Common beliefs about the incidence of mental illness in sex offenders, aside from paraphilias, have also been challenged by careful observation. Our research at the University of Cincinnati revealed high rates of mental illness and substance abuse in a group of sex offenders released from prison to a residential treatment center. Offenders with paraphilias had even higher rates of mood, anxiety, and impulse control disorders (Table).4 Concurrently, Nancy Raymond and her colleagues reported similar findings with a group of residential and outpatient child molesters in Minnesota.5 Data from both these studies suggest that:
- Axis I conditions, especially those related to increased sexual drive or impaired impulse control (such as bipolar disorder), have some importance in treatment.
- Some relationship exists between Axis I disorders and the expression of underlying paraphilic interests.
It is clear that sexual compulsions are not homogeneous, and different characteristics exist across different populations. In our sample, for instance, pedophiles had lower rates of antisocial personality disorder but higher rates of anxiety than other offenders. Pharmacologically, Martin Kafka found that self-identified, noncriminal clients with sexual compulsions responded well to selective serotonin reuptake inhibitors (SSRIs) and stimulants,6 whereas patients at the University of Cincinnati program had a far less robust response to SSRI treatment.7 In essence, one style of intervention may not fit all patients.
Table
COMMON AXIS I DIAGNOSES IN 113 CONVICTED SEX OFFENDERS WITH AND WITHOUT PARAPHILIAS*
| Diagnosis | Total | With paraphilias | Without paraphilias | |||
|---|---|---|---|---|---|---|
| N | (%) | N | (%) | N | (%) | |
| Mood disorders (any) | 66 | (58.4) | 61 | (72.6) | 5 | (19.2) |
| Major depressive | 27 | (23.9) | 26 | (31.0) | 1 | (3.8) |
| Bipolar I | 28 | (24.8) | 25 | (29.8) | 2 | (7.7) |
| Substance abuse (any) | 96 | (85.0) | 69 | (82.1) | 26 | (100.0) |
| Anxiety disorders (any) | 26 | (23.0) | 24 | (28.6) | 2 | (7.7) |
| Eating disorders (any) | 10 | (8.8) | 10 | (11.9) | 0 | (0) |
| Impulse control disorders (any) | 43 | (38.1) | 38 | (45.2) | 4 | (15.4) |
| Compulsive buying | 11 | (9.7) | 11 | (13.1) | 0 | (0) |
| * Among the 113 subjects, 110 were evaluated for paraphilias. In that group, 84 were diagnosed as paraphilic and 26 as nonparaphilic. Mood disorders, major depressive disorder, bipolar affective disorder type I, and impulse control disorders were significantly more prevalent among paraphilic sex offenders. Individuals without paraphilias were significantly more likely than those with paraphilias to have a substance abuse disorder. Anxiety disorders and compulsive buying were more prevalent among paraphilic sex offenders. | ||||||
One other problem has plagued the forensic setting: Sex offenders lie about their sexual urges. In our program, they often appeared to “comply” with the program but concealed their sexual urges and fantasies. Sometimes they were embarrassed, ashamed, or simply in denial. We found that serial polygraph testing was essential for gauging treatment because it allowed us to objectively examine the information that the patients offered.
Frequently, I have heard people assert that an individual who seeks treatment actually wants treatment. Few sex offenders self-identify, however, and many more enter treatment as a condition of probation or parole. Thus most have an external motivation to participate. And with sex offenders, voluntary treatment is less successful than mandated treatment.1
Summary
Ultimately, self-help, 12-step, and psychodynamic approaches have an unproven role in managing problem sexual behaviors. The most appropriate intervention is a multidisciplinary team approach with screening for Axis I disorders and paraphilias, a thorough psychological assessment, substance abuse treatment, and a cognitive relapse prevention program. Forensic patients additionally benefit from collateral data such as polygraph testing and ongoing monitoring by community corrections personnel.