Overview | Clinical Scenarios | Additional Tips | References

By Renée Sorrentino and Abhishek Jain

OVERVIEW

Definitions

Sexual Offender: “Sexual offender” refers to an individual charged or convicted of a sexual crime. Individuals who commit sex offenses are a heterogenous group with various types of offenses and no single profile. This term also does not convey any information about an offender’s clinical characteristics.

Individuals who sexually offend vary in their: motivations to offend, choice of victims, and type of personality. This makes it difficult to profile sexual offenders as a group. Some individuals who sexually offend have a paraphilic or deviant sexual interest, while others do not.

Paraphilic Disorders: As outlined in the DSM-5-TR, paraphilic disorders are conditions in which the individual experiences recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects or nonconsenting partners (APA, 2022).

The etiology of paraphilic disorders is not well understood but is thought to be multifactorial and lifelong.
Research has shown a high prevalence of non-paraphilic psychiatric disorders in individuals with paraphilic sexual offenses (Kafka, 2012). While mental health professionals may be involved in treating general psychiatric disorders in this population, evaluating and treating paraphilic sexual offenses require specialized knowledge.

General Principles

Some individuals who commit sexual offenses take advantage of situational or environmental opportunities, while others sexually offend in a planned, purposeful manner. Attempts to categorize individuals who commit sexual offenses into typologies have been described, but these have failed to have predictive value for either identifying an individual’s treatment needs or risk of committing a future sexual offense.

Research has identified psychological factors most strongly associated with sexual offense recidivism in adults. However, these factors have an unclear role for first-time offenders. The strongest predictors of sexual recidivism are factors such as deviant sexual interests, history of sexual offending, age of first sexual offending behavior, and having committed varied types of sexual offenses. Other factors are listed in the table below (Brankley et al, 2021).

Static Risk Factors	*Dynamic Risk Factors*
Young Age	Lifestyle instability
History of sexual offenses	Social influences (negative/positive significant relationships)
Absence of co-habitation with a romantic partner for at least 2 years	Hostility towards women
Victim factors (male gender or stranger victims are higher risk)	General social rejection (loneliness)
History of any violent offenses	Poor cognitive problem solving
	Lack of concern for others
	Impulsive acts
	Sexual preoccupation
	Sex as coping
	Lack of cooperation with supervision

The evaluation of an individual with problematic sexual behaviors, including sexual offenses, is referred to as a psychosexual evaluation. The components of a psychosexual evaluation are outlined below:

Clinical Interview

Detailed sexual history, including childhood exposure to sexual acts
Adult sexual interests (masturbation pattern) and behaviors
Review of systems for all the paraphilias
A general medical and psychiatric history is important to assess whether these might be a factor in the etiology or formulation of the sexual offenses or problematic sexual behaviors (such as a dementia contributing to hypersexual or impulsive sexual behavior).

Objective Testing

Objective testing (outlined below) may be indicated in cases in which an individual’s sexual interests are unclear. These tests help understand which stimuli result in an individual’s sexual arousal.
- Penile plethysmography (PPG), which measures penile tumescence in response to sexual stimuli.
- Visual reaction tests associate visual reaction time with sexual interest.
- Polygraphy is not typically a component of clinical work unless mandated by a supervisory agent such as a probation or parole officer

Best practices in assessing an individual’s risk of committing another sexual offense are to utilize an empirically derived risk assessment tool (ATSA, 2014).

Forensic and Jurisdictional Considerations

Forensic evaluations of individuals who commit sexual offenses include criminal evaluations that focus on criminal responsibility, mitigation, or aid in sentencing. Civil evaluations include the civil commitment of sexually dangerous or violent predators, negligence related to entities that employ individuals who subsequently commit sexual offenses and fitness for duty examinations in individuals with a history of problematic sexual behaviors.

Civil Commitment of Individuals Convicted of Sexual Offenses

The most common forensic evaluations in this population are evaluations to determine if an individual meets the statutory criteria of a sexually dangerous person or sexually violent predator. Nationally, 20 states have such specialized civil commitment statutes for individuals who have been convicted of a sexual offense and have the potential to commit future sexual crimes (ATSA, 2014).

These statutes vary by jurisdiction but generally refer to three components (ATSA, 2014):

the individual committed a sexual offense
the individual has a qualifying mental condition
the individual’s mental condition makes it difficult for the individual to control his behavior, resulting in a high likelihood of sexually reoffending.

The trier of fact determines whether an individual meets the statutory criteria based on expert witness testimony. Individuals who are found to meet the criteria for civil commitment under these specialized laws are committed to treatment facilities until they are no longer sexually dangerous.

Mandated Reporting

Mental health professionals who work with individuals who commit sexual offenses or engage in problematic sexual behaviors will encounter clinical situations which warrant mandated reporting. The definition of mandated reporting varies by jurisdiction. Generally, it refers to mandated reporters’ duty to make a report when they have reasonable cause to believe that a child under 18 is suffering from abuse or neglect. Mandated reporting can challenge mental health providers who work with individuals who have sexual fantasies of children and difficulty controlling their behaviors to determine what qualifies as mandated reporting. Mental health professionals who work with this population should be comfortable identifying situations that warrant mandated reporting.

CLINICAL SCENARIOS

Scenario #1. This is a 34-year-old man with a history of pedophilic disorder, exclusive type, and three prior sexual offenses related to child sexual assaults. He has been committed, under specialized state law, as a sexually dangerous person for the past five years. He is requesting chemical castration to address his risk factors for reoffending in an effort to increase the likelihood of discharge.

Approach. Chemical castration refers to using medication to suppress testosterone to prepubertal or castration levels. Chemical castration has been shown to decrease sexual urges, fantasies, and behaviors, resulting in a lower risk of reoffending (Thibault et al., 2020). Such treatment should be considered in individuals who are appropriate candidates (e.g., failed previous treatments, met criteria for a paraphilic disorder, have a history of dangerous sexual behaviors, and provide relevant, informed consent).

Scenario #2. A 42-year-old man with no psychiatric history was convicted of Rape of a Child related to sexual contact with his 12-year-old daughter. The Court has requested a psychosexual evaluation to determine his treatment needs.

Approach. A psychosexual evaluation should include both a clinical interview and objective testing to assess for pedophilic interests. Generally, individuals who commit incest offenses are not paraphilic and have been found to have a low rate of reoffending (Firestone et al, 1999; Lasher et al, 2015). Risk assessment tools should be utilized. If the individual’s risk is low, sex offender-specific therapy is not warranted.

ADDITIONAL TIPS

Working with individuals who commit sexual offenses or have problematic sexual behaviors requires training and experience in conducting psychosexual evaluations as well as applying risk assessment tools.

REFERENCES

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Adult Practice Guidelines developed by the Association for Treatment of Sexual Abusers (2015). Last accessed 04/18/2023 https://www.atsa.com/Members/Adult/ATSA_2014_Adult_Practice_Guidelines.pdf
Brankley, A.E., Babchishin, K.M., Hanson, R.K. (2021). STABLE-2007 Demonstrates Predictive and Incremental Validity in Assessing Risk-Relevant Propensities for Sexual Offending: A Meta-Analysis. Sex Abuse, 33(1), 34-62. doi 10.1177/1079063219871572.
Firestone, Philip & Bradford, John & Greenberg, David & Mccoy, Marcia & Larose, Michel & Curry, Susan. (1999). Prediction of Recidivism in Incest Offenders. Journal of Interpersonal Violence. 14. 511-531. 10.1177/088626099014005004.
Kafka, M. Axis I psychiatric disorders, paraphilic sexual offending and implications for pharmacological treatment. Israel J Psychiatry Relat Sci. 2012; 49:255-261.
Lasher, M. P., McGrath, R. J., & Cumming, G. F. (2015). Sex Offender Modus Operandi Stability and Relationship With Actuarial Risk Assessment. Journal of Interpersonal Violence, 30(6), 911–927. https://doi.org/10.1177/0886260514539757
Thibaut F, Cosyns P, Fedoroff JP, Briken P, Goethals K, Bradford JMW; WFSBP Task Force on Paraphilias. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry. 2020 Jul;21(6):412-490. doi 10.1080/15622975.2020.1744723. Epub 2020 May 26. PMID: 32452729.