Relevant Conditions

OVERVIEW

“Studies of sexual abusers, men with paraphilias, and those with non-paraphilic expressions of ‘hypersexuality’ suggest that mood disorders (dysthymic disorder, major depression, and bipolar spectrum disorders), certain anxiety disorders (especially social anxiety disorder and childhood–onset post–traumatic stress disorder), psychoactive substance abuse disorders (especially alcohol abuse), Attention–deficit/hyperactivity disorder (ADHD), and neuropsychological conditions (e.g., schizophrenia, autism spectrum disorder, and head injury) may occur more frequently than expected in sexually impulsive men, including those who sexually abuse.”[1]

Included here are conditions most likely to be relevant to sex offending, alongside a simplified account of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria. If a client presents any of the following criteria, it might be worth considering a mental health evaluation for an official diagnosis.

[1] Association for the Treatment of Sexual Abusers. “ATSA Practice Guidelines for the Assessment, Treatment, and Management of Male Adult Sexual Abusers.” Beaverton: Oregon, 2014.

AUTISM SPECTRUM DISORDER

Diagnostic Criteria:

1. Deficits in social communication and interaction
   1. Deficits in social-emotional reciprocity
   2. Deficits in nonverbal communicative behaviors used for social interaction
   3. Deficits in developing, maintaining, and understanding relationships
      1. Social communication problems range from normal language accompanied by odd body language to a total absence of verbal and nonverbal communication
2. Restricted, repetitive patterns of behavior, interests, or activities
   1. Stereotyped or repetitive motor movements, use of objects, or speech
   2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior
   3. Highly restricted, fixated interests that are abnormal in intensity or focus
   4. Respond to to sensory input in unusual ways, engagement in self-stimulation
3. Symptoms must be present early in life, but may not fully manifest until heightened social demands later in life, or may be masked
4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

Autism’s Relevance

Research suggests a correlation between Autism Spectrum Disorder (ASD) and the development of non-normative sexual behaviors and interests. This connection arises from the core symptoms present in ASD, including deficits in social skills, sensory sensitivities, and repetitive behaviors. The manifestation of inappropriate sexual behaviors among people with ASD is of particular concern during adolescence, as the lack of socialization and understanding of social norms may contribute to this behavior.[2]

Research also underscores the legal implications of inappropriate sexual behaviors among people with ASD. If a juror is not aware of a defendant’s ASD, they may have misconceptions and misinterpretations of sexualized behaviors, potentially compromising the fair application of legal standards.[3]

Hiring an Expert

When looking to hire an expert in autism spectrum disorder, one approach is to seek out experts who are members of the American Psychological Association Division 33: Intellectual & Developmental Disabilities / Autism Spectrum Disorder.[4] Finding an expert with a specific background in the area you are concerned with can help ensure that they have the knowledge and skills relevant to your case.

[2] “Sex Offense: Autism Spectrum Disorder and Sex Offense.” Arizona Forensics, LLC, n.d. https://arizonaforensics.com/autism-spectrum-disorder-and-sex-offense/.; Schottle, Danielle, et al. Dialogues in Clinical Neuroscience. December 2017. 19(4): 381-393

[3] A psycho-legal perspective on sexual offending in individuals with autism spectrum disorder.
Creaby-Attwood, C.S. Allely. International Journal of Law and Psychiatry, 2017. 55, 72-80.

[4] APA Division 33: IDD/ASD, n.d. http://www.division33.org/.

INTELLECTUAL DISABILITY

Diagnostic Criteria:

Diagnosis is based on both clinical assessment and standardized testing of intellectual and adaptive functions. All three of the following criteria must be met:

1. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience
2. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility
   1. Can limit functioning in communication, social participation, and independent living
   2. Involves deficits in: conceptual (academic) domain, social domain, and practical domain
3. Onset of intellectual and adaptive deficits during the developmental (childhood/adolescence) period

Intellectual Disability’s Relevance

Difficulties with social judgment, assessment of risk, and self-management of behavior, emotion, or interpersonal relationships are associated with intellectual disability. Aggression and disruptive behaviors may also be predisposed by a lack of communication skills. “Gullibility and lack of awareness of risk may result in exploitation by others and possible victimization, fraud, unintentional criminal involvement, false confessions, and risk for physical and sexual abuse.”[5]

Communication (understanding consequences, expressing emotions), sex education (consent, appropriate touch, and healthy expressions of sexuality), seeking help from peers or professionals, moral reasoning (understanding right from wrong), identifying and becoming involved in leisure activities, and other skills identified as important in community integration (a factor proven to reduce recidivism) are all basic skill areas that are often found lacking in sex offenders with intellectual disability.[6]

The Arc’s National Center on Criminal Justice and Disability recommends that criminal justice professionals do the following:[7]

• Proactively examine fact patterns of sex offense cases involving people with Intellectual Disability
  • Watch for instances where the person was victimized or manipulated
  • Did they understand the consequences of their actions?
• Strongly consider the role disability plays in these types of offenses
  • Is the person used to a highly supervised setting?
  • Have they ever received education about the offense they committed?
• Find alternatives to incarceration and sex offender registries when appropriate
  • Create a community safety plan
  • Look for employment programs like Class, Inc.
• Increase education and prevention work, thereby reducing initial offenses and recidivism
  • If you observe potentially problematic behavior, address it early
  • Do not infantilize the person and assume behavior is harmless

Hiring an Expert

When looking to hire an expert in intellectual disabilities, one approach is to seek out experts who are members of the American Psychological Association Division 33: Intellectual & Developmental Disabilities / Autism Spectrum Disorder.[8] Finding an expert with a specific background in the area you are concerned with can help ensure that they have the knowledge and skills relevant to your case.

[5] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[6] Association for the Treatment of Sexual Abusers, Assessment, Treatment and Supervision of Individuals with Intellectual Disabilities and Problematic Sexual Behaviors, at 18 (2014). (May also lead to difficulties navigating consent).

[7] The Arc’s National Center on Criminal Justice and Disability (NCCJD). “Sex Offenders with Intellectual/Developmental Disabilities: A Call to Action for the Criminal Justice Community.” Washington, D.C.: The Arc, 2015.

[8] APA Division 33: IDD/ASD, n.d. http://www.division33.org/.

BIPOLAR DISORDER

Diagnostic Criteria for Bipolar I:

1. Experience of at least one manic episode.
   1. Manic episodes are distinct periods of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy for at least one week
      1. Three or more of the following symptoms are present: inflated self-esteem or grandiosity, decreased need for sleep, more talkative, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in activities that have a high potential for painful consequences
   2. The mood disturbance is severe enough to impair functioning or to require hospitalization
2. Experience of major depression is not required for Bipolar I, but most people who have experienced an episode of mania also experience episodes of depression

Diagnostic Criteria for Bipolar II:

1. Experience at least one episode of major depression
   1. A major depressive episode is characterized by five or more of the following symptoms for at least two weeks nearly every day (at least one symptom must be either depressed mood or a loss of interest or pleasure): depressed mood, markedly diminished interest or pleasure in almost all activities, significant weight loss or gain or decrease or increase in appetite, insomnia or hypersomnia, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think of concentrate or indecisiveness, recurrent thoughts of death or suicidal ideation/attempt
   2. The symptoms mus cause clinically significant distress or impairment in functioning
2. Experience at least one hypomanic episode
   1. Hypomania is an episode of increased energy that is shorter (at least four days) and less severe than a manic episode. At least three of the symptoms of a manic episode are present. Such disturbance is usually not severe enough to impair functioning or require hospitalization, but is a noticeable change in the person’s functioning.

Bipolar’s Relevance

The increase in goal-directed activity during a manic episode often consists in the participation in sexual activities, sexual promiscuity, and people experience increased sexual drive, fantasies, and behavior (i.e. infidelity or indiscriminate sexual encounters with strangers while disregarding the risk of interpersonal consequences). Furthermore, difficulties with the law often result from poor judgment, loss of insight, and hyperactivity.[9]

[9] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

OBSESSIVE-COMPULSIVE DISORDER (OCD)

Diagnostic Criteria

1. Presence of obsessions or compulsions (most people with OCD experience both)
   1. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, and cause marked anxiety or distress for most people. The person attempts to ignore, suppress, or neutralize such thoughts, urges, or images.
   2. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rigid rules. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation, but are not connected in a realistic way (or clearly are excessive) with what they are designed to neutralize or prevent.
2. The obsessions or compulsions take more than one hour per day or cause clinically significant distress in important areas of functioning.

OCD’s Relevance

A common theme of obsessions and compulsions is forbidden or taboo thoughts (e.g., aggressive or sexual obsession and related compulsions).[10]

[10] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

HOARDING DISORDER (OCD-RELATED DISORDER)

Diagnostic Criteria

1. Persistent difficulty discarding or parting with possessions
2. This difficulty is due to a perceived need to save the items and to distress associated with discarding them (hoarding behaviors are associated with positive emotion)
3. This difficulty results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use (can become dangerous)
4. The hoarding causes clinically significant distress or impairment in important areas of functioning

Hoarding Disorder’s Relevance

Hoarding disorder is not always that relevant, but theoretically could be. People with hoarding disorder would be more focused on the collection of the material, rather than the content of the material itself.

PARAPHILIC DISORDERS

Paraphilic disorders’ inclusion in the DSM-5 and relevance in the criminal legal system are both controversial. A 2017 study found that the majority of federal sex offenders were diagnosed with one or more paraphilias: pedophilia (57%), pornography addiction (43%), paraphilia not otherwise specified (35%), exhibitionism (26%), and voyeurism (21%).[11] However, not all people diagnosed with a paraphilic disorder have acted upon their sexual interests, and many sex offenders are not paraphilic.[12] Furthermore, “a paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention.”[13] In other words, while some child pornography offenders are pedophilic, others are not, and many cases involve post pubescent rather than prepubescent children.

“Paraphilia” refers to “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.”[14] The DSM-5 includes the following paraphilic disorders: voyeuristic disorder (spying on others in private activities), exhibitionist disorder (exposing the genitals), frotteuristic disorder (touching or rubbing against a nonconsenting individual), sexual masochism disorder (undergoing humiliation, bondage, or suffering), sexual sadism disorder (inflicting humiliation, bondage, or suffering), pedophilic disorder (sexual focus on children), fetishistic disorder (using nonliving objects or having a highly specific focus on nongenital body parts), and transvestic disorder (engaging in sexually arousing cross-dressing). Exhibitionistic, Frotteuristic, Pedophilic, and Voyeuristic Disorders all require a nonconsenting person, and thus acting on these sexual urges constitutes a crime, so these diagnoses are considered “criminal” paraphilic disorders.[15]

Some of these disorders “entail actions for their satisfaction that, because of their noxiousness or potential harm to others, are classified as criminal offenses.”[16]

Of the paraphilic disorders, pedophilic disorder might be the most relevant in a child pornography case. The diagnostic criteria for pedophilic disorder are:

1. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally 13 or younger)
2. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty
3. The person is at least 16 years old and at least 5 years older than the child/children in Criterion A
   1. This does not include people in late adolescence involved in an ongoing sexual relationship with a 12 or 13 year old.

The presence of a paraphilic disorder is associated with an increased risk of recidivism,[17] so a diagnosis is “likely to result in the imposition of a longer sentence or the assignment of the individual to a higher risk category after being released into the community,” as well as “determine the sex offender treatment that will be mandated during incarceration.”[18] The Motivation-Facilitation Model of Sexual Offending posits that those who are both pedophilic and antisocial are at higher risk and more likely to act out on their sexual interest in children.[19] Those who are exclusively pedophilic and have no sexual interest in adults or post pubescent children are of higher risk. Those with nonexclusive pedophilic interest have five times lower sexual recidivism than those who are exclusively pedophilic, as well as lower rates of contact offenses. The term “hebephilia” may be used to describe a sexual interest in pubescent children, and “teleiophilia” refers to sexual interest in mature, post pubescent bodies.

Criticisms of the inclusion of paraphilic disorders in the DSM-5 include:

• To be considered “in full remission” of a paraphilic disorder requires a person to be symptom free for “at least 5 years while in an uncontrolled environment.”[20] Thus, it is “difficult, if not impossible, for [incarcerated or hospitalized people] ever to be judged as successfully treated (in full remission) and eventually released.”[21]
• Assessing whether or not a person’s distress and impairment “are special in being the immediate or ultimate result of the paraphilia and not primarily the result of some other factor” is incredibly difficult.[22]
• There is no research that shows that the strength of any sexual interest is constant over time, so even if paraphilic interests decrease, “the paraphilia is still noted.”[23]
• The clinical utility of paraphilic disorder diagnoses is questionable, and “mandatory reporting laws limit the number of individuals with criminal Paraphilic Disorders who might seek treatment or be candid with their therapists for fear of being reported to the authorities.”[24]
• The diagnostic criteria for pedophilic disorder do not correspond with biology’s understanding of the age of prepubescence
• The APA states that they “support continued efforts to develop treatments for those with pedophilic disorder with the goal of preventing future acts of abuse,”[25] which implies that “they are not treating those individuals with Pedophilic Disorder to relieve their pain and suffering, but rather to prevent future crimes.”[26]
• Some definitions consider pedophilia to be a “sexual orientation,” which is not amenable to change, making Sexually Violent Predator programs which incarcerate people for treatment rather than preventative custody “legally questionable.”[27]

Treatment for those with pedophilic disorders is aimed at helping people manage their interest, such as by gradually aging the material they consume.

[11] Drury, A., Heinrichs, T., Elbert, M., Tahja, K., DeLisi, M. and Caropreso, D. (2017), “Adverse childhood experiences, paraphilias, and serious criminal violence among federal sex offenders,” Journal of Criminal Psychology, Vol. 7 No. 2, pp. 105-119. https://doi.org/10.1108/JCP-11-2016-0039

[12] Cantor J.M., McPhail I.V. Non-offending pedophiles. Current Sex. Health Rep. 2016; 8:121–128. doi: 10.1007/s11930-016-0076-z.; Seto M.C. Internet Sex Offenders. American Psychological Association; Washington, DC, USA: 2013.

[13] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[14] Ibid.

[15] Moser, M. “DSM-5, Paraphilias, and the Paraphilic Disorders: Confusion Reigns. Archives of Sexual Behavior (2019) 48:681-689. https://doi.org/10.1007/s10508-018-1356-7.

[16] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

[17] Mann RM, Hanson RK, Thornton D: Assessing risk for sexual recidivism: some proposals on the nature of psychologically meaningful risk factors. Sex Abuse 22:191–217, 2010

[18] First, M. B. “DSM-5 and Paraphilic Disorders.” J Am Acad Psychiatry Law 42:191-201, 2014.

[19] Seto, M. C. (2019). The Motivation-Facilitation Model of Sexual Offending. Sexual Abuse, 31(1), 3-24. https://doi.org/10.1177/1079063217720919

[20] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press.

[21] Moser, M. “DSM-5, Paraphilias, and the Paraphilic Disorders: Confusion Reigns. Archives of Sexual Behavior (2019) 48:681-689. https://doi.org/10.1007/s10508-018-1356-7.

[22] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press. p. 686.

[23] Moser, M. “DSM-5, Paraphilias, and the Paraphilic Disorders: Confusion Reigns. Archives of Sexual Behavior (2019) 48:681-689. https://doi.org/10.1007/s10508-018-1356-7. P. 684

[24] Ibid. p. 685

[25] American Psychiatric Association. (2013). APA statement on DSM-5 text error.

[26] Moser, M. “DSM-5, Paraphilias, and the Paraphilic Disorders: Confusion Reigns. Archives of Sexual Behavior (2019) 48:681-689. https://doi.org/10.1007/s10508-018-1356-7. P. 686.

[27] Ibid.

PSYCHOLOGY & TECHNOLOGY

Psychology plays an especially unique role in online offenses. The online disinhibition effect maintains that “while online, some people self-disclose or act out more frequently or intensely than they would in person.”[28] In other words, due to factors such as anonymity, people think, feel, and behave differently online than they do in the real world. While this does not offer a complete explanation for online offenses, it is a significant facilitating and contributing factor, leading people to push boundaries and take risks. Use of the Internet also leads to a “distance” between the offender and the people they are talking to or viewing, making the fact that those people are minors less salient. Internet use also leads to early exposure to pornography in general. All of this indicates that the psychology of technology in addition to mental health factors provides greater context for online child pornography offenses, especially for those with no criminal history, history of contact offenses, or those who are not pedophilic.

[28] Suler, J. “The online disinhibition effect.” Cyberpsychology & Behavior. 2004 Jun;7(3):321-6. doi: 10.1089/1094931041291295.