Assessing sexual violence

1. Assessing sexual violence Melissa M. Sisco University of Arizona

2. Overview • Assessment in general health settings • Definitions of sexual violence • Methods of assessment • Key areas • Important considerations • Wrap up • Question/answer period

3. Assessment in general health settings

4. Contact with medical providers Pool of sex offenders Offenders seen in medical setting

5. Contact with the court Pool of sex offenders Court contact

6. Contact with medical providers Pool of sex offenders Victims seen in medical setting Court contact

7. Lifetime prevalence rates

8. The danger from within • The majority of victims (79%) know their offender well (Harned, 2004) • The majority of women who are physically abused by an intimate partner are also sexually abused (Tjaden & Thoennes, 2000) • 7.7% only spousal sexual abuse • 22.1% solely physical assault • 24.8% both during the lifetime

9. “Who else would know?” • 95% of crimes come to the attention of the police through direct citizen report as opposed to police contact (Fisher , Daigle, Cullen, & Turner, 2003) • 2 out of 3 sexual assaults go unreported to authorities (BJS, 1998) • 70% of victims report sexual assaults to trusted friends or loved ones (as opposed to 6% who report to police) (Harned, 2004)

10. Studies documenting the benefit of general assessment. • Though no comparative studies were found regarding sexual violence… • In a pediatric setting, when a physician began actively asking all parents to fill out a questionnaire regarding child abuse, reports increased 1500% in just 1 year (Sisk, 2002)

11. Defining sexual violence

12. “What is sexual violence?” • Reprehensible- Joking, harassing, lying to or pressuring a person into engaging in sexual forum or behaviors after the person expressed objection • Prosecutable- Any sexually motivated act that involve a person who is unwilling or unable to consent due to intoxication, covert drugging, state of awareness, age/maturity or physical force

13. Levels of sexual violence • There are many dimensions to consider: • Level of contact • Relation to the victim • Prior history of criminal activity • Legal offense description • Strategy of offense • Motives • Comorbidity with other disorders • Think about how these would infer different treatment implications

14. Sexual violence and mental health • Possible connections between sexual violence and mental illness: (1) a disorder may decrease the person’s ability to decipher social cues (e.g. autism) (2) sexual violence may be a marker for a disorder (e.g. antisocial personality disorder) (3) a disorder can drive the offensive behavior (e.g. delusional states) (Chesire, 2004)

15. Methods of assessment

16. Assessment purposes • Ensuring current victim, providers, and offender safety • Detecting acts of sexual violence • Judging the likelihood of re-offense • Exploring treatment effectiveness

17. 4 assessment tools • Self-report questionnaires • Guided clinical interviews • Unstructured clinical interviews • Physiological response tests *Note: The assessments that will be discussed focus on evaluation of offenders.

18. Self-report questionnaires • Description: Paper or computer based questions that ask for self-report on personal behavior or attitudes. • Sample item: Please indicate your stance on a scale of 1 (disagree strongly) to 5 (agree strongly)… “A woman in a short skirt is asking for it” (Burt, 1980) • Benefits: The same for all, cost-effective, quick, can be scientifically validated and ‘normed’. • Draw-backs: Educational/reading level required, ‘lying’, only self-report (no family/friends feelings about the respondent), lack of clinical judgment

19. Key term description • ‘Norm’ • 1,000s of sex offenders respond to a series of items. Their responses are analyzed to determine if there are common underlying characteristics of their answering styles. These answering patterns are called ‘norms’ which are described in mathematical statements giving ‘weight’ to the strongest factors. • New respondent’s answers are statistically compared to the offenders patterned ‘norms’ to test for similarity. • Highly similar answers suggest further assessment is necessary and the probability of offense may be likely

20. Structured clinical interviews • Description: A manual that trained clinicians use to loosely guide the areas that should be addressed in a forensic interview. Use requires specified training • Sample item: A general topic with suggested questions. • Benefits: Based on actuarial ‘norms’while allowing clinician to use some clinical judgment and to tailor the language to the respondent • Draw-backs: Costly, restricted to use by trained forensic professionals, not a perfect predictor of future behavior, not perfectly similar for all respondents

21. Unstructured clinical interviews • Description: A free-flowing conversational interview guided solely by clinical judgment • Benefits: Very tailored to each client, common to most health appointments, good preliminary investigation • Draw-backs: Studies have shown that clinical judgment alone functions only slightly better than chance at predicting future criminal behaviors

22. Physiological response test • Description: Scientific apparatus that monitors the physiological arousal in response to certain stimuli • Examples: The polygraph or the plethysmograph • Benefits: Concrete output, possible treatment benefits (“Get it all out, I’ll know if you are lying”) • Draw-backs: Costly, can be fooled by trained individuals, and can give false impressions regarding physiological arousal (response to normative stimuli can be misinterpreted)

23. Key areas of assessment Static, stable-dynamic and acute-changing factors

24. Preparation • Information is obtained before an interview • We typically use multiple sources: corroborative interviews with providers/friends/family, review of treatment notes, police reports, victim reports, investigational materials, psychiatric evaluations, psychological testing, children’s agency reports, and recorded testimony (Maletsky, 1997)

25. 3 main topic areas in assessment • Static factors • Stable-dynamic factors • Acute changing factors

26. Static factors • A static risk factor is a permanent fact that makes a person more likely to be in danger of sexually offending. Static factors are the personal experiences someone uses to evaluate how they should act. • E.g. Life history, experiences, past behaviors • Developed from weighted norms • Common to structured clinical interviews • Must use multiple informants

27. Commonly assessed static factors • Family violence^ (a) severity (b) age of onset • Physical/sexual abuse^ (a) force used (b) degree of penetration (c) relation to perpetrator, (d) age of onset, (e) duration • Prior sexual offenses* (a) age at offense, (b) victim age/sex (c) undue force used (d) degree of penetration (e) setting • Prior violent acts* (a) age at offense, (b) victim age/sex (c) undue force used (d) degree of penetration (e) setting • Prior criminal record* (a) incarceration record (b) prior delinquency • Life stability* (a) married (b) employment (c) education (d) social network (e) family support • Demographics* (a) culture/race, (b) age, (d) socio-economic status *Included in almost every static risk assessment tool ^Shown to be a significant predictor of sexual offense in juveniles, but not directly tied to adult offenders

28. Prediction based on static factors • Problems: (1) not case specific, (2) lack of clinical judgment, and (3) although there is high sensitivity, i.e. catching 80-90% of reoffenders, there is low specificity, i.e. wrongly accusing 40-70% of non-reoffenders • Benefit: IDing high-risk individuals • Use: An initial risk indicator ranking a person as “Low”, “Medium”, or “High” risk for the purpose of initial assignment to a supervision group • Frequency: Since these factors do not change, one might only evaluate these initially and as warranted

29. Stable-dynamic factors • Stable-dynamic factors are sets of semi-permanent factors that treatment aims to correct. These systems are basically our values • E.g. attitudes, cognitive distortions, and preferred coping skills • Mostly developed through fiat • Questionnaires and interviews

30. Commonly assessed stable-dynamic factors • Attitudes towards women (a) hostile masculinity (b) masculine role stress (c) attitudes towards women (d) traditional patriarchal beliefs (e) rape myth beliefs (f) societal norms (g) family norms • Personal/social adjustment (a) isolation (b) pathological deceitfulness (c) coping strategy / present stress (d) life/social functioning skills • Personality (a) psychopathy (b) impulsivity (c) emotional detachment (d) antisociality (e) free-floating aggression (f) controlling demeanor • Sexual belief / knowledge (a) experience (promiscuity, impersonal sex, sexual appropriateness beliefs), (b) fantasy (deviance or preoccupation), (c) sexual education, (d) functioning (compulsivity, fixation, preoccupation, physiological ability) • Intimacy belief / knowledge (a) perception of intimacy (b) dating script knowledge (c) interpretation of sexual cues (d) empathy

31. Prediction based on stable-dynamic factors • Problems: Not the most commonly used marker of recidivism and due to the large variation among sex offender etiology, no universal set of dynamic risk factors • Benefits: The specificity and sensitivity are weaker than the stable factor structure’s, i.e. about 50-70% of real reoffenders and nonoffenders are identified • Use: As a compliment to original static assessment • Frequency: They should be re-assessed periodically throughout treatment to indicate progress

32. Acute changing factors • Acute changing variables are the constantly changing situations that make a person more inclined to act in a certain fashion. Although ‘triggers’ cannot be eliminated, the offender can learn how to recognize, avoid or cope with them. • E.g. emotional states, intoxication, environments high in temptation, distressing events, etc. • Common in all forensic interviews • No specified list of acute changing factors, case by case assessment.

33. Prediction based on acute changing factors • Problems: New method, no normative data exists • Benefits: In a Thornton study, offenders who attended treatment that focused on the “bad decision” that led to the crime as opposed to the sexual crime itself were less likely to reoffend • Use: In conjunction with the other batteries, this should be explored extensively asking for a description of all ‘bad decisions’ and used to guide treatment and forensic recommendation of terms of sentence • Later in treatment, the clinician should bring these factors to the clients attention and help train the client to identify and get out of these risky situations • Frequency: Extensively initially and rechecked throughout treatment

34. Important considerations

35. Incorporating screening into your practice • Be sensitive to situations in which there seem to be signs of distress (extreme couple conflict, physical signs of abuse, history of domestic violence, drug/alcohol abuse, or violent propensity) • Have crisis and treatment information on hand. • Ask questions: “You won’t know if you don’t ask.” • Use precaution in the types of questions asked… know your clinical boundaries • Be ready to refer

36. “Not another Inquisition” • Be reluctant to jump to conclusions… people devote careers to the assessment of sexual violence • An assessment instrument cannot definitively indicate that a person has or will sexually offended • Professionals typically use a calculated assortment of assessment tools and clinical judgments relying on multiple sources to make predictions of possibilities of offenses

37. Mandatory reporting procedure • In most service fields, acts of suspected child abuse and sexual violence must be immediately reported to law enforcement authorities. Know the limits of confidentiality and legal obligations of your field! • Exemptions: Clergy and lawyers

38. Safety of disclosure • Inform all respondents about the limits of your confidentiality / reporting duties • Screen possible victims in environments where an offender is not likely to be present, like a medical office or school (AAPCCAN, 1998)

39. Language choices • Avoid loaded language • Terms with negative connotations are likely to evoke a defensive response • Behavior (penetration when…) vs. label (rape) • Use language that is appropriate to the respondent’s educational level • Use caution to avoid the discomfort or offense of the respondent

40. Cognitive distortions • Most offenders have an intricate system of distorted justifications for their actions. Many are not able to consciously understand that these values are incorrect because this would mean that they had done ‘wrong’. • Example: “She wanted it, she was dressed for sex” or “She didn’t say no and she kissed me first, so she really meant yes”

41. Social desirability • People have a tendency to gloss over personal flaws and focus on positive features • Not as much a concern if the respondent has a high level of cognitive distortions and does not feel judged by the clinician but… • Some questionnaires use lie scales to measure this tendency • Clinicians must constantly consider this issue

42. Acting within your professional limits • Get informed: consult with a fellow mental health professional who is more specialized or refer to educational resources (see appendix) • Connect the client to a specialized provider: If the situation arises, referrals are common and welcome

43. Brief wrap up: The 3 Ws

44. What? • Different types of sexual violence • Reprehensible vs. illegal • Level of contact • Relation to the victim • Prior history of criminal activity • Legal offense description • Strategy of offense • Reason for actions • Comorbidity with other disorders

45. Why? • Reasons for assessment in general settings • Link between mental health and sexual violence • Underreporting issues • Promising increase seen in universal screening

46. How? • Methods of assessment • Questionnaires, unstructured interviews, structured interviews, physiological response measurement • Key questions • Static, stable-dynamic, and acute changing factors • Important considerations • Multiple sources to assess, mandatory reporting laws, safety of disclosure, language choice, cognitive distortion, social desirability, and professional limits

47. Questions or comments? Thank you for your time! For more information feel free to contact me at sisco@u.arizona.edu

48. References • American Academy of Pediatrics Committee on Child Abuse and Neglect (AAPCCAN) (1998). The role of the pediatrician in recognizing and intervening on behalf of abused women. Pediatrics, 101, 1091-1092. • Bachman, R. (2000). A comparison of annual incidence rates and contextual characteristics of intimate partner violence. Violence Against Women, 6(8), 839-867. • Beebe, D. K., Gulledge, K. M., Lee, C. M., and Replogle, W. (1994). Prevalence of sexual assault among women patients seen in family practice clinics. Family Practice Research Journal, 14(3), 223-228. • Bernhard, L. A. (2000). Physical and sexual violence experienced by lesbian and heterosexual women. Violence Against Women, 6(1), 68-79. • Burt, M.R. (1980). Cultural myths and support for rape. Journal of Personality and Social Psychology, 38, 217-230.

49. References • Bureau of Justice Statistics (December 1998). National Crime Victimization Survey. Washington, DC: U.S. Department of Justice. • Cameron, P., Proctor, K., Coburn, W.J., Forde, N., Larson, H., and Cameron, K. (1986). Child molestation and homosexuality. Psychology Report, 58, 327-337. • Coxell, A., King, M., Mezey, G., and Gordon, D. (1999). Lifetime prevalence, characteristics and associated problems of non-consensual sex in men: Cross sectional survey. British Medical Journal, 318, 846-850. • Coyle, B. S., Wolan, D. L., and Van Horn, A. S. (1996). The prevalence of physical and sexual abuse in women veterans seeking care at a veteran’s affairs medical center. Military Medicine, 161(10), 588-593. • Finkelhor, D., Hotaling, G., Lewis, I.A., and Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19-28. • Fisher, B.S., Daigle, L.E., Cullen, F.T., and Turner, M.G. (2003). Reporting sexual victimization to the police and others: Results from a national-level study of college women. Criminal justice and behavior, 30(1), 6-38.

50. References • Harned, M.S. (2004). Does it matter what you call it? The relationship between labeling unwanted sexual experiences and distress. Journal of Consulting and Clinical Psychology, 72(6), 1090-1099. • Maletsky, B.M. (1997). Exhibitionism: Assessment and treatment. In D.R. Laws and W. O’Donahue (Eds.), Sexual deviance: Theory, assessment, and treatment, (pp.40-74). • Merrill, L. L., Hervig, L. K., Newell, C. E., Gold, S. R., Milner, J. S., and Rosswork, S. G. (1998). Prevalence of premilitary adult sexual victimization and aggression in a Navy recruit sample. Military Medicine, 163(4), 209-212. • Sisk, D. (2002, June 4). Domestic violence screening in a pediatric clinic. Arizona’s Child Abuse Infocenter. Retrieved April 4, 2004 from http://www.ahsc.arizona.edu/acainfo/index2.htm . • Sorenson, S.B., Stein, J.A., Siegel, J.M., Golding, J.M., and Burnam, M.A. (1987). The prevalence of adult sexual assault. The Los Angeles Epidemiologic Catchment Area Project. American Journal of Epidemiology, 126, 1154-1164. • Tjaden, P., & Thoennes, N. (2000). Full report of the prevalence, incidence, and consequences of violence against women (Rep. No. NCJ 183781). Rockville, MD: Office of Justice Programs, National Institute of Justice.