SEXUAL BEHAVIOUR & THE MENTAL HEALTH ACT Don Grubin

The old: Exceptions to ‘mental disorder’ By reason only of: promiscuity other immoral conduct sexual deviancy dependence on alcohol or drugs

The new: Removal of the exclusions promiscuity other immoral conduct sexual deviancy “Clinically, neither promiscuity nor ‘other immoral conduct’ by itself is regarded as a mental disorder, so the deletion of that exclusion makes no practical difference. However there are disorders of sexual preference which are recognised clinically as mental disorders. Some of these disorders might be considered ‘sexual deviance’ in the terms of the current exclusion (e.g. paraphilias like fetishism or paedophilia). On that basis, the amendment would bring such disorders within the scope of the 1983 Act.” Explanatory Notes to the Act

psychiatry and sex offending {being repulsed by a behaviour doesn’t mean we have to diagnose it}

The ‘medical model’? sex offenders are not mentally ill medicalisation removes responsibility “The disease model has retarded efforts to arrive at a general explanation for sexual violence”. the tablet

The medical model The whole history of psychiatry has been built on hallucinations and delusions. Without them - without serious mental illness - there would be no psychiatry. We’d be nothing. Why, we’d be... psychologists.

sexual offending sexual deviance paraphilia (mental disorder) social control v medical treatment the needs of societypriority is the patient

Do sex offenders have a mental disorder? DSM: Paraphilias ICD: Disorders of Sexual Preference

Do we rely on the DSM or ICD? "The DSM is no more than a distillate of the prejudices and power plays of a group of aging American academics... " Pathe & Mullen (1993) Journal of Law and Medicine 1:47-51

Paraphilia recurrent, intense sexually arousing fantasies, urges, or behaviours associated with clinically significant distress or impairment of function {children, suffering, non-human}

How many paraphilias are there? Paul Federoff: 105 “Mother would be proud.” ICD: DSM: 6 (+) 8 (+) John Money: ~ 40 ICD: other disorders... each being relatively uncommon (e.g. obscene telephone calls, frotteurism); DSM: ‘Paraphilia not otherwise specified’ Paraphilia or Sexual Deviance?

Kinky sex involves the use of duck feathers. Perverted sex involves the whole duck.

Paraphilias as medical conditions not involving deviancy OCD spectrum addictive spectrum impulse control manifestation of personality disorder hypersexuality affective disorder/ADHD

Models of paraphilias as medical conditions OCD spectrum: -ruminations (recurrent and persistent thoughts, impulses and images) - compulsive behaviour - ego dystonic/attempts to ignore or suppress? (need not recognize as excessive or unreasonable most of the time)

Models of paraphilias as medical conditions hypersexuality (not a DSM diagnosis)

No longer an exception; The other hurdles own health or safety or risk to others availability of appropriate medical treatment - paraphilias which by definition are against the law * exhibitionism* sadomasochism * voyeurism* frotteurism * paedophilia* necrophilia {fetishism?}

Appropriate Treatment (Guidance from the Code) It should never be assumed that any disorders, or any patients, are inherently or inevitably untreatable treatment may be appropriate even though it consists only of nursing and specialist day-to day care … in a safe and therapeutic environment with a structured regime treatments which require the patient’s co-operation can potentially remain appropriate even if the patient “does not currently wish to engage with them

Appropriate treatments for sex offenders anti-androgen and SSRI medication cognitive behavioural treatment behavioural modification psychodynamic psychotherapy (even though it is unlikely to work) castration

Does Treatment Work? ATSA meta-analysis (Hanson)

DOES TREATMENT WORK?

ATSA meta-analysis (Hanson)

Adherence to Risk, Need, Responsivity Risk Rarely (3/24) Need Sometimes (12/24) Responsivity Most programs (18/24)

Effect Size By R/N/R Adherence Odds ratioN (k) None1.051,200 (4) One0.821,209 (6) Two0.575,147 (12) All three (1)

Sex Offender Treatment (Losel & Schmucker, 2005) Odds Ratio hormonal medication3.08 Cog Behav Therapy1.45 ‘insight oriented’ psychotherapy 0.98 Therapeutic Community0.86 Reduces recidivism by (6% or 33%) (increased reoffending in the low risk?) 69 studies, 22,000+ offenders Mean effect size: Odds Ratio = 1.7

Triptorelin (Rosler & Witztum, 1998) n = 30 “hypersexual”: masturbate 32/week fantasise 48/week behaviour 5/month failed on other Rx

Triptorelin (Rosler & Witztum, 1998) RESULTS follow-up to 3 1/2 years masturbation = 0-1 per week deviant fantasies = 0 behaviours = 0 reoffences= 0 {except for 2 side effect drop outs} dropout = 6 (20%) {3 from side effects}

depo-Provera (Oregon) (Maletzky, Tolan & McFarland, 2006) ProveraNo ProveraNot recom. n=79 n=55 n=141 sex recidivism010 (18%) 21 (15%) sex breech112 (22%) 6 (4%) in prison011 (20%)19 (13%) ‘doing well’ 70 (89%)24 (44%)89 (63%)

Psychiatric treatment of sex offenders medical treatment v social control - consent - doctor/patient relationship

What are we to do? The mental disorder......is of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital.

Medical Treatment v Social Control Medical Treatment + IPP’s SOPOs extended sentences polygraph conditions