Treating Sex Offenders

1
Treating Sex Offenders

• Dr Jeremy ODea
• Forensic Psychiatrist

2
Sex Offenders

• Heterogenous Group
• Defined by Diverse group of Illegal Behaviours
• Cf to thieves
• Change over time eg Homosexuality
• Variety of psychiatric problems and diagnoses
• Differing treatment needs
• ?Antidepressants for all who attempt suicide

3
Risk of Sexual Recidivism

• Relatively Low
• 10-13
• Sexual Deviance
• History Sexual Offending
• Sexually Deviant Arousal
• Small group with multiple re-offending
• Identify/treat/reduce risk

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Risk Assessment

• Actuarial Risk Assessment
• Static 99
• SONAR

• Clinical Risk Assessment
• Psychiatric Assessment
• Paraphilias
• HCL 20
• ?Penile Plethysmography

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Actuarial Risk Assessment

• Objective and Reliable
• Empirically Driven with Little Theoretical
  Foundation
• Questionable generalisation to other populations
• Static historical data generating Static risk
• Not amenable to change
• Ignore individual factors
• Make statements about groups not individuals
• Little use in low frequency behaviours like
  sexual recidivism with individuals

6
Clinical Risk Assessment

• Thorough psychiatric assessment with reasoned
  opinion
• Understanding phenomenology of sexual behaviours
  for the purpose of treatment/risk management
• Paraphilias
• Patient focused and treatment orientated
• Should take into consideration actuarial risk
  assessment tools
• Both static and dynamic risks

7
Static 99Actuarial Risk Assessment Tool

• Over 1000
• Prisoners and secure psychiatric patients
• Canada and UK
• Followed for up to 30 years
• Looked at factors on RRASOR and SACJ-Min that
  best predicted recidivism

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Static 99, Items

• Prior Sex Offences 3
• Charges/Convictions
• Prior Sentencing Dates (4) 1
• Any Convictions for 1
• non-contact sex offences
• Index Non Sexual Violence 1
• Prior Non Sexual Violence 1
• Any Unrelated Victim 1
• Any Stranger Victim 1
• Any Male Victim 1
• Age Under 25 1
• Single No 2 year live in relationship 1

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Static 99, Risk Categories

• Low 0,1/12
• Medium-Low 2,3/12
• Medium-High 4,5/12
• High 6/12

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Static 99,Hanson, Thornton, 2002

• Moderate predictive accuracy
• Sexual Recidivism
• Violent Recidivism
• Critics could suggest that insufficient for
  decision making
• Correlation 0.3
• Only accounts for 10 of the variance
• Given its lack of dynamic factors, it cannot be
  used to
• select treatment targets
• measure change
• evaluate whether offenders have benefited from
  treatment

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Dynamic Risk Factors

• Sexual Deviance - Paraphilias
• Substance Abuse
• Psychiatric Illness
• ?Personality Disorder
• Social Situation
• Other

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Preventative Detention

• Queensland
• Dangerous Prisoners (Sexual Offenders) Act 2003
  (Q) Act
• Empowers State court to order continuing
  detention of persons convicted of serious sexual
  offences after expiry of their sentence where
  there is an "unacceptable risk" of the prisoner
  committing a serious sexual offence in the future
• Upheld by High Court, Oct 2004

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Civil Commitment

• Kansas v Hendricks (1997)
• Confinement to Mental Institution
• Dangerousness without Mental Illness
• Judge or Jury Decision
• Substantial Probability of engaging in sexually
  violent acts
• Beyond Reasonable Doubt

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Treatment Programs in NSW

• Custody Based Treatment Programs
• DCS Psychology
• Based on risk assessment on Static 99
• CUBIT and others
• Relapse prevention
• Community Based Treatment
• DCS Psychology
• Others

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SOTEP

• 1985
• Sex Offender Treatment and Evaluation Project
• California
• Sentenced Prisoners
• Rape
• Child Molestation

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Eligible Participants

• Inclusion Criteria
• Within 14 to 30 months of release
• Between 18 and 60
• No more than 2 prior convictions
• Admit committing their offence(s)
• No pending warrants
• IQ above 80
• Speak English
• No psychotic or organic mental disorder
• Not medically debilitated
• No prison management problems

• Exclusion Criteria
• Gang Rapists
• Biological Incest Only

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3 Groups

• Volunteer Group
• Treatment Group
• Volunteer Control Group
• Non Volunteer Group
• Non Volunteer Control Group

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Treatment

• Relapse Prevention
• CBT
• Atascadero State Hospital
• 2 years
• 40 50 hours per week
• Sex Offender Aftercare Program
• 1 year

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Published

• 1994, Behaviour Research and Therapy
• Omitted treatment Drop Outs
• 1994, Criminal Justice and Behaviour
• Included Treatment Drop Outs
• Not cited by Cochrane
• 1999, Journal of Interpersonal Violence

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Statistical Significance

• Treatment subjects showed lower risk for new sex
  offences than did Volunteers only
• Higher rate of sex re-offences for Ex-treatment
  group compared to Completed Treatment Group
• For Child Molesters Treatment Group at lower
  risk for violent offences than was the Volunteer
  Control Group only
• The married men in the treatment group had a
  lower risk of sex re-offence only against the
  NonVolunteer Control Group

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Negative Findings - Overall

• Volunteer Controls did better than the Treatment
  Group in terms of sex re-offending
• Treatment Group had the highest rate of violent
  re-offending

22
Negative Findings - Rapists

• Non Volunteer Control Rapists had the lowest risk
  of sex re-offending
• Treated Rapists had the highest rate of violent
  re-offending

23
Negative Findings - Child Molesters

• Treated Child Molesters re-offended at a higher
  rate than Volunteer Controls
• If married men did better with treatment, single
  men did much worse

24
NSW

• As no evidence that Relapse Prevention
  significantly reduces risk of sexual recidivism
• ?Appropriateness of tailoring prison sentence to
  accommodate completion of such treatment program
• ?Appropriateness of delaying parole to complete
  program

25
Other Psychological Treatments

• Community Based
• Supervision
• CBT
• Relapse Prevention
• Psychological treatments in combination with
  Psychotrophic Medication in selected individuals

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Psychopharmacological treatments

• In selected patients with paraphilias

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Castration

• USA
• Chemical and Surgical
• 9 States
• Voluntary and Mandatory

28
NSW

• Call to castrate child sex offenders
• Opposition justice spokesperson
• ?Condition of parole
• ?Mandatory

29
France

• Justice Minister
• 2 year trial
• Leuproreline and Cyproterone Acetate
• Voluntary
• 48 repeat offenders
• Denmark,Sweden,Canada

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Psychiatric Treatment

• Appropriate patient populations
• Paraphilias v Sex Offences
• DSM IV TR
• Efficacy
• Tolerability
• Best available option
• Consent

31
Consent to Treatment

• Involuntary
• Guardianship Tribunal
• Mental Health Acts
• ?Mandatory Treatment
• Risk/Benefit
• Evidence Base

32
What is the medical evidence?

• Where does it come from?

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Evidence

• Animal Husbandry
• Eunuchs and Castrati
• Surgical Castration Studies
• Voluntary and Involuntary
• Testosterone and Sexual Behaviour in Men
• Testosterone Lowering Medications
• Antipsychotics and Antidepressants

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Surgical Castration
Study Follow up Period (Years) Number of Subjects Pre-op rate of recidivism () Post-op rate of recidivism () Comparison group rate of recidivism ()
Germany, Langeluddeke, 1963 Up to 20 1036 84 2.3 39
Switzerland, Cornu, 1973 5 127 77 7.4 4.1 66 - 52
Norway, Bremer, 1959 1 - 10 215 58 2.9 - 7 -
Denmark, Sands, 1964 Up to 30 738 - 1.4 2.4 9.7
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Medication(Chemical Control)

• Oestrogens
• Progestogens
• Medroxy Progesterone Acetate (MPA), Provera
• Anti-androgens
• Cyproterone Acetate (CPA), Androcur
• Flutamide
• Nilutamide
• SSRIs
• Others

36
Medication(Chemical Control)

• GNRH agonists
• Triptorelin
• LHRH Agonists
• Leuprolide acetate
• Goserelin

37
Therapeutic Trials

• Methodological Problems
• Heterogenous Groups
• Small Sample Sizes
• Single Case Studies
• Double blind/Placebo controlled
• Drop Outs
• Self Report
• Follow up periods

38
CPA

• Bradford and Pawlak, 1993
• Double-blind placebo crossover trial
• Superior to placebo
• Self Report and physiological measures
• Some preferential targeting of deviant fantasies
• Cooper, 1992
• MPA and CPA equally effective in double
  blind-placebo controlled comparison

39
GNRH/LHRH Analogues

• 4 case reports, 1 case control study
• 7 open uncontrolled studies
• 1 study comparing with CPA
• Rosler and Witztum, 1998
• Triptorelin
• Observational, uncontrolled study
• 30 paraphiliacs over 42 months

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SSRIs

• Case Reports
• Small open label studies
• 50-90 response rates