Renee Sorrentino, MD

Today, 25 years after the Lorena Bobbitt trial, the case has gained a renewed interest. The #MeToo and Time’s Up movements have begun to identify the widespread problem of sexually abusive behaviors in both social and occupational arenas. In light of these crusades, filmmaker and producer Jordan Peele (

) has created a four-part docuseries reexamining the Lorena Bobbitt case.

 A look back at the case is a reflection of how far we have-and haven’t-come in conceptualizing sexual violence, including gender bias in the determination of culpability as examined in Bobbitt’s not guilty by reason of insanity (NGRI) acquittal.

Twenty-five years ago, after she took a knife to her husband’s genitals, Lorena Bobbitt became a household name. At her trial, she and others testified that she had been trapped in an abusive marriage with a husband who raped, beat, and belittled her. The media, at that time, adopted comedic commentaries and headline puns in covering the story, depicting Lorena as a crazed woman who falsely claimed rape.

After the trial, Lorena’s popularity dissipated, and she faded into a quiet life in Manassas, Virginia. Her ex-husband, John Wayne Bobbitt, remained in the spotlight, starring in adult films, giving interviews on talk shows, and getting paid to appear at events around the country. He was subsequently charged, on more than one occasion, with battery.

The not guilty by reason of insanity plea

On the evening of June 23, 1993, Lorena Bobbitt cut off her husband’s penis with a kitchen knife as he slept. She left the house, appendage in hand, and subsequently threw the penis out of her car window, near a 7-Eleven, and called 911. Lorena later told police that John was sexually, physically, and emotionally abusive. She reported that just before she cut her husband, he raped her. John’s version of events was that he had come home after an evening of drinking with a friend and went to sleep. He stated that Lorena attempted to make sexual advances toward him and that there was “some petting,” but they did not have sex. Lorena was charged with malicious wounding, and John was charged with marital sexual assault.

At Lorena’s trial, she testified to the years of abuse that occurred in her marriage, including being forced by her husband to undergo an abortion. She discussed in detail the rape on the evening of the incident for which she was charged. She testified that following the rape, she went to the kitchen to get a glass of water and attempt to calm down. While there, she had memories of the traumatic events she had undergone at the hands of her husband. Lorena said she did not remember cutting her husband. Both the defense and prosecution offered psychiatric testimony. While both psychiatrists agreed that Lorena suffered from a mental illness, their opinions differed regarding Lorena’s criminal responsibility.

Dr Susan Fiester, the defense expert, made a diagnosis of MDD, PTSD, and panic disorder. She described Lorena as a classic example of a “battered wife,” weakened by years of abuse and fearful of leaving her husband. She testified that John’s assault on Lorena on the evening of June 23 led to “an acute deterioration of her mental state,” and she “became psychotic.” Dr Fiester further opined that Lorena did not have control over her actions when she assaulted her husband.

Dr Miller Ryans, the prosecution expert, testified that although he did not doubt Lorena was raped, he did not detect any evidence that she was “out of touch with reality or experiencing any delusions” at the time of the assault on her husband. He concluded that Lorena’s actions were not an “irresistible impulse” but rather “an impulse she did not resist.” The defense prevailed, and Lorena was found NGRI.

The insanity defense is a legal construct, which in some circumstances can allow for an individual to be found not legally responsible for his or her criminal behavior due to mental illness. The standard for insanity, or criminal responsibility, varies by jurisdiction, and some states do not recognize an insanity defense.

Legal standards are categorized by the presence of a cognitive or a volitional prong. The cognitive prong refers to whether mental illness prevents an individual from appreciating the wrongfulness of the act. The volitional prong, often used interchangeably with the “irresistible impulse test,” focuses on whether the mental disease or defect prevented the individual from controlling his or her behavior at the time of the offense. While the standard in most states includes a cognitive prong, 16 states and the District of Columbia recognize a volitional prong for the insanity defense.

Irresistible impulse or impulse not resisted

No state relies on irresistible impulse as the only test of insanity, largely because of the difficulty in distinguishing an “irresistible impulse” from an “impulse not resisted.” This means that those individuals, such as Lorena Bobbitt, who are found NGRI based on the volitional prong would have been found guilty in most other states.

The irresistible impulse test was first used successfully in the English case of Regina v Oxford in 1840. In this case, Edward Oxford was indicted for treason for attempting to shoot Queen Victoria. His defense was on the grounds of insanity, largely relying on a family history of insanity and his own prior “insane acts.”

 At the trial, Justice Denman charged, “If some controlling disease was . . . the acting power within him which he could not resist, then he will not be responsible.”

The idea of an “irresistible impulse” was raised in the 1843 trial of Daniel M’Naghten, who shot and killed the secretary of Sir Robert Peel, while believing that he was being persecuted by Sir Robert Peel and the Tory Party. In his successful defense of M’Naghten, defense attorney Alexander Cockburn described M’Naghten’s murderous act as an “irresistible impulse.” Following this trial, multiple states added an irresistible impulse rule to their insanity standards, and by 1944, 17 states included an irresistible impulse rule.

 Practically, the difficulty in applying this defense is in establishing the difference between an irresistible impulse and an impulse not resisted. This proved to be a key issue in the Bobbitt trial, and where Dr Fiester and Dr Ryans differed in their opinions.

The question of whether Lorena Bobbitt sufficiently met the criteria for an NGRI defense can be answered by examining the two necessary components of a successful insanity defense, the presence of a mental disease or defect at the commission of the criminal act and whether the disease or defect impaired cognition or volition. All three clinicians who evaluated Bobbitt concluded that she was a “battered woman,” a psychological diagnostic shorthand that persisted throughout the trial and associated media coverage.

 Based on the pioneering work of Dr Lenore Walker, battered woman syndrome provided a rubric for understanding the complex, often counter-intuitive, responses of domestic violence victims.

The battered woman syndrome has been used as a defensive strategy to justify a broad array of behavior, ranging from self-defense and provocation, to insanity and diminished capacity. The 1977 case of Francine Hughes marked one of the earliest high-profile criminal cases to use battered woman syndrome as a defensive strategy. At the time of the trial, Hughes was a 29-year-old housewife, married to a man who had violently and repeatedly abused her over 13 years. On March 29, 1977, after being humiliated, raped, and beaten, Francine set her sleeping husband’s bed on fire and was subsequently charged with first-degree murder. Following a trial by jury that included expert witness testimony, Hughes was found not guilty by reason of temporary insanity.

. . . the basic premise of such a defense [temporary insanity] would be that the defendant, at the time of the killing, suffered from severe stress and an impaired mental state as a result of the battering relationship, and that this impaired mental state caused her to kill the batterer. The causal link between the woman’s impaired mental state and the killing can be established by showing that the woman viewed her predicament from a psychologically distorted perspective and thus was unable to perceive her options accurately, or by showing that the “woman was driven to the breaking point by the circumstances of her situation and therefore was substantially unable” to conform [her] conduct to the requirements of law.

In contrast to the successful use of battered woman syndrome in the Hughes’ defense, the case 

 in 1979 highlighted early conflict about the validity of the diagnosis.

 Following years of spousal abuse, Beverly Tamas shot her husband and was charged with second-degree murder while armed. After a guilty verdict, the case was taken to appeal, claiming the court had erred in excluding the expert testimony by Dr Lenore Walker on battered woman syndrome. Following appeal, the case was remanded to a lower court for reconsideration. The trial court concluded that the “defendant failed to establish a general acceptance by the expert’s colleagues of the methodology used in the expert’s study of battered women.”

 In doing so, the court proceedings highlighted concerns that Dr Walker’s reports, while compelling and relevant, were limited by a paucity of supporting scientific data.

As part of the 1994 Violence Against Women Act,

 the federal government released a report reviewing the medical and psychological evidence for battered woman syndrome. The report noted that Dr Walker’s cycle of violence was not universally replicable throughout battering relationships and, as such, should not be used to define the psychology of those within the relationship. In addition, the report stated that available data contradict the theory’s proposal that abused women are universally helpless and passive. However, “expert testimony on battering and its effects can be based on and supported by an extensive body of scientific and clinical knowledge on the dynamics of domestic violence and traumatic stress reactions.” In doing so, the construct of battered woman syndrome was viewed as being limited and overly simplistic, but the overarching body of trauma literature was an invaluable resource in expert testimony.

While Dr Walker has referred to battered woman syndrome as a sub-type of PTSD, it is important to note that this view is not supported by the American Psychiatric Association, as evidenced by the exclusion of battered woman syndrome from multiple subsequent iterations of DSM. While it is certainly likely that a woman with a history of intimate partner violence could meet criteria for PTSD, the experience of a traumatic event is necessary but not sufficient for a PTSD diagnosis. Dr Walker’s battered woman syndrome overlaps with PTSD criteria by including intrusion symptoms [re-experiencing the trauma], high levels of anxiety and arousal, and high levels of avoidance behaviors. Unlike PTSD, the syndrome shifts to include disrupted interpersonal relationships because of the isolation, power and control by the batterer, distorted body image, and physical health and sexual issues.

The experts who evaluated Lorena Bobbitt agreed that she suffered from a mental illness at the time of the criminal offense. However, the use of the battered wife syndrome as a diagnosis was questionable in 1993 and remains so today. Although the definition of a mental illness or defect for the purpose of an insanity defense does not specifically reference DSM, most experts rely on DSM. The use of diagnoses not described in DSM raises questions about the scientific validity and acceptability of such diagnoses. The relevance of battered wife syndrome to the outcome of the Bobbitt case is unclear. Those who doubt the disorder speculate that battered wife syndrome was a way to recognize Lorena’s abuse and generate a narrative to address female victimhood and gender stereotypes.

At the request of Lorena’s defense team, the judge instructed the jurors on irresistible impulse, requiring only that they find that Lorena’s mind was “so impaired by disease that she was unable to resist the impulse to commit the crime.”

 The jury found that Lorena met criteria for the volitional prong-namely that she cut off her husband’s penis because of an irresistible impulse fueled by her traumatic experiences.

Whether Lorena met criteria for an insanity defense may not be the most significant analysis of the case. Perhaps more important, and undeniably interwoven, is the impact this case has had on American society. Coverage of the Bobbitt case stimulated a discussion about whether describing women as “battered” fuels the stereotype of women as weak, helpless, or pathetic. Although some herald Lorena as “fighting back” against male aggression, her overall demeanor, including witness accounts, portrayed her as a fragile, “beaten” woman. Others identified Lorena as a symbol of female empowerment, resisting gender suppression.

Lorena’s acquittal may resonate with another societal misperception, that women are not perpetrators of violence, but rather victims. Women in general receive lighter sentences in the judicial system than their male counterparts. Models of sanity are gendered, and female sanity, or proper femininity, revolves around the belief that violent women are either seen as not sane or not women, because sane women are never violent.

 What is clear from this case is America’s irresistible impulse to view women as victims and men as perpetrators.

Does this cultural perception permeate society today? Are the #MeToo and Time’s Up movements evidence of a less gendered perception of violence? Although such progress has provided support to many victims, a closer look yields the same heterosexual script of violence-women are victimized by strong men. Revisiting Bobbitt 25 years later reminds us how little progress we’ve made in abandoning gender disparities especially as they relate to violence, sex, and criminal conduct.

Dr Sorrentino is Assistant Professor, Harvard Medical School and Associate Psychiatrist, Massachusetts General Hospital (MGH), Boston, MA; Dr Musselman is an MGH/Mclean Psychiatry Resident; Dr Broderick is an MGH/Mclean Psychiatry Resident. The authors report no conflicts of interest concerning the subject matter of this article.

 Chozick A. You know the Lorena Bobbitt story. But not all of it. 

https://www.nytimes.com/2019/01/30/arts/television/lorena-bobbitt-documentary-jordan-peele.html

 American Academy of Psychiatry and the Law. AAPL Practice Guideline for forensic psychiatric evaluation of defendants raising the insanity defense. 

 Crotty HD. History of insanity as a defense to crime in English criminal law. 

 Felthous AR. Criminal responsibility. Rosner R, Scott CL, Eds. 

Principles and Practice of Forensic Psychiatry

 Walker LE. Battered women syndrome and self-defense. Notre Dame J Law Ethics Public Pol. 1992;6:321-332.

 Grimes W. Francine Hughes Wilson, 69, domestic violence victim who took action, dies. 

https://www.nytimes.com/2017/03/31/us/francine-hughes-wilson-dead-burning-bed-defendant.html

 Cipparone RC. The defense of battered women who kill. 

 US Department of Justice. The Validity and Use of Evidence Concerning Battering and Its Effects in Criminal Trials. May 1996. 

https://www.ncjrs.gov/pdffiles/batter.pdf

 Margolick D. Lorena Bobbitt acquitted in mutilation of husband. The New York Times. January 22, 1994. 

https://www.nytimes.com/1994/01/22/us/lorena-bobbitt-acquitted-in-mutilation-of-husband.html

 Grindstaff L, McCaughey M. Feminism psychoanalysis, and (male) hysteria over John Bobbitt’s missing manhood. 

Articles

Today, 25 years after the Lorena Bobbitt trial, the case has gained a renewed interest. A look back shows how far we have-and haven’t-come in conceptualizing sexual violence.

Battered Woman Syndrome: Is It Enough for a Not Guilty by Reason of Insanity Plea?

Dr Sorrentino is Assistant Professor, Harvard Medical School, Boston and Medical Director, Institute for Sexual Wellness, Weymouth, MA. Dr Turban is a resident physician in adult-child and adolescent psychiatry, Massachusetts General Hospital and McLean Hospital, Belmont, MA. 

The authors report no conflicts of interest concerning the subject matter of this article.

 (directed by Luca Guadagnino) draws the moviegoer into the romantic and sexual development of Elio, a 17-year-old adolescent boy living in Northern Italy. The viewer watches him run through the typical trials of a teen working to understand sex and intimacy. At the start, he has a girlfriend who appears close to his age, with whom he experiments romantically. When a 24-year old American graduate student named Oliver moves into his house to study with Elio’s father, a professor, the movie takes an unexpected turn.

As Elio and Oliver spend time together exploring the town, their relationship becomes flirtatious. Elio finds himself sexually attracted to this older man but does not share his feelings with anyone. In Oliver’s early move, he gives Elio a massage while they’re outside. Elio, embarrassed, recoils. Elio next has sex with his girlfriend and relays this to Oliver, hoping for a jealous reaction. We then watch Elio sneak into Oliver’s room to smell his bathing suit. The process of Elio coming to understand his sexuality and how to communicate these things is a cumbersome process, and it all plays out onscreen.

Later in the film, Elio openly expresses his affection to Oliver. Oliver immediately tells Elio that they cannot act on this attraction, although he does not give an explicit reason why. Given that the movie takes place in the 1980s in Italy, the main fear is likely the stigma of homosexuality. The age consideration is likely an afterthought, particularly as the age of consent in Italy is 14. Despite Oliver’s initial hesitation, the two eventually initiate a sexual relationship. Elio’s parents seem to endorse this, and they approve for the two to go on a trip to Bergamo together.

Scenes quickly escalate to Elio and Oliver running drunk through the streets of Italy. Graduate student Oliver manages his alcohol tolerance well. Teenager Elio throws up, and Oliver subsequently kisses him-there is an implication that they then have sex. Questions of consent are raised in the viewer’s mind but not discussed in the film. Is it appropriate for a 24-year-old experienced in drinking to have sex with an inebriated and vomiting 17-year-old? Little is mentioned, and after the three-day fling, Oliver leaves and Elio returns home heartbroken. Elio’s father consoles him and speaks fondly of the experiences Elio has had with Oliver, suggesting he should savor the memories.

Developing intimacy as a gay or bisexual adolescent

Much of the movie is realistic. The adolescent process of developing romance and sexuality is complicated. For gay and bisexual young boys, it can be even more challenging. These kids are often afraid to talk to their parents or other confidants about their romantic and sexual interests for fear of rejection, and instead they go underground. In Elio’s case, he did not discuss his sexual exploration with anyone other than Oliver, who given his older age and experience, had significant power in the relationship and the potential to be exploitative.

Today in the US, the parallel activity is for teenage boys to experiment sexually online and on social networking apps (eg, Grindr). Taken together, data from the CDC

 suggest that one in four gay and bisexual boys between the ages of 14 and 17 are on these “hookup” apps. A total of 69% have had sex with someone from the apps and only 25% use condoms consistently.

 Because young gay and bisexual boys are exploring their sexuality in secret, they are vulnerable to exploitation and abuse. In a 

, gay and bisexual young men opened up about how they were exploited, in secret, by older men on these apps purportedly geared toward adults.

Some controversial political pundits have argued that relationships between closeted young gay men and older gay men are beneficial. 

Some of those relationships between younger boys and older men, the sort of coming of age relationships, the relationships in which those older men help those young boys to discover who they are and give them security and safety and provide them with love and a reliable and sort of a rock where they can’t speak to their parents.

This is a cognitive distortion. It’s true that these young gay people need support and affirmation. It should not be in the context of a “relationship” with an older man who can be exploitative.

Elio’s father provides him with a strong message of affirmation at the end of the movie, accepting him for his homosexuality instead of shaming or chastising him. There is strong 

 that such messages of affirmation are associated with better mental health for LGBT kids.

 What was missing, however, was any concern about whether the relationship may have been dangerous. His father did not ask a single question about whether Elio felt in control in the relationship, if the power-dynamic was problematic, or if his sex was safe and consensual.

Age of consent vs developmentally appropriate consent

Age of consent varies dramatically from place to place. In Italy, the age of consent is 14. In California, it’s 18. Some have pointed out that these cutoffs are fairly arbitrary. What these laws are likely reaching toward is an understanding of when a relationship is developmentally inappropriate. In the case of Elio and Oliver, many viewers are likely uncomfortable because the poised and mature graduate student Oliver seems to have a strong power differential over Elio, who is younger and dependent on his parents. Elio’s immature limerence for the more confident and worldly Oliver may appear to come as a potential setup for manipulation.

Although this film may empower gay adolescents to embrace their sexuality, the film is not without peril. Critiques have chastised this film as “pedophilic.” This film is 

 about pedophilia (sexual attraction to prepubescent individuals) or hebephilia (sexual attraction to peripubescent individuals). This film is about sexual predation. Oliver looks much older than his reported age of 24 while Elio looks like a very young 17-year-old. The power disparity in the relationship is clear. Elio is fragile and sexually naive. Oliver is experienced and directive in the relationship. One could argue that Oliver grooms Elio by moving into the household, spending time with him, endearing trust before advancing to a sexual relationship that is secretive. Elio’s parents are portrayed as supportive of the relationship.

In the end, Elio is heartbroken when he learns that Oliver has moved on to another relationship. In the scene in which Elio’s father speaks favorably about the connection, there is no discussion about whether Elio felt manipulated or exploited. As is common with grooming, onlookers don’t identify or question the coercive nature of the relationship. Heralding such a film as a “masterpiece” is dangerous because it dismisses the exploitation in the relationship and is yet another example of the public’s reluctance to identify problematic sexual behavior. In light of the “Me Too Movement” and the endeavor to eradicate sexual abuse bred by an inappropriate power dynamic, this film promotes a dangerous message.

This article was originally published on 8/17/18 and has since been updated.

1. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System (YRBSS). June 14, 2018. 

https://www.cdc.gov/healthyyouth/data/yrbs/index.htm

2. Macapagal K, Moskowitz DA, Li DH, et al. 

Hookup App Use, Sexual Behavior, and Sexual Health Among Adolescent Men Who Have Sex With Men in the United States

3. Hanna B. Young Gay Men Talk About the Dangers of Having to Hide Their Love Lives 

https://www.vice.com/en_us/article/59k4vq/young-gay-men-talk-about-the-dangers-of-having-to-hide-your-dating-life

https://en.wikiquote.org/wiki/Milo_Yiannopoulos

5. Ryan C, Russell ST, Huebner D, et al. 

Family acceptance in adolescence and the health of LGBT young adults

The typical trials of an teen working to understand sex and intimacy is compromised by an inappropriate power dynamic in this film, according to the authors.

Call Me by Your Name: Not Pedophilia, Still Problematic

C. personality disorders and certain other nonpsychotic mental disorders

DSM originally characterized sexual deviations with psychopathic personality disorders based on the belief that sexual deviations were criminal acts, and thereby those individuals who engaged in sexual deviations were unlawful or psychopathic.

DSM-II defined sexual deviations in a broad category as “personality disorders and certain other nonpsychotic mental disorders.” DSM-II sexual deviations included sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestism, exhibitionism, voyeurism, sadism, masochism, and “other sexual deviation.”

DSM-5 and Paraphilias: What Psychiatrists Need to Know

Poll

A quiz on significant changes in DSM-5 nomenclature as they relate to sexual disorders.

Mini Quiz: Characterizing Sexual Deviation

Paraphilic disorders are rarely part of the curriculum for psychiatry residents or fellows. As a result, there are few psychiatrists who work with individuals who have paraphilic disorders.

In the past few decades, research on sexual offenders has shown that those with paraphilic disorders are at high risk for committing future sexual offenses. Psychiatrists can serve a pivotal role in reducing sexual offender recidivism by treating individuals with paraphilic disorders.

DSM originally characterized sexual deviations with psychopathic personality disorders based on the belief that sexual deviations were criminal acts, and thereby those individuals who engaged in sexual deviations were unlawful or psychopathic. DSM-II defined sexual deviations in a broad category as “personality disorders and certain other nonpsychotic mental disorders.” DSM-II sexual deviations included sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestism, exhibitionism, voyeurism, sadism, masochism, and “other sexual deviation.”

The term paraphilias was introduced in DSM-III. The paraphilias were classified as psychosexual disorders, which included gender identity disorder, psychosexual dysfunctions, and ego-dystonic homosexuality. DSM-IV maintained the diagnostic classification of paraphilias. DSM-IV-TR moved transvestism from a disorder of gender identity to a paraphilia called transvestic fetishism.

The significant changes in DSM-5 include the change in nomenclature from “paraphilia” to “paraphilic disorder.” DSM-5 also introduced specifier terms such as “in remission,” and clarification between behavior and paraphilias.

In DSM-5 the term paraphilia is defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physiologically mature, consenting human partners.” Paraphilias, however, may not necessarily classify as “intense and persistent” but rather preferential sexual interests or sexual interests that are greater than nonparaphilic sexual interests. The addition of the word “disorder” to the classification of paraphilias is new to DSM-5.

Previous DSM classifications did not include the word “disorder.” The term “disorder” was specifically added to DSM-5 to indicate a paraphilia that is causing distress or impairment to the individual or a paraphilia whereby satisfaction entailed personal harm, or risk of harm, to others. This distinction was made in an effort to identify those sexual behaviors and interests that are of clinical significance.

With the change in nomenclature, some sexual behaviors may be classified as paraphilic but not disordered. In other words, some sexual behaviors may be outside normophilic interests but of no clinical significance.

Other significant changes to the paraphilias include the addition of specifiers to indicate the current status of the paraphilic interests and the grouping of disorders into classification schemes. The first group of disorders is classified as anomalous activity preferences. These anomalous activity preferences are subdivided into courtship disorders, voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, and algolagnic disorders, which involve pain and suffering (sexual masochism disorder and sexual sadism disorder).

The second group of disorders is classified as anomalous target preferences, which include pedophilic disorder, fetishistic disorder, and transvestic disorder. Paraphilia not otherwise specified has been replaced with specified paraphilic disorder and unspecified paraphilic disorder. The specifier “in a controlled environment” is used to refer to individuals living in institutional or other settings in which the object of sexual gratification is restricted. The specifier “in full remission” refers to the absence of distress or impairment in social, occupational, or other areas of function for at least 5 years.

Two new paraphilic disorders, paraphilic coercive disorder and hypersexual disorder, and one revision, pedophilic disorder to pedohebephilic disorder, were considered for inclusion in DSM-5. Paraphilic coercive disorder refers to a diagnostic category based on sexual arousal to coercion or non-consenting sexual behavior. Hypersexual disorder refers to an excessive level of sexual behavior or preoccupation that results in clinically significant impairment in functioning. Pedohebophilic disorder was coined to refer to sexual attraction to peripubescent children. The Paraphilia’s Sub-workgroup did not include any of these proposed changes, which suggests that the proposed changes did not satisfy the general consensus of the scientific community.

The management of sexual offenders in the US has largely been under the clinical expertise of psychologists. However, when the construct for civil commitment of sexually dangerous persons was enacted almost 20 years ago, psychiatrists, including the American Psychiatric Association, were in a position to become involved in sex offender management.

Although the role of psychiatrists in sexual offender management has been accepted by some, others have rejected the role of psychiatrists in this area, identifying a lack of training and experience as well as a lack of clarity as to what specifically psychiatrists can offer sexual offenders. The risk of committing future sexual offenses is lowered with the combination of biologic and psychologic treatments. More specifically, evidence-based practice supports the use of biologic treatment, namely antiandrogen and hormonal medications, in dangerous sexual offenders.

The costs and consequences of sexual violence are vast. The best available research tells us that sexual violence victimization costs the US $450 billion annually.

The answer to preventing sexual abuse is effective evaluation and treatment of sexual offenders. Psychiatrists are an integral part of this solution.

Only some individuals with paraphilic disorders commit sexual offenses. Studies vary but suggest that many individuals who meet criteria for paraphilic disorders do not act on their sexual orientation. Psychiatrists have a unique role in primary prevention by treating paraphilic disorders with the goal of preventing future sexual offenses.

Research shows there is a high comorbidity of general psychiatric disorders in paraphilic sexual offenders.3 Axis I disorders including mood disorders, social anxiety disorder, autistic spectrum disorders, ADHD, and Axis II neurodevelopmental conditions such as intellectual disabilities (eg, fetal alcohol spectrum disorder) are psychopathologies reported as co-associated with paraphilic sexual offending.

The concurrent psychiatric treatment of Axis I and Axis II comorbidities may reduce paraphilic behavior. Axis III conditions such as traumatic brain injury, temporal lobe epilepsy, and neurodegenerative conditions can present with paraphilic-like symptoms. The recognition of such medical conditions can lead to appropriate treatment. Psychiatrists can have an indirect role in decreasing sexual offending by adequately treating the comorbid, nonparaphilic disorder or treating the medical condition that presents as a paraphilia (

The etiology of paraphilias is unknown, but it is probably a learned behavior. Paraphilias occur primarily in males with an average onset between ages 8 and 12. They are a lifelong condition. Treatment is focused on decreasing the arousal to the deviant sexual behavior, rather than extinguishing the sexual orientation. The evaluation of an individual with problematic sexual behavior includes both a clinical (subjective) and testing (objective) component. The clinical interview includes a detailed sexual history, inquiring about childhood exposure to sexual acts, sexual partners, and sexual functioning such as masturbation pattern. A general medical and psychiatric history should be obtained to identify psychiatric comorbidity or medical conditions that mimic paraphilias (traumatic brain injuries, dopaminergic agents). Paraphilias may co-occur or change from one to another (“crossing-over”). The clinical interview should include a complete review of systems for each of the paraphilic disorders.

Individuals with paraphilic disorders or sexual offending may be unwilling to disclose their sexual interests. Objective testing to determine sexual interests include sexual history polygraphs, the Abel screen (associating visual reaction time with sexual interests), and the penile plethysmograph (measuring penile tumescence to sexual stimuli). Objective testing can be helpful in identifying problematic sexual orientation as well as measuring an individual’s response to treatment (

Historically, psychotherapy was thought to be effective for the treatment of paraphilias and sexual offending. In the past decade, research has shown the most effective treatment of sexual offenders includes medication, behavioral therapy, social skills training, sex education, cognitive behavioral therapy, and monitoring with polygraph and penile plethysmograph.

 Paraphilic disorders have not conventionally been viewed as major mental illnesses for the purposes of civil commitment to general psychiatric hospitals. Most general psychiatric units do not have expertise in the paraphilic disorders and as such do not offer inpatient treatment. Sexual offenders who have been adjudicated as sexually violent offenders or sexually dangerous offenders are civilly committed at designated facilities.

 Psychiatrists who work with individuals with problematic sexual behaviors, namely pedophilia, should be comfortable with their role in mandated reporting. Psychiatrists are mandated to report suspected cases of child abuse or neglect. In order to be an effective clinician, psychiatrists who work with pedophilias must be comfortable identifying what clinical situations mandate reporting. Currently, California is the only state that mandates reporting of individuals engaged in child pornography.

Currently, there are few psychiatrists trained in the area of paraphilic disorders. Most of the general psychiatric residencies and forensic fellowships do not provide clinical experience in this area. As a result, there remains a growing demand for psychiatrists with such expertise.

Psychiatrists who have an interest in the paraphilias may gain experience by working with an expert in the field. Although there are currently no paraphilia fellowship training programs, some experts in the field offer clinical rotations in the field. One way to familiarize yourself with such experts is to contact the Association for the Treatment of Sexual Abusers (ATSA) and inquire about state and local chapters. ATSA also provides awards and grants to individuals starting in the field.

One of the challenges of working in this area is the overlap of legal, social, political, and ethical considerations, which factor into the evaluation and treatment of sexual offenders. In my opinion, this overlap provides for a stimulating, diverse multidisciplinary approach to the treatment of patients.

The field of sex offender research has grown exponentially in the past 20 years. Today, a competent psychiatrist in this area must be familiar with the current evaluation and treatment guidelines, standard of care actuarial assessments, and sex offender laws in his or her jurisdiction.

Dr. Sorrentino is Clinical Instructor at Harvard Medical School in Boston and Medical Director of the Institute for Sexual Wellness in Weymouth, MA. She reports no conflicts of interest concerning the subject matter of this article.

 Thibaut F, De La Barra F, Gordon H, et al. The World Federation of Societies of Biological Psychiatry Guidelines for the biological treatment of paraphilias. 

 National Institute of Justice. Victim costs and consequences: a new look. Washington, DC: US Department of Justice, Office of Justice Programs. 

https://www.ncjrs.gov/pdffiles/victcost.pdf

 Kafka, M. Axis I psychiatric disorders, paraphilic sexual offending and implications for pharmacological treatment. 

Psychiatrists can serve a pivotal role in reducing sexual offender recidivism by treating individuals with paraphilic disorders. Details here.

“If it takes a village to raise a child, it takes a village to abuse one.”

 emphasizes the sad fact that when something horrible happens, most people don’t want to know about it. And-as psychiatrists-we know too well that those closest to the victim can “turn a blind eye.”

The 2016 Oscar winner for Best Picture does an excellent job of portraying the brave and thorough work of the 

’s investigative journalism team known as “Spotlight.” The 

 would later go on to win the 2003 Pulitzer Prize for the exposÃ© that was the result of the investigation dramatized in this film.

Sometimes silence is loud. The film sheds light on the important issue of sexual abuse and illustrates the most damaging part of abuse-the failure of those who were supposed to protect the victim.

Our experience living and training in Boston made 

 particularly disturbing to watch. We have savored the hot dogs at Fenway Park. We recognized the South End Buttery. We know the steeples rising amidst the rundown triple-deckers. How could its inhabitants have been blind to such a devastating problem for so long?

As a psychiatrist who specializes in paraphilic disorders in the Boston area and as a student of Ed Messner, MD-a psychiatrist whose patient was the notorious Father Geoghan, who sexually abused children while assigned to various parishes in the Boston Archdiocese-I (Dr. Sorrentino) was heartened to see the attention 

 brought to the subject of child sexual abuse. The CDC estimates that approximately 1 in 6 boys and 1 in 4 girls are sexually abused before age 18.

 Estimated average lifetime expenses per victim of child abuse are $210,012, costing the US billions annually.

 However, the financial expense of child sexual abuse is secondary to the emotional trauma and psychological damage to both the victim and society at large.

Public awareness of and concern about childhood sexual abuse have advanced scientific knowledge in this field. Sexual abuse research has identified both typologies of offenders and risk factors associated with sexual offender recidivism. About 90% of child victims of sexual abuse know their abuser.

 Offenders in positions of authority and to whom children are entrusted, use the relationship to groom and gain access to the victim, as the film depicts.

 follows the investigative team as it does the painstaking work of uncovering a network of abusive priests, the children they abused, and the system that concealed the abuses. There are 4 team members: Walter “Robby” Robinson (Michael Keaton), Michael Rezendes (Mark Ruffalo), Sacha Pfeiffer (Rachel McAdams), and Matty Carroll (Brian d’Arcy James).

 hires a new editor, Marty Baron (Liev Schreiber). Baron asks the 

 staff whether they had followed up on a story they had published about a priest charged with sexually abusing children. No one can explain why there had been no follow-up, and the reporters are clearly uncomfortable when Baron suggests that they do so. This discomfort can be explained by the ties that each journalist has to the Catholic Church. It takes Baron, an outsider from Miami, “an unmarried man of the Jewish faith who hates baseball,” to open their eyes to the horrifying truth. [See: "

The Spotlight team learns how the priests groom and target the most vulnerable: boys, who are thought to be less likely than girls to “talk,” and children from underprivileged families and broken homes. They also learn how the abuse affects the 

-frequently leading to substance use, self-injurious behavior, and even suicide. Although the team views the victimization as a huge story on its own, Marty Baron keeps pushing Spotlight to dig deeper to figure out whether it is just “a few bad apples” or whether the problem is systemic.

As the team discovers the extent of the problem, they wrestle with their own faith. Pfeiffer becomes uncomfortable attending Sunday Mass with her grandmother. Rezendes makes the agonizing realization that he will never return to the Church. Yet the team members are surprised to learn that the psychiatrist, Richard Sipe, who has spent 30 years studying abusive priests, still considers himself Catholic. He explains, “My faith is eternal. I try to separate the two.”

The characters are complicated and believable. Few are simply “good” or “bad.” We learn that some Church insiders tried to address the issue years ago, whereas some of those currently working to uncover the truth failed to take action when they had the opportunity.

We appreciated the transparency of the film; any effort to glamorize the issue of 

 would have been inappropriate. Much of the movie takes place in dingy, poorly lit basements, complete with disorderly stacks of papers, scuffed desks, and even the occasional dead rat. The viewer feels as if he or she were right there, slogging away with the tireless reporters as they discuss the daunting project over leftover pizza.

The few scenes filmed in posh environments-the Catholic Charities Gala, the golf range-all feature Church insiders. In one scene, we flash between a beautifully decorated Church, where children are singing “Silent Night,” and a variety of dreary workspaces where reporters are putting final touches on their work. This contrast exemplifies the privilege awarded the Church up until that time. However, even in the church scene, we see Rezendes standing in the back, clearly worrying about the safety of the children.

In one of the final scenes, Rezendes hand-delivers a copy of the 

 article to lawyer Mitchell Garabedian (Stanley Tucci). As Rezendes leaves the office, he sees 2 small children playing in the waiting room. Garabedian explains that both of them had been abused by a priest 2 weeks earlier. This clearly makes the point that although the Globe’s work is a good first step, there is still much more to be done. What can psychiatrists do to get the conversation going?

A public health response to the Catholic Church sexual abuse crisis should include educating the public about “acquaintance maintenance” and not simply “stranger danger.” Acquaintance maintenance refers to educating children about appropriate and inappropriate behaviors in those individuals with whom they are familiar or acquainted.

The ability to diagnose pedophilia is key to preventing child sexual abuse (

): it makes possible accurate risk assessment and informed decisions regarding who is safe to work with children-and who is not.

 has raised the public consciousness about child sexual abuse. But we as a society need to move from awareness to prevention, lest we become as guilty as those upon whom we cast guilt.

This article was originally posted on 4/13/2016 and has since been updated.

Dr Nesbit is a third year psychiatry resident at Cambridge Hospital in Cambridge, Massachusetts. Dr Sorrentino is a forensic psychiatrist who specializes in the treatment of paraphilic disorders and sexual offenders. Dr Sorrentino is the Medical Director at the Institute for Sexual Wellness and Clinical Assistant in Psychiatry at Massachusetts General Hospital in Boston, Massachusetts.

 Centers for Disease Control and Prevention. 

Adverse Childhood Experiences Study: Data and Statistics

. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2005.

 Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. 

 Finkelhor D, Shattuck A. Characteristics of crimes against juveniles. Durham, NH: Crimes Against Children Research Center; 2012. 

http://www.unh.edu/ccrc/pdf/CV26_Revised%20Characteristics%20of%20Crimes%20against%20Juveniles_5-2-12.pdf

The ability to diagnose pedophilia is key to preventing child sexual abuse: it makes possible accurate risk assessment and informed decisions regarding who is safe to work with children-and who is not.

Psychiatric Spotlight on Child Sexual Abuse

Consultation-liaison psychiatrists frequently encounter clinical situationsthat have legal implications. The most common legal issue that arises in consultationpsychiatry is the question of competence. Practitioners often turn to thepsychiatric consultant for an opinion on whether a patient is competent when apatient is unable to consent to treatment or refuses a medically indicatedprocedure. The consultation request is often framed as a question (e.g., "IsMr. Smith competent to refuse surgery?").

This consultation request reflects a common misconception regarding theissue of competence. 

 is alegal state, not a medical one. Competence refers to the degree of mentalsoundness necessary to make decisions about a specific issue or to carry out aspecific act. All adults are presumed to be competent unless adjudicatedotherwise by a court. 

 isdefined by one's functional deficits (e.g., due to mental illness, mentalretardation or other mental condition), which are judged to be sufficientlygreat that the person cannot meet the demands of a specific decision-makingsituation, weighed in light of its potential consequences (Grissoet al., 1995). Only a court can make a determination of incompetence.

In contrast, psychiatric consultants can and should opine about a patient'scapacity to make an informed decision or judgment. 

 is defined as an individual's ability to make an informeddecision. Any licensed physician may make a determination of capacity. Forensicpsychiatrists, however, are especially suited to assess a person's mentalstatus and its potential for interfering with specific areas of functioning. Anindividual who lacks capacity to make an informed decision or give consent mayneed to be referred for a competency hearing or need to have a guardianappointed. The psychiatric consultation results in an opinion regarding whethersuch actions are indicated.

Moreover, competence is issue specific. Some physicians who misconstruecompetence to be a global, black or white issue will ask psychiatricconsultants for a broad consultation on whether thepatient is competent or not. The response of the psychiatric consultant shouldbe, "Competent for what?" The capacity to make a competent, informed decisionon the issue at hand needs to be investigated. Other aspects of the patient'smental status or diagnosis are not as relevant as their abilityto comprehend and make voluntary, informed decisions regarding the immediateproblem.

Features of Patients Referred forEvaluations

The most common reason for a competency evaluation is a patient's refusal toaccept medical treatment. Frequently, this refusal stems from the patient's poorunderstanding of the proposed treatment. Many questions regarding the patient'scompetence arise from miscommunication that can be directly addressed andrectified. As a physician, the psychiatric consultant is in a unique positionto facilitate patient education about the proposed treatment and to improvecommunication between the patient and the treatment team.

Components of a Capacity Evaluation:Informed Consent

Components of the capacity evaluation include comprehension, free orvoluntary choice, and reliability. The first component of a capacity evaluationregards the comprehension of relevant information. Does the patient demonstratean understanding of their condition? If the patient does not demonstrate anunderstanding of "what is wrong," the consultant should attempt to educate thepatient. Once the patient demonstrates an understanding of their clinicalcondition, the consultant should determine the patient'sunderstanding of the proposed treatment (i.e., "What do the doctors wantto do?").

To assess capacity, the consultation psychiatrist must have a clearunderstanding of the components of informed consent. In order for consent formedical treatment to be valid, three things are required: 1) The patient musthave knowledge; 2) the patient must be competent; and 3) the consent must bevoluntary. Before capacity can be assessed, the patient should be advised ofthe risks and benefits of the proposed treatment and the risks and benefits ofelecting to forgo the proposed treatment. Patient understanding of thisinformation and the reasons for acceptance or refusal of treatment willdetermine an opinion regarding capacity. If the patient lacks capacity to giveinformed consent to medical treatment, the patient may need to be referred forlegal adjudication of competence.

The second component of a capacity evaluation is the concept of free choice.The patient's decision to accept or reject treatment must be voluntary. Inassessing the patient's capacity, the consultant should determine whetherchoices have been rendered impossible due to unrealistic fears about treatmentor other impairments in mental processes.

The final component of a capacity evaluation is reliability. Reliabilityrefers to the patient's ability to make a decision and stick to it. Indecisiveor vacillating decision-makers are not reliable. The consultant shoulddetermine if the patient's decision is stable over time.

Courts recognize the following four exceptions to informed consent: 1)emergency; 2) incompetence or lack of capacity to make decisions that must bemade without the benefit of the court; 3) waiver; and 4) therapeutic privilege.The emergency exception refers to the delivery of treatment without consent toa patient who is unconscious or in imminent danger of serious harm.Consultation psychiatrists are not likely to be involved in such emergencysituations.

Incompetent patients, by definition, cannot give informed consent. In thiscase, consent should be obtained from a guardian or substitute decision-maker.Consultation psychiatrists are frequently involved in these cases.

The third exception to informed consent, waiver, refers to the patient'sright to waive disclosure of information. For example, a patient may tell thedoctor: "Don't tell me what's happening, just do what you think is best."Patients who waive their right to informed consent are accepting the doctor'sdecision to make unilateral medical decisions.

Finally, therapeutic privilege refers to a doctor's decision to withholdinformation from a patient because telling the patient would causepsychological damage or render the patient ineffective in decision making.Consultant psychiatrists may be asked to determine whether the disclosure ofinformation would result in psychological damage to the patient or bring aboutan irrational decision.

In the medical model, patients have a right to refuse various types oftreatment, including life-saving surgery and chemotherapy. When an incompetentpatient refuses psychiatric treatment the court may become the vicariousdecision-maker. The standards of vicarious decision making are "best interests"and "substituted judgment." In the best interestsstandard, the decision to treat an incompetent refuseris based on "What would be in the best interests of the patient?" 

 is defined as that courseof action that maximizes what is best for a ward (patient), and it includesconsideration of the least intrusive, most normalizing and least restrictivecourse of action given the needs of the ward (Casasantoet al., 1989). In the substituted judgment standard, the decision is based onwhat the patient would have wanted if competent, rather than what isnecessarily in the patient's best interests.

A guardian is an individual who has the legal authority and the duty to carefor another's person or property (Garner, 1999). The ward is the person forwhom the guardian is appointed. The decision to appoint a guardian is made by acourt. States differ in the test by which the court determines whether aguardian should be appointed. Most jurisdictions require that individuals mustbe incapable of taking care of themselves. The court must find that there is aneed for a guardian and that no less restrictive alternative would be possibleand effective. If the court determines that a guardian is necessary andappropriate, the ward becomes a legal "nonentity." The ward, from that pointon, may not enter into contracts, manage funds, file lawsuits or consent totreatment.

If the matter at hand is of an urgent nature, the consultant may recommendthe appointment of a temporary guardian. Temporary guardianship is limited tothe immediate question. If the issues at hand are non-acute, the consultant mayrecommend that a guardian be obtained to address medical decisions in thefuture.

An advance directive is a legal document explaining a person's wish aboutmedical treatment if one becomes incompetent or unable to communicate (Garner,1999). Advance directives include living wills and proxy directives or durablepower of attorney. A living will is a legal document that outlines anindividual's preferences regarding medical treatment if they become terminallyill or unable to communicate. Individuals may identify a particular person,called a 

,to make medical decisions if they become incompetent.

Consultation psychiatrists may be asked to consult in cases in which thepatient is refusing a decision made by their durable power of attorney. Inthese cases, the consultant's task is to determine whether the patient has thecapacity to make medical decisions. If the patient is found to have capacity tomake medical decisions, the patient's preference for treatment should befollowed. However, if the patient does not have the capacity to make medicaldecisions, the durable power of attorney will act as the substitutedecision-maker. In the event of incompetence and the absence of an advance directive,some states have statutes that recognize family members as appropriatedecision-makers.

Confidentiality and Privilege inConsultations

 refers to thephysician's obligation to keep information learned in a professionalrelationship private from other parties. Ethically, the psychiatrist maydisclose only that information which is relevant to a given situation. Forexample, it is usually unnecessary to report sensitive information such as anindividual's sexual orientation or their fantasies (Bronheimet al., 1998).

 refers to the patient'sright to prevent a physician from providing testimony about personal medicalinformation. The psychiatrist has a duty to honor the patient's privilegeunless ordered to testify by a judge. Information gained in confidence about apatient may not be released without the authorization of the patient. However,there are a number of exceptions to this. They include mandatory reporting(child abuse, elder abuse and infectious disease), court-ordered examinations,patient litigant exceptions (patient puts their mental condition at issue), and(in some states) commitment proceedings and treatment refusal hearings. In anemergency, the physician may also breach confidentiality. For example, apatient presents to the emergency department with a complaint of depression andfeeling hopeless. The patient denies feeling suicidal. However, the patient'shistory is significant for two previous suicide attempts. The patient insistson discharge home. The patient cannot forbid the physician from contactingrelatives to ascertain information necessary to assess the suicide risk.

The role of the psychiatric consultant in against medical advice (AMA)discharge is to understand why a patient chooses to leave the hospital againstthe advice of their physician and to evaluate whether the patient meetsinvoluntary commitment criteria. More specifically, the psychiatric consultant'sresponsibility is to determine whether the patient has the capacity to refusehospital treatment. The first step in evaluating a patient who is threateningto leave AMA is to speak to the treatment team and gather information regardingthe patient's clinical course. The consultant should understand the severity ofthe patient's illness, the proposed treatment, the risks and benefits of thetreatment, and the risk associated with leaving the hospital.

The psychiatric consultant is then in a position to determine whether the patientalso understands the severity of their illness, the proposed treatment, itsrisks and benefits, and the risks of leaving the hospital. If the patient lackscapacity to understand this information and meets the state criteria forinvoluntary commitment, the consultant may recommend that steps to obtaininvoluntary commitment be undertaken. In cases where the patient's motivationfor leaving the hospital is based on distrust of the treatment team, theconsultant may be in a unique position to serve as a mediator. The psychiatristcan bring the patient's concerns to the team and propose a way to work throughthem.

Consultation-liaison psychiatrists frequently encounter clinical situations that have legal implications. Competency evaluations, which are the most common legal question in C&L psychiatry, are reviewed in this article. In addition, the authors discuss guardianship, decision making in patients who refuse treatment, confidentiality and the role of the psychiatric consultant in against medical advice discharges.