1. Public Defenders Sydney 14 May 2005 1 Treating Sex Offenders Dr Jeremy O’Dea Forensic Psychiatrist

2. Public Defenders Sydney 14 May 2005 2 Sex Offenders Heterogenous Group Defined by Diverse group of Illegal Behaviours –Cf to thieves –Change over time eg Homosexuality –Variety of psychiatric problems and diagnoses –Differing treatment needs ?Antidepressants for all who attempt suicide

3. Public Defenders Sydney 14 May 2005 3 Risk of Sexual Recidivism Relatively Low 10%-13% Sexual Deviance –History Sexual Offending –Sexually Deviant Arousal Small group with multiple re-offending –Identify/treat/reduce risk

4. Public Defenders Sydney 14 May 2005 4 Risk Assessment Actuarial Risk Assessment –Static 99 –SONAR Clinical Risk Assessment –Psychiatric Assessment –Paraphilias –HCL 20 –?Penile Plethysmography

5. Public Defenders Sydney 14 May 2005 5 Actuarial Risk Assessment Objective and Reliable Empirically Driven with Little Theoretical Foundation Questionable generalisation to other populations Static historical data generating Static risk Not amenable to change Ignore individual factors Make statements about groups not individuals Little use in low frequency behaviours like sexual recidivism with individuals

6. Public Defenders Sydney 14 May 2005 6 Clinical Risk Assessment Thorough psychiatric assessment with reasoned opinion Understanding phenomenology of sexual behaviours for the purpose of treatment/risk management –Paraphilias Patient focused and treatment orientated Should take into consideration actuarial risk assessment tools Both static and dynamic risks

7. Public Defenders Sydney 14 May 2005 7 Static 99 Actuarial Risk Assessment Tool Over 1000 Prisoners and secure psychiatric patients Canada and UK Followed for up to 30 years Looked at factors on RRASOR and SACJ- Min that best predicted recidivism

8. Public Defenders Sydney 14 May 2005 8 Static 99, Items Prior Sex Offences3 –Charges/Convictions Prior Sentencing Dates(4+)1 Any Convictions for1 non-contact sex offences Index Non Sexual Violence1 Prior Non Sexual Violence1 Any Unrelated Victim1 Any Stranger Victim1 Any Male Victim1 Age – Under 251 Single – No 2 year live in relationship1

9. Public Defenders Sydney 14 May 2005 9 Static 99, Risk Categories Low 0,1/12 Medium-Low 2,3/12 Medium-High4,5/12 High6+/12

10. Public Defenders Sydney 14 May 2005 10 Static 99, Hanson, Thornton, 2002 Moderate predictive accuracy –Sexual Recidivism –Violent Recidivism Critics could suggest that insufficient for decision making –Correlation 0.3 –Only accounts for 10% of the variance Given its lack of dynamic factors, it cannot be used to –select treatment targets –measure change –evaluate whether offenders have benefited from treatment

11. Public Defenders Sydney 14 May 2005 11 Dynamic Risk Factors Sexual Deviance - Paraphilias Substance Abuse Psychiatric Illness ?Personality Disorder Social Situation Other

12. Public Defenders Sydney 14 May 2005 12 Preventative Detention Queensland –Dangerous Prisoners (Sexual Offenders) Act 2003 (Q) Act –Empowers State court to order continuing detention of persons convicted of serious sexual offences after expiry of their sentence where there is an "unacceptable risk" of the prisoner committing a serious sexual offence in the future –Upheld by High Court, Oct 2004

13. Public Defenders Sydney 14 May 2005 13 Civil Commitment Kansas v Hendricks (1997) –Confinement to Mental Institution –Dangerousness without Mental Illness –Judge or Jury Decision –“Substantial Probability” of engaging in sexually violent acts –“Beyond Reasonable Doubt”

14. Public Defenders Sydney 14 May 2005 14 Treatment Programs in NSW Custody Based Treatment Programs –DCS Psychology –Based on risk assessment on Static 99 –CUBIT and others –Relapse prevention Community Based Treatment –DCS Psychology –Others

15. Public Defenders Sydney 14 May 2005 15 SOTEP 1985 Sex Offender Treatment and Evaluation Project California Sentenced Prisoners –Rape –Child Molestation

16. Public Defenders Sydney 14 May 2005 16 Eligible Participants Inclusion Criteria Within 14 to 30 months of release Between 18 and 60 No more than 2 prior convictions Admit committing their offence(s) No pending warrants IQ above 80 Speak English No psychotic or organic mental disorder Not medically debilitated No prison management problems Exclusion Criteria –Gang Rapists –Biological Incest Only

17. Public Defenders Sydney 14 May 2005 17 3 Groups Volunteer Group –Treatment Group –Volunteer Control Group Non Volunteer Group –Non Volunteer Control Group

18. Public Defenders Sydney 14 May 2005 18 Treatment Relapse Prevention –CBT Atascadero State Hospital –2 years –40 – 50 hours per week Sex Offender Aftercare Program –1 year

19. Public Defenders Sydney 14 May 2005 19 Published 1994, Behaviour Research and Therapy –Omitted treatment Drop Outs 1994, Criminal Justice and Behaviour –Included Treatment Drop Outs –Not cited by Cochrane 1999, Journal of Interpersonal Violence

20. Public Defenders Sydney 14 May 2005 20 Statistical Significance Treatment subjects showed lower risk for new sex offences than did Volunteers only Higher rate of sex re-offences for Ex-treatment group compared to Completed Treatment Group For Child Molesters: Treatment Group at lower risk for violent offences than was the Volunteer Control Group only The married men in the treatment group had a lower risk of sex re-offence only against the NonVolunteer Control Group

21. Public Defenders Sydney 14 May 2005 21 Negative Findings - Overall Volunteer Control’s did better than the Treatment Group in terms of sex re- offending Treatment Group had the highest rate of violent re-offending

22. Public Defenders Sydney 14 May 2005 22 Negative Findings - Rapists Non Volunteer Control Rapists had the lowest risk of sex re-offending Treated Rapists had the highest rate of violent re-offending

23. Public Defenders Sydney 14 May 2005 23 Negative Findings - Child Molesters Treated Child Molesters re-offended at a higher rate than Volunteer Controls If married men did better with treatment, single men did much worse

24. Public Defenders Sydney 14 May 2005 24 NSW As no evidence that Relapse Prevention significantly reduces risk of sexual recidivism ?Appropriateness of tailoring prison sentence to accommodate completion of such treatment program ?Appropriateness of delaying parole to complete program

25. Public Defenders Sydney 14 May 2005 25 Other Psychological Treatments Community Based –Supervision –CBT –Relapse Prevention Psychological treatments in combination with Psychotrophic Medication in selected individuals

26. Public Defenders Sydney 14 May 2005 26 Psychopharmacological treatments In selected patients with paraphilias

27. Public Defenders Sydney 14 May 2005 27 Castration USA –Chemical and Surgical –9 States –Voluntary and Mandatory

28. Public Defenders Sydney 14 May 2005 28 NSW Call to “castrate’ child sex offenders –Opposition justice spokesperson –?Condition of parole –?Mandatory

29. Public Defenders Sydney 14 May 2005 29 France Justice Minister 2 year trial Leuproreline and Cyproterone Acetate Voluntary 48 repeat offenders Denmark,Sweden,Canada

30. Public Defenders Sydney 14 May 2005 30 Psychiatric Treatment Appropriate patient populations –Paraphilias v Sex Offences –DSM IV TR Efficacy Tolerability Best available option Consent

31. Public Defenders Sydney 14 May 2005 31 Consent to Treatment Involuntary –Guardianship Tribunal –Mental Health Acts –?Mandatory Treatment Risk/Benefit Evidence Base

32. Public Defenders Sydney 14 May 2005 32 What is the medical evidence? Where does it come from?

33. Public Defenders Sydney 14 May 2005 33 Evidence Animal Husbandry Eunuchs and Castrati Surgical Castration Studies –Voluntary and Involuntary Testosterone and Sexual Behaviour in Men Testosterone Lowering Medications Antipsychotics and Antidepressants

34. Public Defenders Sydney 14 May 2005 34 Surgical Castration StudyFollow up Period (Years) Number of Subjects Pre-op rate of recidivism (%) Post-op rate of recidivism (%) Comparison group rate of recidivism (%) Germany, Langeluddeke, 1963 Up to 201036842.339 Switzerland, Cornu, 1973 5 +127777.4 – 4.166 - 52 Norway, Bremer, 1959 1 - 10215582.9 - 7- Denmark, Sands, 1964 Up to 30738-1.4 – 2.49.7

35. Public Defenders Sydney 14 May 2005 35 Medication (Chemical Control) Oestrogens Progestogens –Medroxy Progesterone Acetate (MPA), Provera Anti-androgens –Cyproterone Acetate (CPA), Androcur –Flutamide –Nilutamide SSRI’s Others

36. Public Defenders Sydney 14 May 2005 36 Medication (Chemical Control) GNRH agonists –Triptorelin LHRH Agonists –Leuprolide acetate –Goserelin

37. Public Defenders Sydney 14 May 2005 37 Therapeutic Trials Methodological Problems –Heterogenous Groups –Small Sample Sizes Single Case Studies –Double blind/Placebo controlled –Drop Outs –Self Report –Follow up periods

38. Public Defenders Sydney 14 May 2005 38 CPA Bradford and Pawlak, 1993 –Double-blind placebo crossover trial –Superior to placebo –Self Report and physiological measures –Some preferential targeting of deviant fantasies Cooper, 1992 –MPA and CPA equally effective in double blind-placebo controlled comparison

39. Public Defenders Sydney 14 May 2005 39 GNRH/LHRH Analogues 4 case reports, 1 case control study 7 open uncontrolled studies 1 study comparing with CPA Rosler and Witztum, 1998 –Triptorelin –Observational, uncontrolled study –30 paraphiliacs over 42 months

40. Public Defenders Sydney 14 May 2005 40 SSRI’s Case Reports Small open label studies 50-90% response rates