexual offense committed by
an adolescent to their later risk of committing sexual
offenses as an adult?
The formulation of a generalized link between
a mental disorder and a volitional impairment is
more easily established for pedophilia, a diagnostic
category which by definition provides a ready-made
link to a volitional impairment and risk. Conduct
disorder, for instance, bears no specific relationship
with sexual recidivism. A conduct disorder or APD in
conjunction with prior delinquency adjudication for a
sexual offense along with the testimony of expert witnesses who concluded that the individuals conduct
disorder or APD in his particular case predisposed
him to violent sexual acts may provide the necessary
nexus between a mental disorder and the predisposition for violent sexual acts. But such a line of clinical
reasoning opens the door for potential tautological
thinking: A person has an APD because he has prior
acts of sexual violence and his prior acts of sexual violence provide the necessary evidence that his particular form of APD results in a volitional impairment to
control such acts from occurring in the future.
The demonstration that the individual facing
potential civil commitment poses a substantial risk
of committing future acts of sexual violence is often
another criterion required for involuntary commitment as a sexual offender. The problem with this
criterion in the context of the civil commitment
of juveniles or the commitment of adults whose
only sexual offense occurred while they were juveniles is that the research literature has consistently
reported a low sexual recidivism rate for juvenile sexual offenders, lower than for adult sexual offenders
and very much lower than for general delinquency
for juveniles (Caldwell, 2002; Righthand, & Welch,
2001; Weinrott, 1996; Worling, & Langstrom, 2006;
Zimring, 2004). Two related issues emerge regarding the prediction of sexual recidivism for juveniles
and for adults whose only offense occurred while
they were juveniles. First, given that the base rate of
sexual recidivism is relatively low can an argument
be credibly made that a particular juveniles risk to
commit future sexual acts of violence when the recidivism rate is so low for the aggregate of juvenile sexual
offenders? Second, should juveniles or for that matter adults whose only sexual offense occurred when
they were juveniles be assessed with actuarial prediction instruments that were developed and normed on
adult sexual offenders?

Problems emerge when juvenile sex offenders

or adults whose only sexual offense occurred when
they were juveniles are assessed on the number of
actuarial assessment instruments that have been
developed for adult sexual offenders (Maurutto &
Hannah-Moffat, 2007). For instance, the Minnesota
Sex Offender Screening Tool-Revised (MnSOST-R;
Epperson, Kaul, Huot, Hesselton, Alexander, &
Goldman, 1999) does not provide criteria for how to
score the case of a person who has been incarcerated
since age 15 and may have been a full-time student at
the time of his initial detainment on the employment
history item. An item on the Static-99 (Hanson, &
Thornton, 1999) asks if the offender ever lived with a
lover for at least 2 years. But how is such an item to be
scored in the case of a dependent adolescent who still
lived with his parents at the time of his arrest?
There have been a number of actuarial risk assessment instruments developed specifically for juvenile
sex offenders in the past decade such as the Juvenile
Sex Offender Assessment Protocol-II (J-SOAP-II;
Prentky & Righthand, 2003), the Estimated Risk of
Adolescent Sex Offender Risk (ERASOR; Worling,
2004; Worling, & Curwen, 2001), and the Sexual Offense Recidivism Risk Assessment Tool-II
(JSORRAT-II; Epperson, Ralston, Fowers, & Gore,
2006). Overall, these risk assessment instruments
which assess various combinations of static and
dynamic factors of sexual recidivism risk have established good reliability and to some extent concurrent
validity with other established measures and external criterion but have not as yet been able to report
any predictive validity data. The problem uniformly
across them has been the apparently insurmountable
issue of the consistently low sexual recidivism rate of
juvenile sexual offenders which has prevented these
test authors from establishing the predictive validity of their instruments, a vital psychometric characteristic allowing for their use in contexts like civil
commitment proceedings where the validity of such
predictions will be a central issue.
There is no national data currently about how
many juvenile sexual offenders or how many adults
whose only sexual offense was committed as a juvenile have been civilly committed as sexually dangerous or violent persons. The direct interface of the
juvenile justice system and SDP proceedings unveils
some potentially unanticipated fault lines such as
whether juveniles have been properly informed of the
collateral use of their delinquent pleas in SDP hearings before their tendering such pleas.

SEXUAL PREDATOR LAWS AND THEIR HISTORY

The requisite presence of a mental abnormality

or personality disorder is deeply problematized in the
case of juvenile sexual offenders. First, it is unclear
if young adolescents are able to be diagnosed with
a paraphilia, particularly pedophilia, before the age
16. Also other frequent diagnoses such as APD and
Conduct Disorder do not provide a specific nexus
to a volitional impairment or risk for future sexual
offending. It is necessary that evidence for the nexus
be established in the specific case through the presence of prior sexual offending which opens the door
to potential tautological reasoning: Their prior sexual
offense is used to support the presence of a mental
disorder and the nexus of their mental disorder to a
volitional impairment is the presence of a prior history of sexual offending. Finally, problems emerge
when attempts are made to establish their future risk
of sexually violent acts. First, juvenile sexual offenders
have an empirically established lower recidivism than
adult sexual offenders, making the argument about
their future risk more difficult to establish. Second, it
is unclear that the actuarial assessment instruments in
wide use with adult sexual offenders can be employed
with juvenile sexual offenders or even with adults
whose only sexual offense occurred when they were
juveniles. Lastly, there has been a number of actuarial assessment instruments developed over the past
decade designed and normed specifically on juvenile
sexual offenders. However, these instruments have
yet to establish sufficient predictive validity, mostly
due to the low base rates of sexual recidivism for juveniles that have posed difficult, even insurmountable,
problems for the test developer.
Notes
1. The Group for the Advancement of Psychiatry
(GAP) was founded in 1946 by a group of physicians
under the leadership of William Menninger. GAP advocates for greater public awareness of the need for new
programs in mental health and analyzes significant data
in psychiatry and human relations, reevaluates old concepts, develops new ones, and applies this knowledge for
the advancement of mental health.
2. For our purposes, since treatment is the justification for civil commitment of sex offenders, and since the
concepts of mental illness and sexual offending are often
confounded within the law, the origins of treatment
rationales are relevant.
3. Up until a few decades into the nineteenth century
the medical profession knew little about mental disorder
and believed insanity to be incurable. The treatments
that were attempted, such as those involving leeches to
remove tainted blood from the insane were futile.

407

4. Such illness, disability, or disorder is not understood to be freely chosen although susceptibility or
recovery is linked in part to choices offenders have made
or can potentially make. It is hypothesized that this
sickness can be cured by proper classification, segregation, training, education, and supervision.
5. It is important to understand that the strength of
a conclusion is a function of both the quality of the evidence provided in its support and the a priori reliability
of the claim being supported.
6. Canada enacted its first Criminal Code in 1892
and s.145 made the Unnatural Offence punishable by
penal servitude up to life.
7. Transportation from Britain ended officially in
1868. In theory it should have been the perfect solution to the problem. It has been tried and abandoned
by England, France, Russia, Portugal, Spain, Italy,
Holland, Denmark, and others, it has been a complete
failure every time.
8. The ambitious new law embodied the Gladstone
Committees finding that, There but few prisoners
other than those who are in a hopeless state through
physical or mental deficiencies who are irreconcilable.
Even in the case of habitual criminals there appears
to come a time when repeated imprisonments or the
gradual awakening of better feelings wean them from
habitual crime. (Gladstone Report, 1895; See also
Leon Radzinowicz and Roger Hood, The Emergence of
Penal Policy in Victorian and Edwardian England in A
History of English Criminal Law and its Administration
from 1750, Vol. 5 (London, 1986) at 231397).
9. In 1900, a small group of boys in London were
drawn together and separated from adult prisoners in
Bedford prison and carefully selected according to their
likely ability to respond to specialized vocational training and ability to be managed on discharge from prison.
Later, in 1902 a wing of the convict prison at Borstal,
now Rochester Borstal was taken over for a similar purpose. These beginnings formed the basis of the Borstal
system by which boys would be carefully chosen, made
subject to strict discipline, expected to work hard, and
given special supervision on discharge through the
Borstal Association. The model for habitual offenders
emulated the Borstal experiment. Regrettably, the impetus to expand well-funded training facilities for young
offenders and habitual offenders was undermined by
resources shortages.
10. Psychopathy is a term derived from the Greek
psyche (mind) and pathos (suffering) and was once used
to denote any form of mental illness. It is now regarded
as a personality syndrome or constellation of affective,
interpersonal, and behavioral characteristics, including
egocentricity; impulsivity; irresponsibility; shallow emotions; lack of empathy, guilt, or remorse; lying; manipulativeness; and the persistent violation of social norms
and expectations.
11. It is hardly surprising that the views of the public, mental health professionals, and the legal profession
were divergent as to what criterion defines the sexual
psychopath. The consequence was the indeterminate
civil commitment of offenders who deviated from sexual

408 FORENSICS
norms, but did not present a significant threat of future
sexual violence.
12. Transcript in the authors possession, copy provided upon request.
13. The British social experiment was faltering and
the dual-track system was abandoned by 1948. Then the
English Criminal Justice Act. 1948 was enacted providing that if the court is satisfied that it is expedient for
the protection of the public, [the dangerous offender]
should be detained for a substantial period of time.
The statute made no mention of the types of offenses
for which a person could be subjected to an indefinite
sentence for and consequently, many property offenders were deemed dangerous by the courts. By the 1960s,
however, the scope of dangerous offender provisions had
narrowed to focus primarily on sex offenders.
14. Two years later in 1950, the Criminal Code was
amended to require that the notice of an application
to find a person to be a criminal sexual psychopath
must be in writing and filed with the court, but nothing
further (An Act to amend the Criminal Code S.C. 1950,
c. 11, s. 19).
15. The Applicants primary focus in this case is not
upon the purported behaviour by an offender, associated with the offense for which he or she has been convicted, that is of such a brutal nature as to compel the
conclusion that the offenders behavior in the future is
unlikely to be inhibited by normal standards of behavioral restraint pursuant to s. 753(1) (iii) of the Criminal
Code.
16. The elements of s. 753.1(1) (a) and 753.1(2) (i) are
(1) a pattern of repetitive behavior, (2) but the predicate
offenses must form only a part of that pattern, (3) the
predicate offenses must be such that a 2-year sentence of
imprisonment will be imposed, and (4) the pattern must
be proof of a likelihood of the offenders causing death
or injury to other persons or inflicting severe psychological damage on other persons. With the exception of the
2-year sentence precondition, the elements are the same
as those required by s.753 (1) (a) (i).
17. Section 753.1(2) (ii) is similar to the single incident/nonpattern analysis in section 753 (a) (iii). However,
there are two important differences: (1) The LTO provision is limited to conduct in sexual matters and (2) the
DO enactment requires compelling proof of only one
conclusion in section while the LTO enactment requires
only proof of a likelihood of causing injury, pain, or
other evil to other persons in the future through similar
offenses.
18. The preventative measures of Part XXIV of the
Criminal Code have not been evaluated on the basis of
how successful they are at actually reducing recidivism.
19. See also R. vs. M.B., decided May 4, 2000 where
Knazan J. (at para. 245246, 280303) found that the
accused met the definition for a dangerous offender but
that a determinate sentence was appropriate refusing to
adopt the reasoning of the British Columbia Court of
Appeal in the Turley case. In R. v. Ferguson, [2000] O.J.
No. 3008 (Ont. S.C.) at para. 97& 99) and R. v. Payne,
[2001], O.J. No. 146 (S.C.J.) at para. 107116) where

Hill J. held that the long-term offender provisions were

still available where it can be established that there
remains a reasonable possibility of eventual control in
the community. In R. v. Mason (2001), 156 C.C.C. (3d) 97
(Ont. C.A.) the Court of Appeal for Ontario declined, in
R. v. Mason, to settle the law in Ontario. Rosenberg J.A.
(at para. 29) held that because Mr. Mason had not tendered sufficient evidence to show that there was a reasonable possibility of eventual control of the risk in the
community, the Court did not have to consider the the
relationship between the dangerous offender and longterm offender provisions and whether the new provisions
give the judge a discretion not to make a finding that the
accused is a dangerous offender because he or she meets
the long-term offender pre-requisites.
20. There is no sentence a Judge can typically
impose that will fully assuage the feelings of the victim,
her family, and the community at large in a sex offender
case. Every sex offender leaves in his or her wake varying amounts of sorrow, grief, anger, fear, and frustration.
In many cases lives are shattered or ruined and families
are devastated and torn apart. Its a normal public sentiment to wish the perpetrator to be locked up forever,
tortured, and even killed. The imposition of sentence,
however, is governed by statute and fixed principle, not
by emotional reaction. It does not measure the value of
the victims either in absolute or in relative terms and
it is not revenge. The principles of sentencing dictate
that a sentencing court must impose a fit sentence; no
moreno less. It is not justifiable to then further encumber a defendants liberty and justify the special restraint
on the basis of fear. Fear that those who are charged with
the responsibility of sentence implementation will fail.
A sentence enhanced on that basis would be is unfit.
Further, the failure of governments to provide reasonable treatment and infrastructure cannot justify indeterminate detention (R. v. Nikolovski, [2002] O.J. No. 5026
(S.C.J.) at para. 263269; Affd (2005), 194 O.A.C. 258
(Ont. C.A.). See also R. v. Nault (2002), 59 O.R. (3d) 388
(C.A.) at 391).
21. Christopher Webster, Bernard Dickens and
Susan Addario, Constructing Dangerousness: Scientific,
Legal and Policy Implications (Toronto, 1985) at 4748,
144145.
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Chapter 28

Community-Based Management
of Sex Offenders: An Examination
of Sex Offender Registries and
Community Notification in the
United States and Canada
Lisa Murphy, Daniel J. Brodsky, S. Jan Brakel, Michael
Petrunik, J. Paul Fedoroff, and Albert J. Grudzinskas, Jr.

In Western societies, there is no victim more sacred

than a child and no offender more profane than one
who spoils the innocence of children (Petrunik,
2003, p. 352). During the 1980s and 1990s, sexual
abuse of children emerged as a major social problem with high-profile incidents in the United States,
Canada, and Europe arousing shock and anger
among community members and acting as a catalyst
for legislative innovation (Petrunik, 2005; Petrunik &
Weisman, 2005; Jenkins, 2001). In addition to highprofile incidents, research began to be published
showing the prevalence of sexual abuse was far
higher than it had been previously thought to be. In
the United States, one estimate is that as many as
one in five children are sexually abused before the
age of 18 years (Freeman-Longo, 1996). In Canada, a
national victimization survey found just over one in
two adult females and nearly one in three adult males
reported being the victim of at least one unwanted
sexual act over the course of their lifetime with over
80% of these acts occurring before the age of 18 years

(Committee on Sexual Offences Against Children

and Youth, 1984).
In the late twentieth century a broad spectrum of
sex offender policies were introduced across North
America, Britain, Australia, New Zealand, and parts
of continental Europe in response to an emerging perception of sex offending as a serious social problem.
Their underpinnings can be traced to the junction
of two trends in modern criminology: the expanding
influence of the psychiatric interpretation of crime as
symptomatic of mental disorder and increasing confidence in the scientific method and empirical analysis
to understand human behavior. The innovation in the
name of science was the community protection model
justifying preventive legal action based upon deduction or hypothesis, rather than empirical proof or
proven guilt for acts committed (Grant, 1998; Jackson,
1982; Krueger, 2007; Leggatt, 1984; Ouimet, 1969).
The community protection model also reflects the
concerns of victim rights groups, crime prevention
advocates, and the general public that sex offending,

412

COMMUNITY-BASED MANAGEMENT OF SEX OFFENDERS

especially against children, is a serious problem

necessitating strict and comprehensive measures of
control (Jenkins, 2001; Petrunik, 2002; Petrunik &
Deutschmann, 2008). According to this model, the
best approach to the management of the high-risk sex
offenders is a combination of social controls including longer sentences and stricter limits on parole,
intensive community supervision, sex offender registration, community notification, orders restricting
freedom of movement and association, mandatory
antiandrogen treatment as a parole or probation
condition, and criminal and civil statutes providing
for indeterminate confinement based on findings
of dangerousness and severe personality disorder
(Petrunik, 1994, 2002, 2003, 2005).
The emergence and maintenance of two dominant forms of community-based risk management for
sexual offenders within the United States and Canada
are examined in this chapter: sex offender registries
(SORs) and community notification of a previously
confined sex offenders release. It will examine the
rationale behind the use of these mechanisms for
offender risk management and the events that led to
the emergence of these legislative approaches, discuss
how the policies work in practice, and identify some
of their problematic consequences.

U NDER STA NDING THE R AT IONA LE

BEHIND SE X OFFENDER R EGIST R IES
A ND PUBLIC NOT IFICAT ION

Sex offender registries (SORs) require that convicted

sex offenders or those found not criminally responsible or individuals designated as sexually violent
predators (SVPs) when released from psychiatric
institutions register with local police, provide personal details about themselves, and report future
changes in their life circumstances (e.g., change in
address). In Canada, these offenses may include sexual interference, invitation to sexual touching, sexual
exploitation, sexual assault, the creation, possession
and distribution of child pornography, and bestiality
(Ministry of Community Safety and Correctional
Services, 2004). In the United States, these offenses
may include felony offenses such as rape, indecent
assault and battery on a child under 14 years, indecent
assault and battery on a mentally retarded person,
rape of a child under 16 with force, rape and abuse
of a child under 16, and drugging persons for sexual

413

intercourse. They may also include such crimes as:

open and gross lewdness and lascivious behavior and
accosting or annoying persons of the opposite sex
and lewd, wanton and lascivious speech or behavior,
and any attempt to commit any of the aforementioned crimes or a like violation of the laws of another
state, the United States or a military, territorial or
Indian tribal authority any other offense, the facts of
which, under the totality of the circumstances, manifest a sexual motivation or pattern of conduct or series
of acts of sexually-motivated offenses (Mass. Genl
Law, ch. 123 1).
SORs are based on the hypothesis that having current reliable data about convicted sex offenders, particularly where they live, can reduce the risk of their
reoffending and help police identify and apprehend
suspects (Brodsky, 2006; Cole & Petrunik, 2006,
2007; Hudson, 2005).
According to Matravers (2003), persistent attention to sex offenders is based on the construct of
the predatory pedophile, who while neither normal nor insane, is a high-risk threat to the safety of
children. Reports by commercial media often sensationalize high-profile cases resulting in facilitation
of the spectre of an invisible stranger in our midst,
preying on the vulnerable young (Matravers, 2003,
p. 110). The image of predators sharing common characteristics lurking behind bushes waiting to pounce
on unsuspecting victims is not rooted in reality. The
vast majority of sexual offenses are committed by
someone who is well-known to the victim (Greenfield,
1997). This is particularly true for child victims. A
recent review of research (McAlinden, 2007) found
that 80% to 98% of child sexual abuse victims are
abused by someone known to them. If most offenders
are already known to their victims, one may question
whether SORs and public notification add significant
protection (Freeman-Longo, 1996).
In Canada, access to the National SOR and
Ontarios SOR is restricted to specific designated
criminal justice officials. In the United States, SORs
are more publically accessible, in most states via
the Internet (please see discussion of the Walsh Act
herein), and are directly linked with systems of community notification that disclose various amounts
and kinds of information about convicted sex offenders residing in the community (Matson & Lieb,
1996). The use of public notification works from the
assumption that registration alone inadequately protects community members from known sex offenders.

414 FORENSICS

Notification is thought to help prevent further sexual

offenses by alerting communities to the arrival of
individuals with histories of criminal sexual behavior.
The idea or hope is that public safety is enhanced as
parents warn their children about allegedly dangerous members of the community and report suspicious
behavior to the authorities (Petrosino & Petrosino,
1999). The concomitant belief is that potential reoffenders may be deterred from seeking new victims
(Freeman-Longo, 1996).
While most jurisdictions in the United States mandate formal community notification to some degree,
in the case of all registered sex offenders, community
notification in Canada is not linked to the registration
process and occurs only in some provinces under the
auspices of provincial community safety legislation
and even there, only rarely (Petrunik, 2003). Despite
variation in the specifics of SOR and notification systems, there are some common principles. Decisions
regarding who warrants a community notification
and which communities are informed are typically
based on estimates of the offenders risk to the community. In determining whether to initiate a public
notification, criminal justice officials must work to
achieve a balance between the safety of the public
and the offenders right to privacy.
In the United States, notification decisions in most
states are based on a three-tier model which ranks
individuals at a high-, moderate-, or low-risk to reoffend and provides information accordingly. Generally,
the more dangerous the offender is deemed to be the
wider the range of entities to be notified. Typically,
there is an independent board which makes an individual risk assessment and then determines how
much of a danger the offender poses upon release.
In the case of individuals designated as low-risk only
local law enforcement agencies will be informed.
Examples of low-risk offenders could include a man
convicted of incest who is deemed unlikely to offend
again against a family member or anyone outside of
his immediate family or an adolescent convicted of
statutory rape for having sex with a girlfriend who is a
few years younger. For those designated as moderate
risk a broader spectrum of community organizations
may be notified including schools and recreational
organizations. Those deemed high-risk require notification of the general public or all those living within
a certain radius of the offenders residence (Center
for Sex Offender Management, 1997; Kabat, 1998;
Matson & Lieb, 1996).

Photographs and maps showing where registered offenders reside may also be provided on staterun web sites (Kabat, 1998; Matson & Lieb, 1996;
Petrunik, 2005). In some states, sex offenders placed
on probation or convicted for failure to register may
be required to wear a global positioning device (GPS)
monitored by local law enforcement and/or probation
officials (See Mass. Genl Law, ch. 6 178 C-Q; c. 127
133D, 2006).
In Canada, formal public notification does not
occur with all or even most sex offenders and is not
limited just to sex offenders. Formal notification is
used by police and local offender risk-assessment
committees only in the case of offenders considered
to pose an immediate and serious risk of a violent
offense or sexual offense. Generally, formal notification is rare although there are some frequency variations among municipalities with certain local police
forces electing to use provincial community safety
legislation more than others.
When looking at these tools it is important to
examine the historical development which led to the
implementation of such measurements for the community management of sexual offenders and how
these mechanisms work.

LEGISL AT I V E DEV ELOPMEN TS W ITHIN

THE UNIT ED STAT ES

A key event sparking the emergence of the community

protection approach in the United States was the 1989
abduction, sexual assault, and mutilation of a 7-yearold boy in the state of Washington by Earl Shriner, a
mentally disordered offender with a long history of
sexual violence. Public outrage ensued when it was
learned that, although Shriners residence was on a
street used by many children to go to school, school
officials had allegedly not been informed of Shriners
presence nearby because of constraints posed by state
privacy legislation. The subsequent aggressive lobbying by the victims mother and various victim advocacy groups led to the appointment of a Community
Protection Task Force (CPTF). On the basis of the
recommendations of the task force, the Washington
Senate passed the Community Protection Act (CPA).
This included a set of measures that allowed for postsentence civil commitment of individuals who met
the criteria for the newly created category of SVP,
the implementation of a statewide sex offender registry

COMMUNITY-BASED MANAGEMENT OF SEX OFFENDERS

(SOR) and a three-tiered approach to community

notification (Petrunik, 2003; State of Washington,
1989) (See Table 28.1).
At about the same time, victim rights organizations across the United States began to lobby for
child protection legislation and following the lead
of Washington, many other states enacted laws for
the community-based management of sexual offenders. The legislation was often named after the victims of sex crimes. This was the case of the federal
Jacob Wetterling Law mandating states to set up sex
offender registration systems, the federal and the state
of New Jerseys Megans Law mandating community
notification, and Zacharys Law in Indiana which created the first online SOR to allow the public to access
specific sexual offender information via the internet.
Currently, there are over 30 states that allow for the
online access to SORs (Petrunik, 2003).
The 1994 Jacob Wetterling Crimes against Children and Sexually Violent Offender Registration Act
or JWA required all states to set up a functioning
SOR within 3 years or receive a penalty consisting of

415

a 10% cut in state federal funding for criminal justice

initiatives (Lewis, 1996). The law required that the
Registry include at a minimum the names, identifying features such as scars or tattoos, residence information, offenses, and treatment histories of released
sex offenders (Jacob Wetterling Crimes Against
Children and Sexually Violent Offender Registration
Act, 1994). Currently, every state in the United
States requires some form of sex offender registration
(Petrunik, 2005).
While the specific characteristics of SORs tend to
vary by jurisdiction, most share a set of common features. Across the United States, registries tend to be
run by state agencies that delegate law enforcement
officials to collect offender information including
photos, fingerprints, social security numbers, places
of employment, and vehicle registrations. A smaller
number of states also collect blood samples for DNA
identification (Finn, 1997).
The time frame for initial registration can vary
from before release, to immediately upon release and
up to 1 year post release. The most common time is

Table 28.1 U.S. Legislative Developments for SORs and Community Notification
Year

Legislative Change

Location

Implications

June 1989

Community Protection Task

Force (CPTF)

Washington

Governor sets up force to deal with intense

community reaction over abduction of a
young boy by Earl Shriner

February 1990

Community Protection Act

(CPA)

Washington

Based on recommendations by CPTF, policy

is implemented for civil commitment of
SVPs, state-wide SOR and approach to
public notification

June 1994

Zacharys Law

Indiana

Sets up first online SOR

JulyOctober
1994

Megans Law

New Jersey

Modeled after Washingtons CPA. Passed

within 89 days

September 1994

Jacob Wetterling Act (JWA)

National

Requires all states to set up a SOR within

3 years or receive a criminal justice funding cut

May 1996

Megans Law

National

Amendments to JWA. All states required to

set up community notification process
within 3 years or receive criminal justice
funding cut

October 1996

Pam Lychner Sex Offender tracking & Identification Act

National

FBI mandated to establish National SOR and

requires lifetime registration for sex offenders with victims under 12

July 2006

Adam Walsh Child Protection

Act

National

National SOR based on three-tiered system;

requires unified system of criteria for
online SOR; makes failure to comply a
felony

416 FORENSICS

within 30 days of the offenders release. This is logical

as the defendant has 30 days to file a notice of appeal.
For most of the states the required duration of registration is a minimum of 10 years. In some cases, registration can be for life, at least for the most serious tier
of offenders. It is possible for an offender to challenge
their classification and time on the registry. It is possible to make this challenge even after initially being
placed on the registry. The time designated to be on a
SOR is typically influenced by offense type, sentence
length, and age and number of victims (Finn, 1997).
In 1996, an amendment to the federal JWA known
as Megans Law (there is also a New Jersey law by that
name after Megan Kanka who was assaulted and
murdered by a sex offender in that state) required all
states to implement mechanisms, based on federal
standards, to provide members of the community
with specific information on registered sex offenders
deemed relevant to protect the public (notably, place
of residence). States not complying within 3 years
faced criminal justice funding cutbacks similar to
those outlined under the JWA (Brakel & Cavanaugh,
2000). By the end of 1996, 32 states had initiated notification policies which enabled individuals to submit
requests for offender information or to require law
enforcement agencies to disseminate offender information upon their release within the community
(Finn, 1997). Currently, all states in the United States
provide formal community notification of the whereabouts and characteristics of registered sex offenders
(Petrunik, 2005).
In about half the states that have notification legislation, law enforcement officials have discretion
to determine the extent to which community agencies and members of the public need to be notified
about the presence of a given sex offender. The privacy rights of both victims and offenders come into
play, particularly in the case of intrafamilial offenses
where the risk of recidivism may be low and notification could be harmful to healing and reconciliation
between and among family members (Kabat, 1998).
Under a subsequent amendment to the JWA
known as the Pam Lychner Sexual Offender Tracking
and Identification Act of 1996 the Federal Bureau
of Investigation was required to establish a National
SOR which linked individual state databases to
enable officials to track sex offenders across state
lines. Additionally, this law required lifetime registration for sexual offenders whose victims were below
12 years of age. All states were also required to make

failure to register at least a misdemeanor (Wetterling

Act at 1407[d]).
In 2006, the United States Congress repealed the
Wetterling Act and replaced it with the Walsh Act (18
USCS 2250 and 42 USCS 16901), which organizes offenders according to a three-tiered system:
15-year registration for tier I offenders; 25 years for
tier II; and lifetime for tier III. States are to follow a
unified set of criteria for posting offender information
on internet accessible SORs taking into account designations of offender risk level. Failure to comply by
an offender is a felony offense. Other elements provided for within the Act include registration before
release from custody, or within 3 days thereof for all
levels of sex offenders, including juveniles 14 years
or older if convicted of aggravated sexual abuse (as
federally defined) and a requirement on the part
of authorities to obtain a DNA sample from each
offender. Information must also be disseminated to
law enforcement, social service agencies, volunteer
agencies, and other organizations in the community
where the person lives, works, and attends school.
Again, states failing to comply face the loss of specific
federal crime-fighting funds.

LEGISL AT I V E DEV ELOPMEN TS IN

THE CA NA DI A N CON T E X T

Compared to the rapid development of American

sexual offender laws and policies, Canadian developments generally came at a slower pace (Petrunik,
2003) (see Table 28.2). Indeed, it was not a particularly infamous offender or shocking crime that
initially brought the problem of violent sexual recidivism to the forefront of public attention in Canada
to spur legislative action. The post-war world just
seemed to be a more dangerous place as the troops
returned home and attention was increasingly redirected to issues of public safety on the home front.
In particular, Canadians were sensitized by popular
American media portrayals of sex offenders driven by
uncontrollable perverted lust (Chenier, 2008). Later,
in the late 1980s and 1990s the community containment approach in Canada, as in the United States,
escalated in response to the sensational media coverage of a high-profile sexual offender, the victims left
behind and the demands of an alarmed public.
The widely publicized abduction, sexual assault,
and murder of Christopher Stephenson by Joseph

COMMUNITY-BASED MANAGEMENT OF SEX OFFENDERS

417

Table 28.2 Canadian Legislative Development for SORs and Community Notification
Year

Legislative Change

Location

Implications

March 1992

Bill C-36 under Corrections

and Conditional Release Act

National

Allows for correctional officials to provide

information to the police pertaining to
the release of an offender where there is
reasonable grounds to believe that the
offender will pose a significant threat to
persons in the community

September
1992Janruary 1993

Coroners Inquest into death of

Christopher Stephenson

Ontario

Releases recommendation for the adoption of a SOR, a law modeled after

Washingtons SVP statute, 10 years of
probation (postsentence) for high-risk
offenders and changes to CPIC to allow
better data on high-risk offenders

February 1995

Community safety Legislation

Manitoba

First to introduce community notification

protocol allowing police to notify public
about presence of high-risk offenders in
community. Other provinces quickly
follow suit

March 2001

Canadian Alliance Party advocates NSOR

National

House of Commons unanimously supports

creation of NSOR. But Solicitor General
states Canadian Police Information
Centre (CPIC) can function as SOR

April 2001

Bill 31 creates Christophers

Law

Ontario

Implements Canadas first provincial SOR

in memory of Christopher Stephenson.
Other provinces and territories begin to
follow

May 2001

Plans for Provincial interlinking

SORs to create NSOR

Provincial

Provinces provide political pressure by

announcing plans to develop provincially interlinking SORs to create NSOR

December 2004

Bill C-23 creates Sex Offender

Information Registration Act
(SOIRA)

National

Creation of NSOR

Fredericks in 1988 acted as a catalyst for change

and set the stage for Canadian legislative reform.
Fredericks was a convicted pedophile and diagnosed
psychopath who had spent over two decades in a
high security psychiatric hospital and had been out
of prison on federal statutory release for only a few
months when he murdered his victim. Christophers
parents began a highly public attempt to understand
how and why such a predator with a lifelong history of
sexual violence had been released to the community.
As a result of their efforts, in 1992 a Coroners Inquest
was initiated into the circumstances of Christophers
death and the evident failure of the criminal justice and mental health system to protect the public
(Petrunik & Weisman, 2005).
One of the recommendations flowing from
the Inquest was for the creation of a National Sex

Offender Registry (NSOR) which required such

offenders to register with their local police station.
It was suggested that this SOR be modeled after
Washingtons 1990 CPA (Petrunik & Weisman,
2005). The recommendations reflected the perceived
need for policy that allowed for more comprehensive monitoring of sexual offenders within the community. Initially, neither the federal nor provincial
governments responded to the recommendations to
enact a SOR but, in 1999, Ontario acted on its own
to become the first jurisdiction in Canada to set up
a SOR. With the public support of the Stephenson
family, law enforcement organizations and victims
rights groups, the Ontario legislature made the registry a reality when it proclaimed Christophers Law
in April of 2001 (Ministry of Community Safety and
Correctional Services, 2004).

418 FORENSICS

The Ontario Sex Offender Registry is maintained

by the Ontario Provincial Police (OPP) on behalf of
the Ministry of Community Safety and Correctional
Services. Under Christophers Law, all Ontario residents convicted of a sexual offense (as defined by the
legislation since the policys implementation) and any
resident serving a sentence for a sexual offense on
the day that the policy came into force, are subject to
registration. Also required to register are individuals
found not criminally responsible by reason of mental disorder of a designated sex offense and juvenile
offenders convicted of a designated sex offense and
sentenced as adults. All individuals meeting at least
one of these criteria are automatically placed on the
Ontario SOR.
Anyone convicted of a designated sex offense must
report in person to a specified police station or detachment within 15 days of being released from custody if
incarcerated, after a conviction if not given a custodial
sentence, after a change in address, after becoming
an Ontario resident, or after ceasing to be an Ontario
resident. Individuals meeting these criteria are also
required to register annually within the 11th and 12th
month of the last reporting period. The designated
reporting period is either 10 years or life, depending
on the maximum length of the sentence and the number of criteria offenses committed. A person may be
put on the registry for 10 years if the maximum sentence for the offense for which he was convicted is less
than 10 years. If the maximum sentence is more than
10 years and/or the person has committed more than
one designated sex offense registration may be for life.
Information that appears on the registry includes the
offenders name, date of birth, current address, a photograph, and the sex offense(s) for which they have
been convicted (Christophers Law, 2000).
Failure to comply with registration requirements
can result in significant penalties. A first conviction
of failure to register can result in a fine of no more
than $25,000, a term of imprisonment for no more
than 1 year, or both. All subsequent offenses of failure to comply warrant a fine of $25,000, a term of
imprisonment of no more than 2 years less, a day,
or both. Currently, the only way to have ones name
removed from the Registry is to obtain a formal pardon. Unlike U.S. SORs, those in Canada are not open
to the public. While the national sex offender database in Canada is maintained by the Royal Canadian
Mounted Police (RCMP), it may be searched by any
police agency across the country to investigate crimes

of a sexual nature. Ontarios database cannot be used

for the purposes of public notification under provincial legislation (Christophers Law, 2000).
Upon the implementation of the Ontario SOR,
several other provinces indicated they would follow
suit. However, Canadas national government was
initially quite resistant to the pressures to implement
a NSOR similar to the United States. Rather than
responding swiftly, the federal officials created a federal, provincial, and territorial task force to address
the issue. As a result of proceeding so cautiously, legislative reforms that were established within a few
years in the United States took well over a decade to
emerge within the Canadian context. It was not until
other provinces besides Ontario announced plans to
independently establish a system of interlinked registries across Canada that the national government
announced plans to take action (Petrunik, 2003).
The Sex Offender Information Registration Act
(SOIRA) came into force on December 15, 2004.
The RCMP is responsible for the administration
and maintenance of the NSOR. It is accessible to
police agencies in every province and territory across
Canada. SOIRA works to ensure that only specific
individuals are able to access the information on the
registry. This includes law enforcement personnel
who are investigating a crime in which there is reasonable grounds to suspect that the offense is of a sexual nature. There is substantial controversy over this
issue. During abduction investigations, time is of the
essence and unless investigators provide reasonable
grounds that an offense is of a sexual nature, they
are unable to access the National database. This is
one of the main differences between the NSOR and
the Ontario SOR, since Christophers Law contains
no such restriction (Ministry of Community Safety
and Correctional Services, 2004).
Other individuals who are permitted to access the
registry include employees at the registration centre
who maintain the database and those who ensure that
offenders are complying with the established requirements. Also, individuals who have been retained by
the Commissioner to conduct research under the
act are permitted access (Sex Offender Information
Registration Act, 2005).
The SOIRA amends the Criminal Code by allowing prosecutors to make a formal request to the
court for the offenders inclusion on the NSOR (Sex
Offender Information Registration Act, 2005). Unlike
the Ontario SOR where the sex offenders are placed on

COMMUNITY-BASED MANAGEMENT OF SEX OFFENDERS

the registry automatically, a sexual offender is placed

on the NSOR only if a formal request is made at the
time of sentencing. The SOIRA makes it an offense
to fail to comply with the order or to report false information (Sex Offender Information Registration Act,
2005). The NSOR is not retroactive; so an offender
who completed his or her sentence before the date
the legislation became law is not registered. However,
all sex offenders who were under sentence for a designated offense on the date the legislation became
law were served a Notice of Obligation to Comply
with SOIRA and be registered. From December 15,
2004 onward prosecutors may apply to a Judge for an
order to comply with the SOIRA after the sentencing
of an offender for a designated sex offense. After an
order is granted, the offender will be registered on the
database.
Under the SOIRA a sex offender may be required
to report for a period of 10 years, 20 years or life,
depending on the maximum length of the sentence.
The Act requires that all registrants report on an
annual basis and 15 days before a change in residence
or legal name. The information required by the NSOR
is more extensive than is the case with the Ontario
SOR. It includes the offenders name and aliases, date
of birth, height, weight, distinguishing marks, finger
prints, residential address, telephone number(s), place
of work, paid or volunteer, or educational institution,
type, date and place of offense(s), age and gender of
victim(s), and the duration of registration required by
the statute (Sex Offender Information Registration
Act, 2005).
If the registrant does not comply or provides
false information, as a first offense he is subject to
a fine of $10,000, a sentence of 6 months, or both.
On subsequent offenses the penalty increases to a
fine of $10,000, a sentence of 2 years, less a day, or
both. Similar to the Ontario SOR, the NSOR is not
retroactive, meaning individuals will be placed on the
NSOR only if they are convicted of a designated sexual offense after the implementation of the SOIRA,
or were serving a sentence for a designated offense on
the day that the act came into effect (Sex Offender
Information Registration Act, 2005).
Although the use of SORs and the process of community notification have been directly linked across
the United States, both Canada and the United
Kingdom have resisted legislation requiring notification of the community about the location of registered
sex offenders and their identifying characteristics.

419

The reason for this resistance is the belief that notification has more negative consequences than benefits.
In particular, there is a concern that public notification has the effect of decreasing SOR compliance.
This notion is supported by data indicating that in
the United States compliance rates though varying
are overall much lower than the over 95% compliance
rates reported in Canada and the United Kingdom
(Cole & Petrunik, 2006, 2007).
Subsection 25(3) of the 1992 Corrections and
Conditional Release Act requires correctional officials to inform local police of the release from custody
of all offenders detained to warrant expiry or on temporary absence, parole, or mandatory supervision. In
the case of offenders released on warrant expiry who
are considered to poses a significant threat to persons
in the community, correctional officials are required
to provide the police with all information within their
control pertaining to the perceived threat posed by
the released offender (Corrections and Conditional
Release Act, 1992). The decision to make a community notification about the release of a sexual offender
into the community takes place under provincial
community safety legislation and is decided by the
police and sometimes involves high-risk offender
committees.
In February 1995, Manitoba became the first
province to enact a specific protocol for community
notification which authorized police agencies to disclose information to the public regarding the release
of a high-risk sex offender (Sutherland, 1999). Once
the dam was broken in Manitoba other provinces
followed. In 1998 Ontario created its own notification protocol with the enactment of Bill 102, the
Community Safety Act (Petrunik, 2003).
Most of the offenders who are subject to notification are judged to be at such a high risk that they are
kept to warrant expiry; that is, to the end of their sentence when the criminal justice system no longer has
any controls over the offender. This also means, however, that at that point the offender is free to go into the
community irrespective of his lingering risk to recidivate. The law includes guidance points for municipal
police on the release of information on high-risk sex
offenders (National Joint Committee, 2006).
While the Canadian SORs, in contrast to those
of the United States, do not allow community notification, such notification may occur under separate
provincial community legislation in specific cases.
Currently, there is no single method of notifying

420 FORENSICS

the community under provincial legislation; the

approaches are diverse. Methods include holding
community forums, notifying particular institutions
such as schools or recreation centers, creating bulletin boards, and issuing press releases (Brodsky, 2006).
At least one province (Alberta) has an Internet site
providing information on offenders for whom public
notification is appropriate under provincial community safety legislation (Petrunik, 2003).

LIMITAT IONS A ND CH A LLENGES TO

SOR S A ND PUBLIC NOT IFICAT ION

Sex offender registration and public notification

are controversial concepts and have been subject to
considerable litigation across the United States and
Canada. Opponents of SORs and public notification have drawn attention to a number of problematic issues with regard to fundamental human rights.
These critics argue that it is not fair to impose additional measures on sex offenders after the completion
of their sentence on the ground that they have already
paid their debt to society and should not be burdened
with additional scrutiny from which normal offenders would be immune.
Because legislators have designated sex offenders
to be a greater risk to community safety than other
kinds of offenders those who have committed sex
crimes have been subject to extensive monitoring and
restrictions on their freedom of movement and association even after the completion of sentence. This can
be challenged on several grounds. First, sex offenders as a general category do not have higher rates
of recorded new offenses than the categories of nonsexual violent offender and nonviolent offender
(Hanson & Bussiere, 1998). Second, sexual offenders are not a homogenous group. Different types of
offenders vary greatly in their risk of future offending
and their amenability to treatment.
Meta-analysis of 61 studies by Hanson and
Bussiere (1998), that followed up sex offenders for
4 to 5 years after release from prison found that the
average rate of conviction for a subsequent offense
was 13.4%. A comprehensive study by Quinsey et al.
(1998) found that among a population of convicted
child molesters, intrafamilial (incest) offenders with
opposite sex victims posed a much lower risk of
being detected, apprehended and convicted in the
commission of subsequent sexual offenses than did

extrafamilial offenders whose victims were of the

same sex or of both sexes. Pedophiles with boy victims
have the highest rates of apprehension and conviction
for new offenses.
Many sex offenders only commit a single, situational sexual offense that is not part of any broader
pattern of offending. By virtue of the generic label of
sexual offender, this one-time offender is grouped
within the same category as a predatory, multiplevictim offender. Insult is added to injury so to speak
when criminal justice agencies use investigative and
assessment methods that do not distinguish between
risk levels for specific offender types.
The aforementioned becomes more problematic yet when SORs are publiclly accessible via the
Internet. Although the mechanism of notification is
supposed to elicit a process of support and supervision by the community, it often also creates feelings
of anger and increases the danger of vigilantism
(Brodsky, 2006). There have already been incidents
of serious violence associated with notification and
online access to offender information in the United
States. In the state of Washington, following a notification an angry mob from the community surrounded
the house of a known sex offender and burned it down.
In New Jersey, an innocent man was mistaken for a
sex offender and assaulted (Freeman-Longo, 1996). A
20-year-old man from New Brunswick Canada shot
and killed two individuals whose name, photo, and
home address appeared on the neighbouring State of
Maines online SOR, and then took his own life. One
of the individuals killed had been convicted of a statutory offense after having sexual intercourse with his
girlfriend who was only a few years younger than he
was but legally a minor (Ranalli & Heinz, 2006).
Encouragement to take personal action against sex
offenders has increased with groups such as Perverted
Justice, which has a website spreading fear and resentment against sexual predators. This group consists
of private citizens who work together against sexual
victimization and they have hinted at the use of force
in some instances. The group, which claims to be a
nonprofit organization, seeks to portray sex offenders
as an uncontrollable group and encourages site visitors to join forces in the protest movement designed to
instil a chilling effect within the network of sexual
offenders (see perverted-justice.com).
An additional consequence of notification concerns the privacy of the victims and their families. In
instances where the case has been publicized and the

COMMUNITY-BASED MANAGEMENT OF SEX OFFENDERS

victim is known to the community, notification often

draws unwanted attention to the victim. Although
victims names do not appear directly on SORs, when
the authorities notify the public there is a risk of exposing the identities of victims of offenses. This issue is
a particular concern in cases where a child was a victim of an incest offense. Notification can stigmatize
victims and other family members and impede efforts
to achieve healing and reconciliation. Research in
New Jersey has found that incidents of incest offenses
are not being reported as victims fear a variety of negative consequences as a result of notification. This
problem is especially acute when the victim is living
with the offender (Freeman-Longo, 1996).
Other concerns arise in connection with the use
of these community containment techniques as a
mechanism for general social control. Because the
majority of sexual offenses are not committed by
strangers but by someone known to the victim, public
notification provides a false sense of security for the
community (Freeman-Longo, 1996). Furthermore,
even if SORs and community notification provide
members of the public with a general feeling of safety,
such feelings may be illusory. Indeed, some research
has shown that widespread community notification
without effectively utilizing public education tends to
heighten general fear of victimization (Brodsky, 2006;
Zevitz & Farkas, 2000a).
The cost to implement and successfully maintain state or provincial as well as National SORs and
notification systems is high. Many of the criticisms
about SORs focus on the costs of keeping information in the databases accurate and up to date. Since
sex offenders are required to register from periods of
10 years up until life, it is foreseeable that maintenance costs will continue to increase substantially, as
there is currently no set or ready way for most offenders to get off of the Registry.
Various cases across the United States and Canada
have challenged the laws based on the offenders
rights to privacy. Many courts have deferred rulings
in anticipation of changes in legislation or have had
their decisions rendered moot with the enactment of
newer legislation. However, some cases have proved
to be an exception to this scenario.
Challenges which claim that the law is an imposition of a new or second penalty and therefore violates constitutional prohibitions against ex post facto
laws and double jeopardy have met with little success. Basically, courts in the United States have held

421

that the Eight Amendment (which prohibits cruel

and unusual punishment) or the Fifth Amendment
(which contains the double jeopardy prohibition) do
not apply to registration since it is a civil process whose
manifest intention is to regulate future behavior and
not punish someone for a past offense. However, the
imposition of enhanced penalties (lifetime community parole) for violating the registration requirement
before the laws enactment has prompted at least one
court to declare that the enhanced penalties are permitted only for violations committed after the statute
went into effect (Commonwealth v. Talbot, 2005).
Governmental privacy invasions may under some
circumstances be permitted but they must be supported by adequate, if not compelling, justification and
must be minimally impairing. At least one New Jersey
case has held that the SOR and community notification are not in violation of the offenders constitutional
right to privacy (Doe v. Poritz, 1995). However, a later
(2001) New Jersey decision held that giving complete
public access to all sex offender information is unconstitutional and ordered that the home address of sex
offenders must be withdrawn from the states online
notification system (A.A. v. New Jersey, 2001).
In Ontario, if it is found that the requirement for
an individual to register as a sex offender is a grossly
disproportionate violation of the offenders rights to
privacy under the Canadian Charter of Rights and
Freedoms then that individual can be exempted from
registering (R. v. Burke, 2005). However, in R. v. Ayoob
(2005) the court did not find that there was a grossly disproportionate violation of the offenders privacy rights
and he was not exempt from the process. The outcome
in these cases ultimately turned on the extent of the
offenders criminal record and the relative seriousness
of the offense violation. In the case of R. v. Dyck, in
December of 2005, the Ontario Superior Court of
Justice ruled in favor of the Ontario SOR stating that
being placed on the Registry was not in violation of
offenders constitutional rights under the Charter.
Now that SORs and public notification are established mechanisms, research should consider the
effectiveness of such community management tools.

R ESE A RCH ON R EGIST R AT ION

A ND NOT IFICAT ION

The literature on SORs and public notification

tends to be classified into four broad types: statistical

422 FORENSICS

profiles of registrants demographics, evaluations of

the effect on recidivism, assessments of the accuracy
of reported information, and examinations of the collateral consequences of the process of registration
(Mustaine, Tewksbury, & Stengel, 2006).
Since a fundamental goal of the utilization of
SORs and public notification systems is to decrease
recidivism and victimization, research to establish
how effective they are should arguably play a pivotal role in justifying the use of such tools. However,
there currently exists no research that demonstrates
the effectiveness of registration and notification in
decreasing recidivism. A study by Schram and Milloy
(1995) examined the impact of notification on subsequent recidivism in a group of Washington sex
offender who received notifications as compared to
a group of sex offenders who did not receive notification. The results were measured over a 4.5 year
follow-up and showed no statistically significant difference in the overall levels of general recidivism and
for sexual recidivism the rates differed insignificantly.
The main difference between the two groups was that
the offenders subject to notification requirements
tended to be rearrested sooner than those without
notification.
A study conducted in Iowa assessed the impact
of SORs on recidivism and found mixed effects on
the rates of reoffending (Adkins, Huff, & Stageberg,
2000). Such research indicates that overall SORs
and notification have little, if any, effectiveness in
reducing sex offenders propensity to commit new
crimes.
Research shows that results in terms of level of
compliance are disappointing. Criminal investigators in Iowa estimate that 40% of sex offenders who
are supposed to be registered actually are not so registered (Scholle, 2000). In 2003, Californias SOR system reported it had lost track of 33,296 registrants.
These were sex offenders who had, at one point, been
properly registered and then were just forgotten about.
Most likely these are individuals who were registered
but failed to report a change of address and it was
never noticed. This means that California lost contact
with a staggering 44% of all registrants across the state
(Cohen & Jeglic, 2007). Canada has demonstrated
compliance rates of about 95% showing significant
difference in compliance rates of Canadian and U.S.
sex offenders.
Another area of interest is the potential collateral consequences experienced by the sex offenders

subject to registration and notification. Insight

into this area is provided by interviews with registered sex offenders who experienced community
notification. Results show that the most common
problems reported by sex offenders are difficulties obtaining employment and securing housing,
being ostracized and harassed by the community,
and financial loss. Many offenders also explained
that it caused emotional issues for their family and
as a result some family members ostracized the
offender (Pogrebin, Dodge, & Katsampes, 2001;
Zevitz & Farkas, 2000b). According to Tewksbury
(2005) differences in patterns across groups reveal
that registrants in nonmetropolitan communities
are subject to more social consequences as a result
of registration.
This research suggests that the process of registration and notification sets the stage for many
potentially negative social consequences for the
offender. When the public learns that a sex offender
resides within their community they may become
more fearful and harass, discriminate against, or
even victimize the registered offender. As a result,
the offender may experience an increase in stress
and frustration whereby the offender may become
more isolated. Such events could act as a possible
antecedent to a relapse. Thus, aggressive responses
of the community to registered sex offenders may
heighten stress levels which may indirectly contribute to subsequent reoffending (Zevitz & Farkas,
2000b).
Surprisingly, postrelease sex offenders may be less
opposed to SORs then generally assumed. Some say
the requirement to register yearly is no more onerous than renewing their drivers license. Others even
claim that being on an SOR has decreased the number of times they are interviewed by police when a new
unsolved sex offense occurs since they can be ruled
out more quickly (P. Fedoroff, personal communication). What offenders do object to is any measure that
increases their visibility in the community. Measures
such as police checks by officers in unmarked cars
and in plain clothes create less chance of stigmatization. In contrast, postrelease offenders who are publicaly identified are much more likely to lose their
jobs, their social supports, and their accommodations.
Paradoxically, in these cases, public notification may
actually increase risk to the community by destabilizing the offender and interfering with his ability to seek
treatment.

COMMUNITY-BASED MANAGEMENT OF SEX OFFENDERS

CONCLUSION

The process of maintaining a balance between protection of the public and individuals rights to privacy
becomes increasingly difficult when the offender is
considered dangerous or morally tainted. Mechanisms such as SORs and community notification have
been implemented as a political response to highly
publicized cases of sexual victimization. Supporters
of these interventions claim that such supervisory
methods will deter sexual offenders from reoffending
while providing information on which the public may
act to protect its children and others who may be vulnerable and at the same time giving an investigative
tool with which police can more efficiently solve
sexual offenses.
In contrast, opponents of SORs and community
notification stress concerns about a discriminatory
aspect to the regulations that specifically targets sex
offenders when there is an absence of evidence that
sex offenders, as a general category, are at a greater
risk to reoffend than other categories of offenders.
Additionally, critics have raised concerns about the
ethics or legality of infringing on the rights of a segment of the population whose targets have already
served their sentence and paid the penalty for their
misconduct. These contending positions make clear
that the underlying value and utility of SORs and
community notification need to be realigned with
the stated goals of these mechanisms, while eliminating to the extent possible the unintended negative
costs and consequences.
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Chapter 29

Ethical Issues in the Treatment

of Sex Offenders
Howard Zonana and Alec Buchanan

The evaluation, treatment, and lack of treatment of

sex offenders are fraught with many ethical questions and pitfalls. A common thread underlying the
unique rules applying to sex offenders is that there is
a special depravity associated with sexually related
crimes, to the extent that sex offenders are perceived
as especially vile and loathsome people who really
do not deserve to be treated like defendants in other
crimes (Lanyon, 1997). Many of these dilemmas have
become more prominent since the passage of the sexually violent predator (SVP) commitment statutes
and the developing of sex offender treatment programs both within and outside of prisons. Some
treatment programs raise questions regarding the
ability to obtain meaningful consent from prisoners, as participating in treatment is tied to conditions
of release or parole. Forensic evaluations required
by the SVP statutes have also posed other difficult
questions relating to the psychiatrists ability to predict future dangerousness. Actuarial risk assessment

instruments, touted as more accurate than clinically

based evaluations are not applicable or well validated
for the specific questions asked in SVP statutes. Some
are based on different populations than the individual who is being evaluated. How should the lack of a
personal examination, because of refusals to participate by the inmate, be handled and what is the impact
upon the conclusions that can be drawn? Issues of
permissible intrusiveness have been raised by the use
of polygraph testing or monitoring, and penile plethysmography. This chapter will attempt to review some
of the major issues.

ISSUES A ROU ND T R I A L

Pretrial Evaluations for Defense Attorneys

Sex crimes are defined by both federal law and individual states. At the present time downloading a

425

426 FORENSICS

single pornographic picture of a minor is a federal

crime.1 These crimes are being actively prosecuted
in the United States and Canada. The profiles of
individuals who are engaged in this activity are very
broadfrom college students competing with each
other to see who can download the most pornography, to men who are schizoid, socially isolated, and
have major impairments in their ability to socially
relate to others. There are also aggressive pedophiles
who use the Internet to arrange trysts with minors or
have them perform sexual activities using webcams
online (Eichenwald, 2005). Because of the increasingly severe penalties and mandatory minimum sentences of imprisonment meted out to sex offenders,
defense attorneys have sought out psychiatric and
psychological evaluations of defendants very early
in the criminal process. Such requests may be made
before the individual has been arrested, but after he
has become aware that an investigation is ongoing
and has hired an attorney. At this point the attorney is looking for information that might be useful
in convincing the prosecutor to reduce the possible
charges from the outset or to negotiate an acceptable
plea bargain. This strategy has become increasingly
utilized by defense attorneys at every stage of a criminal proceeding before trial and then later during postconviction proceedings such as parole hearings and
appeals.
One of the problems that has emerged during
the course of these evaluations (and apply to other
evaluations of sex offenders as well) is that during the
course of a comprehensive evaluation, including a
careful longitudinal history of the defendants sexual
development and history, the defendant/evaluee may
reveal information that is sufficiently detailed about
other crimes or activities that bring into play mandatory child abuse reporting statutes. All 50 states have
such statutes and the laws of Canada create equivalent obligations. These statutes often have no time
limits on the obligation to report. They also designate
psychiatrists as mandated reporters. When this information is included in reports additional investigations
will ensue and further charges may be laid. Canada
does not have a statute of limitations and historic
sex crimes are prosecuted with vigor. In the United
States, the statutes of limitations on sexual crimes
against minors have been extended in many states
in the wake of reports of clergy abuse and repressed
memory research.2 We have also heard of threatened

prosecution or licensure board referral of the expert

for not making child abuse reports for such events
when they were included in their report but not
reported to the state agency responsible for Child
Protective Services. This has led to recognizing the
importance of warning evaluees, at the outset of the
evaluation, regarding their reporting of information
that would make a prior, heretofore unknown, young
victim identifiable, and thus trigger reporting requirements even though the forensic evaluation was generally protected under attorneyclient privilege.
Other possible exceptions exist, such as Tarasoff
obligations, if specific threats are disclosed during
the course of a forensic evaluation. In one case, a
defendant who fire bombed his therapists home causing the death of her husband and severe burns to
the therapist, made further threats to kill the therapists brother as well as his former wifes employer.
He stated he could accomplish this while in jail by
hiring another inmate who was about to be released.
After an in-camera hearing at the first penalty trial,
the trial court ruled that an exception to the psychotherapistpatient privilege permitted disclosure of the
defendants threats to kill. The defendant also argued
that since it was a forensic evaluation it was covered
by the attorneyclient privilege and should not have
been disclosed. The California Supreme Court did
not definitively resolve the attorneyclient issue but
said, in this case, that even if erroneously admitted,
the evidence was not prejudicial.3
The Canadian Supreme Court did create a specific exception to the solicitorclient privilege in
1999.4 In this case a man awaiting trial for aggravated
sexual assault on a prostitute told the evaluating psychiatrist that he had intended to kill her and was still
going to the same area. The majority noted that
despite its importance, the (solicitorclient) privilege is not absolute and remains subject to limited
exceptions, including the public safety exception.
While only a compelling public interest can justify setting aside solicitor-client privilege, danger
to public safety can, in appropriate circumstances,
provide such a justification.
They felt the following three factors needed to be
taken into consideration in assessing the public safety
considerations: (1) Is there a clear risk to an identifiable person or group of persons? (2) Is there a risk of

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

serious bodily harm or death? (3) Is the danger imminent? They concluded the solicitorclient privilege
must be set aside for the public protection. In this case
he defendant was diagnosed with multiple paraphilias,
in particular sexual sadism and the group of victims
prostitutes in a specific areawas deemed sufficiently
specific. He also had detailed plans for the attack which
were to result in death and violated his bail conditions
by returning to the area after his arrest while awaiting
sentencing which the court felt was sufficient to see
the threat as imminent. The court also noted that so
long as the psychological harm substantially interferes
with the health or well-being of the complainant, it
properly comes within the scope of the phrase serious
bodily harm. There can be no doubt that psychological harm may often be more pervasive and permanent
in its effect than any physical harm. In Canada both
the psychiatrist and the attorney can be obligated to
warn or take other appropriate steps to protect.
If the overall summary of the clinical findings
indicate that it would not be useful to the legal representation of the case, reports to protective services are
still required even if the attorney does not want a formal written report. It is also important to remember
that reports to Protective Services may only require
sufficient information to document the basis for the
reporting but not every detail of the offense known to
the evaluator (State v. Andring). There remains some
tension between the reporting requirements and the
physicianpatient privilege. Reporting statutes generally override patient privilege but the subsequent use
of additional data the physician possesses, to convict
the person, may be more protected. Because of the
consequence of possible new criminal charges it is
important to review such obligations with the defense
attorney before beginning the evaluation.
Another consequence of the aggressive prosecution policy regarding the downloading of child pornography to personal computers is the increased risk
for suicide by these defendants (Los Angeles Times,
2004). Many of these individuals fear the consequences of public disclosure which will have a substantial detrimental impact on their jobs careers as
well as on family relationships. An important part of
the forensic assessment when it occurs before arrest
or arraignment is to explore the potential consequences of having the charges become public for the
individual as well as making sure that appropriate
treatment or hospitalization, if necessary, is obtained.

427

Because many psychiatrists do not treat sex offenders, they are frequently unaware of the reactions
that may be precipitated or the difficulty that some
offenders have in stopping the downloading in spite
of the fact that they are being prosecuted. They are
also unaware of appropriate medications that might
be used to decrease the sexual drive. In some cases,
it has become difficult to maintain clear boundaries for the forensic evaluation when clinical issues
become severe enough to warrant emergency treatment or hospitalization. Even after hospitalization,
we have seen evaluees who do not tell their therapists they have guns at home and continue to harbor
strong suicidal impulses but are willing to tell that
information to the forensic evaluator consulting to
their attorney. Concerns about splitting may make it
imperative to have the evaluees permission to confer
with their treatment team about information derived
from the forensic evaluation.
Presentence Reports
Probation and parole services are generally involved
in the preparation of presentence and postsentence
reports following a conviction and may also be monitoring the offender following release from prison if
there is a supervised probationary or parole period.
Collaboration in careful demarcation of boundaries can be an important aid in treatment planning
and providing incentives to participate in treatment.
Historically many treatment programs were unwilling
to work with law enforcement personnel or lawyers but experience with substance abusers and sex
offenders have changed that opinion especially when
treatment is a condition of probation or parole. It is
important to have a clear contract about what information will be shared and what remains confidential at
the outset of the relationship. For example, attendance
and remaining in good standing in treatment are often
factors that are reported. This permits programs to
develop guidelines that do not require the reporting
of every dirty urine test unless specifically required as
a condition of probation (to remain in good standing
many programs require more than three dirty urines
in a defined time period). Likewise, mere appearance
for treatment but not participation in the process,
for example, remaining mute for an hour, is not fulfilling the minimum requirements of being in treatment. The details of the contract should be clear to

428 FORENSICS

the probationer. We have seen some boundary issues

where probation officers become treatment providers
as well as trying to maintain their probation role.

T R E AT MEN T A ND COERCION

Treatment in Prison
Treatment of prisoners within the correctional institution poses a number of problems that differ from
treatment in mental health settings. There are special
problems relating to maintaining the confidentiality of
medical/psychiatric records from custodial staff as well
as obligations which require the reporting of potential
escape plans. Mental health records are frequently
requested by parole boards as part of their consideration
of early release. Some prison conditions may deter sex
offender treatment in correctional settings. First, there
is stigmatization by other inmates if the treatment itself
becomes public knowledge. Pedophiles are often at the
bottom of the pecking order in prisons and many will
avoid treatment to maintain a degree of deniability. In
addition, a recent U.S. Supreme Court case illustrates
some additional complexities in different jurisdictions
(McKune v. Lile).
In 1982, Robert Lile lured a high school student
into his car as she was returning home from school.
At gunpoint, he forced the victim to perform oral
sodomy on him and then drove to a field where he
raped her. After the sexual assault, the victim went
to her school, where, crying and upset, she reported
the crime. The police arrested Lile and recovered on
his person the weapon he used to facilitate the crime
(State v. Lile).
Although Lile maintained that the sexual intercourse was consensual, a jury convicted him of rape,
aggravated sodomy, and aggravated kidnapping. Both
the Kansas Supreme Court and a Federal District
Court concluded that the evidence was sufficient to
sustain conviction on all charges.
In 1994, a few years before he was scheduled to
be released, prison officials ordered him to participate
in a Sexual Abuse Treatment Program (SATP). The
program requires participating inmates to complete
and sign an Admission of Responsibility form, in
which they discuss and accept responsibility for the
crime for which they have been sentenced. They
also are required to complete a sexual history form,
which details all prior sexual activities, regardless of

whether such activities constitute uncharged criminal offenses. A polygraph examination is used to verify the accuracy and completeness of the offenders
sexual history.
While such information is felt to enhance treatment and rehabilitative goals, the information is not
privileged. Kansas leaves open the possibility that
new evidence might be used against sex offenders
in future criminal proceedings. In addition, Kansas
law requires the SATP staff to report any uncharged
sexual offenses involving minors to law enforcement
authorities. According to Kansas authorities, no
inmate has ever been charged or prosecuted for any
offense based on information disclosed during treatment. At the Supreme Court, there was no contention that the program was a mere subterfuge for the
conduct of a criminal investigation. The possibility of
prosecution, however, remains.
Prison officials informed Mr. Lile that if he
refused to participate in the SATP, his privilege status would be reduced back from Level III to Level I.
As part of this reduction, respondents visitation
rights, earnings, work opportunities, ability to send
money to family, canteen expenditures, access to a
personal television, and other privileges automatically would be curtailed. In addition, he would be
transferred back to a maximum-security unit, where
his movement would be more limited, he would
be moved from a two-person to a four-person cell,
and he would be in a potentially more dangerous
environment.
Lile refused to participate in the SATP on the
ground that the required disclosures of his criminal
history would violate his Fifth Amendment privilege
against self-incrimination. He brought an action
under 42 U.S.C. 1983 against the warden and the
secretary of the Department, seeking an injunction to
prevent them from withdrawing his prison privileges
and transferring him to a different housing unit. The
trial and appellate courts granted him relief feeling
that the state had other alternatives and that the consequences were quite severe. The Supreme Court in
a narrow 54 decision reversed the trial and appellate courts. The majority gave more discretion to the
program with their review standard.
Determining what constitutes unconstitutional
compulsion involves a question of judgment:
Courts must decide whether the consequences of
an inmates choice to remain silent are closer to the

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

physical torture against which the Constitution

clearly protects or the de minimis harms against
which it does not (536 US 24 at 41).
The majority noted
Although no program participant has ever been
prosecuted or penalized based on information
revealed during the SATP, the potential for additional punishment reinforces the gravity of the
participants offenses and thereby aids in their
rehabilitation. If inmates know society will not
punish them for their past offenses, they may be
left with the false impression that society does not
consider those crimes to be serious ones. The practical effect of guaranteed immunity for SATP participants would be to absolve many sex offenders of
any and all cost for their earlier crimes. This is the
precise opposite of the rehabilitative objective.
Another case cited by the Court of Appeals (1st Cir.)
(Ainsworth v. Risley) noted that some program conditions requiring disclosure might not meet constitutional standards.
A treatment program that conditioned participation on incriminating admissions might violate
the Fifth Amendment if that program was in turn
a condition of probation or of maintaining parole,
but a program that conditioned participation on
incriminating admissions as a condition of obtaining release on parole does not. Case law recognizes
this distinction. Some courts have found Fifth
Amendment violations where sex offenders were
required to disclose past misconduct for treatment
programs that were a condition of probation or a
court-suspended sentence.
Some states address the incrimination dilemma posed
by sex offender treatment programs by asking inmates
seeking treatment only to admit to misconduct of
which law enforcement officials are already aware
(Neal v. Shimoda).5
A grant of limited use immunity need not conflict
with public safety, since it allows the state to prosecute the recipient for any crime of which he may be
guilty . . . provided only that his own compelled testimony is not used to convict him (see Lefkowitz v.
Cunningham, comparing use immunity to broader
transactional immunity which immunizes witnesses
from prosecution for any transaction about which
they testify). Granting use immunity may in fact

429

further the states goal of rehabilitation by encouraging inmates to admit their sex offenses, thus removing an obstacle to treatment. Use immunity is the
solution proposed by commentators concerned about
the tension between an inmates right against selfincrimination and the states interest in pressing sex
offenders to admit past misconduct as a first step
toward effective treatment.
In a strongly worded dissent written by Justice
Stevens and joined by Souter, Ginsberg, and Breyer
they argued:
No one could possibly disagree with the pluralitys
statement that offering inmates minimal incentives to participate [in a rehabilitation program]
does not amount to compelled self-incrimination
prohibited by the Fifth Amendment. The question that this case presents, however, is whether
the State may punish an inmates assertion of
his Fifth Amendment privilege with the same
mandatory sanction that follows a disciplinary
conviction for an offense such as theft, sodomy,
riot arson, or assault. Until today the Court has
never characterized a threatened harm as a minimal incentive. Nor have we ever held that a
person who has made a valid assertion of the privilege may nevertheless be ordered to incriminate
himself and sanctioned for disobeying such an
order. This is truly a watershed case (McKune vs.
Lile at 54).
They emphasized that because he had testified
at trial that his sexual intercourse with the victim
before driving her back to her car was consensual, the
District Court found that a written admission on this
form would subject respondent to a possible charge
of perjury (24 F. Supp. 2d 1152, 1157 (Kan. 1998)). In
addition, the SATP requires participants to
generate a written sexual history which includes
all prior sexual activities, regardless of whether
such activities constitute uncharged criminal
offenses (ibid. at 1155). The District Court found
that the form clearly seeks information that could
incriminate the prisoner and subject him to further criminal charges (ibid. at 1157).
Through its treatment program, Kansas seeks to
achieve the admirable goal of reducing recidivism
among sex offenders. In the process, however, the
State demands an impermissible and unwarranted
sacrifice from the participants. No matter what the
goal, inmates should not be compelled to forfeit
the privilege against self-incrimination simply

430 FORENSICS

because the ends are legitimate or because they

have been convicted of sex offenses. Particularly in
a case like this one, in which respondent has protested his innocence all along and is being compelled to confess to a crime that he still insists he
did not commit, we ought to ask ourselveswhat
if this is one of those rare cases in which the jury
made a mistake and he is actually innocent? And
in answering that question, we should consider
that even members of the Star Chamber thought
they were pursuing righteous ends (McKune v.
Lile at 70).
While this is an interpretation of Kansas law, it is clear
that states and the federal system have chosen different procedures and guidelines for their sex offender
treatment programs. Any treater within a correctional setting should be acquainted with the appropriate standards under which they are operating and
be clear with prospective patients about the requirements and consequences of electing to participate in
sex offender treatment. As the preceding discussion
illustrates, these guidelines can be quite intricate and
complicated. Thus, consultation with knowledgeable
staff or attorneys may be necessary. Kansas and other
states, as noted, may use polygraph testing, plethysmography or other tests to monitor treatment. These
protocols are more akin to treatment and monitoring
of substance abusers than usual psychotherapy or
group therapy modalities.

regarding side effects. Some states provide explicit

immunity for prescribing physicians but Montana
does not. There is also no required therapy in addition to the medication. Texas offers the opportunity
only for surgical castration. They, however, ask the
Medical Board to appoint a monitor in addition to
the physician who obtains consent to be sure that the
consent is not coerced.
The antiandrogen treatments are generally mandated until either the defendant or the state Departments
of Correction (or Correctional Service of Canada
[CSC]) determines that it is no longer necessary. These
statutorily prescribed treatments may pose a number
of ethical concerns for psychiatrists including the adequacy of the consent, the capacity to give consent, the
adequacy of the overall treatment program as well as
appropriate continued monitoring. One of the more
difficult issues will be when a person requests the
medication as an aid in obtaining parole but continues to deny doing the original crime and the history
of paraphilia is marginal or nonexistent. Is the medication medically indicated under these circumstances
or is it being prescribed to facilitate release? Or are
antiandrogens medically indicated for the antisocial
rapist with no paraphilia? These cases do not have any
scientific literature to guide decision-making.

SE X UA LLY V IOLEN T PR EDATOR

EVA LUAT IONS

Consent and Castration

A good example of a treatment which raises some
interesting ethical questions of consent involve the
use of chemical or surgical castration for offenders
who are seeking favorable parole or probation consideration. As a means to control sex offender recidivism, nine states have passed legislation since 1996,
authorizing the use of chemical or physical castration. In many of these statutes, release back to the
community is predicated on the acceptance of mandated hormonal therapy. The states that have passed
such laws include California, Florida, Georgia, Iowa,
Louisiana, Montana, Oregon, Texas, and Wisconsin
(Scott & Holmberg, 2003).
Montanas statute is a good example.6 The statutes
vary as to whether a medical evaluation is statutorily
required. While not explicit in Montana the statute
does specify that the treatment be medically safe
drug treatment and the person must be informed

The Content of the Statutes

In 1997 Canada enacted criminal law that permits
trial judges to label convicts as dangerous offenders
and thereafter impose a sentence of detention in a
penitentiary for an indeterminate period in lieu of
any other sentence that might be imposed for the
offense for which the defendant had been convicted
(Part XXIV of the Canadian Criminal Code). In the
United States, after several decades during which
sexual psychopath laws had fallen into disuse, the
state of Washington passed legislation permitting the
detention of sexual offenders beyond the end of their
prison sentences in 1990 (Fitch & Hammen, 2003).
Seventeen U.S. states have since adopted sexually
violent predator (SVP) statutes. The American statutes provide for the control and supervision of people
found by a judge or jury to pose a continued risk of
sexual offending. The administration of the laws and

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

the treatment of those subject to them vary. Texas, for

instance, requires outpatient treatment while other
states require confinement.
California requires that an SVP have two or more
victims while most states require only one offense
(Lieb, 2003). Under all of the U.S. statutes confinement depends on an SVP suffering from some form
of mental abnormality. The name given to the abnormality varies. The laws of Florida and New Jersey
state that personality disorders qualify. Those of Iowa
and Kansas do not. While all of the statutes refer to
a risk of future offending the nature of this offending varies also. Thus while Texas and Washington
have statutes that refer to predatory sexual violence,
Arizonas refers to sexual violence and that of
Minnesota only to harmful sexual conduct (Lieb,
2003). The level of risk required for detention ranges
from likely (Arizona) to substantially probable
(Illinois and Wisconsin) and more likely than not
(Missouri).

431

avoid providing an opinion on whether the assessed

person should be made subject to the SVP statute. But
it is difficult to see how he or she can avoid answering questions such as, does he suffer from a mental abnormality and, does he present a substantial
risk, the answers to which, taken together, amount to
much the same thing.
The second difficulty concerns the effect on a
court of an experts assessment of dangerousness.
Even reviews that are otherwise supportive of lay
peoples abilities to make complicated decisions in
legal settings acknowledge that juries find evidence
relating to probabilities particularly difficult (Jacobs,
1993). One way clinicians have been advised to
maximize the accuracy of their predictions is to use
actuarial scales. Actuarial scales, however, seem particularly prone to the hazards of what Tribe (1971,
p.1360) called the overpowering number: an illusion
of precision arising from the use of statistical terms.
Similar concerns have been expressed by reviewers
more recently (Grisso, 2000).

General Issues Raised by the Statutes

Psychiatry and Preventive Detention
The Problem of Operationally
Defining Legal Language
A medical witness in a legal forum faces questions
that are couched in legal terms. SVP statutes require
assessors to testify to some legally derived qualities
that have no direct clinical equivalents. SVP detention
requires volitional impairment (Kansas v. Crane).
The absence of a meaningful clinical distinction
between a recidivist with a volitional impairment
and one without, however, caused both the American
Psychiatric Association (APA) and the American Bar
Association to oppose the inclusion of a volitional limb
in the insanity defense (American Bar Association,
1989; American Psychiatric Association, 1984). The
consequent difficulty for medical and psychological
witnesses is made more acute by a tendency on the
part of courts to accept whatever operational definition a witness has adopted (Doren, 2002).
The Presentation of Evidence
Experts who are concerned to present their evidence
to minimize the chances of its being used improperly
face two difficulties in SVP hearings. The first is the
possibility that evidence will be treated as conclusory on the ultimate issue. A clinician can seek to

SVP statutes are a form of preventive detention

(Doren, 2002). To describe them otherwise, for
instance as a means of providing necessary treatment, seems to ignore the timing of SVP legislation
(in the wake of publicized atrocities), the (limited)
degree to which psychiatric services have previously
provided treatment to this group, and the (seemingly
slim) likelihood of treatment leading to release for
many of those detained. Preventive detention has
been criticized by English (Everett v. Ribbands) and
American courts. It is . . . difficult to reconcile with
traditional American law, wrote the United States
Court of Appeals, the jailing of persons by the
courts because of anticipated but as yet uncommitted
crimes (Williamson v. United States at 282).
Preventive detention in criminal law, however, has
also had its authoritative supporters (Blackstone, 1783,
p. 251; Holmes, 1881, p. 43). The U.S. Supreme Court
has been offered the chance to declare preventive
detention unconstitutional and has declined to do so
(Dershowitz, 1973). The Supreme Court has also
found psychiatric evidence on the likelihood of future
offending to be admissible at the sentencing stage of
criminal trials (Barefoot v. Estelle). Civil detention in
a psychiatric hospital itself seems to involve an element of preventive detention. Taken alone, the fact

432 FORENSICS

that a statute legislates for preventive detention seems

not to preclude clinical involvement.
SVP laws represent a particular form of preventive
detention, however. First, and while rates of sexual
offending are particularly difficult to measure, the
laws are targeted at a group that does not appear to
have a higher recidivism rate than many other groups
of offenders (Hanson, 2003; U.S. Department of
Justice, 2005). The selection of this group for special
legislation seems, instead, to relate to the revulsion
that sexual offenses arouse (see introduction to this
chapter). Second, while SVP statutes make provision for regular reassessment, most of those detained
seem likely to remain incarcerated for long periods.
As of December 2004, of 3493 people held for evaluation or committed under the statutes, only 12% had
been released (Washington State Institute for Public
Policy, 2005). This may reflect the fact that the most
valid predictors of future offending in this group do
not change with time or treatment (Hanson, 2003).
Third, when psychiatrists contribute to preventive detention by recommending civil commitment
there is a therapeutic justification. A patient is
receiving care and treatment that they need and that
they would not otherwise receive. The care and treatment provided under SVP statutes is likely to differ
substantially from that which psychiatrists are used
to providing, not least because the psychiatric conditions that are being treated are also different. To the
extent that clinicians see the provision of necessary
care and treatment as one justification for compulsory admission to a psychiatric hospital, SVP statutes
require them to consider the extent to which the same
justification applies to this new group.
The passing of the SVP statutes in the United
States and similar legislation in other jurisdictions
has presented new challenges to the use of diagnoses
in court. In civil commitment hearings, as in psychiatric practice generally, diagnoses help clinicians to
describe their patients mental disorder, the treatments available and, sometimes, the likely response.
The diagnosis is seldom required to act as a gatekeeper to detention: the history and mental state
usually suffice to demonstrate that a mental disorder
of some kind is present. When detention in hospital is
proposed, the court can then concentrate on whether
the risk is sufficient to justify this.
In SVP hearings, on the other hand, the risk is frequently obvious. The question that then determines
whether the person will be detained is whether he

suffers from the required mental condition or not.

Using diagnosis in this way seems to run counter
to the injunctions in diagnostic manuals that they
not be used to reach legal conclusions (American
Psychiatric Association, 1994). Because they have
been designed to serve purposes that are largely descriptive, modern psychiatric diagnoses are ill suited to
act as justifications for detention (Buchanan, 2005).
Risk Under the Statutes
Actuarial and Clinical Aspects of the
Assessment of Risk
All SVP Statutes make detention dependent on risk.
The approaches that mental health professionals use
to assess risk are usually divided into the actuarial
and the clinical. Most actuarial approaches use
instruments that were initially developed to predict
all forms of violent recidivism, sometimes referred
to as generic instruments (Janus & Prentky, 2003).
The degree to which they are appropriate for use in
assessing the risk of sexual recidivism is controversial (Conroy, 2003; Harris, Rice, & Quinsey, 1998;
Rogers & Jackson, 2005) and probably varies from
one instrument to another (Doren, 2002, Rice &
Harris, 1997).
The appropriateness of a scale that has been
developed for use in one setting for use in a different situation is sometimes referred to as the fit of
a scale. Two aspects of fit seem to be particularly
relevant to the use of actuarial instruments in SVP
hearings. First, the person being assessed may not
resemble those on whom the predictive accuracy of
the scale was measured. Second, different behaviors
are predicted with different levels of accuracy by the
same scale (Sjstedt & Grann, 2002) and the behavior that the scale was developed to assess may not be
the behavior that the SVP statute requires experts to
predict (Rogers & Jackson, 2005). Some SVP statutes,
for instance, require the expert to assess the risk of
offending in the presence of supervision (Janus &
Prentky, 2003).
The period since the passing of Washingtons SVP
statute has also, however, seen the development of
specialized instruments for the estimation of recidivism in sex offenders. These include the SORAG,
(Quinsey, Rice, & Harris, 1995) the Static-99
(Hanson & Thornton, 1999) and the RRASOR
(Hanson, 1998). The accuracy of these specialized

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

scales has now been shown to be on par with that of

instruments for the prediction of all kinds of violence
(Harris, Rice, Quinsey, Lalumire, Boer, & Lang,
2003). Inevitably, however, the newer instruments are
less extensively cross-validated and less fully described
(for instance, in terms of their standard error rates),
leading some to argue that their use in court cannot
yet be justified (Janus & Prentky, 2003).
Actuarial instruments nevertheless seem to offer
a number of advantages over unstructured clinical
judgment. They can help to ensure that evaluations
are impartial, systematic and thorough (Mossman,
2002). They are by nature transparent: those not
practiced in their use can see what is being scored
and why. In a field where forensic psychologists who
can successfully predict general violence sometimes perform no better than chance with respect to
sexual violence (Jackson, Rogers, & Shuman, 2004)
they offer a means whereby specialist expertise can
be disseminated. Finally, assessors can minimize the
impact of the idiosyncrasies of particular instruments
by using multiple actuarial approaches simultaneously (Grisso, 2000).
The disadvantages of actuarial instruments
include the difficulty of adapting them for use in
different circumstances without generating a need
for further testing. Doubts over the applicability of
actuarial instruments have contributed to their being
excluded from hearings (Rogers & Schuman, 2005).
The Static-99 and RRASOR were both held by the
Illinois courts to fail the Frye, or general acceptance test of admissibility (In re Detention of Jeffrey
Hargett). More often, however, courts seem to have
been willing to admit evidence based on the use of
actuarial scales (People v. Ward). The scales are now
in widespread use in SVP evaluations (Doren, 2002).
Potential assessors contemplating a purely clinical approach to the assessment of risk will note also
that most reviews have found actuarial approaches
to be more accurate, particularly when the predictions sought cover periods longer than a few weeks
(Quinsey, Harris, Rice, & Cormier, 1998; but see
also Litwack, 2001). Many of the strongest reasons
to doubt the accuracy of actuarial predictions, such
as the status of the information on which the prediction is based, apply equally to clinical approaches.
Actuarial methods seem at least to be potential starting points in the light of which other factors, such as
the persons past response to treatment and current
intentions can be considered (Mossman, 2002).

433

Limits to the Accuracy of

Risk Assessment
Predictive accuracy can be described in terms of the
area under the Receiver Operating Characteristic
(ROC) curve. An area under the ROC curve (AUC)
of 1 reflects perfect prediction and an AUC of 0.5
reflects an accuracy that is no better than chance.
Mossmans review suggested an area under the ROC
curve (AUC) for all violence prediction techniques of
0.78. This fell to 0.71 and 0.67 for validated actuarial and clinical approaches respectively (Mossman,
1994). Subsequent reviews of actuarial instruments
suggest similar levels of accuracy (Buchanan &
Leese, 2001). Validation of the most recent actuarial
approach, an iterative classification tree, generates
an AUC of 0.63 (Monahan et al., 2005).
The ROC curve has the advantage of making a
description of predictive accuracy that is independent of the base rate of violence in the sample in which
the instrument was tested. It seems unlikely, however,
that courts will always understand what the practical
implications are. One way of describing those implications uses a different statistic, the number needed
to detain. Used on a population where the base rate
of violence is 9.5% and where detaining 10 people at
random could therefore be expected to prevent one
offense, modern approaches to risk assessment would
require the detention of 6 people to achieve the same
end (Buchanan & Leese, 2001).
No one knows what the base rates of offending
are in those assessed for detention under SVP legislation. Three problems follow. First, the accuracy of
actuarial risk assessments is greatest when they are
used on a population where the base rate of violence
is similar to the base rate in population in which
the instrument was tested. Deviation from that base
rate reduces the accuracy of predictions. The degree
to which this happens depends on the difference
between the two base rates. If this difference is not
known, the accuracy of the procedure cannot be
assessed. Second, when the base rate is not known it
becomes difficult for an assessor to describe the accuracy of the procedure that he or she is using. Without
knowledge of the base rate, for instance, no assessor
can say how many false positives and false negatives
there are likely to be.
Finally, the number needed to detain changes
with the base rate. When the base rate is lower it
becomes more difficult to identify accurately people

434 FORENSICS

who will act violently because the proportion of the

time that the assessor is right by chance is lower
also. The U.S. Department of Justice gives a 3-year
rearrest rate for sex crimes among male sex offenders released from prisons in 1994 of 5.3% (U.S.
Department of Justice, 2005). Applied to a population
where the base rate is 5%, modern actuarial instruments would result in the detention of 14 people to
prevent one unwanted event (Buchanan & Leese,
2001). Any failure to obtain all of the information
on which to base an assessment of risk will further
decrease the accuracy of any assessment.
Conclusions Regarding the Ethical
Issues Raised by SVP Statutes
SVP statutes have survived the legal challenges of
Kansas v. Hendricks. As others have pointed out, however, this does not make giving testimony in SVP
proceedings ethical (Grisso, 2000). In the absence of
directives from the usual professional organizations,
practitioners facing a choice over whether and how to
participate are likely to be influenced by what they see.
Some will note the difficulties inherent in operationally defining qualities such as volitional impairment, in presenting evidence so that it will not be
used inappropriately and in accurately assessing the
type of risk defined by each statute and decide not
to undertake SVP assessments. Others are likely to
make the same choice because they question the
appropriateness of using psychiatric categories to
authorize the preventive detention of a group whose
status as psychiatric patients, newly conferred by statute, seems arbitrary.
Clinicians choosing whether to participate will
also be influenced by the extent to which they think
that they can communicate to a court not only their
conclusions regarding diagnosis and risk but also
their level of confidence in those conclusions. One
ethical requirement must be for candor but candor is
only possible if a witness is capable of describing the
approach, its reliability, and its predictive validity in
terms that the court will understand.
Finally, clinicians choosing whether to participate
will be influenced by local conditions. Those who see
an arbitrary process where no guidelines are provided
to help prosecutors decide who will be assessed for
detention, where practitioners are discouraged from
discussing what they do, where public defenders work
with inadequate resources, and where prosecutors

go shopping for psychiatric opinions that support

continued detention (Mansnerus, 2003) will presumably not become involved. Those who see a system
that provides detention in humane conditions, where
effective treatment is provided and where there is the
realistic prospect of release if treatment is successful
may reach different conclusions.
What seems clear is that technology is not about to
resolve the clinicians dilemma. There will, presumably, be some further improvement in the accuracy of
generic predictions of violence and further progress
in applying these improvements to scales designed
specifically to predict sexual recidivism. The research
gives little reason to suppose, however, that these
developments will soon produce instruments that
perform substantially better than those that require,
at a base rate of 5%, the detention of approximately
15 people to prevent one unwanted event.
These error rates (and worse) have been accepted
in psychiatry for many years. They have not led to the
abandonment of civil detention, presumably because
a number of additional factors help to justify the compulsory hospitalization of some psychiatric patients.
These additional factors include the provision of
nursing care and psychiatric treatment to people who
are mentally unwell and whose psychiatric condition
impairs their ability to choose such things for themselves. It is the absence of these additional factors that
is likely to mean that the current generation of SVP
statutes will remain ethically problematic for many
clinicians.

ETHICA L ASPECTS OF OBTA INING

INFOR M AT ION

Offering Opinions without Examination

A part of the SVP evaluation process permits or
requires a personal examination of the inmate by a
mental health professional. In a significant number
of cases the person potentially subject to commitment
refuses to participate in the evaluation. When this
occurs the psychiatrist will usually feel some unease
as the APA ethical guidelines appears to say that it is
unethical to offer a diagnostic opinion. Section 7 (3)
of the Guidelines states
On occasion psychiatrists are asked for an opinion
about an individual who is in the light of public

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

attention or who has disclosed information about

himself/herself through public media. In such
circumstances, a psychiatrist may share with the
public his or her expertise about psychiatric issues
in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or
she has conducted an examination and has been
granted proper authorization for such a statement
(American Psychiatric Association, 2001).
This statement was developed in the context of a
FACT magazine poll asking if psychiatrists thought
that Barry Goldwater was psychologically fit to be
President of the United States. Many psychiatrists
filled out the questionnaire, offering what appeared
to be a professional opinion. This guideline has
remained very questionable as to its scope and application as it would seem to preclude not only SVP
evaluation conclusions without an interview but also
any book or article discussing psychological profiles
of public figures, world leaders or developing profiles of historical figures based on documents or even
medical records.
Other professional organizations have developed
guidelines for this contingency; for example, the
Ethical Guidelines from the American Psychological
Association leave room for reports without a personal
examination.7 The Ethical Guidelines developed by
the American Academy of Psychiatry and the Law
also takes a more pragmatic approach and states
Honesty, objectivity and the adequacy of the clinical evaluation may be called into question when
an expert opinion is offered without a personal
examination. For certain evaluations (such as
record reviews for malpractice cases), a personal
examination is not required. In all other forensic
evaluations, if, after appropriate effort, it is not feasible to conduct a personal examination, an opinion may nonetheless be rendered on the basis of
other information. Under these circumstances, it
is the responsibility of psychiatrists to make earnest efforts to ensure that their statements, opinions and any reports or testimony based on those
opinions, clearly state that there was no personal
examination and note any resulting limitations to
their opinions (American Academy of Psychiatry
and the Law, 2005).
This latter approach recognizes that some conclusions can be drawn in the absence of a personal
examination but some appraisal of the information is

435

necessary. If, for example there is a 20-year history

of multiple hospitalizations and a consistent diagnosis of Chronic Paranoid Schizophrenia with well
documented symptoms it would be within reasonable
practice criteria to say the diagnosis was reasonably
well established. This does not mean that the individual could not have other diagnoses of relevance that
have been of more recent origin. Data which would
require a personal examination might be the assessment of the effects of treatment, if there were not a
good paper record or the availability of prior treaters.
In addition, not all information found in records
is necessarily accurate. An interview permits further
exploration of details or discrepancies which can be
further evaluated, if necessary. In some states the
evaluations are court ordered so that full informed
consent may not be a formal legal requirement, but,
from an ethical standpoint, notice to the evaluee
should be provided. This should minimally include
the purpose of the evaluation and lack of confidentiality of the evaluation.
Interviews with Victims
Another potentially thorny ethical issue involves the
use of collateral interviews from victims. Victims who
have been traumatized by the original crime can be
retraumatized as a result of an interview that reviews
the details of the original assault. Yet victims often
are concerned about the potential release of offenders and are often willing to appear to testify at parole
hearings. Sensitivity to this can be shown by talking
first with the states attorney who has had prior contact
and experience with the victim. They can be aware of
the victims attitudes and wishes and may also be in a
better position to make the initial contact.

ETHICA L ISSUES IN THE USE OF USUA L

COMMIT MEN T STAT U T ES

During the last half of 2005, the Governors of

New York State and Rhode Island have publicly
expressed dismay at the release of sex offenders from
prisons at the end of their sentences. These concerns
were precipitated by horrendous crimes committed by
recently released felons with histories of prior sexual
offenses. They have taken an unusual step in attempting to use the regular civil commitment statutes to
keep these offenders confined.

436 FORENSICS

New York has subsequently passed a commitment

statutes.
Most general civil commitment statutes generally
require, or have been interpreted to require, a recent
predicate act indicating dangerousness in addition to
the presence of a mental disorder. Thus, it came as a
surprise to many mental health professionals to see
Governors attempt to use these statutes and to be able
to find psychiatrists willing to find such individuals
certifiable.
The two governors requested psychiatrists within
correctional facilities to review the sex offenders
who were about to be released and to use the usual
civil commitment statutes for those who were felt to
be mentally ill and dangerous to have them transferred to mental health facilities rather than permitting them to be released into the community. In
New York, 12 individuals were recently committed
to Department of Mental Health facilities and they
immediately challenged their confinement. The initial court rulings were that the proper procedures
had not been followed, since independent physicians had not been appointed and a judge had not
made the necessary findings before the transfer, as
required following the US Supreme Court decision
in Vitek v. Jones. As of mid 2008, these procedures
have been clarified and approximately 180 individuals have been committed in New York State under
the new SVP statute.
One individual was admitted voluntarily to
the State hospital in Rhode Island under questionable legal proceedings. When this occurred, the
Superintendent of the facility resigned in protest.
Rhode Islands civil commitment statute contains an
interesting caveat If a patient has been incarcerated,
or institutionalized, or in a controlled environment of
any kind, the court may give great weight to such prior
acts, diagnosis, words, or thoughts.8
These events have raised many questions. One is
a question of what disorders can be used as a basis
for civil commitment. Hendricks and the predator
statutes clearly changed the ground rules as the legislature began defining mental abnormality very
broadly to include those that they wanted hospitalized. Even the DSM-IV has a caveat, stating that the
clinical and scientific considerations involved in categorization of these conditions as mental disorders
may not be wholly relevant to legal judgments.
It may be difficult to understand how psychiatry
can be excluded from the decision-making process in

an area in which psychiatric input has usually been

dispositive. Organized psychiatry has not wanted to
be overly restricted by diagnostic categories and saw
no need to answer it as long as physicians were making the decision to hospitalize patients that they felt
required hospitalization. For many years, most civil
commitment statutes were, and many continue to
be, written in very broad language. For example, in
Connecticut, for the first two-thirds of the last century the commitment criteria required the presence
of a mental illness, which was defined as a mental
or emotional condition which has substantial adverse
effects upon his or her ability to function and who
requires care and treatment, as well as a finding that
the person was a fit subject for confinement. This
was the legislatures way of giving physicians broad
discretion in hospitalizing the mentally ill, with the
implicit message that physicians knew who should
be hospitalized and could be trusted to use that
authority appropriately with the protection of judicial
review. With the civil rights revolution, this broad
trust was narrowed and dangerousness and/or grave
disability became required minimal criteria, not
only in Connecticut, but also in all states.
However, the definitions of mental disorders have
remained quite broad. This has opened the door for
some pressure to be placed on physicians in prisons to
think about petitioning to commit more individuals
who are emerging from prison. The DSM-IV is the
psychiatric compendium of mental disorders which
now includes over 250 such disorders. The manual
makes no list of disorders which qualify for use as a
basis for civil commitment and those that do not. The
model civil commitment statute developed by the
APA talks about serious mental disorders that suggest psychoses but leave much flexibility. Most psychiatrists would not want to exclude personality disorders
per se as an inappropriate basis for civil commitment,
for example, many individuals with borderline personality disorders can become seriously suicidal, have
significant impairments in reality testing and require
hospitalization. Pedophilia is an Axis I diagnosis but
had not been widely used in the past as a basis for
commitment, since there was no formal thought disorder and most individuals had sufficient control so as
not to be seen detainable on that basis. The inclusion
of antisocial personality disorder (APD) as the only
mental abnormality, however, has generally not been
seen by physicians, in this country, as a sufficient
predicate to justify involuntary commitment.

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

The U.S. Supreme Court has also acknowledged

that there must be some way to distinguish the typical prison felon with APD from the individual
whose commitment is being sought in these special
circumstances.
And we recognize that in cases where lack of control is at issue, inability to control behavior will
not be demonstrable with mathematical precision. It is enough to say that there must be proof
of serious difficulty in controlling behavior. And
this, when viewed in light of such features of the
case as the nature of the psychiatric diagnosis, and
the severity of the mental abnormality itself, must
be sufficient to distinguish the dangerous sexual
offender whose serious mental illness, abnormality, or disorder subjects him to civil commitment
from the dangerous but typical recidivist convicted
in an ordinary criminal case (Kansan v. Crane).
Governors and the public do not have these compunctions and thus it is interesting to see how this will play
out once the procedural issues get resolved and more
substantive questions arise in the courts.
The Rhode Island case raises different questions.
The individual involved there was diagnosed with
schizophrenia as well as being a sexual offender.
Here, the Superintendent had concluded that the
schizophrenia was not a contributing factor in the sexual offenses, and that the individual was adequately
treated for his schizophrenia; and on that basis did
not require hospitalization. Presumably, if he felt the
schizophrenia was a contributing factor and was not
adequately treated he would not have objected. These
distinctions are not easily drawn and good treatment
plans should include appropriate treatments for the
paraphilia as well. The Rhode Island civil commitment statutes have an interesting provision that have
not been seen in many others:
(ii) In determining whether there exists a likelihood of serious harm the physician and the court
may consider previous acts, diagnosis, words or
thoughts of the patient. If a patient has been incarcerated, or institutionalized, or in a controlled
environment of any kind, the court may give great
weight to such prior acts, diagnosis, words, or
thoughts.
This may broadens the basis for civil commitment in
Rhode Island and may be so interpreted by the courts.

437

Thus, we may see more use of ordinary civil commitment statutes or efforts to amend them.
The courts have not agreed with organized psychiatrys view that the SVP commitment redefines sexual
criminal behavior as a mental illness for the purpose
of allowing continued preventive detentionan unacceptable medicalization of deviance. While most of
us would agree that hospitals are not appropriate for
most, if not all, antisocial rapists, the paraphilias do
represent a different cluster of disorders which also
offer significant treatment prospects. I believe most
of us would admit a pedophile requesting admission
because he was fearful of reoffending and wanted
to obtain treatment. The challenge remains how to
avoid becoming a warehouse/prison for individuals
who are indistinguishable from ordinary criminals
and yet be open to those needing treatment. Our civil
commitment statutes should not become so flimsy
as to make a mockery of mental disorders so as to
accomplish preventive detention for individuals who
are not seriously ill. The ethical dilemma for psychiatrists working in correctional facilities will be how to
apply these broad definitions of mental disorder usually found in civil commitment statutes to individuals
who are to be released in the face of political pressures and the absence of clear professional guidelines.
This will be easier in states where the statutes require
recent evidence of dangerousness. In addition, once
committed, the decision to release is totally in the
physicians discretion and generally has not been
challenged by the state.

THE PROBLEM OF T R E AT MEN T

AVA IL A BILIT Y

While an ethical problem only in the abstract sense,

it is noteworthy that treating sex offenders has not
been an area of large interest for most psychiatrists.
Many do not read the research literature and few have
experience with the use of antiandrogens or other
hormonal treatments. While there are legitimate
arguments about the misuse of psychiatry by civilly
committing convicted felons with the sole diagnosis
of antisocial personality at the end of their sentences,
this does not deal with the effects of paraphilic disorders that can take over and destroy peoples lives. How
much of this a legacy of the last centurys classification of homosexuality as a mental disorder or fears
of being held responsible for relapses if new offenses

438 FORENSICS

occur while someone is in treatment is not possible to

discern. We remain at a primitive level of understanding of sexual object choice and arousal patterns. Our
current treatments are presently directed at correcting cognitive distortions, decreasing the intensity of a
persons sexual drive, and offering social supports.
Even in states that do not have SVP laws the growing numbers of patients who are listed on sex offender
registries make this a group that cannot be ignored.
Risk assessment demands by community agencies
and treatment plans that address these issues are
growing needs. Our Canadian colleagues seem to
have developed a more positive attitude and approach
to treating these patients and report gratifying results.
Even the older literature shows some positive benefits
of treatment. Of course, the public expectation of 0%
recidivism as the only acceptable standard is unrealistic, but this is an area of great public health need
and research.

CONCLUSION

Clinicians who assess and treat offenders sometimes

become aware of criminal activity not known to the
police. The expectation that an assessment conducted at the request of the defense attorney will be
confidential can conflict with the need to communicate worrying information with treating clinicians.
Treating psychiatrists can find that their understanding of what they are, and are not, expected to regard
as confidential is different from that of the probation
service staff. Treatment in prison raises issues of confidentiality. Making treatment a condition of release
raises the question of the extent to which that treatment is voluntary.
None of these ethical questions are unique to the
treatment of sex offenders. Treatment of this group,
however, does present familiar problems in new
guises. The relative newness of SVP legislation, in
particular, means that many important questions,
including whether treatment can lead to release and
the meaning of volitional impairment, as yet have
no answers. Some of the answers will be provided by
empirical research. Other answers, however, can only
be provided by the response of the health professions
to the challenge that a group, previously peripheral
to the concern of most psychiatric services, can now
more readily be detained and treated by psychiatric
services.

Notes
1. Any person who . . . knowingly possesses any book,
magazine, periodical, film, videotape, computer disk,
or any other material that contains an image of child
pornography that has been mailed, or shipped or transported in interstate or foreign commerce by any means,
including by computer, or that was produced using materials that have been mailed, or shipped or transported in
interstate or foreign commerce by any means, including
by computer . . . shall be punished . . . . 18 U.S.C. 2252A
(a)(5)(B). Every person who transmits, makes available,
distributes, sells, advertises, imports, exports, accesses,
possesses any child pornography is guilty and liable to
a minimum punishment of imprisonment. See also
Section 163.1 of the Criminal Code of Canada.
2. See Connecticut General Statutes 52577d.
Limitation of action for damages to minor caused by
sexual abuse, exploitation, or assault. Notwithstanding
the provisions of section 52577, no action to recover
damages for personal injury to a minor, including emotional distress, caused by sexual abuse, sexual exploitation, or sexual assault may be brought by such person
later than 30 years from the date such person attains the
age of majority.
3. People v. Clark 789 P.2d 127 (Cal 1990).
4. James Jones v. John Smith, [1999] 1 S.C. R. 455;
1999 s.C.R. LEXIS 13.
5. In Neal v. Shimoda, the court referred to a sex
offender consent that stated, I understand that I am
not required to provide information about crimes that
no one knows about; see also, Russell v. Eaves. Courts
have also suggested that states grant use immunity to sex
offenders before requiring them to disclose past misconduct during the course of treatment. See Lile v. McKune;
Montana v. Imlay; Mace v. Amnesty; State v. Fuller.
6. Mont. Code Anno., 455-512 (2005) 455-512
Chemical treatment of sex offenders. (1) A person convicted of a first offense under 455-502(3), 455-503(3),
or 455-507(4) may, in addition to the sentence imposed
under those sections, be sentenced to undergo medically safe medroxyprogesterone acetate treatment or its
chemical equivalent or other medically safe drug treatment that reduces sexual fantasies, sex drive, or both,
administered by the department of corrections or its
agent pursuant to subsection (4). (2) A person convicted
of a second or subsequent offense under 455-502(3),
455-503, or 455-507 may, in addition to the sentence
imposed under those sections, be sentenced to undergo
medically safe medroxyprogesterone acetate treatment
or its chemical equivalent or other medically safe drug
treatment that reduces sexual fantasies, sex drive, or
both, administered by the department of corrections or
its agent pursuant to subsection (4). (3) A person convicted of a first or subsequent offense under 455-502,
455-503, or 455-507 who is not sentenced to undergo
medically safe medroxyprogesterone acetate treatment
or its chemical equivalent or other medically safe drug
treatment that reduces sexual fantasies, sex drive, or

ETHICAL ISSUES IN THE TREATMENT OF SEX OFFENDERS

both, may voluntarily undergo such treatment, which

must be administered by the department of corrections
or its agent and paid for by the department of corrections. (4) Treatment under subsection (1) or (2) must
begin 1 week before release from confinement and must
continue until the department of corrections determines
that the treatment is no longer necessary. Failure to continue treatment as ordered by the department of corrections constitutes a criminal contempt of court for failure
to comply with the sentence, for which the sentencing
court shall impose a term of incarceration without possibility of parole of not less than 10 years or more than
100 years. (5) Before chemical treatment under this section, the person must be fully medically informed of its
effects. (6) A state employee who is a professional medical person may not be compelled against the employees wishes to administer chemical treatment under this
section.
7. American Psychological Association (2002) states
the following 9.01 Bases for Assessments (a) Psychologists
base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements,
including forensic testimony, on information and techniques sufficient to substantiate their findings (See
also Standard 2.04, Bases for Scientific and Professional
Judgments).(b) Except as noted in 9.01c psychologists
provide opinions of the psychological characteristics of
individuals only after they have conducted an examination of the individuals adequate to support their statements or conclusions. When, despite reasonable efforts,
such an examination is not practical, psychologists
document the efforts they made and the result of those
efforts, clarify the probable impact of their limited information on the reliability and validity of their opinions,
and appropriately limit the nature and extent of their
conclusions or recommendations (See also Standards
2.01, Boundaries of Competence, and 9.06, Interpreting
Assessment Results).(c) When psychologists conduct a
record review or provide consultation or supervision and
an individual examination is not warranted or necessary for the opinion, psychologists explain this and the
sources of information on which they based their conclusions and recommendations.
8. R.I. Gen. Laws 40.15-2.

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Chapter 30

Commentary
James C. Beck

One of the editors was kind enough to offer me the

opportunity to write this comment, and I was honored to accept. I say kind enough because I began
by reading the booka valuable experience I would
not have had otherwise. This is an excellent compendium of what we know as well as what we do not know
about sex offenders: identification, risk assessment,
treatment, and legal issues.
The editor has chosen a commentator with
extensive forensic experience but not someone who
would hold himself out as an expert on sex offenders. Once I get beyond a factual summary of what
the book concerns, my commentary will necessarily
reflect who I am and my experience. Since this is a
book that is addressed to a wide audience, not just
to the fellow experts in the field, perhaps the editor
has made a sensible choice in asking a nonexpert for
commentary. In any case, in fairness to the reader,
here is a summary of what you need to know about
me to judge the relevance of my commentary to your
own experience.

My clinical experience includes 17 years as a court

clinic psychiatrist, and in that role I evaluated all types
of criminal defendants. In my private practice I have
evaluated and treated several dozen clinicians and
patients who were involved in a sexual relationship.
I was one of the earlier psychiatrists who tried to bring
this problem into sharper focus for the professiona
profession unfortunately that took longer than it
should have to acknowledge its own transgressions
and to adopt a code of ethics that recognized that sex
with patients is never ok. I have seen enough psychiatrists, and heard enough from their former patients
to have some clinical sense of what drove these men.
I have also evaluated half a dozen men who were
sexually abused by catholic clergy. I have a very clear
idea of what this experience has done to the victims.
I think it is safe to say that sex offenders stir up
stronger feelings than almost any other perpetrators
of violence. Incest, child sexual abuse, rape, necrophilia, and violation of fiduciary duties to patients,
clients or parishioners arouse strong feelings of anger,

441

442 FORENSICS

revulsion, and disgust, mixed perhaps with some

degree of sympathy for the perpetrator if or when we
happen to know enough about him so that we get
beyond the offense to the person. In my clinical practice I have a reputation, which I believe is accurate,
for being more civil libertarian than most psychiatrists. My threshold for involuntary hospitalization is
higher than that of my colleagues. For that reason it
is surprising to me that I find myself uncomfortable
enough with the idea of, for example, pedophiles running loose in the community that my idea of least
restrictive alternative treatment for these men is
quite restrictive indeed.
With that introduction, I turn to the book. What
I propose to do in this commentary is to summarize
the contents and add my own comments where I have
opinions based solidly on my professional experience.
There are four editorstwo psychiatrists and two
attorneys. The psychiatrists have substantial experience in the legal context and the attorneys have exercised their legal expertise in relation to a wide range
of clinical problems. The four editors represent an
enormous amount of relevant expertise packed into a
small group of people. How efficient.
This is an excellent book, and will serve as a valuable reference or introduction to the subject for a
wide range of people in the clinical and legal fields.
Because it is so comprehensive, it can serve on the one
hand as an introduction for people who know nothing about the fieldfor example, students in a college
course on abnormal psychology, for medical students
or residents, or law students taking a course in criminal law. For the more experienced clinician or attorney who has any need to know more about any of the
topics in this book, this is an excellent place to start.
The editors have clearly instructed their contributors
to include a comprehensive literature review and the
contributors have met that obligation. In the areas I
know wellforensic assessment, competency to consent to evaluation, risk assessment, and sexual abuse
by fiduciariesI am impressed that the authors have
covered their piece of the waterfront thoroughly.
Paul Appelbaums foreward begins with a review
of the current social climatea climate in which society inposes punitive legal sanctions for sex offenders.
He makes the important point, as do several following
chapters, that sex offenders are not a homogeneous
group, either in what they do or in who they are. To
the extent that we understand it, the developmental
path to incest is different from the path toward rape.

The author goes on to say, the only hope for escaping the legal, ethical, and political tangle associated
with sex offenders is the development of effective
treatment, and here we come to the first statement
of what I see as a serious problem. Treatment in its
usual meaning is medical, or more broadly, clinical.
I question whether it is realistic to hope for effective
treatment, if by treatment we mean some degree of
voluntary engagement with a clinician as distinct
from forced compliance. There are incest perpetrators who know that what they are doing is wrong, and
are deeply conflicted about it. For them, treatment is
an option. The mental health professions have treatment for people like these.
By contrast there are sex offenders who believe that
what they are doing is right, that society is wrong in
criminalizing it, and they will do whatever they can
in order to continue offending. It is hard for me to see
that treatment for these people is a reasonable goal.
Management of their risk or even control may be a
reasonable goal, but not treatment.
The second aspect of the problem is that it is difficult, and at times impossible, to assess the effectiveness of any proposed treatment, or for that matter, any
proposed method of control. The reason is simple.
Accurate assessment of treatment efficacy depends
ultimately on truthful reporting by the subject of his
behavior. When truthful reporting leads to rearrest
and likely incarceration, truth takes a pass.
The book is organized in seven parts: An introduction provides a perspective on what we understand by normality as relating to sexual behavior. The
second chapter describes paraphilia in careful detail,
and introduces the concept of lovemap. As far as I
could see lovemap refers in common parlance to
what turns you on, but does not carry us any further
into understanding why some people are turned on
by paraphilic fantasies.
The second part presents what we know about the
neuropsychology and neurobiology of these disorders.
What was true here, as I read it, was true consistently
throughout the book: we have good data describing
antecedents of offending and good data on associated
conditions. These antecedents and these associated
conditions are both associated with sex offending
and with various other mental disorders and behavioral difficulties in adulthood. What we do not appear
to have at present is sufficient understanding of why
some men with these risk factors go on to become sex
offenders and other men do not.

COMMENTARY

Men (the offenders are almost always men; there is

one chapter on women) who offend are more likely to
be substance abusers, to have attention-deficit hyperactivity disorder (ADHD), or to have other evidence
of neuropsychological impairment. But we appear
to know essentially nothing about why some men
with these conditions go on to become sex offenders
and others do not. Later chapters will document the
association between early childhood abuse or other
maltreatment or neglect and various types of sexual
offending, but again, with no knowledge of why some
children who have these tragic experiences go on to
offend sexually and others do not.
The third part is on diagnosis and assessment.
There is an excellent review of risk assessment for
violence in relation to mental disorder generally followed by a chapter applying what we know about risk
assessment to sexual offending. The authors conclude
that assessment tools cannot estimate the probability
of future sexual offending in the individual case, and
they suggest supplementing the actuarial tool with
structured professional judgment. Buchanan et al.
(2008) reached a similar conclusion for risk assessment generally, and this approach makes the most
sense to me also (Beck, 2008). Estimated recidivism
rates quoted as high as 52% for child molesters and
39% for rapists highlight the importance of improving our capacity to predict and control the behavior
of these offenders. The quoted fact that one-third of
prisoners in some states are sex offenders, speaks of
the importance of not just improved prediction but
for developing improved methods for behavior control in the community.
Two chapters on laboratory methods of assessment are followed by chapters on mental disorder;
psychopathy, and personality disorders generally in
relation to sex offending. These chapters summarize
what we know, and also what we do not. The chapters
on assessment will be of interest primarily to specialists. The descriptive chapters following are relevant
to any clinical or legal professional who evaluates sex
offenders.
The fourth part on treatment begins with a chapter
on psychosocial treatment that has an excellent summary of the relevant history. In particular, the authors
note that relapse prevention therapy continues to be
employed in spite of evidence in a controlled study by
the man who invented it that it may actually be ineffective. Two studies showed that therapists who were
empathic, warm, rewarding, and somewhat directive

443

produced maximal results with these patients. Only

somewhat directive distinguishes these therapists
from the maximally effective therapist for any other
patient. There is an excellent discussion of the risks
and benefits of manually driven versus more individually tailored therapy.
The chapter on orchiectomy is of largely historical interest. The discussion of pharmacological treatments by Saleh is useful for an understanding of how
to manage and mitigate a paraphilic sex offenders
risk for sexual recidividism.
The fifth part on juveniles covers forensic assessment; epidemiology, risk assessment and treatment;
and intervention and treatment in three excellent
chapters. They should serve as cautionary reading for
any clinician who imagines that adult clinical training is sufficient to engage with juveniles either in the
legal or clinical setting. The discussion of forensic
assessment makes very clear just how different this
assessment is for juveniles as opposed to adults. The
chapter on epidemiology presents epidemiologic data
on offenders who are apprehendedas with adults we
have far less accurate data on the incidence and prevalence of these behaviors in the community. Both
this chapter and that following make the important
point that adolescents are not fixed either in development or in behavior in a way that adults are, and
that therefore their prognosis is potentially better. As
with adults, we know little about what distinguishes
juvenile sex offenders from juvenile offenders generally. For example, data are quoted showing that
these adolescents have higher rates of neuropsychological difficulties. We found the same for a sample
of unincarcerated delinquents (Robbins, Beck, Pries,
Cage, & Smith, 1983). Again, we have no idea why
some adolescents with neuropsychological impairments become sex offenders and others become
delinquent.
Part six focuses on special populations.
Chapter 18 presents data, no surprise, that substance abuse is associated with increased risk for sexual offending. Chapter 19 presents the sparse data on
female sexual offenders. Only 1% of sentenced sex
offenders are women. The relative lack of data pertaining to female offenders is clearly one impediment
to learning more about them.
The chapter on professionals who are accused of
sexual boundary violations reviews a subject that for
far too long was tolerated by psychiatry. The authors
discuss boundary violations, ethical obligations,

444 FORENSICS

social response to perpetrators, and their program

for evaluating physicians who have had sexual relations with patients. Missing was any discussion of who
these physicians are. In my experience there has been
a dramatic shift in who commits these violations. In
the 1960s when I trained it was commonly thought
by the residents that more than one of our supervisors had been involved sexually with patients. I have
personally evaluated several dozen women who gave
credible accounts of sexual relationshipsin the most
egregious of these cases I spoke with five women who
reported sex with one psychiatrist and five others who
reported sex with a different psychiatrist. These relationships went on because for many years the women
found that if they complained they were called borderline, the allegations of a sexual relationship were
denied; and the perpetrator continued unchecked.
As society has imposed sanctions and as the profession has taken a firm stand condemning this behavior the few psychiatrists I have seen recently are what
have been described as love sick therapists. These
are typically men who are in bad marriages, angry at
their wives but unable for characterological reasons to
express the anger, who become involved with patients
who have dependent needs of their own. The patient
wants the therapist to care for her. He is empathic
and feels her need. He does not feel his own less conscious need for a new relationship. He responds to the
patient who then asks him to hug her. He does hug
her; once, and then repeatedly. Over time, biology
asserts itself and the cases we see have ended with an
angry, badly damaged patient who makes a complaint
to the appropriate authorities.
If the profession is going to be more successful in
reducing the incidence of these regrettable events we
must do more than publish appropriate ethical guidelines. We need to teach our trainees and our peers
how to recognize the psychosocial states that create a
potential risk of ethical violations with patients.
This part also contains chapters on stalking,
Internet child pornography, clergy sex abuse, sexual
sadism, and intellectual disabilities.
The last part is on forensic issues. The first chapter
on forensic considerations gives a clear and complete
outline of what is involved in a forensic examination.
Then they apply their general paradigm to the forensic evaluation of; sexual offenders. If a general psychiatrist were somehow put in a position to do a forensic
assessment, or a forensic psychiatrist to do an assessment of a sex offender, following this outline would

get them through admirably. The chapter on sexual

predator laws and their history should be required
reading for any judge or other legal or clinical professional involved with these cases. I have lived long
enough to have practiced under the various systems
employed. They may be summarized as follows:
either treatment is provided, or it is not. If it is provided either it is only for those who ask for it, or it
is mandatory for all offenders. Confinement is either
for a fixed or an indeterminate period. It may be in
prison or in a hospital or in a treatment center. All
combinations of the treatment and confinement variables have been tried. There are no data sufficient to
inform the choice. As a practical matter, the choices
are made on sociopolitical grounds. At present in the
United States we come down on the side of incarcerating people for long periods with or without something called treatment that may or may not exist, or
if it exists, have any evidence base of support. When
we release people to the community, we impose conditions that make their lives almost impossible. Civil
libertarians are appropriately troubled. If parents are
troubled, I suspect it is because the offenders have
been released at all. The last chapter reviews current
case and statute law in the United States and Canada,
and addresses the ethical questions musrarise when
the question of self-disclosure of illegal activities is
posed. Their discussion of ethical issues involved in
certifying a person as a sexually violent predator for
purposes of indefinite commitment and treatment
is particularly apt. There are no easy answers to these,
or indeed, any of the questions raised by the assessment and management of men who commit these
crimes.
In this context, I offer my own suggestion for
potentially adequate control of recalcitrant sex offenders in the community. I base this proposal on my own
experience providing psychiatric probation through
a court clinic on mentally ill violent offenders who
had less than no interest in seeing me. My impression was that the experience of having a responsible
person consistently inquiring into their situation and
behavior served to help these men behave themselves.
I adapt this experience here.
First, determinate sentences appropriate to the
crime as the government sees fit. This confinement
would be followed by extremely close supervision in
the community. It costs, per recent estimates I have
seen, $40,000 per year to house a prisoner. This fact
provides a comparative financial basis on which to

COMMENTARY

argue that intensive community supervision can be

delivered in a less costly way that hopefully provides
a better balance between risk to the community and
the civil rights of the offenders.
Suppose we conceive of specially trained probation officers whom we teach what we know clinically
and what we understand practically about probationary supervision. If we pay these men and women $100
K to 120 K per year including fringe and we assign
each officer six offenders to supervise, the state will
save roughly 50% of what it costs now. Lastly, as
part of the team we would include investigators who
would be charged to make random surveillance of the
probationers. Extremely close supervision would be
mandatory, and it would last for many years.
Conviction for reoffending would lead to indefinite
institutionalization. These conditions are severe, but
not as severe as incarceration. Some long-incarcerated

445

men have learned to prefer the institution to the

street. These offenders could be given a choice after
they maxed out of indefinite commitment or this kind
of probation.
References
Beck, J. C. (2008). Ch. 12. Outpatient settings. In R. I.
Simon & K. Tardiff (Eds.), Textbook of violence assessment and management (pp. 237257). Washington,
D. C.: American Psychiatric Publishing.
Buchanan, A. (2008). Risk of violence by psychiatric patients: Beyond the actuarial versus clinical assessment debate. Psychiatric Services
(Washington, D.C.), 59(2), 18490.
Robbins, D., Beck, J. C., Pries, R., Cage, D. J., & Smith,
C. (1983). Learning disability and neuropsychological impairment in adjudicated, unincarcerated
male delinquents. Journal of the American Academy
of Child Psychiatry, 22, 4046.

This page intentionally left blank

Index

Note: Page numbers in italics refer to figures and tables.

Abel and Becker Cognition Scale (ABCS), 364
Abel Assessment for Interest in Paraphilias, 251
Abel Assessment for Sexual Interests (AASI), 103106, 108,
114, 115
and courts, 109110
problematic sexual behaviors assessed by, 109
VRT assessment of, 103, 105, 229
Abel Screening, Inc., 106, 108
AbelBlasingame Assessment System for individuals with
intellectual disabilities (ABID), 115116
Abuse cycle, 256, 257
Actuarial risk assessment, 58, 70, 383, 403
cross-validation, 81, 82
limitations, 7980
limited clinical utility, 80
limited legal relevance, 8081
predict recidivism has unknown generalizability, 8182
recommendations:
for current practice, 8485
for research, 8384
review, 72
RRAS, 7879
RRASOR, 7475
SONAR, 7778
SORAG, 72, 7374
Static-99/Static-2002, 7576
SVPASI, 78
VASOR, 79
VRS-SO, 76
sexual recidivism assessments, 7172
decision making, 72
substantial margins of error, 8283
SVP statutes, 425, 432433
Acute dynamic factors, 313

Adaptational model, of response styles, 138

Adaptive functioning, intellectual disability person, 362
Addictive-like sexual behavior, 272273
Adolescent Cognition Scale, 228
Adolescent sex offender, 149, 242
physiologic test, 229
psychological test, 228
Adolescent Sexual Interest Card Sort, 228
Aftercare, 235
Age of consent, 245
Age of juvenile sex offenders, 223
Age of victim, 223
Alcohol use. See Substance abuse
Algolagnia, 341
American Academy of Psychiatry and the Law (AAPL), 211
Ethical Guidelines, 212, 435
Amphetamines, 270271
Anabolicandrogenic steroids (AAS), 271272
Androgen deprivation therapy, 172, 176, 177, 181
Androgen receptor blocking (ARB) agents, 175
Animal studies, 173
Antiandrogens, 163, 234, 254, 384, 430
Antimullerian hormone, 39
Antisocial behavior, 150
and sex offending, 152
Antisocial personality disorder (APD), 145, 147, 149, 270,
381, 402, 405, 406, 436
Anxiety, 126, 150, 224, 243, 315
Archambault Commission, 392, 393
Area Under the Curve, (AUC), 73, 113, 433
Aspergers disorder, 363
Assessment:
comprehensive, 357365
of insanity, 217219

447

448 INDEX
Assessment: (Cont.)
of juvenile sex offense, 244247, 257
of pedophiles, 9495
of personality disorder:
categorical models, 145146
dimensional models, 146147
phallometric, 250, 347
PPG, 95, 105
of psychopathy, 132134
risk. See Risk assessment
sexual recidivism, 7172
of substance abuse, 266
violence risk. See Violence risk assessment
VRT, 103, 229
AASI. See Abel Assessment for Sexual Interests
Association for the Treatment of Sexual Abusers (ATSA),
95, 105, 107, 166
Attention-deficit/hyperactivity disorder (ADHD), 29
Attitudes, sexual, 364365
Aversion therapy, 123
Barratt Impulsivity Scale (BIS), 402
Behavior perspective, 78
Behavioral definitions, 296297
Behavioral interventions, 231, 232
Behavioral therapy, 123
Benzodiazepines, 271
Biological treatments, 124125
Bipolar disorder, 4, 190
Borderline personality disorder, 146, 149
Borderline retarded, 30
Boundary, sexual, 288
Boundary crossing, 289290, 332
Brain injury, 3233
Canada, 58, 70
child pornography, legal definitions, 305306
common law origins for, 387388
and preventive detention, 392395
after August 1997, 397402
sex offender registries and public notification:
legislative developments, 416420
limitations and challenges, 420421
rationale behind, 413414
research, 421422
Cannabis, 271
Casper technique, 370
Castration, 171. See also Orchiectomy
animal studies, 173
biological and behavioral effects in, 176177
consent and, 430
ethical issues and use of, 173
human studies, 174
primate studies, 173174
Catholic Church, 107, 116
Cavernosal artery duplex ultrasonography, 174
Celibacy, clergy, 330331
Central nervous system, 39, 40
Child abuse images, 303
Child molestation, 279280
typology of, 280

Child Molester Empathy Measure (CMEM), 151

Child molesters, 148, 150, 151, 165, 309, 312
Child pornography, 311
definition, 303
dynamic risk factors, 313317
on Internet to acquire and distribute, 306
causes and consequences, 310311
individuals interest, 307309
purpose, 309310
legal definitions, 303
Canada, 305306
European Union, 306
United Kingdom, 306
United States, 303305
negative social influences, 317319
recidivism, 311312
risk assessment and management, 312313
Child Protective Services, 213, 426
Child sexual abuse, 102, 104
allegations of, 324
disseminate images of, 309310
perpetrators of, 324
Children and Young Persons Act, 215
Choice reaction time (CRT) paradigm, 104
Civil commitment, 119, 134, 432
ethical issues in, 435437
of juvenile sexual offenders, 404407
Rhode Island in, 436, 437
of sexual predator, 132
as SVP, 347, 395
Classification of Violence Risk (COVR), 56, 59, 5960
Clergy abuse. See Sexual abuse, by clergy
Clericalism, 325, 329
Clinical assessment, 403
intellectual disability people, 357
juvenile sex offender, 211
SVP statutes, 432433
Clinical interview, 49, 227, 247
Cocaine, 268, 270271
Coercion, 247, 428
sexual arousal to, 9192
Cognitive behavior therapy, 124
Cognitive behavioral interventions, 136, 231232
Cognitive behavioral programs, 136, 160, 166, 334
Cognitive behavioral treatment, 160, 162
Cognitive distortions, 317, 364
Cognitive-behavioral techniques, 136, 348
Collateral information, 214, 227228
Community notification. See Public notification
Community Protection Act (CPA), 395, 414
Community protection model, 412413
Community Protection Task Force (CPTF), 414
Comorbid psychiatric illness, 125
among nonparaphilic sex offenders, 125126
among paraphilic sex offenders, 126127
Competency to stand trial (CST), 216217
Compulsion, sexual, 150
Computer assessments, 251
Conduct disorder, 224, 405, 406
Conduct requirements, 296
Confidentiality, juvenile sex offense, 254

INDEX

Consent, 246247, 430

concern for, 357, 360
informed, 193, 195
Content-oriented motivation, 308
Coping/mood management, psychological treatment
program, 165
Corrections and Conditional Release Act, 419
Counterfeit deviance, 356
Course of conduct, 296
Courts, 109110
Covert sensitization, 123, 232
Criminal convictions, 405
Criminal Justice Act, 215
Criminal justice system, 102, 251, 300
liaisoning with, 125
Criminal responsibility, forensic evaluations, 217
Criminal sexual psychopaths, 394395
Criminological model, of response styles, 137
Cyproterone acetate (CPA), 197198, 234
pharmacokinetic properties of, 197
Czechoslovakia, 176, 177
Dangerous offender (DO), 147, 398, 399, 400
Dangerous sex offenders (DSO), 395
Daubert standard, 109, 110
Day parole eligibility date (DPED), 398, 399
Defensiveness, 137
effects on PCL-R, 133
final caution on measure, 139
general tests of, 138139
sex offender specific tests of, 139
Delinquency adjudications, 405
Denial:
of sex deviance, 138
sex offenders, 136, 137, 253
Denier-dissimulators, 113, 114, 115
Denmark, 176
Depo-Provera, 18
Depression, 150, 224, 243
Developmental phenomenology, of
paraphilia, 1617
Deviant sex:
arousal, 149, 198
behaviors, 164, 253
fantasies, 151, 252
interest, 159, 252, 314
The Diana Screen, 116
Dichotomous outcomes, 73
Dihydrotestosterone, 38, 197
Dimension perspective, 56, 7, 10
Direct observation:
as outcome measure, 370
Disease perspective, 45
Disposition hearing, forensic evaluations, 214215
Dopamine, 41, 43
Dost criteria, 304
Drive-reducing medications, 254255
Drug use. See Substance abuse
DSM, 144, 344, 346, 347
DSM-III, 144145, 342, 346
DSM-III-R, 145, 343

449

DSM-IV, 144, 145, 146, 218, 268, 405, 436

for intoxication, substance abuse and dependence, 266
DSM-IV-TR, 12, 121, 122, 145, 189, 346, 356
paraphilic disorders in, 190
Durham rule. See Product test
Dynamic risk factors, 6264, 227, 313, 403404
Ecclesiastic courts, 386, 387
Emotional loneliness, 310, 316
Empathy, 150151, 164
Epidemiological Catchment Area (ECA) Surveys, 50
Epidemiology:
of female sexual offenders, 281282
of juvenile sex offenders, 222223
of psychoactive substance abuse/dependence, 267268
Essentialists, 9
Estimate of Risk of Adolescent Sexual Offense Recidivism
(ERASOR), 228
Estrogen therapy, 195
Ethical issues, 425
civil commitment statutes, 435437
consent and castration, 430
interviews with victims, 435
opinions without examination, 434435
presentence reports, 427428
pre-trial evaluations for defense attorneys, 425427
prison, treatment in, 428430
SVP statutes, 430434
content of, 430431
operational defining legal language, 431
presentation of evidence, 431
preventive detention, 431432
psychiatry, 432
risk assessment, 432434
treatment, problem of, 437438
Ethical principle, of beneficence, 286287
Etiology:
addictive sexual behavior, 272273
of clergy abuse, 331332
of intellectual disability, 363
of specific sexual interests, 102
Eugenics, 354
Europe, 172
European Union:
child pornography, legal definitions, 306
Exhibitionism, 1920, 277
form of, 6
function of, 6
Family therapy, 232
Fantasy:
deviant, 148, 252
paraphilia, 15, 17, 123
sadism, 346
Female sexual abusers, evaluation, 110113
Female sexual offenders, 276
child molestation, 279280
epidemiology, 281282
exhibitionism, 277
incest, 280281
indecency, 277278

450 INDEX
Female sexual offenders (Cont.)
psychiatric disorders, data on, 282283
psychological trauma, 282283
rape, 278
serial murders, 278279
treatment, 283284
types, 281282
Fetishism, 19
5-HT (serotonin) receptor, 36, 42, 195
Flunitrazepame, 271
Fluoxetine, 41, 42, 44, 196, 234
Flutamide, 175, 193
Forensic clinicians, 136
Forensic evaluation, 379, 425
data, 382383
issue, 379380
of juvenile sex offenders, 211
steps:
clarify request, 211212
collateral information, 214
communicate findings, 214
understand legal rights regarding
interview, 212214
types:
CST, 216217
disposition hearing, 214215
insanity, assessment of, 217219
Miranda rights, waiver of, 215216
waivers to adult court, 215
legal criteria, 380382
reasoning, 383385
Forensic psychiatry, 211
Gamma-hydroxybutyrate (GHB), 271
Gender:
of juvenile sex offenders, 223
of victim, 223
General self-regulation, 315316
Genomic action, 39
Germany, 176, 177
Gladstone Committee, 388, 389, 390
Gonadotropin, 38
Gonadotropin-releasing hormone agonist (GNRH), 172,
173, 175
and orchiectomy, comparison, 182183
Good life, 161
Good Lives Model approach, 161, 162, 165, 166
Group therapy, 127, 232
Habitual criminals, 394
Hallucinogens, 271
Hare Psychopathy Checklist, 366
Historical, Clinical, and Risk Management-20 (HCR-20),
56, 5658
Hormonal modulating agents, 234
Hormonal therapy, 172, 173
Hormonal treatments, 163, 195
Hormones, 3739
Human sexual behavior, neurobiology, 36, 4144
Human studies, 174

Hybrid responding, 137

Hyperesthesia sexualis, 272
Hypersexuality, 43
Hypothalamus, 38
Impulsive character disorders, 333
Impulsivity, 149150, 234, 315
Incest:
child sexual abusers, 114
female sexual offenders, 280281
Indecency, female sexual offenders, 277278
Individual therapy, 233
Informed consent, 182, 193, 195
Insanity, forensic evaluations, 217219
Intellectual disability, persons with, 353
comprehensive assessment, 357
concern for consent, 357, 360
context of behavior, 363364
mental status, 362363
relevant history, 360362
sociosexual knowledge and attitudes, 364365
history, 354355
intervention models, 366
develop supportive, positive and reinforcing environment, 368369
habilitative education, 367368
habilitative mental health, 367
outcome, 369375
phallometry, 365
proactive approaches not effective, 371
risk assessment, 365366
risk factors and vulnerabilities, 357, 358359
sexually offending behavior, prevalence of, 355
judicial system, 355
learning and environmental conditions,
355357
Intelligence quotient (IQ), 30, 362
Intelligence tests, intellectual disability person, 362
Intention, 296
Internet offenders, 13, 2022, 302, 309, 312, 316, 319.
See also Child pornography
Interpersonal relations, personality traits, 151152
Inter-rater reliability, 7980, 348
Intervention models, 366
develop supportive, positive and reinforcing environment, 368369
habilitative education, 367368
habilitative mental health, 367
outcome, 369375
Intimacy deficits, 316317
Intoxication, 265, 266
Irresistible impulse test, 218
Iterative Classification Tree (ICT), 56, 59
Jacob Wetterling Act (JWA), 415, 416
Jake (case study), 222
Josh (case study), 221222
Juvenile court, 214, 215, 404405
Juvenile Sex Offender Assessment Protocol-II
(J-SOAP-II), 228

INDEX

Juvenile sex offenders, 221

aftercare, 235
case example, 221222
classification of, 223224
cognitive behavioral interventions, 231232
epidemiology of, 222223
factors associated with, 224
forensic evaluations, 211
steps:
clarify request, 211212
collateral information, 214
communicate findings, 214
understand legal rights regarding interview,
212214
types:
CST, 216217
disposition hearing, 214215
insanity, assessment of, 217219
Miranda rights, waiver of, 215216
waivers to adult court, 215
psychiatric comorbidity in, 231
psychopharmacological interventions, 233235
psychosocial interventions, 232233
recidivism, 225
factors associated with, 226
rates of, 225226
risk assessment, 225, 226227
clinical interview, 227
collateral information, 227228
empirically guided checklists, 228
physiologic test, 229
psychological tests, 228
static vs. dynamic factors, 227
treatability of, 230231
treatment, 229230
treatment planning, 230
Juvenile sex offense, 241
assessment:
factors of comprehensive, 249
of perpetration, 247249
relationship, 244247
coercion, 247
consent, 246247
equality, 247
sexual interests, 251
characteristics, 223
confidentiality, 254
drive-reducing medications, 254255
mental illness, 254
physiological aspects, of treating sexual behavior problems, 254
polygraph test, 251
PPG, 250251
psychological test, 249250
psychotherapy, 255256
risk assessment, 251253
sexual arousal, measurement of, 250251
SSRIs, 255
treatment, 253
treatment outcomes, assessment of, 257

451

Kansas v. Hendricks, 395397

Kinsey (case study), 174
Klinefelters Syndrome, 201
Laboratory assessment, of sexual arousal, 251
Lascivious behavior and intent, 304
Legislative definitions, 296
Legislative developments:
within Canada, 416420
within United States, 414416
Legislative waiver, 215
Leuprolide acetate, 193, 199, 202203
pharmacokinetic properties of, 200
Level of Service Inventory-Revised (LSI-R), 56
Level of Service/Case Management Inventory
(LS/CMI), 56
Life story perspective, 810
Lifestyle impulsivity, 150
Loneliness, feelings of, 330
Long-term supervision (LTS), 398
Love obsessed stalkers, 296, 297
Lovemaps theory, 1315, 2022
definition, 14
and paraphilia, 1516
and pedophilia, 2223
phenomenology, 23
Lust murder, 344
Luteinizing hormone releasing hormone (LHRH)
agonists, 175, 199200, 200201, 234
MNaghten test, 217, 218, 219
MacArthur Violence Risk Assessment Study, 51, 56, 5960,
61
COVR, 59, 5960
Malingering, 137
Masochism, 19, 333, 342
Masturbation, 314
to child pornography, 317
to Internet imagery, 21
Masturbatory satiation, 123
Medical castration, 172, 175
Medroxyprogesterone acetate (MPA), 172, 198199, 234
pharmacokinetic properties of, 198
Megans Law, 415, 416
Mental abnormality, 80, 381, 383, 384, 402, 407, 436
Mental Age (MA), 362
Mental conditions, 13, 405
Mental disorder, 80, 119, 402, 436
Mental health:
intellectual disability person, 362363
in public sphere, 292
Mental health law, 391
Mental health professionals (MHPs), 49, 211, 212, 218, 229,
287288, 402
guideline, 288289
Mental illness, 119, 219, 254
sex offenses, 120121
and violence risk assessments, 50
Mental retardation, 30, 126
Mental status examination, 362363

452 INDEX
Millon Clinical Multiaxial Inventory-III
(MCMI-III), 402
Minnesota Multiphasic Personality Inventory-Adolescent
(MMPI-A), 250
Minnesota Multiphasic Personality Inventory-Second
Edition (MMPI-2), 134, 138
Minnesota Sex Offender Screening Tool-Revised
(MnSOST-R), 7677
Monoamine neurotransmitters, 233
Mood disorder, 126, 150, 255
Moral health, 292
Motivational interviewing, 162
Multiphasic Sex Inventory (MSI), 250
Multiphasic Sex Inventory-II (MSI-II), 139
Multiscale inventories, in forensic assessments, 134
Nave, sexual misconduct, 332
Naltrexone, 234235, 273
Narcissistic character disorders, 333
National Parole Board, 399
National Sex Offender Registry (NSOR), 417, 418, 419
Necrophilia, 343344
the Netherlands, 181
Neurobiology, of sexual behavior, 36, 4144
hormones, 3739
human, 4144
neurohormones, 3738
neurotransmitters, 3738
sexual arousal, 4041
sexual differentiation, 3940
sexual dysfunction, 41
Neurohormones, 3738
Neuropsychological findings, in sex offenders, 27
brain injuries, 3233
grade failures and school dropouts, 2829
handedness, 3132
intelligence, 3031
test battery, 32
Neurosecretory cells, 37, 38
Neurotransmitters, 3738, 40
New Jersey, 78, 380381, 421
Normal to mildly neurotic, sexual misconduct, 332333
Normative tests, sex offender evaluations, 383
Norway, 176
Obsessive-compulsive disorder (OCD), 43
Offense pathways, psychological treatment program, 164
Offense supportive cognitions, 317
Offense-specific treatment, 253, 255
Olfactory stimuli, 40
One size fits all approach, 162
Ontario Sex Offender Registry, 418
Opioid use, 271
Orchiectomy, 124, 125, 171. See also Castration
cases of sex offenders undergoing, 173
description of procedure, 181
ethical and informed consent issues, 182
history, 172173
and long-term GNRH suppression, comparison, 182183
management, 181182

monitoring considerations, 183184

morbidity and mortality, 181
prostate cancer, 174
androgen deprivation therapy, 176
castration effects on sexual functioning, 175
costbenefit analyses, 175
patient preference of medical over surgical treatment
for, 174175
recidivism study, 177181
side effects, 181
testicular cancer study, 174
treatment, 183184
Orgasm, 123
Oscar Wilde, 388389
Osteopenia, 200
Osteoporosis, 181, 200
Oxytocin, 38
Pam Lychner Sexual Offender Tracking and Identification
Act, 416
Paraphilia(s), 12, 2022, 121, 122, 224, 342
categories of, 44
comorbidity of, 268
complementary, 1819
definition, 13
developmental phenomenology of, 1617
diagnosis of, 23, 365
exhibitionism, 1920
and lovemaps, 1516
and medical disorders, relationship between, 127
motivation of, 16
multiplex, 1718
pharmacological treatment for, 44, 195
risk factors and vulnerabilities associated with, 358359
sexual arousal of, 16
and SSRIs, 196197
voyeurism, 1920
Paraphilia-related disorders, 43
Paraphilic mental disorder, sex offense, 121124
Paraphilic sex offenders, pharmacological treatment, 189
case example, 189, 190
CPA, 197198
pharmacokinetic properties of, 197
LH-RH agonists, 199200, 200201
MPA, 198199
pharmacokinetic properties of, 198
osteopenia, 200
osteoporosis, 200
rationale, 190
diagnostic work-up, 190, 193
informed consent, 193, 195
medical work-up, 193
testosterone-lowering treatments, 195
SSRIs, 195197
Parole, sex offenders, 427
Parole boards, 398, 428
Parole eligibility date (PED), 398
Parole officers, 77, 79, 319
Pathogenic model, of response
styles, 137138

INDEX

Paulhus Deception Scale (PDS), 138139

Pavlovs model, 123
Pedophile(s), 22, 27, 426, 428
assessment of, 9495
Pedophilia, 2223, 122, 436
sensitivity and specificity of PPG tests, 95
Penile plethysmography (PPG), 101, 105, 110, 139,
250251, 383
in sexual interests assessment, 89
forensic issues, 9596
historical overview, 8990
measurement techniques, 90
faking and dissimulation, 9394
pedophiles, assessment of, 9495
stimulus sets, 91
testing sexual arousal to coercion, 9192
Penile tumescence testing (PTT), 89, 94
Penitentiary Act, 393
Peptide hormone, 37, 38
Performance IQ (PIQ), 3031
Persistent stalking, 299
Personality Assessment Inventory (PAI), 134, 138
Personality disorder, 381, 383, 384, 407. See also Antisocial
personality disorder; Borderline personality disorder; Sadistic personality disorder
in sexual offending, 144, 147149
assessment:
categorical models of, 145146
dimensional models of, 146147
definition of, 144145
prevalence of, 147
Personality traits, in sexual offending, 149
compulsion, 150
empathy, 150151
impulsivity, 149150
interpersonal relations, 151152
Perversion, 9, 121, 122
Phallometric assessment, 250, 308, 347
Phallometric test:
of individuals with intellectual disability, 365
Pharmacological treatment, of paraphilic sex offenders, 189
case example, 189, 190
CPA, 197198
pharmacokinetic properties of, 197
LH-RH agonists, 199200, 200201
MPA, 198199
pharmacokinetic properties of, 198
osteopenia, 200
osteoporosis, 200
rationale, 190
diagnostic work-up, 190, 193
informed consent, 193, 195
medical work-up, 193
testosterone-lowering treatments, 195
SSRIs, 195197
Pharmacotherapy, 273
Phobias, 13
Physiological arousal tests, sex offender evaluations, 383
Plethysmography, 96, 229, 257
Polygraph test:

in juvenile sex offense, 251

in sex offender treatment, 139
Positron emission tomography (PET) scan, 127
Possible risk factors, 226
PPG. See Penile plethysmography
Prepubescent and postpubescent sexual behaviors,
245246
Preventative indeterminate detention (PID), 399
Primate studies, 173174
Prison reform, 388
Probability values, 113115
Probation, sex offenders, 427
Probation officers, 77, 79, 319
Problems of Immediate Gratification (PIG), 315
Process-oriented motivation, 308
Product test, 218
Professional sexual misconduct, 286
category, 293
by MHPs, 287288
guideline, 288289
Progesterone, 125
Program for Professionals, 290
diagnosis, 292
easy vs. difficult cases, 291292
evaluation, elements of, 290
moral and mental health, in public sphere, 292
referral, sources of, 291
Prolactin (PRL), 37, 38
Promising risk factors, 226
Prostate cancer, 174
androgen deprivation therapy, 176
castration effects on sexual functioning, 175
costbenefit analyses, 175
patient preference of medical over surgical treatment
for, 174175
Prostitutes, 9
Psychiatric comorbidity, 126
in juvenile sex offenders, 224, 231
Psychiatric disorders, 282283
Psychoactive substance abuse/dependence:
on aggressive and sexual behavior, 269
comorbidity of, 268
in sexual offenders:
epidemiology, 267
methodological issues, 267
Psychoeducational interventions, 231
Psychological trauma, 282283
Psychological treatment, of sexual offenders, 159
contentious issues, 160162
integrated positively-oriented treatment program,
162165
acceptance of responsibility, 163164
coping/mood management, 165
life history, 163
offense pathways, 164
self-esteem, 163
self-management plans, 165166
sexual interests, 165
social and relationship skills, 164165
victim harm/empathy, 164

453

454 INDEX
Psychopathic Personality Inventory (PPI), 133
Psychopathic rapists, 131
Psychopathy, in sex offenders:
application:
and recidivism, 131132
subtyping, 131
assessment, 132
multiscale inventories, 134
PCL-R, 130, 131, 132133
PPI, 133
SRP-II, 133134
definition, 130
overview of, 130131
and response styles. See Response styles, in sex offenders
and role in management and treatment, 135136
and sexual predator laws, 134135
Psychopathy Checklist-Revised (PCL-R), 58, 62, 74, 130,
131, 132133
Psychopathy Checklist-Screening Version (PCL-SV), 62
Psychopharmacological interventions, 233235
Psychosocial interventions, 232233
Psychostimulants, 270271
Psychotherapy, 255256
Public notification:
in Canada:
legislative developments, 416420
limitations and challenges, 420421
rationale behind, 413414
research, 421422
in United States:
legislative developments, 414416
limitations and challenges, 420421
rationale behind, 413414
research, 421422
Quality of life, 369
Ralph (case study), 221
Random Controlled Trial (RCT), 162, 166
Rape:
female sexual offenders, 278
of propertied virgin, 387
PPG, 92
Rape proneness, 91, 92
Rapid response impulsivity, 149
Rapid Risk Assessment for Sexual Offense Recidivism
(RRASOR), 7475
Rapists:
and child molesters, comparisons between, 148
paraphilia, 23
preferential, 345
psychopathic, 131
Receiver Operating Characteristic (ROC) curve, 73, 113,
433
Recidivism:
actuarial risk assessment, 7172
child pornography and, 311312
factors associated with, 226
of juvenile sex offenders, 225
as outcome measure, 370

predict, has unknown generalizability, 8182

psychopathy and, 131132
rates of, 225226
stalking, 298300
substance abuse, 273
surgical castration on, 177181
Registrant Risk Assessment Scale (RRAS), 7879
Relapse prevention (RP), 124, 160, 232, 335
Relationship skills, psychological treatment program,
164165
Relief from responsibility, 391
Response styles, in sex offenders, 136
defensiveness, 137
final caution on measure, 139
general tests of, 138139
sex offender specific tests of, 139
definition of, 137
explanatory models of, 137138
adaptational model, 138
criminological model, 137
pathogenic model, 137138
overview of, 136137
Reward delay impulsivity, 149
Rhode Islands civil commitment statute, 436, 437
Risk assessment, 312313
of child pornography, 312313
of intellectual disability persons, 365366
of juvenile sex offenders, 225, 226227, 251253
clinical interview, 227
collateral information, 227228
empirically guided checklists, 228
physiologic test, 229
psychological tests, 228
of sexual predator, 402404
Risk for Sexual Violence Protocol (RSVP), 85
Risk/Needs Model, 161, 162
Roman Catholic Church, 324, 325
Ronald (case study), 222
Royal Canadian Mounted Police (RCMP), 418
Sadism, 19, 340, 342
Sadistic murder, 344345
Sadistic personality disorder, 149, 342
Sadistic rape, 345346
Sadomasochism, 1213, 18, 19
Satiation therapy, 165
Schizophrenia, 52, 127, 190, 437
Selective serotonin-reuptake inhibitors (SSRIs), 42, 163,
195197, 233234, 255
and paraphilias, 196197
Self-confidence, 163
Self-defeating, 333
Self-esteem, 163
Self-management plans, 165166
Self-medication hypothesis, 272
Self-Report of Psychopathy-2nd Edition
(SRP-II), 133134
Self-report personality measures, 145
Serial murders, female sexual offenders, 278279
Serial stalking, 299

INDEX

Serotonergic agents, 125

Serotonin (5-HT) receptor, 36, 42, 195
Sertraline, 44, 196, 283
Severely neurotic, sexual misconduct, 333
Sex Offender Information Registration Act (SOIRA), 418,
419
Sex Offender Need Assessment Rating (SONAR), 7778
Sex offender registries (SORs), 412
in Canada:
legislative developments, 416420
limitations and challenges, 420421
rationale behind, 413414
research, 421422
in United States:
legislative developments, 414416
limitations and challenges, 420421
rationale behind, 413414
research, 421422
Sex Offender Risk Appraisal Guide (SORAG), 72, 7374,
75, 365, 366
Sex offenders. See also individual entries
actuarial risk assessment:
limitations, 7980
limited clinical utility, 80
limited legal relevance, 8081
predict recidivism has unknown generalizability,
8182
recommendations, 8384
review, 7279
sexual recidivism assessments, 7172
substantial margins of error, 8283
addictive-like behavior in etiology of, 272273
civil commitment of, 119
diagnosis of, 23
evaluation of, 135
neuropsychological findings in:
brain injuries, 3233
grade failures and school dropouts, 2829
intelligence, 3031
test results, 3132
psychological treatment, 159
contentious issues, 160162
integrated positively-oriented treatment program,
162166
psychopathy in
application, 131132
assessment, 132134
definition, 130
overview of, 130131
and role in management and treatment, 135136
and sexual predator laws, 134135
response styles in:
defensiveness, 137, 138139
definition of, 137
explanatory models of, 137138
overview of, 136137
Sex offenses. See also individual entries
in context of major mental illness, 120121
treatment considerations, 121
in context of paraphilic mental disorder, 121124

455

cognitive behavior therapy and relapse prevention,

124
treatment considerations, 123124
Sexual abuse, by clergy, 324
direction, 336
etiological factors of, 326332
interpersonal, 328329
intrapersonal, 327328
systemic, 329331
prevalence of, 326
prevention, 333334
screening, 333334
treatment programs, 334335
typology, 332333
Sexual abuse cycle, 256
Sexual Abuse Treatment Program (SATP), 428, 429
Sexual addiction, 330
Sexual aggression, 28, 234, 267
and persons with developmental disabilities, relationship
between, 354, 356
substance use on, 269, 269
treatment for, 235
Sexual arousal, 4041, 102
to coercion, 9192
measurement of, 250251
of paraphilia, 16
phallometric assessment of, 308
Sexual assault, 144, 252
Sexual attraction, 102
Sexual behavior, 102, 195
addictive, 272
neurobiology, 36, 4144
hormones, 3739
human, 4144
neurohormones, 3738
neurotransmitters, 3738
sexual arousal, 4041
sexual differentiation, 3940
sexual dysfunction, 41
normality of, 4, 6, 8, 1011
online, 308, 310, 311, 314
of persons with intellectual disability, 363
physiological aspects, 254
in prepubescent and postpubescent children, 245246
substance use on, 269
Sexual boundary violation, 288, 289
Sexual compulsivity, 150
Sexual contact offending, 311
Sexual crime, 425426
surgical castration studies and castration effects on
recidivism, 178180
Sexual desire, 102
Sexual deviancy syndrome, 224
Sexual deviation, 138, 314
Sexual differentiation, 37, 3940
Sexual dysfunction, 41, 43, 270
Sexual interests, 102, 251
child pornography, 313315
penile response in assessment:
forensic issues, 9596

456 INDEX
Sexual interests (Cont.)
historical overview, 8990
measurement techniques, 90
faking and dissimulation, 9394
pedophiles, assessment of, 9495
stimulus sets, 91
testing sexual arousal to coercion, 9192
psychological treatment program, 165
VRT measures of, 102, 104, 111
Sexual Knowledge, Experience, Feelings and Needs Scale
(Sex Ken-ID), 364365
Sexual misconduct, typology of, 332333
Sexual normality, 3
and behavior perspective, 78
and disease perspective, 45
and dimension perspective, 56
form and function, 67
and life story perspective, 810
Sexual orientation, 41, 90, 102
Sexual predator laws, 386
common law origins, 386388
for Canada, 387388
for United States, 387
and Kansas v. Hendricks, 395397
psychopathy and, 134135
Sexual preference, 41, 102
Sexual psychopath laws, in United States, 391392
Sexual sadism, 340
diagnosis of, 346348
necrophilia and, 343344
prevalence, 341
rating scale for, 349
treatment of, 348
types, 342343
Sexual self-regulation, 313315
Sexual violence, 71, 130
acts of, 381
Sexual Violence Risk-20 (SVR-20), 85
Sexually abusive youths, 242243
classification, 243
recidivism rates, 244
Sexually dangerous person (SDP), 396, 406
Sexually explicit conduct, 304
Sexually violent predator (SVP) statutes, 7072, 134135,
147, 380, 396, 413, 425
content of, 430431
operational defining legal language, 431
presentation of evidence, 431
preventive detention, 431432
psychiatry, 432
risk assessment:
actuarial and clinical aspects of, 432433
limits to accuracy, 433434
Sexually Violent Predator Assessment Screening
Instrument (SVPASI), 78
Simple obsessed stalkers, 296, 297
Single-incident stalking, 299
Social constructionists, 9
Social isolation, 243

Social skills, psychological treatment program, 164165

Sociopathic character disorders, 333
Sociosexual knowledge and attitudes, 364365
SSKAAT-R tool, 364
SORs. See Sex offender registries
Stable dynamic factors, 313
general self-regulation, 315316
intimacy deficits, 316317
offense supportive cognitions, 317
sexual interests/sexual self-regulation, 313315
Stalking, 295
behavioral definitions, 296298
legislative definitions, 296
recidivism profile, 298300
relationship typology, 298
Stand-alone treatment, 125
Static risk factors, 6162, 227, 253, 403
Static-99/Static-2002, 7576, 84
Steroid hormones, 37, 38, 39
Substance abuse, 52, 224, 265, 266, 268270. See also
Psychoactive substance abuse/dependence
assessment, 266
diagnosis, 266
pharmacology, 268
recidivism, 273
treatment, 273
Substance dependence, 266
Supported risk factors, 226
Surgical castration, 171, 172, 174, 175
SVP. See Sexually violent predator
Sweden, 181
Switzerland, 176177
Tactile stimuli, 40
Testicular cancer, treatment of, 174
Testosterone, 37, 38, 41, 124125, 175, 197, 201
lowering treatments, 195
Therapeutic interventions, 231
Threat/control-override (TCO) symptoms, 51, 63
Tourettes disorder symptoms, 43, 363
Transcription factors, 39
Transcriptional complex, 39
Transvestic fetishism, 19
Traumatic brain injury, 3233, 127
Treatment:
biological, 124125
cognitive behavioral, 160, 162
of female sexual offenders, 283284
hormonal, 163, 195
of juvenile sex offenders, 229230
of juvenile sex offense, 253
of mental illness, 121
offense-specific, 253, 255
of orchiectomy, 183184
outcomes, 257
of paraphilic mental disorder, 123124
pharmacological. See Pharmacological treatment, of
paraphilic sex offenders
in prison, 428430

INDEX

problem of, 437438

psychological. See Psychological treatment, of sexual
offenders
psychopathy, 135136
of sexual abuse, by clergy, 334335
for sexual aggression, 235
of sexual sadism, 348
stand-alone, 125
of substance abuse, 273
of testicular cancer, 174
Triptorelin, 201, 202203
Typology:
of child molestation, 280
of sexual misconduct, 332333
stalking relationship, 298
Uniform Law Conference of Canada, 393
United Kingdom, 306
United States, 70, 134, 172173
child pornography, legal definitions, 303305
civil commitment:
of juveniles as sexual violent persons, 404407
common law origins for, 387
National Center for Victims of Crime, 296
risk assessment approaches, 402404
sexual psychopath laws in, 391392
SORs and public notification:
legislative developments, 414416
limitations and challenges, 420421
rationale behind, 413414
research, 421422
Unlikely risk factors, 226
Vaginal photoplethysmography, 110, 111
Vaginal pulse amplitude (VPA) signal, 110, 111
Vampirism, 343
Vandalized lovemap, 15, 16
Verbal IQ (VIQ), 3031
Vermont Assessment of Sex Offender Risk (VASOR), 79
Victim:
age of, 223
of female babysitter perpetrators, 280
gender of, 223
interviews with, 435
relationship to, 223

457

response of, 296

and stalker, relationship between, 300
Victim harm, psychological treatment program, 164
Victim Sensitive Offender Therapy, 335
Violence Risk Appraisal Guide (VRAG), 55, 58, 5859, 74,
366
Violence risk assessments, 49
clinical approach to, 60
vs. clinician-based prediction, 5455
contextual basis for, 4950
factors associated with, 6061, 61
by mental health professional, 52
and mental illness, 50
methods, 53
risk factors for, 60
and TCO symptoms, 51
tools, 5556
Violence Risk Scale (VRS), 56
Violence Risk Scale-Sex Offender Version (VRS-SO), 76
Violence Screening Checklist (VSC), 55
Visual erotic stimulation (VES) tests, 174
Visual reaction time (VRT), 101, 229, 251
AASI and courts, 109110
children in their workplace, 116
early development and validity of, 103107
female sexual abusers, evaluation, 110113
Cronbachs alphas, 112
intellectual disabilities and illiterate, 115116
measurement of, 103, 104, 106, 111
probability values, 113115
screen to assessment instrument, 107109
theoretical foundations, 102103
Voyeurism, 1920, 345
Waivers:
to adult court, 215
of confidentiality, 254
of Miranda rights, 215216
Walsh Act, 416
Wechsler Adult Intelligence Scale-Revised
(WAIS-R), 30, 31
Youth Criminal Justice Act (YCJA), 215
Zacharys Law, 415