Psychosis

Schizophrenia and other psychoses are modestly associated with sexual offending, particularly less serious offending (Reference Alden, Brennan and HodginsAlden 2007; Reference Fazel, Sjostedt and LangstromFazel 2007). Comorbid personality disorder and substance misuse strengthen this association and are associated with more serious offending. In serious sexual offenders with schizophrenia in England and Wales who attacked adult females (Reference SmithSmith 1999a–Reference Smith and Taylord, Reference Smith2000a,Reference Smithb): most had delusions or hallucinations related to offending, but few had symptoms which drove their offending; most were opportunistic or sexually motivated (rather than motivated by anger or sadism); bizarre or extreme behaviour was uncommon; most had interpersonal, emotional and sexual problems found commonly in non-mentally ill offenders, particularly those who offended before illness onset; and very few received psychological treatment to address sexual offending. Positive symptoms, negative symptoms, cognitive deficits, poor social functioning and medication affect various areas of psychosocial functioning of relevance to sexual offending (Reference Drake and PathéDrake 2006). Psychotic illness does not predict recidivism in long-term studies (Reference Mann, Hanson and ThorntonMann 2010). Nevertheless, in sexual offenders with psychosis, the potential role of illness-related factors underpinning stable dynamic factors and acting as acute precipitating factors (e.g. lack of adherence, relapse in mental state) needs to be considered, alongside non-illness-related factors.

Affective and neurotic disorders

Bipolar disorder and depression are less strongly related to sexual offending than schizophrenia (Reference Alden, Brennan and HodginsAlden 2007; Reference Fazel, Sjostedt and LangstromFazel 2007), but there is nevertheless a significant association. In some clinical samples, high rates of depression have been reported (Reference Raymond, Coleman and OhlerkingRaymond 1999; Reference Dunsieth, Nelson and Brusman-LovinsDunsieth 2004). Comorbid personality disorder and substance misuse increase this association. Mania causes sexual disinhibition, recklessness and grandiosity, which may lead to sexual offending, usually relatively minor in nature. Depression is associated with decreased libido, but some individuals use sexual fantasy and behaviour to cope with subclinical low mood, which may then precipitate offending. The presence of mood disorders does not predict sexual reoffending in the long term (Reference Mann, Hanson and ThorntonMann 2010), but changes in mood may be important proximal precipitants. Antidepressants may have sexual side-effects which decrease sexual behaviour or sometimes cause paradoxical problems. For example, anorgasmia may mean that a person spends more time masturbating, and impotence may lead them to devise more stimulating and deviant fantasies.

Anxiety disorders have a modest positive association with sexual offending (Reference Fazel, Sjostedt and LangstromFazel 2007). Poor coping with stress and anxiety are important factors in some sexual offenders, and some cope with stress by using sexual fantasy and behaviour.

Sexual obsessions are not uncommon in obsessive–compulsive disorder, but are not associated with sexual offending. Some clinicians have pointed to similarities between paraphilias and obsessive–compulsive disorder, particularly where sexual fantasies, urges and behaviours appear to be ego-dystonic; but phenomenologically, sexual obsessions are distinct from sexual fantasies – sexual obsessions are not associated with sexual arousal.

Organic disorders and intellectual disability

Organic psychoses are associated with sexual offending (Reference Alden, Brennan and HodginsAlden 2007). Dementia may lead to sexually offensive behaviour through disinhibition, deterioration in personality and cognitive decline. Sexual disinhibition may occur with frontal pathology. Delirium may precipitate disorganised impulsive sexual behaviour. Elevated rates of intellectual disability have been reported in sexual offenders (Reference Griffits, Federoff, Saleh, Grudzinskas and BradfordGriffiths 2009). For example, some individuals with autism spectrum disorders commit sexual offences. Poor perspective-taking, poor social and interpersonal skills, repetitive preoccupations and isolation may play a role. However, caution needs to be exercised in interpreting findings, as individuals with intellectual disability may be both more likely to be detected and less likely to live in situations where they are afforded privacy for sexual behaviour.

Many sexual offenders with intellectual disability are diverted to health or social care and not convicted. High rates of sexual offending in this group may reflect repressive and restrictive attitudes towards sexuality in people with intellectual disabilities. Impaired social functioning, poor interpersonal and intimacy skills and lack of sexual knowledge may impair their ability to manifest sexuality appropriately. However, some sexual offenders with intellectual disability do not have such problems and are similar in background and characteristics to sex offenders without intellectual disability.

Having an intellectual disability is not in itself associated with recidivism. As with any intervention for people with intellectual disability, it is important that treatment programmes are delivered so as to take into account intellectual deficits.

Personality disorder

Very high rates of personality disorders have been reported in sexual offenders (Reference Fazel, Sjostedt and LangstromFazel 2007; Reference Craissati, Webb and KeenCraissati 2008). Personality disorder is particularly prevalent in high-risk sexual offenders on long or indeterminate sentences (Reference Coid, Yang and UllrichCoid 2007), and among difficult-to-manage sexual offenders in the community (Ministry of Justice National Offender Management Service 2011). Personality pathology is heterogeneous. High rates of antisocial, narcissistic, paranoid and psychopathic traits have been described in adult rapists, with higher rates of avoidant, schizoid and obsessional traits in child and internet offenders. High rates of borderline personality disorder have also been reported. Psychopathy is associated with violent recidivism but not specifically with sexual recidivism (Reference Dematteo, Edens, Hart, Otto and DouglasDematteo 2010). A number of stable dynamic risk factors (see Risk and protective factors, below) are manifestations of dysfunctional personality traits. It is important to understand the personality pathology of a sexual offender when assessing risk, planning management and delivering treatment.

Sexual disorders

Unsurprisingly, paraphilias are associated with sexual offending. But not all sex offenders have paraphilias, and most people with paraphilias do not commit offences (Reference Federoff, Gelder, Andreasen and López-IborFederoff 2009). Rates of paraphilias in sex offenders of between 25 and 75% have been reported (Reference Raymond, Coleman and OhlerkingRaymond 1999; Reference Dunsieth, Nelson and Brusman-LovinsDunsieth 2004; Reference Hanson, Harris and ScottHanson 2007). In child molesters, extra-familial offenders have high rates of paedophilia, but most incest offenders are not paedophilic. Most rapists do not have paraphilias and very few are sexually sadistic. However, up to 80% of sexual murderers have paraphilias (Reference Hill, Habermann and BernerHill 2007; Reference Proulx, Beauregard and CussonProulx 2007).

Some sexual offenders have multiple paraphilias. Deviant sexual interests, particularly paedophilia, sexual sadism and multiple paraphilias, are associated with sexual recidivism. Other paraphilias probably increase the risk of reoffending in specific types of offenders (e.g. frotteurism in a man convicted of breach of the peace for rubbing himself against women on buses). Phallometric assessment of internet child pornography offenders shows that they have higher rates of paedophilia than contact offenders (Reference Quayle, Laws and O'DonohueQuayle 2008). Sexual dysfunctions, particularly erectile problems, are sometimes encountered. Hypersexual arousal (a suggested sexual dysfunction for DSM-5) is associated with reoffending. There does not appear to be an association between gender dysphoria and sexual offending.

Historical/static risk factors

Historical/static factors fall into two broad categories: antisocial and sexual. Antisocial factors are associated with sexual and non-sexual recidivism, and sexual factors with sexual recidivism only. Examples of historical antisocial factors are: young age, employment problems, use of drugs and alcohol, childhood behavioural problems, non-sexual violence history, general offending history and breaches of supervision. Inability to form stable intimate relationships is a factor that encompasses both antisocial and sexual elements. Like employment problems, inability to form intimate relationships is a marker for a variety of underlying problems including impulsivity, emotional dysregulation, attachment problems or distorted attitudes towards women. Difficulties in non-intimate relationships is not a factor statistically related to sexual recidivism, but, as with intimate relationships, may be a marker for a number of stable dynamic factors.

In terms of sexual factors, having previous sexual offences and the number of these are associated with reoffending. The nature of the offences, degree of violence used, escalation and diversity in offending, victim type and use of physical and/or psychological coercion are important areas to consider. Having male victims (particularly where victims are children), a history of non-contact offending, offending against unrelated or stranger victims, victims of both genders, and both adult and child victims are related to sexual recidivism. Statistically, the degree of injury caused to victims is inversely related to the likelihood of recidivism, but the degree of harm to victims is important when assessing the potential for serious harm.

Stable dynamic/dispositional risk factors

Stable dynamic factors (Box 1) have been identified and described by Reference Hanson and HarrisHanson & Harris (2000) and Reference Beech, Fisher and ThorntonBeech et al (2003). They can be divided into four categories:

1. 1 sexual interests/sexual self-regulation

2. 2 attitudes

3. 3 socio-affective functioning

4. 4 general self-regulation.

They are relatively stable over time, but amenable to change through treatment and time, in the medium to long term. They are the most important things to focus on in treatment and when looking for underlying change of longer-term significance.

Reference Mann, Hanson and ThorntonMann et al (2010) described these factors as ‘psychologically meaningful […] propensities’ that may or may not manifest at a point in time. Most static factors are just markers for these more meaningful factors (e.g. ‘number of sexual offences against young boys’ is a marker for ‘sexual deviance’). Mann et al define ‘psychologically meaningful risk factors’ as having: (a) a plausible rationale that the factor causes sexual offending; and (b) strong evidence that it predicts sexual recidivism. They used the second of these criteria to look at the strength of evidence supporting the use of various factors, separating them out into five categories (Box 2):

1. 1 empirically supported

2. 2 promising

3. 3 unsupported but with interesting exceptions

4. 4 worth looking at

5. 5 not risk factors.

Although there is evidence for the risk factors discussed below, their causal role is yet to be identified. Also, no one factor is strongly statistically related to recidivism, so no factor can be used in isolation and factors must be combined when assessing risk.

Acute factors

Acute factors are proximal to an offence and indicate that offending may be imminent (Reference Hanson and HarrisHanson 2000). The evidence base for acute factors is not strong, but it is difficult to research factors that act over minutes, hours or days. Based on our experience and practice, these proximal factors are important and make sense conceptually.

The following factors may act as triggers: escalation in alcohol or drug use; deteriorating intimate and non-intimate relationships; loss of social support; increased contact with antisocial or pro-sexual offending peers; loss of employment or problems at work; stress; access to potential victims through creating opportunities, change in circumstances or others being less vigilant.

The following may reflect the person’s state of mind or a situation which makes sexual offending more imminent: sexual preoccupation (with deviant or non-deviant themes); mood/mental state (increasing anxiety, depression, hostility, frustration, psychotic symptoms); evidence that the person is planning to offend or making an opportunity to offend (e.g. carrying a weapon or driving around the streets); lack of cooperation with supervision or treatment (not turning up for appointments, not complying with conditions, poor behaviour in sessions); intoxication with alcohol or drugs as a dysfunctional way of coping with negative emotions; isolation; lifestyle becoming increasingly chaotic.

Protective factors

In addition to risk factors, it is important to consider protective factors. Unfortunately, there has been relatively little research on protective factors in sexual offending, and they rarely feature in risk assessment tools. A recent development has been the Structured Assessment of Protective Factors (Reference de Vogel, De Ruiter and BoumanSAPROF; de Vogel 2009), an instrument that helps with the identification and assessment of protective factors, which can be used alongside structured professional judgement risk assessment instruments (discussed below). A protective factor is not merely the absence of a risk factor, although the absence of certain risk factors (e.g. a history of sexual offending) in a general way indicates a relatively low likelihood of future offending.

There are two types of protective factors: personal strengths and external supports/controls. Personal strengths to consider include ability to: cope with stress and interpersonal conflict; form age-appropriate intimate relationships; and engage with others. Some strengths may be life-long, and some may develop with help, support and intervention. A key issue to consider is whether there is evidence that the person has the skills, ability and inclination to lead a pro-social life, meeting their needs (for relationships, occupation, friendship, self-worth, acquiring material goods) in a way that does not involve offending.

Beyond intrinsic strengths, external supports, relationships and circumstances may help the individual to not reoffend. Looking at periods of an offender’s life where they have not offended and positive responses to previous management can help identify protective factors in a case. The literature on desistance from offending (i.e. the natural process by which a person turns away from offending and moves towards a pro-social life) provides useful pointers towards factors that may be protective in the longer term and things that we should promote when working with sexual offenders (Reference Laws and WardLaws 2011).

Actuarial approaches

Actuarial instruments use a limited number of historical static factors. Their development involves following up a sample and using statistical methods to identify and combine factors mathematically to best predict recidivism. Factors are weighted depending on their predictive strength. Only a few facts about a person are required. Advocates of the actuarial approach laud this scientific, objective and defensible approach to predicting recidivism (Reference Quinsey, Harris and RiceQuinsey 2006), but opponents argue that they tell you little or nothing about the individual and that a risk level based on group statistics does not help prevent offending through guiding risk management (Reference Vincent, Maney, Hart, Saleh, Grudzinskas and BradfordVincent 2009; Reference Cooke, Michie, McSherry and KezerCooke 2011).

In long-term follow-up studies of groups of offenders, actuarial tools tend to perform better statistically than structured professional judgement tools, which in turn perform better than unstructured clinical judgement, which in most studies is no better than chance. If the person being assessed has little in common with the offenders in development or validation samples, the tool should not be used. These tools are also limited to long-term likelihood of recidivism and not other facets of risk such as nature, severity of harm, imminence or frequency of offending.

Dynamic approaches

Dynamic risk assessment instruments identify and combine dynamic factors (stable and perhaps acute factors) rather than static ones, and can be used to inform treatment, monitor change over time and assess risk of recidivism. They have been developed from research on factors of relevance to sexual offending.

The best researched and validated dynamic tool is the Stable and Acute 2007 (Reference Hanson, Harris and ScottHanson 2007). Like static actuarial tools, this tool has been developed and validated in particular samples, and so should be used with caution in offenders who are unusual. The summation of scores for each factor gives a total score, which indicates a risk level. These levels improve on the use of static actuarial tools alone in predicting recidivism (Reference Hanson and HarrisHanson 2001, Reference Hanson, Harris and Scott2007; Reference Beech, Fisher and ThorntonBeech 2003; Reference Olver and WongOlver 2011).

In practice, however, it is difficult to know how to combine the results of a static and dynamic tool in an individual case. If the assessor looks at the factors present rather than the ‘total score’, the tools are useful in identifying factors of relevance to treatment. The Structured Assessment of Risk and Needs is used in this way (as a structured professional judgement tool) rather than yielding a total score and risk level. It is important that those who use these assessments know their strengths and limitations, and have received appropriate training in their use and interpretation.

Structured professional judgement approaches

Structured professional judgement tools, also known as ‘structured clinical judgement’, ‘structured clinical risk assessment’ and ‘structured professional guidelines’, are developed from reviewing the research literature on factors related to recidivism. The evidence-based factors identified are listed with explicit criteria. The most commonly used structured professional judgement tool, which many clinicians are familiar with, is the Historical, Clinical, Risk Management-20 (HCR-20; Reference Webster, Douglas and EavesWebster 1997) used for non-sexual violence. As these tools require clinical judgement, they are mainly used by clinicians (particularly psychologists and psychiatrists). The users of these tools are expected to possess certain clinical qualifications, to have knowledge, experience and training in forensic assessment and the type of risk under consideration, and to be up to date with the literature.

When initially introduced in the late 1990s, the structured professional judgement approach involved rating risk factors, adding scores and making a judgement about risk level. This approach has evolved significantly since then. The assessor considers whether each factor is present, partially present or absent (according to specified criteria), and then whether the factor is definitely, partially or not relevant to future risk management (through a relationship with either the behaviour of concern or responsivity to risk management). Risk factors are combined through formulation using clinical judgement, rather than in a predetermined fashion using a mathematical formula, as is done in actuarial assessment. Narrative risk scenarios are generated to outline how the offender may reoffend in the future, including information about the nature, severity, frequency and imminence of such offences, likely victims and the contexts when offending may occur. These scenarios are used to develop a management plan to mitigate risk. Last, consideration is given to case prioritisation (relative to other cases), whether there is a risk of serious physical harm and whether immediate action is necessary. The Sexual Violence Risk-20 instrument (SVR-20; Reference Boer, Hart and KroppBoer 1997) (Box 4) and the Risk for Sexual Violence Protocol (RSVP; Reference Hart, Kropp and LawsHart 2003) (Box 5) are the two most commonly used structured professional judgement tools for sex offenders (Reference Hart, Boer, Otto and DouglasHart 2010).

The key difference between the actuarial and the structured professional judgement approach is how risk factors are combined to form a risk conclusion. If a structured professional judgement tool is used as a pseudo-actuarial tool by adding up factor scores to give a total, it generally performs less well than an actuarial tool in predicting recidivism in the long-term. However, if SPJ tools are used in research as they are in clinical practice, not through adding scores but through generating a clinical judgement about risk, then they perform better (Reference Heilbrun, Yasuhara, Shah, Otto and DouglasHeilbrun 2010).

It is worth noting that there has been little research on the reliability or validity of the risk scenarios generated using structured professional judgement approaches. Critics argue these approaches are mathematically inferior to (and at best no better than) actuarial approaches; they require resources, time and clinical experience; and the incorporation of clinical judgement, even within a structured approach, weakens their predictive validity. Proponents argue that structured professional judgement approaches provide an evidence-based individualised assessment, allowing for factors to be combined in different ways, offering flexibility and enabling consideration of unusual or complex cases, and that they help prevent offending through guiding the development of risk management plans.

Conclusions

We have attempted to give an overview of what clinicians need to know before assessing risk in a sexual offender. Despite the popular public stereotype of the dangerous predatory paedophile or rapist, sex offenders are heterogeneous and few fulfil these images. Although there are some commonalities between sex offenders (hence aetiological models, typologies and evidence-based risk factors), it is important to understand the particular factors in an individual case.

Most sexual offenders have mental disorders, particularly personality disorders, paraphilias and substance misuse, but also psychosis, affective disorders, neurotic disorders, organic disorders and intellectual disabilities. Clinicians need to understand the role of any mental disorder in sexual offending, and must consider factors unrelated to the disorder when assessing and managing risk.

Risk factors for sexual offending can be usefully divided into static, stable dynamic and acute. Most risk factors for sexual violence relate to antisociality or sexual problems. Victim empathy and denial are not evidence-based risk factors. Protective factors have been less well researched, but include personal strengths and extrinsic supports. Risk assessment instruments attempt to combine risk factors to provide a conclusion about risk. There are actuarial, dynamic and structured professional judgement instruments. Proponents of each make strong arguments for a particular approach and against others, but the important things when using any instrument are to be trained and qualified to use them, to know their strengths and limitations and to know how to interpret them. Structured professional judgement approaches are particularly useful for sexual offenders who are mentally disordered, complex or unusual.

In the next article we will set out how to use a structured professional judgement approach to assess risk and plan risk management.

MCQs

Select the single best option for each question stem

1. 1 The rate of recidivism for a new sexual offence in sexual offenders over 5–10 years is about:

   1. a 5%

   2. b 15%

   3. c 35%

   4. d 50%

   5. e 65%.

2. 2 Which of the following is a structured professional judgement risk assessment instrument for sexual offending?

   1. a HCR-20

   2. b Static-99

   3. c RSVP

   4. d Risk Matrix 2000

   5. e SORAG.

3. 3 Which of the following is not an evidence-based risk factor for sexual recidivism:

   1. a number of previous sexual offences

   2. b sexual deviance

   3. c antisocial personality disorder

   4. d lack of victim empathy

   5. e sexual preoccupation.

4. 4 Sexual offending and mental illness:

   1. a there is no epidemiological relationship

   2. b delusions usually drive offending

   3. c offences are usually bizarre

   4. d illness-related factors do not usually adequately explain offending

   5. e having a mental illness is an important predictor of long-term recidivism.

5. 5 Stable dynamic risk factors for sexual offending:

   1. a are historical facts about the individual

   2. b include victim access and deteriorating emotional state

   3. c are proximal precipitants of sexual offences

   4. d are psychological dispositions which may change slowly with time or treatment

   5. e are not related to mental disorder.

MCQ answers

1

b

2

c

3

d

4

d

5

d