A record audience of over 170 assembled for Sex, Psychiatry and the Law, the 24th annual conference of the Tri-State Chapter of AAPL in New York City on January 23, 1999. Chapter President Dr. Stephen B. Billick began with a report summarizing current information, set in its historical context, on normal sexual development. His approach was strictly empirical, making it clear that abundant evidence has accumulated on how often and early male infants experience erections, that babies indulge in ample and thorough body exploration, and that preschoolers play games of dressing and undressing and playing nurse and doctor (despite the deprivations of managed care).
Dr. Billick pointed out that a society’s level of cultural permissiveness is inversely proportional to its children’s concealment of their sexual interests from adults, perhaps explaining what Freud called latency. He added convincing data based on large numbers of mothers asked to report on their children’s sexual behavior in two studies, and reviewed data from reports on teenagers across a wide time range. Lamenting the relative scarcity of recent information, the speaker presented congruent results from some key exceptions including Lamb, Friedrich, and Money. From this work, he pointed out the physician’s job to distinguish normal sex play from the abnormal. Abnormal play might be consistent with (but cannot ever prove) a history of being sexually abused.
Worthwhile points brought out by questions included the importance and the difficulty of keeping information on the topic up to date. Tom Gutheil reminded us that the child’s sexual vocabulary is mistaken as sure evidence of abuse. Jonas Rappeport made the further point that the forensic expert needs to deal with the effects of lawyers’, judges’ and jurors’ psychological defenses, including the insidious potential for a kind of group hysteria.
Fred S. Berlin MD PhD, Associate Professor of Psychiatry at Johns Hopkins, entitled his superb talk "Sex Offenders: Criminals or Patients?" He explained that similar behaviors can occur for different reasons, sometimes related to psychiatric disorder and sometimes not. For example, sex offenders may or may not be paraphiles. Assessment for possible sex offender status must address four issues: behavior, partner(s), intensity, and attitude.
Regarding behavior, some is strictly limited to fantasy, some fantasy being quite intense as in transvestitic fetishism and exhibitionism. The other end of the behavior gamut can be seen as that of sadism and masochism. Partners cover a wide range, from the more bizarre such as animals or corpses, to children, including the problem represented by the drunken father coming home and raping his attractive and sexually mature daughter of 13 or 14.
The issue of intensity is in some legal flux, as we see Internet technology transforming behavior that might be experienced as quietly private into a federal crime with a mandatory jail sentence. Assessing attitude involves distinguishing the ego-syntonic offenders from the more tortured individuals who lose the struggle for control. Similarly, offenders may be cruel or kind, conscientious or careless, and may have other personality variations that may or may not constitute an Axis II diagnosis and can often be erroneously confused with sex-related problems.
Etiology was the speaker’s next area, one whose progress is impaired by stigma. Yet it is still a good question to ask: why are most of us attracted sexually to age-congruent humans of their opposite gender, but some to children of their same gender? It is clearly not a volitional choice, any more than one can choose to be schizophrenic. Being a victim of sexual abuse has been considered a risk factor, since any group of paraphiles will predominantly report it; yet most who are sexually abused grow up with normal arousal. (Just as most smokers do not contract squamous cell carcinoma of the lung, while most victims of this disease turn out to have been heavy smokers). Sex is biological, so it makes sense to expect a biological cause here, but so far there is only preliminary evidence.
Treatment came next in Dr. Berlin’s talk, beginning with the dissonance between the obvious inefficaciousness of the volitional approach ("just say no") and the law’s requirement assuming that all can conform. The evidence is strong that people cannot always conform, otherwise obesity would vanish as its victims all took up just eating a little less each day. This is a familiar point dating back to the field’s earliest investigators and leading to such infelicitous terms as "sexual addiction." Because it feels good, it is hard to stop, and the craving returns recurrently as often as it is satiated.
Despite this reality, four kinds of treatment can be mentioned for paraphilic disorders (leaving comorbid Axis II problems aside). Though it may once have held sway, not many now see insight-oriented individual psychotherapy as the treatment of choice. Behavior therapy based on the reconditioning approach can alter laboratory measurements of attraction patterns, but there is major difficulty transferring the results from the treatment setting to the real world. Treatment using aversion is an abysmal failure. Behavior therapy based on the cognitive approach can be helpful, said the speaker, particularly for the problem of craving, as the Betty Ford Clinic’s well regarded experience demonstrates. This includes group treatment and probably works because it so directly confronts the denial and rationalization that sustain the disorder. This of course assumes that the individual is serious enough to get involved in open and honest dialogue. Relapse prevention also comes under this heading, identifying and implementing the needed changes in lifestyle. There was not time for detailed discussion of the biological modalities, surgery and medication, except to point out that so far these cannot change one’s orientation, but are helpful in reducing the intensity of the drive.
Meg S. Kaplan PhD, Associate Clinical Professor at Columbia gave a condensed review of juvenile issues. She stressed familiar data from Abel and Becker that the age of onset of paraphilia tends to fall in the early teen years. She mentioned that one-fifth of adult rape victims report being assaulted by an adolescent and that the same may be true for up to half of child victims. Thus, the ages set in the DSM-IV are misleadingly high. Also, terminology itself poses difficulties, such as trivializing expressions like "mini-perp." The speaker suggested using the term "child with inappropriate sexual behavior."
Juvenile sex offenders are a more heterogeneous group than their adult counterparts, reflecting a combination of causes and following a variety of courses. Assessment properly begins with a quality clinical interview that develops trust and then continues with appropriate tests. There are many approaches to draw from, but unless there is a long and serious history the plethysmograph is inappropriate before age 16 because of its provocative nature. Assessment must deal with denial and cover several risk factors including deviant fantasies, behavioral rehearsal, isolation, and poor impulse control. Finally, there are encouraging indications that younger psychopaths can be successfully treated if there is sufficient monitoring, supervision, and integration into the community.
A lively question period followed with speakers Berlin and Kaplan responding jointly. Asked to say more about medications, Dr. Berlin pointed out that phenothiazines have long been employed because of their potential libido-reducing side effects. He pointed out that SSRIs may usefully treat a comorbid depression, have helpful anti-obsession properties, and may even address the role of serotonin in sex drive (this yet to be fully determined). He reminded us that a great deal is known about the mechanisms of the anti-androgens and that these should be clearly accepted as the first-line class of medication for sex offender treatment. Asked about how to assess fantasy content, Dr. Kaplan pointed out that the popular emphasis on content without evaluating exclusiveness is too narrow. Several other issues, including polygraphs, dopaminergic agents, childhood PTSD as a consequence of incest, and child pornography on the internet also received attention.
Harvard Professor Thomas Gutheil MD reviewed sexual harassment in the workplace, opening with a strong statement that it is bad, illegal, and deserving of punishment, but not so much so that invalid claims should ever be rewarded. He described the criteria of quid pro quo and hostile environment, reviewed a series of causes, and the prominence of the slippery-slope nature of the problem. He provided an interesting list of recent cases, summarizing their import in terms of injury not being required, same-sex complaints not being covered, the importance of deliberate indifference, and the value of being able to show that reasonable steps were being taken.
Next, a series of issues served to demonstrate how the harassment issue is changing the workplace and opening up important non-forensic roles for therapists. The forensic assessment role is a demanding one, especially assessing the workplace atmosphere in situ and carefully evaluating all participants while striving to remain objective. One must recognize alternative explanations, including factitious claims and other possible defenses, and give them due consideration.
Finally, Laurence R Tancredi MD JD, Clinical Professor of Psychiatry at the New York University carried off the challenging anchor position with a systematic and compelling description of several policy implications of the sexual predator laws. He noted that such statutes were rather commonplace early in this century, until all but 11 states and the District of Columbia repealed them as civil rights gained recognition during the late 1970s. Then, as one bad case after another emerged, beginning with that of Earl Shriner in Washington in 1990, these statutes have been making a gradual comeback. They are based, he noted, on the existence of sexual psychopathy as an entity characterizing identifiable individuals who can be assessed for their risk of recidivism and treated to reduce it.
Dr. Tancredi pointed out the circularity of the legal definitions of mental abnormality, adding that it is a dangerous notion because it combines the mad with the bad. It is aimed at establishing a system of social control. He pointed out problems with the Supreme Court’s attempt in Hendricks at defining a distinction based on the individual’s level of behavioral control, adding that with few exceptions the prisons offer no serious treatment. The speaker took a narrow view of effective treatments, noting that the few reports of recidivism rates so far have covered short periods of time and shown discouraging results. He pointed out the ethical and efficacy problems of surgical approaches and a finding of increased recidivism after group therapy in one study (contrasting with what Dr. Berlin had mentioned earlier).
The extremes associated with so-called Megan’s laws are becoming worrisome, evoking images of The Scarlet Letter. Encouragingly, there are data to suggest that second sex offenses tend to be less severe when they do occur. Dr. Tancredi suggested that a kind of therapeutic jurisprudence could be set up, for example by constructing laws allowing an individual to progress through successively greater levels of freedom through regular assessments. Unfortunately, in most instances experience with existing laws has shown a mostly anti-therapeutic impact, along with discouraging costs. As he concluded, the speaker called attention to a forthcoming APA Task Force report on sex offenders.