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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. 

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?

We take this worrisome opportunity to look back at how psychiatry has engaged climate concerns over the last decade and what our priorities might be going forward.

 contributor who addressed climate change and its association with mental health. 

It was back about a decade ago when I was asked to start writing blogs for Psychiatric Times. For my first one, I chose “

.” I wondered whether the subject would be acceptable to a psychiatric publication. It was, thankfully. Why did I pick that topic at that time? I had an epiphany at the grocery store after my third grandchild was born. Getting a few things for her, the clerk asked: paper or plastic? I froze. What was the right answer? I finally said I don’t need a bag, grabbed the few groceries, and found out the general answer was to bring your own if you were concerned about the climate and the environment.

I wondered, then, did psychiatry have anything to contribute to this issue? After inquiring, the American Psychiatric Association (APA) did not seem interested; the response I got for many years was that we have enough acute problems and to just work on this as a citizen. I could not find many other colleagues that were interested either.

My research into the subject has suggested otherwise, especially because our area of expertise is irrefutably relevant. Why was there so much psychological denial of this problem? After all, heat waves are associated with more alcohol use; rising summer temperatures increase aggressive and violent behavior; and the world was beginning to see “climate refugees.”

That first blog was posted January 7, 2010. I was going to wait until about January 7, 2020 to write a decade long summary of how we’ve done as a profession since-that is, until it dawned on me that January might be a bad time to write about global warming in 2010 and would be in 2020 because, at least in the US, that is a time of increasing cold, not warmth. That time of year makes it even easier for the naysayers to deny the problem.

Recently, most of the country experienced heat alerts. In my neck of the woods, Chicago and Milwaukee had a heat index of up to 115 degrees. However, even TV weatherman Al Roker is not saying that the extreme heat relates to global warming. Some of the usual physical and mental health risks will inevitably increase: medication that causes more dehydration; anxiety about the climate; and societal conflict about what to do.

More than ever, it is clear that it was increasingly risky for me to wait, even for six months. As carbon (and methane) collects in the atmosphere, feedback loops reduce the ability of our atmosphere to pull back from climate change. We take this worrisome opportunity to look back at how psychiatry has engaged climate concerns over the last decade and what our priorities might be going forward.

I continued to write intermittent climate-related articles for 

 Some of the topics covered over the years:

• the terminology could be more psychologically relevant (eg, switching from global warming to 

Psychiatric Preparation for Climate Instability

• global warming may relate to the rising epidemic of burnout in physicians (See: 

What Do Climate Change and Physician Burnout Have in Common?

• disaster psychiatry should include slowly developing disasters, not just traditional "acute" disasters

• how to make climate change a “sexier” topic (See: 

• wear green for the subliminal message of environmental concern. I have worn a Jolly Green Giant (of Psychiatry) outfit for presentations on the subject as well as costume parties (where I won a first prize!) (See: 

• climate is an ethical priority for us because of the physical and mental health risks to our society (See: 

Eco-Psychiatry: Why We Need to Keep the Environment in Mind

I also started the informal Psychiatrists for Environment Action and Knowledge (PEAK). PEAK then morphed into the more formal 

 (CPA), and CPA has contributed a series of exclusive, in-depth articles about climate psychiatry for 

 over recent months. The CPA has also achieved the status of a caucus within the APA and it has become clear that many more psychiatrists are concerned with climate.

There are enough psychiatrists concerned for a concerted professional effort, though many more are welcome to join in. Though we can all make individual contributions, as a profession we have a different type of influence. We have written plenty of scientifically based articles and presented many times at national meetings. It is apparent, however, that not been nearly enough progress has been made. Moreover, as the public and patients have become more concerned, so what are our basic clinical roles? Here, then, are some recommendations, not for the next decade, but for the next few months:

• find ways to make rapid and cogent press releases, tweets, and the like whenever there is a societal climate event like this current heat wave

• be on the alert for climate anxiety in our patients, but not to the extent that we implant fears (think about the false memories of trauma that occurred in the 1970s)

• produce a psychiatric book (or two) that is an ongoing resource of basic knowledge on the psychiatric aspects of climate

• connect with psychiatrists around the world who are concerned about the climate, for this is a global challenge

• develop a new model of psychiatry, expanding from the bio-psycho-social to the bio-psycho-social-environmental model

In the meantime, stay cool, both physically and mentally.

–Dedicated to Noah Goldstein, Mira Goldstein, Hannah Moffic, and Allie Moffic

Dr Moffic is an editorial board member and regular contributor to Psychiatric Times. He was a tenured Professor at the Medical College of Wisconsin. Currently, Dr Moffic is focused on three major advocacy initiatives: physician burnout, climate change, and Islamophobia.

A climate change and mental health pioneer goes down memory lane with the Times.

A Decade of Psychiatry and Our Climate

In the spirit of Human Trafficking Awareness Month, we hope this short quiz raises awareness when considering clinical vulnerability in victims.

Human Trafficking Training in Health Care

This article will briefly review the definition of sexual harassment, its prevalence among physicians and medical students, and its potential impact on physicians and trainees. It will also provide some guidance about its management.

Public awareness about the topic has increased since the 1990s when Attorney Anita Hill made allegations of sexual harassment about Supreme Court Justice Clarence Thomas. The authors became interested in this topic after a third-year medical student approached her Clerkship Coordinator to report she was confused about what to do because a male patient had brushed his hand on her backside on the inpatient psychiatric unit. When she reported the incident to her female supervisor, she was told, “Don’t make a big deal about it, it happens.”

For purposes of this article, we use the Equal Employment Opportunity Commission (EEOC) definition of sexual harassment. In 1980, the EEOC defined sexual harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature.

The US Merit Systems Protection Board conducted surveys in 1980, 1987, and 1994, and each of the surveys yielded similar results.

 In the first survey, 42% of women and 15% of men reported sexual harassment on the job; in the second survey, the same percentage of women and 14% of men reported sexual harassment; and in the third survey, 44% of women and 19% of men reported sexual harassment.

Sexual harassment appears to be common during medical training. A meta-analysis of data on the topic reported that 59.4% of medical trainees, including medical students, interns, and residents in all specialties, had experienced some form of harassment.

 Another study of emergency medicine residents found that 68.9% of women and 41.9% of men responders reported sexual harassment.

A 1994 survey of interns and residents in an internal medicine residency program showed that a total of 83 episodes of sexual harassment had occurred.

 Of these, 41 occurred during medical school and 42 during residency. About 77% of women did not report the harassment because they were not confident it would help, and 82% of men felt they could deal with the problem with no outside help. Women also reported fear of retaliation and feelings of shame and guilt. Other reasons were fear of not being believed, embarrassment, lack of trust in authority figures, and lack of familiarity with available resources.

A New Zealand study in 2001 that included trainees from all specialties showed that 20% of them had been sexually harassed: women were more likely to report the harassment than men were.

 Most harassers of women in hospitals tend to be male-whether attending physicians or others-and most episodes are likely to happen during medical school. Harassers of men were reported to be mostly nurses; these incidents tended to occur during residency and were found to be mostly non-physical in nature.

A British survey of 100 male and female psychiatric trainees showed that 86% reported unwanted sexual contacts such as deliberate touching, leaning over or cornering, letters, telephone calls, and exposure to sexual material. Most of the offenses were perpetrated by patients.

Findings indicate that female doctors are mostly harassed in their offices by their patients, but also in high-risk areas such as inpatient wards or walk-in clinics.

 Harassment also occurs in emergency departments, where there is a large proportion of previously unknown patients, as well as patients under the influence of alcohol or drugs.

In the New Zealand study, more than half of all trainees reported some form of threat by patients, and one-fifth had been sexually harassed. Psychiatric trainees were identified as being more at risk than other trainees in medicine, obstetrics and gynecology, and surgery (

Harassment is not limited to medical trainees. A 1995 cross-sectional survey showed that 52% of women compared with 5% of men on US academic medical faculties reported having been harassed.

 The hospital environment might foster such behaviors because doctors and trainees spend long hours working in a very stressful environment, doing physical examinations as well as discussing contraception, marital infidelities, sexual abuse, and other “sexual” topics.

A 2014 study that looked at both sexual harassment and gender discrimination among academic medicine faculty showed that 30% of women and 4% of men reported sexual harassment; 47% of the women noted that these experiences negatively affected their professional advancement, although no specifics were provided.

 In the same study, 66% of women and 56% of men reported experiencing gender bias in professional advancement.

 found a higher prevalence of sexual harassment in psychiatric practices than in primary family medicine practices. Many incidents were reported but dismissed as “part of the job.” In addition, when harassers were patients, their psychiatric diagnoses often altered the perception of their behavior. For example, delirium and psychoses were protective of accusations of sexual harassment. Other diagnoses such as dementia, mania, schizophrenia, depression, substance use disorders, and personality disorders were also perceived as protective of patients, even when they exhibited unwanted sexual behaviors. These findings suggest that psychiatrists may be at an increased risk for violence and sexual victimization by psychiatric patients.

A survey of medical residents revealed types of sexual harassment: sexual remarks, offensive comments about one’s body, unwanted sexual attention and flirtation, verbal advances or inquiries, offensive displays of sexual videos/pictures, repeated leering, standing too close, rubbing, fondling, brushing, pinching, patting, threats of punishment for refusal of sexual favors or offering better grades or promotion in return for sexual favors and, finally, attempted rape and rape. 

 compares sexual harassment behaviors reported by men and women using data from a survey conducted by Komaromy and colleagues

Harassment by patients of female doctors often includes suggestive looks and gestures, sexual remarks, inappropriate gifts and phone calls, exposure of body parts, inappropriate touching and requests for unwarranted physical examinations, attempted rape, and rape. Male doctors also are not exempt from harassment by patients, although it is less common.

The sequelae associated with sexual harassment are psychological, somatic, and work-related. Psychological effects include isolation, depression, guilt, anger, fear, low self-esteem, and helplessness. Somatic complaints are disrupted sleep, nightmares, headaches, fatigue, poor appetite, gastrointestinal disturbances, and weight loss. Work-related consequences include absenteeism, poor work evaluation, and poor work performance. An increased likelihood of depression, drug use, or suicidal thoughts has been reported as a consequence of being harassed or belittled by superiors.

Common psychiatric diagnoses associated with victims of sexual harassment include adjustment disorder; major depression; and anxiety disorders, such as panic disorder, generalized anxiety disorder, and PTSD. The estimated percentage of victims who suffer emotional distress as a result of these offending behaviors is as high as 90%.

 However, there is no single diagnosis associated per se with sexual harassment; additional studies are needed to address the relationship between the severity of the aggression and the psychological impact on victims.

Given the prevalence of sexual harassment in the medical field, a clinician may seek treatment from a psychiatrist for the above-mentioned conditions. The psychiatrist may also have to treat a harasser as a patient and might be asked to serve as an expert witness in a court of law. Because of bias, the psychiatrist is precluded from treating and testifying in a case of the same patient. Furthermore, the dual role of the psychiatrist may ruin the patient-doctor relationship and even worsen the patient’s condition. Therefore, an understanding of the legal issues related to sexual harassment is important.

 A “quid pro quo” when the employer enters into a relationship with the employee to obtain or retain employment, which is considered sexual bribery.

 When the employer creates a hostile, intimidating environment for the employee.

Of course, simple words can also be misinterpreted, and a man’s perspective for judging a hostile environment may be different than a woman’s. This was notable in a 1991 California court ruling that “the appropriate perspective for judging a hostile environment claim” (when a woman is a victim) is that of “a reasonable woman.” Words can often be taken out of context: telling a woman “you look attractive today” can be meant as a compliment and taken as such, while saying to a woman “this skirt shows your great legs, wear it more often” can be seen differently.

Recommendations and management of sexual harassment

Litigation is frequently not the answer to harassment-it can lead to resentment, shame, and defensiveness. The main goal in dealing with sexual harassment is prevention and education. The following are some recommendations when interacting with patients:

• In an office setting, consider installing a reliable alarm system

• As much as possible, avoid booking new patients at the end of the day because his or her history of previous violence is unknown until evaluated

• Avoid performing physical examinations on your own

• Inpatient psychiatric wards should be equipped with security systems, panic buttons, and other warning systems in appropriate locations such as interview and treatment rooms

• High-risk patients and those with repetitive disruptive behaviors should be readily identified by incident report analysis

Training programs should take into account the long-term psychological consequences of sexual harassment and ensure that rapid responses are available. Hospital staff and medical trainees need to be educated about sexual harassment. Moreover, institution of a zero-tolerance policy and elimination of the code of silence are highly recommended. It is crucial that easy methods are used to help victims file grievances, keep complaints confidential, and appoint neutral individuals to investigate complaints.

 When harassment has occurred, employers need to take immediate and appropriate action. An unbiased approach will not only demonstrate a commitment to establishing a comfortable working and training environment, but it will also help reinforce the importance of the issue and prevent further harassment.

All medical professionals should learn to recognize sexual harassment behavior and not tolerate it. Victims need to quickly respond to the harasser rather than standing by meekly or stoically. If the harassment persists, it is recommended that the victim compile a written report of the occurrences. Trainees should not feel ashamed or guilty, nor feel compelled to leave their training. Such attitudes may have a serious impact not only on their education but also prevent them from reaching further professional goals.

Harassment of trainees should be reported to general medical education Deans, Chairs of departments, and residency training and clerkship Directors. Volunteer peer crisis intervention, debriefing, counseling, or psychotherapy should be made available to victims. Procedures for both investigations and disciplinary actions should be prioritized when necessary.

The authors express their gratitude to Jacques Vital-Herne, MD, for his contribution to this article. The authors acknowledge the Academy of Psychosomatic Medicine (APM) for helping to bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr. St. Victor is Board Certified in Psychiatry and Psychosomatic Medicine, a Fellow of the American Psychiatric Association, and a Fellow of the Academy of Psychosomatic Medicine. She works as the Assistant Clinical Director of Psychosomatic Medicine and the Clerkship Director for Medical Students at the Nassau University Medical Center, East Meadow, NY. Dr. Wichman is Associate Professor of Psychiatry and Obstetrics and Gynecology; Director of Women’s Mental Health, Director of the Inpatient Psychiatry Consultation Service at Froedtert Hospital; and Program Director of Psychosomatic Medicine Fellowship at the Medical College of Wisconsin in Milwaukee, WI. Ms. Malakkla is currently a third-year medical student at the American University of the Caribbean, doing her clerkship at Nassau University Medical Center, East Meadow, NY.

Dr. St. Victor and Dr. Wichman report no conflicts of interest concerning the subject matter of this article.

 Phillips SP, Schneider MS. Sexual harassment of female doctors by patients. 

 Jorgenson LM. Workplace sexual harassment: incidence, legal analysis, and the role of the psychiatrist. 

 Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training. 

 Schnapp B, Slovis B, Shah A, et al. Workplace violence and harassment against emergency medicine residents. 

 Komaromy M, Bindman AB, Haber RJ, et al. Sexual harassment in medical training. 

 Coverdale J, Gale C, Weeks S, et al. A survey of threats and violent acts by patients against training physicians. 

 Morgan JF, Porter S. Sexual harassment of psychiatric trainees: experiences and attitudes. 

 Carr PL. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. 

 Jagsi R, Griffith KA, Jones R, et al. Sexual harassment and discrimination experiences of academic medical faculty. 

 Miedema B, Easley J, Fortin P, et al. Disrespect, harassment, and abuse: all in a day’s work for family physicians. 

 Kinard JL, Mclaurin JR, Little B. Sexual harassment in the hospital industry: an empirical inquiry. 

 Gardner S, Johnson PR. Sexual harassment in healthcare: strategies for employers. 

Here: a review of the definition of sexual harassment, its prevalence among physicians and medical students, its potential impact on physicians and trainees, and guidance about its management. 

Speaking Up: Sexual Harassment in the Medical Setting

[[{"type":"media","view_mode":"media_crop","fid":"31621","attributes":{"alt":"Sexually violent predators","class":"media-image","id":"media_crop_9033870991125","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3333","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"","typeof":"foaf:Image"}}]]The United States Constitution does not allow preventive detention-a much abused prerogative of royal power in Europe that was abhorrent to the founding fathers. No imprisonment on suspicion that someone might commit a crime and no keeping someone in prison beyond his allotted sentence just because someone thinks he might still be dangerous. We are meant to be a country of law, not arbitrary, idiosyncratic opinion.

Sexually violent predator (SVP) laws in 20 states are an exception. Indefinite preventive detention in a psychiatric facility (really a prison in all but name) is permitted if the individual committed a violent sexual crime and has a mental disorder that predisposes to its repetition. The US Supreme Court in a narrow 5-4 decision found this constitutional, but explicitly only if the perpetrator has a definite mental disorder that would distinguish him from the much more common run-of-the-mill, opportunistic criminal rapist. No mental disorder, no preventive detention.

In an attempt to facilitate preventive detention under SVP commitment statutes, the majority of state evaluators routinely misused the inherently unreliable paraphilia not otherwise specified (NOS) as a qualifying diagnosis in cases that were no more than typical, 

. For many years juries bought it-unjustly committing common criminals to inappropriate psychiatric commitments.

This has now changed. DSM-5 recently confirmed that rape is not a mental disorder (the fourth DSM to reject rape in 40 years). Paraphilia NOS is now widely recognized for the fake diagnosis it always was.

Undeterred by any respect for proper diagnostic practice, state evaluators have come up with a new fake diagnosis intended to convert ineligible common criminality into SVP ready mental disorder. The same patients who before we routinely mislabeled paraphilia NOS are now being mislabled as sexual sadists.

I have no sympathy for rapists and think they deserve long sentences. But I have even less sympathy for the misuse of psychiatric testimony in the courtroom and for evaluators who play loose with proper diagnostic practice.

If a perpetrator meets criteria for sexual sadism, he definitely deserves SVP commitment. But this is a very disorder being up-diagnosed in simple criminals by inexperienced, incompetent, and/or inexpert “experts.”

Railroading people inappropriately into psychiatric hospitals is a slippery slope that can lead to grave violation of human rights and distortion of societal institutions.

The author concludes that people inappropriately placed in psychiatric hospitals can lead to grave violation of human rights.

The Latest in Sexually Violent Predator Expert Testimony

The 2015 joint American Society for Adolescent Psychiatry (ASAP) and International Society for Adolescent Psychiatry and Psychology (ISAPP) 

 will be held in New York City, March 26 through 29, 2015. Among the 90 presentations, symposia, workshops, and posters focused on adolescent mental health and substance abuse with 27.25 

 offered, I will be presenting two sessions that address adolescent sexuality and sexual development issues.

LGBTQ and Adolescence: Identity, Peers, Family, School and Society

This session offers an evidence-based overview of adolescent sexual development with a focus on mental health assessment for identifying and addressing pathology. It addresses the sometimes confused labels of sexual identity, gender identify, gender role, sexual orientation, and sexual behavior.

Childhood, and in particular adolescence, is a time of exploration and growth across all domains of life. Sexuality and sexual behavior are no exceptions, but are areas not infrequently cloaked in secrecy by both the adolescents and the adults in their lives.

Unlike other realms of growth, these areas can garner more judgmental responses, attempts to control expression, and negative impact on future functioning. These negative consequences can be mitigated through education, understanding, and tolerance by all concerned. The intent of this presentation is to provide tools for education facilitating 

“Sexually Violent Predators”: Could Adolescents Meet Criteria?

This presentation addresses adolescent sexual problem/offending behaviors with a focus on “Sexually Violent Predator” law, assessment, and treatment. The goal is to provide attendees with the key components of a diagnostic and sexual offending risk assessment for an adolescent who has committed a sex offense.

In addition, the session includes identification of psychological and somatic interventions to treat and manage sexual problem/offending behaviors by adolescents. The premise is that adolescence is a time of development, personal exploration, and trial and error. As such, new behaviors are attempted and conducted, different paths are tried and at times abandoned, and mistakes are made. Sexual development and behaviors as a facet of human development and existence fit this pattern.

What is defined as appropriate, acceptable, and legal even, is in part a function of social, cultural, medical, governmental, political, and religious definitions. These definitions change and vary across time and populations. “Sexually Violent Predator" is a legal term, which tends to solicit strong reactions from the public at large and government entities responsible for law enforcement and corrections.

What happens when an adolescent’s sexual behavior becomes the focus of these systems? Can, and if yes should, adolescents be given the label of “Sexually Violent Predator”? A review of our evidence-based knowledge will be presented for attendees to consider an answer to this question.

The annual meeting will also feature resumption of ASAP’s certification examination in adolescent psychiatry, which is designed for generally-trained psychiatrists who are either interested in or are actively working with adolescents to gain certification as an expert in the field. For further information regarding the conference or the certification examination, please visit 

http://adolescent-psychiatry.org/news-events/2015-annual-meeting.

Dr Dwyer is a former ASAP President and the current Director of the Community and Public Safety Psychiatry Division and Sexual Behaviors Clinic and Lab of the Medical University of South Carolina Department of Psychiatry and Behavioral Sciences in Charelston, South Carolina.

A look at the 2015 joint American Society for Adolescent Psychiatry (ASAP) and International Society for Adolescent Psychiatry and Psychology (ISAPP) Scientific Meeting in March. There, the author will be presenting two sessions that address adolescent sexuality and sexual development issues.

Conference Preview from the Cutting Edge

Medicine and law have a rich collaborative history in the management of persons convicted of sex offenses. Despite different assumptions about the offender and different perspectives about management and goals that may only partly overlap, each discipline offers significant expertise that promotes healing and risk management strategies while increasing community safety.

The term “sex offender” is a legal, not a psychiatric, designation. Sex offenders make up a psychiatrically heterogeneous group of individuals whose only unifying characteristic is that they have violated the law governing sexual expression in a given culture.

 The law may not greatly concern itself with the biopsychosocial antecedents of illegal sexual behavior, although it recognizes that questions of intent and incompetence or diminished capacity are important considerations.

Psychiatrists, like all physicians, view sexual behavior in terms of health. Normal sexual behavior is roughly equated with healthy sexual behavior; abnormal sexual behavior invites psychiatric intervention to restore a patient’s sexual health.

In our experience, psychiatrists infer the presence of a sexual disorder or abnormality from certain statistically rare sexual behaviors and/or self-reported distress. Like all physicians, psychiatrists then arrive at a diagnosis congruent with the clinical picture. Differential diagnosis is important because identical behaviors or symptoms often have very different etiologies. Diagnosis typically informs the psychiatrist’s choice of therapies intended to diminish or control the patient’s sexually abnormal behavior.

Psychiatrists tend to believe that factors that motivate sexual behavior are intrinsic to the organism. Such intrinsic factors might include psychosis, PTSD, and abnormal biological drive states and, therefore, are more constant across history than the ethical and philosophical underpinnings of a culture as expressed in its laws. The legal construct of a “sex offense,” is more tightly culture-bound. Social attitudes toward sexual behaviors are not immutable, however, and laws change, both reflecting and reshaping cultural values.

In contrast to psychiatry, the law may criminalize conduct irrespective of the underlying cause or motivation. The law tries to enforce compliance by imposing such sanctions as fines, incarceration, “assisted” outpatient treatment, and civil commitment.

The concept of sexual illness or wellness is often influenced by prevailing social values concerning what sexual behavior is appropriate or inappropriate. The distinction between lawful and unlawful sexual conduct has also been affected by psychiatric views of what constitutes mentally ill sexual behavior and what does not.

For example, in the past 50 years, society and psychiatry have radically changed perspective and judgment of homosexuality. Before the 1970s, most of the psychiatric community viewed homosexuality as a mental disorder, a concept enshrined in DSM in 1952. In this first DSM, homosexuality was categorized as a “sexual deviation” presumed to be a “personality disorder of psychogenic origin or without clearly defined tangible cause or structural change.” In 1973, the American Psychiatric Association eliminated homosexuality as a mental disorder in the sixth printing of DSM-II, substituting a new category, Sexual Orientation Disturbance.

Laws about homosexuality also reflect changing psychiatric and social attitudes. Legally, same sex behavior could be lawful in one state and criminalized in another. For example, in 1986, the US Supreme Court affirmed the illegality of engaging in homosexual behavior in Georgia that was not illegal in other states, declaring that “to hold that the act of homosexual sodomy is somehow protected as a fundamental right would be to cast aside millennia of moral teaching.”

 Thus, Georgians engaging in sodomy were officially “sex offenders” while residents of many other states who engaged in sodomy were not. Less than 2 decades later, however, the Court reversed itself, declaring that laws prohibiting sodomy between consenting adults, in the 14 states that still had them, were unconstitutional.

In the past year, 2 of those states (Montana and Virginia) have repealed their anti-sodomy statutes, but in 12 other states (Alabama, Florida, Idaho, Kansas, Louisiana, Michigan, Mississippi, North Carolina, Oklahoma, South Carolina, Texas, and Utah), engaging in consensual sodomy (ie, oral and/or anal sexual activity) continues to make one a sex offender.

Psychiatric and legal professionals agree that some sex offenders can be dangerous to society. Both professions are invested in preventing dangerous sex offenders from doing harm to others and to the social order. From the legal perspective, harm prevention generally means removing offenders from free society through incarceration or involuntary detention.

Under the law, there are 5 commonly accepted goals of incarceration: incapacitation, punishment, rehabilitation, deterrence, and restitution.

 More recently, in the era of sexually violent predator statutes, isolation from the culture at large may continue following incarceration by stigmatizing the offender with the lifelong designation of registered sex offender and possible indefinite civil commitment for treatment.

The perspective is somewhat different for psychiatrists, particularly those who do not consider themselves to be forensic specialists. Without denying that sex offenders have committed crimes, some psychiatrists may see the individual offender as a patient first and an offender second. The physician-patient relationship includes a fiduciary duty to ameliorate the patient’s pain and suffering and restore him or her to healthier psychosocial functioning. For some psychiatrists, this duty clashes with such legal requirements as reporting mandates.

The psychiatrist’s understanding of sexual behavior, legal or illegal, is that sexual activity takes place in the context of arousal mediated by a biologically based drive. Disordered arousal and behavior are the legitimate focus of psychiatric intervention. Psychiatrists also know that disordered sexual behavior is a feature of a number of psychiatric conditions other than arousal disorders.

 reported on a series of 6 case examples of rape with disparate motivation: a sociopathic, opportunistic rapist; an “angry” rapist; a developmentally impaired rapist; a psychotic rapist; a sexually driven rapist; and sexual assault by a voyeuristic rapist (a rare case). Rape is clearly criminal behavior. Thus, all of Berlin and associates’ patients were sex offenders. Psychiatry would perceive these patients’ criminal conduct as having very different causes. Treatment would also vary. Courts and prisons would attend to victim harm, mitigating factors, treatment efficacy, rehabilitative potential, and future risk to society to determine the prisoner’s condition and duration of confinement.

Psychiatrists also know that some criminalized sexual behaviors are not directly related to mental disorders. Exposing one’s genitals to unsuspecting victims, for example, may be a focus of both legal and psychiatric concern in the context of paraphilic exhibitionism, traumatic brain injury, or command auditory hallucinations. While “streaking” at a football game or public urination may be construed as indecent exposure and, therefore, sex offenses, psychiatrists are unlikely to see these behaviors as mentally disordered.

Sexual Offenses

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A Decade of Psychiatry and Our Climate

Human Trafficking Training in Health Care

Speaking Up: Sexual Harassment in the Medical Setting

The Latest in Sexually Violent Predator Expert Testimony

Conference Preview from the Cutting Edge

The Role of Psychiatry in Sex Offender Management

Interventions for Perpetrators of Intimate Partner Violence

Psychiatric Patients in Prisons Are Frequent Rape Victims

Trauma Associated With Living in Violent Neighborhoods