Merrill Rotter, MD

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.

 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 

 hospitalization laws are predicated on the idea that the predisposition to sexually violent behavior constitutes a mental abnormality for which psychiatric hospitalization is appropriate.

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.

 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.

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.

 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.

Demographic and diagnostic considerations

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 (

 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%).

With reference to their offending behaviors, the majority (56%) offended with adult females only; 16% were exclusively pedophilic. About half of the offenses involved violence, but the vast majority of patients (79%) scored very low on the Rapid Risk Assess-ment for Sexual Offense Recidivism (RRASOR). The RRASOR is a 4-item scale that examines prior sex offenses, current age, victim gender, and relationship to victim to rate the potential for recidivism.

This cohort of sexual offenders represented an actuarially low-risk, heterogeneous group who were diagnostically distinguishable from sexual offenders without mental illness. The approach to assessment and intervention should be equally distinguishable.

The assessment approach my colleagues and I advocate begins by examining the overlapping causes of sexual offending behavior with which our patients present (

). The 3 Ps-psychosis, paraphilia, and psychopathy-are our shorthand for the various contributions of serious mental illness, primary sexual deviance, and underlying character pathology, respectively.	

Serious mental illnesses (eg, schizophrenia or bipolar disorder) may be associated with delusions, command hallucinations, or impulsivity and hypersexuality that drive the offending behavior; the associated social dysfunction or awkwardness may also be a contributing factor. Individuals with paraphilias are, by definition, driven primarily by inappropriate sexual desires. Those with character pathology, such as psychopathy, may be so grossly self-centered and unempathic that the offending behavior fits in with a pattern of self-serving and rule-breaking behavior in other arenas.	

Each of these P components requires a unique intervention, some of which are more associated with traditional mental health treatment than others. Our patients often present with 2 or more of these factors, but this template is a good starting point for structuring our thinking. (Substance abuse, a well-established risk factor for sexual offending behavior, may exacerbate the predispositions driven by any of the Ps.)

A 43-year-old man with the diagnoses of schizophrenia and polysubstance abuse, characterized by auditory hallucinations, delusions of control, and suicide attempts was admitted to a hospital upon conditional release from prison. He was incarcerated for the rapes of a 3-year-old and a 5-year-old. He had a history of a "revenge" rape of a 5-year-old at the age of 13.

A 28-year-old with the diagnosis of schizophrenia and polysubstance abuse characterized by delusions, hallucinations, agitation, and thought disorder, was admitted from the local hospital. The patient's presentation was noteworthy for a history of obscenity and public lewdness in the community, exhibitionism, and touching women in the hospital.

A 56-year-old with a diagnosis of schizophrenia was admitted to the hospital upon conditional release from prison where he had been incarcerated for multiple rapes of women committed over several weeks. The patient's history included early antisocial behavior; his presentation on admis-sion was characterized by severe negative symptoms.

General characteristics particularly associated with sexual offending behavior include deviant sexual interest, cognitive distortions, anger management difficulty, poor social skills, denial, and lack of victim empathy. Although these characteristics may be present in sexual offenders without mental illness, they may be a symptom of, or exacerbated by, an underlying mental disorder.

In a person with mental illness, deviant sexual interest may be related to the hypersexuality of a manic phase in bipolar disorder or a response to the command hallucinations in schizophrenia. Common cognitive distortions, such as a pedophile who thinks that children want to have sex with him, may rise to the level of a delusional belief that a sexual relationship with a child actually exists. One patient with whom we worked had the delusion that he himself was a child; thus, he reasoned that his sexual interest in children was as a peer rather than as a partici-pant in an adult-child relationship.

Negative symptoms of mental illness are often associated with poor social skills that can exacerbate a tendency toward sexually inappropriate behavior. Denial, in a seriously mentally ill person, may also rise to the level of a delusional belief that nothing occurred, making it harder to confront than with a nonmentally ill sexual offender. Finally, victim empathy presumes a differentiation between self and others that may not be present, especially when an individual is in the throes of an acute decompensation.

The assessment should begin with a thorough chart review followed by a clinical interview, informed or structured by the Psychopathy Checklist Screening Version (PCL-SV). The structure of the PCL-SV captures the general psychiatric and psychosocial information necessary for diagnosis while focusing on areas of interpersonal relationships, conflict, and criminality that are particularly relevant in an offending population. The data collected are used in the service of an actuarial risk assessment to determine level of risk that, as noted above, is usually low. Most commonly, we use the aforementioned RRASOR. While there are more comprehensive actuarial tools, we have the data to complete the RRASOR on all of the cases we assess. In addition, our focus in clinical treatment planning is on the assessment of the dynamic risk issues (eg, diagnosis, symptoms, and cognitions).

Our assessment of the patient's cognitive functioning includes batteries specific to sexual offenders as well as routine psychological testing. Through broad-prompted inquiry, the offender-specific batteries seek to uncover the range of deviant sexual interest and behavior as well as cognitive distortions that may go along with these behaviors and desires.

Routine psychological testing includes both personality disorder assessment tools, such as the Personality Assessment Inventory and the Minnesota Multiphasic Personality Inventory, and projective testing, such as the Thematic Apperception Test (TAT) and Person Object Drawing and Rorschach tests. In persons with mental illness, these tests have the added value of improving diagnostic accuracy and uncovering internal events such as psychotic experiences, sexual and nonsexual fantasies, distorted cognitions, and unrealistic perceptions of self and others. For example, when presented with a TAT card depicting a man and older woman looking down pensively, one patient reported, "They had words and now he's standing up looking at a corpse he can't see. He's thinking of who he can f**k next." As with some of our other patients, the projective testing opened up an area of sexually and violently charged ideation for this patient who, when confronted directly, calmly denied sexually inappropriate interest or activity.

Thus, the assessment of such patients is enhanced by combining traditional assessment techniques and psychological testing with tools targeted at offending cognition and behavior.

Psychotherapeutic treatment of individuals with serious mental illness often has to be flexible enough to accommodate the intrusion and distractions of psychotic symptoms. This flexibility is not always built into structured and confrontational interventions that are designed to break the cycle of sexual offender recidivism. In the same way that substance abuse treatment had to be modified to address the needs of the patients with mental illness who also abuse substances, we need to think creatively about how to reach the individual with mental illness who is also a sexual offender.

Two approaches are used at our hospital: psychoeducation and modified relapse prevention. The psychoeducational intervention, "Intimacy and Coercion," is predicated on the notion that many patients have social-skills deficits, do not correctly perceive or interpret social cues, and are not familiar with the concept of intimacy and coercion. To that end, the group's coleaders explore the differences between appropriate social interaction and coercive interaction in a nonjudgmental atmosphere. By using neutral examples from commercial films, patients are not forced to speak about their own offenses. The coleaders replay relevant scenes, point out salient features, and initiate brief discussions. Individuals may cycle through the group more than once, which allows for needed repetition of concepts. Pretesting and posttesting provide efficacy and evaluation data. We found that, over time, patients began to share details of their offending behaviors, even though it was not a necessary part of the group interaction.

The focus of the relapse prevention group is to identify the specific inappropriate behavior of the participants, delineate the cycle of events that led to the behavior, and devise a prevention plan. There are some important modifications made to customize this treatment modality for patients with mental illness (as opposed to sexual offenders without mental illness). First and foremost, the recurrent intrusion of symptoms and deficits required the coleaders to deviate from a straightforward, sequential learning of relevant concepts. Not all intrusions were managed. Crucial offense-cycle material was revealed through the psychotic associations of some members. Again, repetition was critical. Treatment goals and concepts had to be reviewed in almost every session. Additional coaching was provided in individual sessions for homework assignments (eg, writing offense-cycle scripts).

Psychopharmacological treatment for the mentally ill sex offender begins with treating the underlying psychiatric disorder, particularly when the origin of the sexually inappropriate behavior falls within the psychosis or seriously mentally ill circle. A decrease in delusions, hallucinations, impulsivity, hostility, and hypersexuality can be associated with decreased untoward sexual behavior. When more specific psychopharmacological intervention is required, SSRIs may provide a decrease in libido and an increase in impulse control. 

Although we have not used specialized agents to date, there are no specific contraindications to the use of other libido-decreasing agents such as depot-leuprolide acetate or medroxyprogesterone in a population with serious mental illness. Androgen reduction therapy with depot-leuprolide acetate is being used in other facilities to treat individuals with paraphilias and those who have a predisposition to sexual aggression. This strategy usually is implemented after pharmacological treatment of other psychiatric disorders has been optimized and after trials of SSRIs (personal communication, Richard Krueger, December 2006). (The prescription of SSRIs and depot-leuprolide acetate for the management of sexual impulsivity is considered off-label use.)

I have herein described our approach to treating individuals with serious mental illness and sexually inappropriate and/or offending behavior. This approach is based on 2 key principles: (1) recognition of our responsibility to address all the untoward behaviors with which our patients present and that can lead to problems with their successful community reintegration; and (2) recognition that sexual offenders with mental illness are a subpopulation of offenders and their unique clinical contributions to their sexually inappropriate behavior require modifications in assessment and treatment. In particular, we have learned that our targeted assessment must also include a screening for cognitive deficits, given the prevalence of low IQ scores among the offenders.

In addition, we have found routine psychological testing valuable in delineating the patient's underlying condition and diagnosing personality disorder as well as uncovering sexual ideas, preoccupations, distortions, and delusions that may not be evident in structured or general clinical interviews. With respect to treatment, our patients can learn about general offending behavior and their specific risk issues, but the intervention requires active leadership, repetition, and an expectation for a nonlinear process of learning and recovery.

The most refractory symptoms that preclude recovery appear to be denial and impulsivity, but a decrease in sexually inappropriate behavior has been achievable in our inpatient setting. Outpatient follow-up that continues to target this behavior would seem to be critical to maintain inpatient gains.

The treatment of individuals with sexual offending behavior remains a controversial area within mental health care, particularly in its increasingly popular form (ie, involuntary civil commitment to psychiatric hospitals). However, making attempts to address all of the needs of those patients who come to us with more traditional indications for psychiatric care should and can include the assessment and treatment of sexually inappropriate behaviors.

 Mansnerus L. Zoning laws that bar pedophiles raise concerns for law enforcers. 

Dangerous Sexual Offenders: A Task Force Report of the American Psychiatric Association

. Washington, DC: American Psychiatric Association; 1999.


Sreenvasan S, Weinberger L, Garrick T. Expert testimony in sexually violent predator commitments: conceptualizing legal standards of "mental disorder" and "likely to reoffend." 

Levenson J. Sexual predator civil commitment: a comparison of selected and released offenders. 

 Raymond NC, Coleman E, Ohlerking F, et al. Psychiatric comorbidity in pedophilic sex offenders. 

 McElroy SL, Soutullo CA, Taylor P Jr, et al. Psychiatric features of 36 men convicted of sexual offenses. 

 Novak B, McDermott B, Scott C, Guillory S. Sexual offenders and insanity: an examination of 42 individuals found not guilty by reason of insanity. Presented at: American Academy of Psychiatry and Law Annual Meeting; October 28, 2006; Chicago.


Narayanan P, Rotter M, Khadivi A. Mentally ill sexual offenders: a descriptive study

Presented at: American Academy of Psychiatry and Law Annual Meeting; 2006; Chicago.


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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.

Merrill Rotter, MD

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