Sexual Offenders With Mental Illness: Special Considerations for a Special Population

Whether or not sexual offending behavior—or the predisposition to such—is a mental illness, there are patients with traditional mental illnesses who also present with sexually inappropriate and even sexual offending behavior. A holistic approach to treating these patients requires attention to all the areas that may pose problems for their successful adjustment to the community. Concern about the potential medicalization of sexual offending behavior as a whole has driven some denial of treatment responsibility from mental health care practitioners. As a result, there is a lack of attention to this problem behavior, even when it is part of a larger psychiatric condition. In this article, I advocate a targeted approach to individuals with co-occurring mental illness and sexual offending behavior akin to the holistic approach that fostered the integrated treatment of mental illness and substance abuse.

Increasing attention is being paid to the assessment and management of individuals who commit or are at risk for committing sexual offenses. The general media and professional literature continue to debate evaluation techniques, effectiveness of treatment, and propriety of restrictions placed on those at risk for recurrent sexual deviance.¹ This debate is largely focused on what to do about individuals who have been convicted of sexual crimes.

Over the past decade, we have witnessed initiatives that require sexual offenders to register with local and state criminal justice agencies, which can restrict sexual offenders from living in large geographic areas and leads to the civil commitment of sexual offenders upon release from prison (the latter is of greatest relevance for mental health practitioners). These so-called sexually violent predator hospitalization laws are predicated on the idea that the predisposition to sexually violent behavior constitutes a mental abnormality for which psychiatric hospitalization is appropriate.²

Many criticisms have been leveled at this public safety-driven conceptualization. It redefines criminal behavior as psychiatric illness by legislative fiat irrespective of the relevant science for treatment and appropriateness of psychiatric hospitalization. It diverts scarce public mental health resources from patients with mental illness who have been traditionally served in hospitals and for whom hospital-based care has demonstrated long-standing effectiveness.³ Finally, these initiatives fail to distinguish between the classic psychotic Axis I diagnoses (eg, schizophrenia) and character pathology (eg, antisocial personality disorder) with respect to the utility of psychiatric hospitalization. In fact, to the extent that they are actually focused on confining individuals who would not have traditionally been hospitalized, those hospitalized under such statutes are more often than not primarily paraphilic, antisocial, or both.^4,5

This attention to sexual deviance based in paraphilia and/or character pathology is paralleled in the clinical literature in which assessment, treatment, and management research is similarly focused. Consequently, there is scant literature addressing sexual offending behavior in the context of serious mental illness.^6-8 Practitioners who work in public sector settings are aware that many of their patients have concomitant sexually inappropriate or offending behavior. There are many areas of overlap between serious mental illness and sexuality (both appropriate and inappropriate). In addition, there are various ways in which serious mental illness can compromise the efficacy of traditional approaches to sexual offending behavior. It therefore behooves us to try to understand this unique subpopulation of sexual offenders.

Findings from a study of 320 inpatients at a community-based state psychiatric center revealed 50 individuals (16%) with sexually inappropriate behavior, 54% of whom had an arrest for a sexual offense; 34% had sexual offending behavior in the community but no arrest history; and 12% had sexually inappropriate conduct only in the hospital (Table).⁹ When these individuals were compared along demographic and diagnostic parameters (eg, age, ethnicity, marital status, and primary diagnosis), there were no significant differences between patients with and those without sexual offending histories. Patients with IQs in the mental retardation range were overrepresented among the sexual offending group (21%).