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Mental illness in convicted sexual offenders

Mental illness in convicted sexual offenders. Seena Fazel, University of Oxford, Dept. of Psychiatry Niklas Langstrom, Gabrielle Sjostedt, Martin Grann, Centre for Violence Prevention, Karolinska Institute Funded by the NHS R&D Programme in Forensic Mental Health . Background statistics.

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Mental illness in convicted sexual offenders

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  1. Mental illness in convicted sexual offenders • Seena Fazel, University of Oxford, Dept. of Psychiatry • Niklas Langstrom, Gabrielle Sjostedt, Martin Grann, Centre for Violence Prevention, Karolinska Institute • Funded by the NHS R&D Programme in Forensic Mental Health

  2. Background statistics Huge burden of morbidity • 13% women, 2% men raped • 25% women sexually coerced Increasing problem? • Doubling of rapes reported to police and convictions in Australia, Canada, Holland, Sweden and UK in the 1990s • In the UK, 60,000 sexual offences reported • UK rapes: 1068 (in 1980) to 14,000 (in 2004)

  3. Pattern of convictions by age in England and Wales as % of all convictions for the respective offence group

  4. Pattern of convictions within their age group as % of total offences

  5. Mental illness and sexual offending?

  6. Previous work • Violence – clear evidence that severe mental illness (SMI) is a risk factor • Sexual offending – expert opinion discounts relationship with SMI (Cf. Faulk’s textbook, articles by Hanson) • Population studies: crude OR = 2.7 (Wallace 1998) • Case series: high rates affective illness, substance abuse, PD (Stinson 2005) • Prison studies: elderly men have higher rates of certain PD traits (Fazel 2002)

  7. Aims • Psychiatric morbidity in sentenced sexual offenders in Sweden • Risk factors for sexual offending • Focus on severe mental illness • National survey 1988-2000

  8. Swedish databases • All individuals, incl. immigrants, have unique 12 digit personal identification number • High quality national registers for hospitalizations and crime • Hospital discharge register (HDR) • Crime register

  9. Hospital register • All hospital admissions centrally registered and given ICD-9/10 discharge diagnosis • Largest inpatient register in the world (9 million population) • Validity for SMI is good (86% concordance for schizophrenia) • Validity for PD and substance abuse is fair (Cohen’s kappa 0.2-0.4) • Computerised from 1988

  10. Criminal register • National criminal register • Sexual offences included rape, indecent assault, indecent exposure, child molestation • Excluded prostitution, hiring of prostitutes, possession of child pornography • Conviction data (incl. mental health disposals, cautions, fines, legally insane, non-custodial) • No plea bargaining in Swedish law • 15+ years old • Good quality – 0.05% convictions have missing identification numbers

  11. Design • Prevalence study: linkage of crime and health registers • 8495 male and 93 female sexual offenders • Case-control: 50,000 randomly chosen individuals, stratified for year of entry, • Those with sexual convictions and under 15s excluded

  12. Results - demographics

  13. Prevalence and risk *Adjusted for age, income, immigrant status

  14. Risk of psychiatric disorders in sexual offenders ORs

  15. Risk of other psychiatric disorders

  16. Rapists vs. child offenders Prevalence %

  17. Conclusions • 8495 male sexual offenders • 10 times larger than previous study • Adjusts for socio-economic confounders • 6x increased risk of psychiatric hospitalization • 2-5x increased risk of psychoses

  18. Role of SMI in sexual offending • Potentially important • Contrary to expert opinion • Is this the same story for psychosis and violent crime?

  19. Mechanism of association • Psychotic symptoms trigger, cf. special hospital sample of 12 out of 15 patients (Phillips 1990) • SMI associated with hostility, cognitive distortions, deviant fantasies, poor social skills, which are risk factors • Non-specific disinhibiting factor (+/-interact with alcohol or drugs)

  20. Other diagnoses • More caution warranted because of diagnostic problems, selection biases • Personality disorder, substance abuse, child and adolescent disorders • Rapists and child molesters different patterns of morbidity • Rapists higher rates of substance abuse, psychoses

  21. Limitations • 13 prevalence • Based on inpatient data • Clinical diagnoses • Official crime data – only 20-30% actual rapes lead to convictions • Those with SMI disproportionately caught

  22. Role of psychiatry • Society moving to harsher sentencing • Improving the detection and treatment of sexual offenders may reduce recidivism, morbidity of prisoners, self-harm and suicide in custody?? • Further work needed esp. longitudinal studies

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