SEX OFFENDERS
From The Individual with Schizophrenia: Evidence-Based Practices for Recovery, presented by Loma Linda
University School of Medicine and Patton State Hospital
Charles L. Scott, MD, Chief, Division of Psychiatry and the Law, and Associate Clinical Professor of Psychiatry,
University of California, Davis, School of Medicine
| Overview and definitions: ≈10% of prisoners incarcerated for violent sex offenses; two-thirds of these victimized
children, and majority of child molesters victimized children <12 yr of age; 75% of all victims women or girls; 12
million women in United States have been raped, and 30% of those <11 yr of age at time of rape; rapists assault average
of 7 victims before being referred for treatment; sex offender—defined as person who was convicted of sex
offense and on release from prison who must register with local law enforcement agency; sexually violent
predator—person who was convicted of sex offense and has diagnosis of mental disease, mental abnormality, sexual
disorder, or personality disorder that makes him or her likely to engage in future predatory acts; paraphilia—
defined by Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) as involving “recurrent,
intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering
or humiliation of oneself or one’s partner, or 3) children, or other nonconsenting persons that occur over a
period of at least 6 mo”
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| Overview of people with paraphilias: have high rate of offending and many victims; often have multiple types
of deviant sexual behavior; often use coercion; have high rate of other nonsexual criminal offenses; poor insight
into their behavior; onset usually 10 to 20 yr of age
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 | Most frequent paraphilias: among those who seek treatment child molestation, followed, in order, by voyeurism, exhibitionism,
fetishism, frottage, and public masturbation; exhibitionism, frottage, pedophilia against boys outside
home, and voyeurism have greatest number of victims
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| Crossing: paraphilic people tend to cross over between touching and non-touching offenses, between family and
non-family members, between male and female victims, between victims of various ages, and between multiple
types of paraphilic behavior; crossing associated with greater risk for recidivism; paraphilia with greatest crossover
is bestiality, followed, in order, by public masturbation, male incest pedophilia, and fetishism
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| Women sex offenders: rate of sexual deviancy about half that of men; more commonly victimize children; high
level of psychopathy, generally Axis II disorders; usually have history of having been abused themselves; often
team with male co-perpetrator
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| Pedophiles: majority of pedophiles heterosexual and molest children they know; ≈55% of victims are girls; almost
all acts of non-touching child molestation involved girls; majority of acts of hands-on molestation perpetrated
against boys; among incest offenders, those who victimized children <6 yr of age more likely to have
history of substance abuse, current alcohol problems, poor sexual functioning, and greater psychiatric disturbance,
and more likely to victimize boys and to deny their offenses
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| Clergy: distinguished from highly educated matched controls in having longer delay before criminal charges
filed or in not having criminal charges filed at all, and in using more force more often in their offenses; 70%
had homosexual pedophilia, but did not differ from controls in this aspect
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| Internet offenders: “traders” exchange child pornography online, but usually do not have hands-on contact with
victims (comprise 59% of Internet offenders); “networkers” use Internet to communicate with like-minded individuals;
“groomers” engage in inappropriate sexual communication with children; “travelers” seek hands-on
experience with children they have met on Internet (comprise 19% of Internet offenders); 95% of Internet offenders
male; one study found most common age range 30 to 39 yr, and another study found most were “middle-aged
men who held comparatively elevated professional positions”
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| History of sexual psychopath legislation: first appeared in 1930s; mandated punishment and treatment; sentences
indeterminate, and prisoner subject to review by parole board before release; reflected view that sex offenders
had mental illness that could be treated by psychiatrists; by 1976, 30 states had “mentally disordered
sex offender” (MDSO) statutes that allowed people charged with certain sexual offenses to be committed to secure
residential treatment programs for indeterminate period; however, “over time, people got very disappointed
with this approach; they found that it wasn’t working”; in legal challenge, United States Supreme Court
found that these statutes violated 14th Amendment right to due process, and during 1980s, most states repealed
MDSO laws and legislated determinate sentencing, which allowed offenders to be released, and some perpetrated
more sexual offenses; however, new legislation tended to make sexual offenses civil, and Supreme Court
ruled that 5th Amendment rights apply only in criminal cases, not in civil cases
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| Recent sexual offender legislation: commitment laws require 1) past course of sexually harmful conduct, 2)
current mental disorder or abnormality, 3) finding of risk for future sexually harmful conduct, and 4) “some
form of connection between the mental abnormality and the danger”; courts have consistently ruled that constitutional
protections apply only in criminal cases, not in civil cases
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| Modern legal trends: treatment occurs after punishment, not in place of punishment; no recent act of sexual violence
required; presence required of mental abnormality or personality disorder that makes perpetrator likely to
engage in predatory acts of violence; in Washington State statute, “mental abnormality” defined as “a congenital
or acquired condition affecting the emotional or volitional capacity which predisposes the person to the commission
of criminal sexual acts,” and this has become the model for legislation in other states; Supreme Court ruled
that these statutes are not unconstitutional
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| Sexual offender registration and notification laws: all state statutes and federal law require that at minimum,
sex offender register with designated law enforcement agency; offender must provide certain information
to law enforcement, although amount and type of in-formation vary by state; federal legislation
(Wetterling Act)—requires all states to establish stringent registration programs for sex offenders; all offenders
must register for minimum of 10 yr, and offenders classified as sexually violent predators must register for
life; states must maintain accurate registries, must distribute registry information to law enforcement, and
must disclose information to public when necessary for public safety; sentencing court must determine
whether offender still sexually violent predator, but states have discretion in regard to timing of that determination;
juveniles—adjudicated or convicted of sex offenses required to register in 28 states
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| Community notification regarding sex offenders (“Megan’s Law”): “community notification” refers to dissemination
of identifying information to citizens and community organizations about sex offenders released into that
community; federal version of Megan’s Law requires states to release registration information about sex offenders
to public “when it is necessary to public safety”; unintended results of notification laws include vigilantism,
failure of offenders to register, failure of registered offenders to find housing, victim identification,
failure of offender to receive treatment, and increased risk of offender’s relapsing due to these additional
stresses; most common challenge based on lack of procedural due process, but, to date, Supreme Court has rejected
these challenges
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| Castration laws: in some states, chemical or surgical castration is condition of probation; some states provide
immunity to providers; not all laws require full informed consent from sex offender
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| Evaluation of sex offenders: sex offenders have high rate of comorbidity, including other mental illnesses, substance
abuse, and other paraphilias; avoid labels; one study showed how sex offenders asked about their own
abuse important in eliciting information (eg, if rapist asked, “have you ever been molested?” rapist said “no”;
but if asked age of first sexual contact and age of that contact, rapist often answered with young age, because
he or she did not consider sexual contact with older individual to be molestation); before beginning evaluation,
obtain written voluntary informed consent; review range of sexual offenses in which interviewee engaged
(questionnaires specific to sexual offenses available); psychological testing can be helpful (but no scale
specific to sexual offenses); actuarial risk-assessment instruments available
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| Plethysmography: measures degree of penile erection in response to auditory or visual stimuli; circumferential
plethysmography used in United States, volume plethysmography in Canada; volume phallometry has sensitivity
of 87%, specificity of 95%; circumferential phallometry had sensitivity of 48%, specificity of 100%;
sensitivities for either procedure not established for rapists of adult women; relationship between sexual
arousal measured by penile tumescence and sexual offending behavior stronger in pedophiles than in rapists;
results not admissible in US courts and not diagnostic, but useful for assessment and treatment; factors that affect
validity include subject’s not attending to stimuli, voluntary suppression, lack of standardized stimuli, denial
of paraphilic interest, variation, duration, and quantity of erection measurement, and lack of correlation
between responses inside and outside of laboratory; no sensitivity, specificity, or efficacy data available for
paraphilias other than pedophilia
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| Visual reaction time (also called Abel Assessment for Sexual Interest [AASI] after its inventor): noninvasive method
for evaluating sexual preferences; questionnaire—asks about sexual thoughts, fantasies, and behaviors, and about
subject’s ability to control his or her sexual behaviors; also contains items to address feigning and cognitive distortions
about interest in sex with children; responses correlated with profile of known child molesters; computerized
assessment—assesses self-reported arousals in response to images of people of both sexes and all ages; as
subject views images of clothed people in varying contexts, length of latency period for him or her to report
sexual interest in image measured; advantages include brief administration time (<1 hr), no special laboratory
needed, can be used for males and females ≥12 yr of age; sexual-interest measurements can be made with non-
nude stimuli; reliability and validity similar to those of plethysmography; disadvantages include lack of standardized
research
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| Polygraphy: 9 states have polygraph programs for sex offenders; results generally not admissible in court, but
may be useful in assessment and treatment; can be used to assess instant offense, past offenses, and future risk
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| Treatment: overall purpose to decrease sex drive; medroxyprogesterone (Depo Provera)— most commonly used
pharmaceutical agent in United States; reduces testosterone levels; side effects include weight gain and hypertension;
generally does not cause gynecomastia, and not considered feminizing hormone; cyproterone—available in
Canada and Europe, but not in United States; decreases testosterone; side effects include liver dysfunction, weight
gain, and feminization; other agents—include leuprolide (Lupron) and triptorelin (Decapeptyl-CR); selective serotonin
reuptake inhibitors (SSRIs)—may be helpful in individuals with sexual obsessions/compulsions and as trial
in adolescents; some authors recommend using SSRIs as first-line treatment of sex offenders, but questions exist
about appropriateness of their use in children and adolescents
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| Sex offenders and recidivism: recidivism in sex offenders may be underestimated because many victims of sexual
assault do not report their victimization to police; study showed released sex offenders 4 times more likely to
be rearrested for sex offense than non-sex offenders; the more prior arrests offenders had, the greater the likelihood
of their being arrested for another sex crime after leaving prison; incest offenders, whether treated or not,
have lower rates of recidivism than pedophiles and rapists; in study of child molesters, individuals who molested
acquaintances not in their family had highest rate of recidivism (16.2%); 25-yr follow-up study found that rapists
and extrafamilial child molesters at risk to re-offend many years after discharge
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| Assessing risk for recidivism: in meta-analysis, overall recidivism rate at 4 to 5 yr was 18.9% for rapists and
12.7% for child molesters; recidivism rate for all sexual offenses, 13.4%; recidivism rate for nonsexual violent
offenses, 22.1% for rapists and 9.9% for child molesters; for pedophiles, best predictor of future sex offense
was plethysmography
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| Treatment outcomes: overall, castration effective, but best outcomes resulted from combination of medications,
cognitive behavioral therapy, and relapse prevention strategies; in recent study, cognitive behavioral therapy
alone found not to have positive benefit; in general, biomedical treatments show more successful outcomes
over long term than psychologic treatments
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Suggested Reading
Alexy EM, Burgess AW, Baker T: Internet offenders: traders, travelers, and combination trader-travelers. J Interpers
Violence 20:804, 2005; Campbell TW: Sexual predator evaluations and phrenology: considering issues of
evidentiary reliability. Behav Sci Law 18:111, 2000; Dunsieth NW Jr et al: Psychiatric and legal features of 113
men convicted of sexual offenses. J Clin Psychiatry 65:293, 2004; Elbogen EB, Patry M, Scalora MJ: The impact
of community notification laws on sex offender treatment attitudes. Int J Law Psychiatry 26:207, 2003; Firestone
P et al: A comparison of incest offenders based on victim age. J Am Acad Psychiatry Law 33:223, 2005;
Firestone P et al: Hostility and recidivism in sexual offenders. Arch Sex Behav 34:277, 2005; Greenberg D et al:
Recidivism of child molesters: a study of victim relationship with the perpetrator. Child Abuse Negl 24:1485, 2000;
Hanson RK et al: First report of the collaborative outcome data project on the effectiveness of psychological treatment
for sex offenders. Sex Abuse 14:169, 2002; Janus ES: Sexual predator commitment laws: lessons for law and
the behavioral sciences. Behav Sci Law 18:5, 2000; Kokish R, Levenson JS, Blasingame GD: Post-conviction
sex offender polygraph examination: client-reported perceptions of utility and accuracy. Sex Abuse 17:211, 2005;
Langevin R, Curnoe S, Bain J: A study of clerics who commit sexual offenses: are they different from other sex
offenders? Child Abuse Negl 24:535, 2000; Lewis CF, Stanley CR: Women accused of sexual offenses. Behav Sci
Law 18:73, 2000; Miller HA, Amenta AE, Conroy MA: Sexually violent predator evaluations: empirical evidence,
strategies for professionals, and research directions. Law Hum Behav 29:29, 2005; Scott CL, Gerbasi JB:
Sex offender registration and community notification challenges: the Supreme Court continues its trend. J Am Acad
Psychiatry Law 31:494, 2003; Scott CL, Holmberg T: Castration of sex offenders: prisoners’ rights versus public
safety. J Am Acad Psychiatry Law 31:502, 2003.
Educational Objectives
| The goal of this program is to improve the assessment and management of sex offenders. After hearing and assimilating
this program, the clinician will be better able to:
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| Supply medical and legal definitions for several categories of sex offenders.
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| Provide an overview of people with paraphilias and estimate the risk for their engaging in more than one form
of paraphilia.
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| Discuss past and present trends in legislation dealing with sex offenders.
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| Evaluate sex offenders in terms of their risk for recidivism.
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| Describe treatments available for sex offenders.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, the Audio-Digest Foundation requires all faculty members
to disclose relevant financial relationships within the past 12 months that might create any personal conflict of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care
education and not a proprietary business or commercial interest. For this program, Dr. Scott indicated nothing to disclose.
Acknowledgements
Dr. Scott was recorded at The Individual with Schizophrenia: Evidence-Based Practices for Recovery, presented April
11, 2007, in Loma Linda, California, and sponsored by Loma Linda University School of Medicine and Patton State Hospital.
The Audio-Digest Foundation thanks Dr. Scott and the sponsors for their cooperation in the production of this program.
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