Rape and other sexual assaults are a public health problem of major proportions. The women's movement has been effective throughout the past 30 years in generating research support and efforts at prevention. However, there is much work yet to be accomplished in the prevention of sexual assaults and the treatment of sex offenders, as evidenced by the high number of sexual assaults that still occur. In the United States in 1998, 110,000 rapes, 89,000 attempted rapes, and 133,000 sexual assaults were reported to authorities, with an estimated 300,000 additional rapes and sexual assaults going unreported. In 1998, 1.5 of every 1,000 persons in the United States were victims of a sexual assault.1
Although these figures represent a significant decline compared with 1993 statistics, rape and sexual assault continue to be a major source of physical and psychiatric morbidity in the United States and heavily influence patterns of interpersonal and sociologie behavior, as well as public policy. Fear of sexual assault and protective behaviors designed to minimize the chances of being sexually assaulted are prevalent among all demographic classes. Studying perpetrators of rape and sexual assault is imperative to develop better models of understanding of the biological, psychological, and social factors that combine to produce a sex offender.
Alcohol and drug dependence are also public health issues of immense proportions. In the United States, the Epidemiological Catchment Area study found a 13.5% lifetime prevalence of alcohol abuse or dependence and a 7% lifetime prevalence of drug dependence.2 Drug and alcohol use disorders are major sources of physical and psychiatric morbidity, with significant impact on the prevalence of accidents, suicides, homicides, fetal anomalies, and many systemic illnesses.3 Alcohol and drug use frequently play a role in the commission of sex offenses. Better understanding of the complex interplay between sex offenders and addictive disorders will result in increased predictive accuracy and more effective treatment programs for sex offenders.
The term sex offense broadly connotes any illegal conduct of a sexual nature. Rape, which is a more specific term, is defined as vaginal, anal, or oral intercourse involving either force or threat of force, forced or covert use of intoxicants, or sex with an underage or incompetent person. Sexual battery is defined as touching of an erogenous zone of another person for the purpose of sexual arousal or gratification, using force or coercion.4 Other sex offenses include gross sexual imposition, voyeurism, importuning, public indecency, pandering obscenity, and corruption of a minor.
Paraphilias are a group of diagnostic entities described in the DSM-IV5 that include such behaviors as exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, voyeurism, and, less commonly, necrophilia and zoophilia. Pedophilia is one of the most abhorrent paraphilias and almost universally evokes strong feelings of repulsion among the general population. Pedophilic acts violate the trust placed in adults by children and uniformly result in substantial morbidity among victims. Pedophilia is relatively uncommon and has a strong male predominance. However, it is often perceived as having a higher prevalence because most pedophiles commit multiple offenses with more than one victim. Abel et al.6 estimated that homosexual pedophiles may commit an average of 240 pedophilic acts.
In the absence of overt pedophilia, many individuals report a subclinical attraction toward children without meeting the DSM-IV criteria for pedophilia. In one study, 22% of adult men and 3% of adult women reported a history of sexual attraction toward children. However, the number of adults reporting sexual fantasies about children (men 4.4%, women 1.1%), masturbation to fantasies about children (men 5.6%, women 0%), and the belief that a sexual encounter with a child was likely (men 3.3%, women 0%) was much lower.7
The term substance dependence implies a duster of cognitive, behavioral, and physiological symptoms, mdicating that the individual continues to use the substance despite significant substance-related problems.5 Symptoms of substance dependence may include compulsive and repeated self-administration of the substance, accompanied by tolerance and withdrawal to the effects of the substance. The term addiction comes from the Latin word addictus, which means "to give assent." A modern definition of addiction is "to give oneself up to some strong habit, usually in the passive voice."8 Clinical definitions of the term addiction generally focus on addiction to substances (eg, opiate addiction), and, to a lesser extent, addiction to gambling. The term addiction connotes preoccupation with a substance or behavior, compulsive use of a substance or a compulsive behavior, and the potential for relapse. References to sexual addiction are common in the lay press, but the concept of sexual addiction has yet to receive general clinical acceptance.
Although not all individuals who commit sex offenses are mentally ill, psychiatric comorbidity may occur in many individuals with deviant sexual behavior, including psychotic disorders, substance abuse or dependence, personality disorders, and learning disabilities.9 McEIroy et al.10 interviewed 36 male sex offenders who were admitted to a residential sex offender treatment facility and found that 83% had a substance use disorder, 58% a paraphilia, 61% a mood disorder (36% with bipolar disorder), 39% an impulse control disorder, 36% an anxiety disorder, and 17% an eating disorder. Twenty-six percent of the subjects met criteria for antisocial personality disorder. Other researchers have also found increased prevalence of mood, anxiety, substance use, and impulse control disorders in adolescent sex offenders,11 adults with compulsive sexual behaviors,12 and adults with paraphilia.13
The number of sexual offenders who offend due to a mental illness has been estimated to range from 0.3% in a sample of alleged rapists,14 to 15% within a medium security psychiatric unit in the United Kingdom,15 to 24% among those released from a maximum security psychiatric setting.16 These hospitalized individuals almost always have a diagnosis of schizophrenia or bipolar disorder.9
Qassifìcation systems that characterize the psychopathology of sexual offenders can facilitate an understanding of offenders' behavior and reduce the risk of further offending on release. Faulk17 proposed a typology for the psychopathology and motives of sex offenders, although sex offenders can have characteristics of more than one group (Table 1).
Persons with pedophilia have been shown to exhibit more deviant sexual arousal than other types of sex offenders, such as nonpedophile rapists and hebephiles (also known as frotteurs).19 There is limited evidence to suggest that clinically nonpsychotic convicted child molesters display subtle psychotic tendencies on projective psychological testing.20'21
In discussing the broad topics of substance dependence, addictions, paraphilias, and sexual offenders, three questions naturally arise:
1. Are paraphilic disorders addictions?
2. What is the relationship between sexual offenders and paraphilias?
3. What is the relationship between sexual offenders and substance abuse disorders?
Typology for the Psychopathology and Motives of Sex Offenders, According to Faulk*
Are Paraphilic Disorders Addictions?
As described earlier, substance dependence has been clearly recognized as an addiction and is the model for studying any type of addictive behavior. There are a number of similarities between the diagnostic criteria and clinical features of paraphilias and substance dependence (Table 2). Paraphilias, by definition, involve recurrent and intense sexually arousing fantasies, urges, or behaviors causing clinically significant distress or impairment in social, occupational, or other important areas of functioning. Substance dependence involves, in addition to certain physiological factors, recurrent use of a substance leading to clinically significant impairment or distress. Both paraphilias and substance dependence involve a recurrent pattern of behavior (paraphilic or intake of a substance) that is compulsive and leads to significant distress or impairment. Many individuals with paraphilia report an escalation of their paraphilic behavior over the course of time, which may be described as a form of tolerance to its effects. Just as substance users often abuse more than one type of substance, Abel et al.22 reported that the paraphilic experience was not one-dimensional; most sex offenders with paraphilia had significant experience with as many as 10 different types of sexual behaviors, without regard to gender, age, and familial relationship to the victim.
Comparison of Paraphilias and Substance Dependence
Further supporting the theory that paraphilias are addictions is the fact that some individuals with paraphilia respond to treatment with 12-step programs modeled after Alcoholics Anonymous. This is consistent with the model that both substance abuse and sexual addiction are forms of pleasure seeking that have become habitual and self-destructive.23
Based on these factors, the argument could be made that paraphilias do have some of the qualities inherent to the concept of addiction. On the other hand, paraphilic disorders lack the physiological qualities of withdrawal inherent in an addiction, and the clear presence of psychodynamic factors in most paraphilias argues against classifying them as addictions. Viewed in this manner, it can be argued that paraphilias are better classified as sexual compulsions, not sexual addictions. The response of paraphilias to serotoninergic medications provides further evidence that these disorders are more compulsive than addictive in nature.
Substantial controversy existed in the formulation of the DSM-III-R regarding whether rape qualifies as a paraphilia and, therefore, is a diagnosable mental disorder. Classifying rapists as persons with a mental disorder could carry significant implications, such as opening the door for an insanity defense in those facing a criminal rape charge. "Paraphilic coercive disorder" was a diagnostic entity approved by the committee charged with formulating the DSM-III-R sexual disorder paraphilic diagnoses. However, at least in part due to philosophical and political factors, the American Psychiatric Association Board of Trustees declined to include this entity in the DSM-III-R (F. S. Berlin, MD, personal communication, November 2, 1999). The DSM-TV mentions rape in the context of sexual sadism, but rape is not otherwise classified as a paraphilia.
Regardless of whether paraphilias are viewed as an addiction, it is clear that society views individuals with paraphilia (as well as those dependent on substances) as having some element of voluntary control over their compulsions. Just as a person who is clearly addicted to alcohol is viewed as having an element of control over the decision to drink or not to drink, individuals with paraphilia are viewed by society as having some measure of control over whether to act on their paraphilic urges. Trie extent that this (some say partial) element of voluntary control constitutes a free choice of whether to act is still open to debate.
What Is the Relationship Between Sexual Offenders and Paraphilias?
Although not every person who commits a rape or sexual assault offends due to a psychiatric disorder, a substantial number of recurrent sex offenders meet the DSM-IV criteria for one or more of the paraphilias. McElroy et al.10 reported that 58% of convicted adult sex offenders met criteria for a paraphilia. Galli et al.11 reported that 100% of adolescent sex offenders met criteria for one paraphilia, and that 95% met criteria for two or more paraphilias. As mentioned earlier, Milton9 reported that a significant number of sex offenders meet criteria for psychosis, substance abuse, and personality disorders. Based on these data, it appears that adolescent sex offenders are uniformly paraphilic, whereas adult sex offenders are a heterogeneous rnixture of individuals with paraphilia, individuals with psychotic, personality, or substance abuse disorders, and individuals with no mental disorder.
What Is the Relationship Between Sexual Offenders and Substance Use Disorders?
There is substantial comorbidity among individuals with substance use disorders and individuals with paraphilic disorders. Sixty-four percent of individuals with a compulsive sexual behavior have a history of a substance use disorder.12 Kafka and Prentky13'24 reported that individuals with paraphilia and individuals without paraphilia but with increased sexual impulsivity had an elevated prevalence (45% to 47%) of substance abuse disorders, especially alcohol abuse (30%). McElroy et al.10 reported that 83% of adult sex offenders and 50% of adolescent sex offenders met criteria for a substance use disorder.
The interaction between substance use and sex offenses may take different forms. A person dependent on substances who would not normally commit sex offenses may, due to lowered inhibition caused by substance use, commit a sex offense. An individual with paraphilia may be more prone to substance abuse in an effort to self-medicate and blunt ego-dystonic sexual impulses. Alternatively, based on the observations of one of the authors (PJR) regarding Jeffrey Dahmer, an individual with paraphilia may use substances to purposely lower his inhibitions to allow him to commit compulsive sex acts that he would normally find repugnant.
Groth and Birnbaum reported that approximately 40% of rapists have a history of chronic drinking, usually dating back to early adolescence. Approximately half of sex offenders used alcohol, other substances, or both immediately prior to committing a sexual assault; however, the use of alcohol and other substances was insufficient to account for the offense. Rather, alcohol and other substances may serve as a releaser only when an individual has already reached a frame of mind in which he is prone to rape.25
SEX OFFENDER AND CIVIL COMMITMENT LAWS
Beginning in the late 1930s, legislative attempts were made to civilly commit dangerous sex offenders to treatment facilities. By the 1960s, a large number of states had enacted these "sexual psychopath" laws, which provided indefinite confinement of sexual offenders for the purposes of treatment and public safety. However, most of these laws were eventually repealed, due to the fact that treatment for these persons at that time was largely ineffectual and expensive. By 1990, only a handful of states retained sexual psychopath laws.
More recently, states have been revisiting this issue. This is due, in part, to the fact that determinate (fixed) sentencing has led to the release of high-risk sex offenders. In 1990, the state of Washington enacted a "sexual predator" law, which was a response to horrific crimes committed by a sex offender after he was released from prison. Since that time, 14 states and the District of Columbia have passed new sexual predator laws that allow for the civil confinement of sexual predators. These sexual predator laws differ from the older sexual psychopath laws in the following ways:
1. They do not require the offender to suffer from a medically recognized mental disorder.
2. They do not require any allegation of recent criminal wrongdoing.
3. Sex offenders must serve their full prison term before coirirnitment can be sought.
4. Some states have no bona fide treatment programs in place.
The primary goal of the newer sexual predator statutes is to provide continued confinement of offenders who are at risk of reoffending. Other states have passed legislation that requires sex offenders to register with authorities on release from prison and notification of schools and neighbors that a sex offender is living in the vicinity.
In the 14 states that have passed legislation allowing for additional confinement of sex offenders, commitment to a treatment facility comes after serving a criminal sentence in a penal institution. Not every person who is convicted of a sexual offense is committed to treatment; only repeat offenders with a history of multiple sex offenses or offenders with a high recidivism risk are targeted. After conviction, an additional judicial hearing takes place where the court considers whether the defendant meets criteria to be designated as a sexually dangerous person or sexual predator. If the court adjudicates the defendant as being sexually dangerous, then the defendant is committed to treatment on conclusion of the prison sentence. States differ on whether the commitment takes place in a corrections or mental health facility, but all statutes agree that the facility and the program must be different from standard corrections or mental health programs.
More than 500 individuals nationwide have been deemed sexual predators and are now civilly committed to treatment facilities. Courts retain jurisdiction over the granting of privileges to and the release of these defendants, and are cautious in releasing sex offenders. As of 1998, only 18 offenders had been released nationwide since the first of these new laws went into effect in the state of Washington in 1990.26
Laws regarding civil commitment of individuals who are dependent on substances vary from state to state. Approximately 60% of the states have special statutes for the commitment of individuals who abuse alcohol, substances, or both.27 Most of these statutes allow for the comrnitment of substance abusers to detoxification or rehabilitation facilities, not to mental health facilities. A few states do not allow for civil commitment solely on the basis of a diagnosis of substance use, but require a diagnosis of mental illness for commitment.
At first glance, involuntary commitment to substance rehabilitation treatment seems like a bad idea, based on the principle that motivation for change and a desire for sobriety are essential to treating substance use disorders. Involuntary commitment to a treatment program would abridge that principle. However, Brecht et al.28 reported that treatment outcomes for voluntary versus court-ordered addicts were equal.
TREATMENT OF SEX OFFENDERS
Treatment of sex offenders involves a multimodal approach. Each person undergoing treatment should receive careful assessment and individualized treatment tailored to his or her specific symptoms. The main goal of treatment is to block the offender's interest in deviant sexual behavior. Most individuals with paraphilias do not seek treatment voluntarily, but are ordered into treatment by the court after conviction of a sex offense. Clinicians should realize that they may be fighting an uphill battle in treating sex offenders with little insight or only external (court) motivation to change their behaviors. Individual motivation to change greatly reduces recidivism rates.
Cliriicians who treat sex offenders must be keenly aware of their own countertransference issues, and must not allow their feelings to erode objectivity. Countertransference may develop as a result of the clinician's feelings of disgust at the nature of the patient's sex offense, or as the result of frustration due to the difficulty in treating these patients and high recidivism rates. Countertransference difficulties may also arise due to comorbid substance use issues, which may be heightened due to sociopathic features present in some individuals who are dependent on substances.
Medication treatment of sex offenders should target any underlying comorbid psychiatric disorder, such as mood or psychotic disorders. Medication treatment of paraphilias without comorbid major mental illness may involve using serotoninergic agents23,29 or hormonal treatments. Serotoninergic agents typically used for sex offenders include domipramine and fluoxetine, although most of the selective serotonin reuptake inhibitors have shown some success in the treatment of sexual compulsions. Hormonal treatments involve using medroxyprogesterone acetate. This reduces plasma testosterone levels with subsequent decrease in sexual tensions and fantasies,30 as well as decreased libido, erections, ejaculations, and spermatogenesis.31
Psychological treatment of sex offenders may involve individual psychodynamic psychotherapy, group psychodynamic psychotherapy, or both, as well as more specific cognitive-behavioral approaches. Inherent in any of the psychological treatments of sex offenders are relapse prevention techniques, which are geared toward identifying specific triggers for sexual acting out and developing alternative coping strategies.
The substance use disorders commonly found in this population must be vigorously addressed. Ongoing substance use will continue to lower inhibitions and present increased risk for acting on paraphilic urges. Sexual offenders who are dependent on substances should, at a mininium, undergo intensive outpatient substance abuse treatment. Intensive inpatient substance abuse treatment may be required. Substance abusers convicted of a sex offense should be required to refrain from using alcohol and all illicit substances. Random screening for alcohol and drugs should be a requirement if the offender is to be granted community control or probation. A common cause of probation violation among this population is relapse on alcohol or drugs. Ine sex offender may be resistant to treatment of sexual issues until the alcohol and drug issues are clearly treated. Treatment of substance abuse will greatly enhance the sexual offender's ability to refrain from acting on deviant sexual impulses.
Estimates vary regarding the efficacy of treatment of individuals with paraphilia and other sex offenders. Recidivism rates, which are one measure of treatment efficacy, are difficult to measure. Sex offenders' self-reports are unreliable, and rearrest rates are a limited indicator of recidivism. Hormonal (anti-androgen) treatments appear to be the most effective, assuming compliance with treatment is not an issue. One literature review32 cited recidivism rates as low as 1% for offenders treated with anti-androgens,33 whereas 68% of the nontreated offenders reoffended.34 However, onethird to two-thirds of offenders refused hormonal treatments,34 and half of those who began hormonal treatments eventually discontinued them.35 Given compliance issues, a combination of antiandrogen and cognitive-behavioral treatments appears to be preferred and reduces recidivism rates from a baseline of 27% in untreated individuals to 19% in individuals who receive treatment,36 which is a reduction of 30%.32 Factors that predicted increased recidivism rates included the number of prior sexual offenses, the severity of sexual deviancy, noncompliance with treatment, failing to complete treatment, and the number of total prior offenses.37
The interrelationships among addictions, sex offenders, and mental disorders are complex. Clinical data must play an important role in further defining the relationships among these phenomena. However, other considerations (philosophical, political, legal, and public policy) currently play a key role in how our society views sex offenders (both with and without substance use disorders) and how the court system ultimately deals with these issues. Clinicians may be of assistance to courts by providing accurate diagnostic information and clear testimony on dangerousness, recidivism, and treatment recommendations. Clinicians may also be of assistance to offenders, victims, and society as a whole by providing rigorous and up-to-date treatment for persons who commit sex offenses and abuse substances.
1. U.S. Department of Justice, Bureau of Justice Statistics. National Crime Victimization Survey, July 1999. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 1999. NCJ Publication No. 176353.
2. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug use. JAMA. 1990;264:2511-2518.
3. Miller NS, Sheppard LM. The role of the physician in addiction prevention and treatment. Psychiatr Clin. North Am. 1999;22:489-505.
4. American Law Institute. Model Penal Code, Article 213, 1955.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press; 1994:522-532.
6. Abel GG, Becker JV, Mittelman M et al Self-reported sex crimes of non-incarcerated paraphiliacs. Journal of Interpersonal Violence. 1987;2:3-25.
7. Smiljanich K, Briere J. Self-reported sexual interest in children; sex differences and psychosocial correlates in a university sample. Violence Vict. 1996;11:39-50.
8. Webster's Nexo World Dictionary of the American Uinguagc, 2nd ed. Cleveland, OH: William Collins Publishers; 1980:16.
9. Milton J. Psychopathology of sexual offenders. Br J Hasp Med. 1997;57:448-450.
10. McElroy SL, Soutullo CA, Taylor P Jr, et al. Psychiatric features of 36 men convicted of sexual offenses. ] Clin Psychiatry. 1999;60:414-420.
11. Galli V, McElroy SL, Soutullo CA, et al. The psychiatric diagnoses of twenty-two adolescents who have sexually molested other children. Compr Psychiatry. 1999;40:85-88.
12. Black DW, Kehrberg LL, Flumerfelt DL, Schlosser SS. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiatry. 1997;154:243-249.
13. Kafka MP, Prentky RA. Preliminary observations of DSMHl-R axis 1 comorbidity in men with paraphilias and paraphilia-related disorders. J Clin Psychiatry. 1994;55:481-487.
14. Henn FA, Herjanic M, Vanderpeaxl RH. Forensic psychiatry: profiles of two types of sex offenders. Am J Psychiatry. 1976;133:694-696.
15. Craissati J, Hodes P. Mentally ill sex offenders: the experience of a regional secure unit. Br J Psychiatry. 1992; 161:846-849.
16. Hui JSH. Recidivism Among Sex Offenders After Treatment in English Maximum Security Mental Hospitals [master's thesis]. Surrey, England: University of Surrey; 1991.
17. Faulk M. Basic Forensic Psychiatry, 2nd ed. Oxford, England: Blackwell; 1994.
38, Rice ME, Harris GT, Quinsey VL. A follow-up of rapiste assessed in a maximum security facility, Journal of Interpersonal Violence. 1990;5:435-448.
19. Baxter DJ, Marshall WL, Barbaree HE, Davidson PR, Malcolm PR. Deviant sexual behaviour: differentiating sex offenders by criminal and personal history, psychometric measures and sexual response. Criminal Justice and Behavior. 1984;11:477-501.
20. Verdón MM, Wysocki BA, Wysocki AC. Human figure drawings of sex offenders. J Clin Psychol. 1977;33:278-284.
21. Levin SM, Stava L. Personality characteristics of sex offenders: a review. Arch Sex Behav. 1987;16:57-79.
22. Abel GG, Becker JV, Cunningham-Rathner J, Mittelman M, Rouleau JL. Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law. 1988;1 6:153168.
23. Stein DJ, Hollander E, Anthony DT, et al. Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clin Psychiatry. 1992;53:267-271.
24. Kafka MP, Prentky RA. Attention-deficit/hyperactivity disorder in males with paraphilias and paraphilia-related disorders: a comorbidity study. J Clin Psychiatry. 1998; 59:388-396.
25. Groth AN, Birnbaum HG. Men Who Rape: The Psychology of the Offender. New York: Plenum Press; 1979.
26. Fitch WL. NASMHPD Update: Civil Commitment of Sex Offenders in the U.S. October 1998.
27. Beane EA, Beck JC. Court based civil comrnitment of alcoholics and substance abusers. Bull Am Acad Psychiatry Law. 1991;19:359-366.
28. Brecht ML, Anglin MD, Wang JG Treatment effectiveness for legally coerced versus voluntary methadone maintenance clients. Am ) Drug Alcohol Abuse. 1993;19:89-106.
29. Kafka MP. Successful antidepressant treatment of nonpaxaphilic sexual addictions and paraphilias in men. J Clin Psychiatry. 1991;52:60-65.
30. Cooper AJ. Progestogens in the treatment of male sex offenders: a review. Can J Psychiatry. 1986;31:73-79.
31. Donovan BT. Hormones and Human Behavior. London, England: Cambridge University Press; 1984.
32. Grossman LS, Martis B, Fichtner CG. Are sex offenders treatable? A research overview. Psychiatr Serv. 1999; 50:349-361.
33. Maletzky BM. Treating the Sexual Offender. Newbury Park, CA: Sage; 1991.
34. Federoff JP, Wisner CR, Dean S, Berlin FS. Medroxyprogesterone acetate in the treatment of paraphilic sexual disorders: rate of relapse Ln paraphilic men treated in long-term group psychotherapy with or without medroxyprogesterone acetate. Journal of Offender Rehabilitation. 1992;18:109-123.
35. Langevin R, Paitich D, Hucker SJ, et al. The effect of assertiveness training, Provera and sex of therapist in the treatment of genital exhibitionism. J Behav Titer Exp Psychiatry. 1979;10:275-282.
36. Hall GC. Sexual offender recidivism revisited: a metaanalysis of recent treatment studies. J Consult Clin Psychol. 1995;63:802-809.
37. Hanson RK, Bussiere MT. Predicting relapse: a metaanalysis of sexual offender recidivism studies. J Consult Clin Psychol. 1998;66:348-362.
Typology for the Psychopathology and Motives of Sex Offenders, According to Faulk*
Comparison of Paraphilias and Substance Dependence