Transcript Treating Sex Offenders

Treating Sex Offenders
Dr Jeremy O’Dea
Forensic Psychiatrist
Public Defenders
Sydney 14 May 2005
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Sex Offenders
• Heterogenous Group
• Defined by Diverse group of Illegal
Behaviours
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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
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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
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Risk Assessment
• Actuarial Risk
Assessment
– Static 99
– SONAR
• Clinical Risk
Assessment
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Psychiatric Assessment
Paraphilias
HCL 20
?Penile
Plethysmography
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Actuarial Risk Assessment
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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
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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
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Static 99
Actuarial Risk Assessment Tool
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Over 1000
Prisoners and secure psychiatric patients
Canada and UK
Followed for up to 30 years
Looked at factors on RRASOR and SACJMin that best predicted recidivism
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Static 99, Items
• Prior Sex Offences
– Charges/Convictions
• Prior Sentencing Dates (4+)
• Any Convictions for
non-contact sex offences
• Index Non Sexual Violence
• Prior Non Sexual Violence
• Any Unrelated Victim
• Any Stranger Victim
• Any Male Victim
• Age – Under 25
• Single – No 2 year live in relationship
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Static 99, Risk Categories
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Low
Medium-Low
Medium-High
High
0,1/12
2,3/12
4,5/12
6+/12
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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
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Dynamic Risk Factors
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Sexual Deviance - Paraphilias
Substance Abuse
Psychiatric Illness
?Personality Disorder
Social Situation
Other
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Sydney 14 May 2005
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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
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Civil Commitment
• Kansas v Hendricks (1997)
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Confinement to Mental Institution
Dangerousness without Mental Illness
Judge or Jury Decision
“Substantial Probability” of engaging in
sexually violent acts
– “Beyond Reasonable Doubt”
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Sydney 14 May 2005
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Treatment Programs in NSW
• Custody Based Treatment Programs
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DCS Psychology
Based on risk assessment on Static 99
CUBIT and others
Relapse prevention
• Community Based Treatment
– DCS Psychology
– Others
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Sydney 14 May 2005
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SOTEP
• 1985
• Sex Offender Treatment and Evaluation
Project
• California
• Sentenced Prisoners
– Rape
– Child Molestation
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Eligible Participants
• Inclusion Criteria
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• Exclusion 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
– Gang Rapists
– Biological Incest Only
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3 Groups
• Volunteer Group
– Treatment Group
– Volunteer Control Group
• Non Volunteer Group
– Non Volunteer Control Group
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Treatment
• Relapse Prevention
– CBT
• Atascadero State Hospital
– 2 years
– 40 – 50 hours per week
• Sex Offender Aftercare Program
– 1 year
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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
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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
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Sydney 14 May 2005
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Negative Findings - Overall
• Volunteer Control’s did better than the
Treatment Group in terms of sex reoffending
• Treatment Group had the highest rate of
violent re-offending
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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
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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
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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
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Sydney 14 May 2005
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Other Psychological Treatments
• Community Based
– Supervision
– CBT
– Relapse Prevention
• Psychological treatments in combination
with Psychotrophic Medication in selected
individuals
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Psychopharmacological
treatments
In selected patients with paraphilias
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Castration
• USA
– Chemical and Surgical
– 9 States
– Voluntary and Mandatory
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NSW
• Call to “castrate’ child sex offenders
– Opposition justice spokesperson
– ?Condition of parole
– ?Mandatory
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France
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Justice Minister
2 year trial
Leuproreline and Cyproterone Acetate
Voluntary
48 repeat offenders
Denmark,Sweden,Canada
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Psychiatric Treatment
• Appropriate patient populations
– Paraphilias v Sex Offences
– DSM IV TR
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Efficacy
Tolerability
Best available option
Consent
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Consent to Treatment
• Involuntary
– Guardianship Tribunal
– Mental Health Acts
– ?Mandatory Treatment
• Risk/Benefit
• Evidence Base
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What is the medical evidence?
Where does it come from?
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Evidence
• Animal Husbandry
• Eunuchs and Castrati
• Surgical Castration Studies
– Voluntary and Involuntary
• Testosterone and Sexual Behaviour in Men
• Testosterone Lowering Medications
• Antipsychotics and Antidepressants
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Surgical Castration
Study
Follow
up
Period
(Years)
Number
of
Subjects
Pre-op
rate of
recidivism
(%)
Post-op
rate of
recidivism
(%)
Comparison
group
rate of
recidivism
(%)
Germany,
Langeluddeke,
1963
Up to 20
1036
84
2.3
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Switzerland,
Cornu, 1973
5+
127
77
7.4 – 4.1
66 - 52
Norway,
Bremer, 1959
1 - 10
215
58
2.9 - 7
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Denmark,
Sands, 1964
Up to 30
738
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1.4 – 2.4
9.7
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Medication
(Chemical Control)
• Oestrogens
• Progestogens
– Medroxy Progesterone Acetate (MPA), Provera
• Anti-androgens
– Cyproterone Acetate (CPA), Androcur
– Flutamide
– Nilutamide
• SSRI’s
• Others
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Sydney 14 May 2005
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Medication
(Chemical Control)
• GNRH agonists
– Triptorelin
• LHRH Agonists
– Leuprolide acetate
– Goserelin
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Therapeutic Trials
• Methodological Problems
– Heterogenous Groups
– Small Sample Sizes
• Single Case Studies
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Double blind/Placebo controlled
Drop Outs
Self Report
Follow up periods
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Sydney 14 May 2005
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CPA
• Bradford and Pawlak, 1993
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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
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GNRH/LHRH Analogues
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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
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SSRI’s
• Case Reports
• Small open label studies
• 50-90% response rates
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Sydney 14 May 2005
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