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Treating Sex Offenders

Treating Sex Offenders. Dr Jeremy O’Dea Forensic Psychiatrist. 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

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Treating Sex Offenders

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  1. Treating Sex Offenders Dr Jeremy O’Dea Forensic Psychiatrist Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  4. Actuarial Risk Assessment Static 99 SONAR Clinical Risk Assessment Psychiatric Assessment Paraphilias HCL 20 ?Penile Plethysmography Risk Assessment Public Defenders Sydney 14 May 2005

  5. 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 Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  8. 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 Public Defenders Sydney 14 May 2005

  9. Static 99, Risk Categories • Low 0,1/12 • Medium-Low 2,3/12 • Medium-High 4,5/12 • High 6+/12 Public Defenders Sydney 14 May 2005

  10. 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 Public Defenders Sydney 14 May 2005

  11. Dynamic Risk Factors • Sexual Deviance - Paraphilias • Substance Abuse • Psychiatric Illness • ?Personality Disorder • Social Situation • Other Public Defenders Sydney 14 May 2005

  12. 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 Public Defenders Sydney 14 May 2005

  13. 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” Public Defenders Sydney 14 May 2005

  14. 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 Public Defenders Sydney 14 May 2005

  15. SOTEP • 1985 • Sex Offender Treatment and Evaluation Project • California • Sentenced Prisoners • Rape • Child Molestation Public Defenders Sydney 14 May 2005

  16. 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 Eligible Participants Public Defenders Sydney 14 May 2005

  17. 3 Groups • Volunteer Group • Treatment Group • Volunteer Control Group • Non Volunteer Group • Non Volunteer Control Group Public Defenders Sydney 14 May 2005

  18. Treatment • Relapse Prevention • CBT • Atascadero State Hospital • 2 years • 40 – 50 hours per week • Sex Offender Aftercare Program • 1 year Public Defenders Sydney 14 May 2005

  19. 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 Public Defenders Sydney 14 May 2005

  20. 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 Public Defenders Sydney 14 May 2005

  21. Negative Findings - Overall • Volunteer Control’s did better than the Treatment Group in terms of sex re-offending • Treatment Group had the highest rate of violent re-offending Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  25. Other Psychological Treatments • Community Based • Supervision • CBT • Relapse Prevention • Psychological treatments in combination with Psychotrophic Medication in selected individuals Public Defenders Sydney 14 May 2005

  26. Psychopharmacological treatments In selected patients with paraphilias Public Defenders Sydney 14 May 2005

  27. Castration • USA • Chemical and Surgical • 9 States • Voluntary and Mandatory Public Defenders Sydney 14 May 2005

  28. NSW • Call to “castrate’ child sex offenders • Opposition justice spokesperson • ?Condition of parole • ?Mandatory Public Defenders Sydney 14 May 2005

  29. France • Justice Minister • 2 year trial • Leuproreline and Cyproterone Acetate • Voluntary • 48 repeat offenders • Denmark,Sweden,Canada Public Defenders Sydney 14 May 2005

  30. Psychiatric Treatment • Appropriate patient populations • Paraphilias v Sex Offences • DSM IV TR • Efficacy • Tolerability • Best available option • Consent Public Defenders Sydney 14 May 2005

  31. Consent to Treatment • Involuntary • Guardianship Tribunal • Mental Health Acts • ?Mandatory Treatment • Risk/Benefit • Evidence Base Public Defenders Sydney 14 May 2005

  32. What is the medical evidence? Where does it come from? Public Defenders Sydney 14 May 2005

  33. Evidence • Animal Husbandry • Eunuchs and Castrati • Surgical Castration Studies • Voluntary and Involuntary • Testosterone and Sexual Behaviour in Men • Testosterone Lowering Medications • Antipsychotics and Antidepressants Public Defenders Sydney 14 May 2005

  34. Surgical Castration Public Defenders Sydney 14 May 2005

  35. Medication(Chemical Control) • Oestrogens • Progestogens • Medroxy Progesterone Acetate (MPA), Provera • Anti-androgens • Cyproterone Acetate (CPA), Androcur • Flutamide • Nilutamide • SSRI’s • Others Public Defenders Sydney 14 May 2005

  36. Medication(Chemical Control) • GNRH agonists • Triptorelin • LHRH Agonists • Leuprolide acetate • Goserelin Public Defenders Sydney 14 May 2005

  37. Therapeutic Trials • Methodological Problems • Heterogenous Groups • Small Sample Sizes • Single Case Studies • Double blind/Placebo controlled • Drop Outs • Self Report • Follow up periods Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  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 Public Defenders Sydney 14 May 2005

  40. SSRI’s • Case Reports • Small open label studies • 50-90% response rates Public Defenders Sydney 14 May 2005

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