669 Chapter 17 Forensic psychiatry Introduction 670 The criminal justice system 672 Crime 674 Homicide 676 Violence 1: theoret ical background 678 Violence 2 680 Sexual offenses 1 682 Sexual offenses 2 684 Stalking 686 Other offenses 688 Mental disorder and offending 1: overview 689 Mental disorder and offen ding 2: speci \201 c disorders and offending 690 Assessing risk of violence 692 Secure hospitals and units 694 Police liaison 1 696 Police l iaison 2 698 Court liaison 699 Prison psychiatry 1: overview 700 Prison psychiatry 2: the r ole of the psychiatrist 702 Legal provisions for transfer of prisoners to hospital 704 Cour t reports and giving evidence 1 706 Court reports and giving evidence 2 708 Suggested forma t for criminal court report 710 Overview of the pathways of mentally disordered offenders through the criminal justice and health systems 712 Fitness to plead 1: assessment 716 Fitness to plead 2: procedures 718 Criminal responsibili ty 1 720 Criminal responsibility 2 722 Assessing \200\230mental state at the time of the o ffense \200\231 724 17_Semple_Chap17.indd 669 12/7/2012 3:49:44 PM CHAPTER 17 Forensic psychiatry 670 Introduction The word \200\230forensic \200\231 derives from the Latin forensis (the forum or court). The scope of forensic psychiatry can be broadly de \201 ned as those areas whe re psychiatry interacts with the law. Although all psychiatrists may be involved, from time to time, in forensic work, forensic psychiatrists in the UK are speci \201 cally involved in the assessment and management of mentally disordered offenders and other patients with mental disorders who are, or have been potentially or actually, violent. Provision of foren - sic services varies across the country and forensic psychiatrists work in a variety of se ttings (e.g. high-security hospitals; medium-secure units; low- secure wards and sometimes open wards; outpatients, day hospitals, and within community teams; prisons). This chapter on forensic psychiatry concentrates on mentally disor- dered offenders. Mental health legislation, incapacity legislation, and other non-criminal legal matters are cover ed in Chapter 21; see also Table 17.1. The practice of forensic psychiatry is dependent on legislation, the criminal justice system, and local service provision. Hence, although some aspects have fairly wide applicability (e.g. the relationship between mental disor- der an d offending), many aspects (e.g. legal provisions for mentally disor- dered offenders) are speci \201 c to a particular jurisdiction. We have tried to cover the main legal jurisdict ions of the British Isles \200\224England and Wales, Scotland, Northern Ireland (NI), and t he Republic of Ireland (RoI) \200\224in some detail. Table 17.1 Abbreviations used to refer to legislation MHA 1983 Mental Health Act 1983 MH(NI)O 1986 Mental Health (Northern Ireland) Order 1986 MH(CT)(S)A 2003 Mental Health (Care and Treatment) (Scotland) Act 2003 CP(S)A 1995 Criminal Procedure (Scotland) Act 1995 Other legislation will be referred to in full, or abbreviations used in tables or boxes wil l be explained where they arise. 17_Semple_Chap17.indd 670 12/7/2012 3:49:44 PM This page intentionally left blank CHAPTER 17 Forensic psychiatry 672 The criminal justice system1,2,3 The criminal justice process The following outlines the ch ain of events that may happen following the commission of an offense: Offense reported to police l police record offense l police investigate offense l police \201 nd suspect l police charge suspect l report to pros- ecutor l decision of prosecutor t o prosecute l initial court appearance (remanded on bail or in custody) l trial l convictio n l sentence (com- munity, prison, \201 ne, discharge, mental health disposal). Most offenders will not go through all these stages (e.g. by pleading guilty an offender ma y go from initial court appearance directly to senten- cing). At various stages there may b e speci \201 c provisions for mentally disor- dered offenders (see b p. 712 for overview a nd b p. 714 for details). Prosecution \200 England and Wales \200\224 Following report by police, Crown Prosecution Service decides wh ether individual should be prosecuted; headed by Director of Public Prosecutions; service d ivided into areas and further into branches each headed by Chief Crown Prosecutor. Some min or offenses prosecuted by police. Scotland heads the Crown Of \201 ce in Edinburgh; most w ork carried out by \200\230advocates-depute \200\231. Procurators \201 scal prosecute le ss serious crime locally. \200 \200\224Department of the Director of Public Prosecutions for NI. Director NI discharges his functions under the superintendence of the Attorney Gen eral. RoI \200\224Lord Advocate responsible for prosecuting serious crimes; \200\224Director of Public Prosecutions responsible for prosecution. Criminal courts England and Wales \200 Magistrates Court to remand on bail or in custody; hear all summary (minor) cases and some indictable (serious) cases; maximum sentence 6mths \200\231 imprisonment; magistrates are mainly lay justices of the peace with legally quali \201 ed stipendiary magistrates in some urban areas. Crown Court committed by the Magistr ates Court for trial and/or sentencing; deals with appeals from Magistrates Court; 6 region s or \200\230circuits \200\231; trials heard by judge and jury (12 adults); sentencing by judge. Youth Court training hear cases; serious cases committed to Crown Court. All adult defendants appear here \201 rst for decision Deals with more serious indictable offenses \200\224cases are Juvenile offenders (10 \200\22317yrs); magistrates with special C \200 ourt of Appeal (criminal division) Usually 3 judges; hears appeals by defendant against conviction or sentence; hears appeals by the Crown against sentence; can increase or reduce sentence. Queen \200\231s Bench Division of the High Court (Divisional C ourt) points of law and procedure. UK Supreme Court and assumed the judicial functions of t he House of Lords in 2009. Appeals on Established by the Constitutional Reform Act 2005 17_Semple_Chap17.indd 672 12/7/2012 3:49:44 PM THE CRIMINAL JUSTICE SYSTEM 673 Highest appeals court in the UK for civil matters and in England and Wales for criminal mat ters. Scotland \200 District Court Minor cases heard by lay justices of peace (maximum sentence 60 days \200 \231 imprisonment) or (only in Glasgow) stipendiary magistrates (similar powers to sheriff) . Sheriff Court (sheriff alone) or some solemn (sheriff and jury) cases heard; maximum sent ence 12mths \200\231 (summary) or 5yrs \200\231 (solemn) imprisonment. High Court of Justic iary (criminal trials) jury (15 adults); unlimited sentencing powers; Edinburgh, Glasgow, a nd on circuit in other towns and cities. High Court of Justiciary (Court of Criminal Appeal ) Highest court of criminal appeal in Scotland. Cases heard by 3 or more judges; no appeal to UK Supreme Court. 6 sheriffdoms, each headed by Sheriff Principal; summary Hears serious cases; judge and NI \200 \200 Essentially as for England and Wales. Diplock Courts terrorist) cases. (judge sitting alone) for indictable scheduled (mainly RoI \200 District Court imprisonment) and some indictable (up to 12mths \200\231 imprisonment) cases heard. Circuit Court appeals from District Court. Central Criminal Court (High Court) and jury; serious indictable cases. Special Criminal Court cases heard by 3 judges. Court of Cr iminal Appeal 1 justice of the Supreme Court and 2 of the High Court hear appeals from Circ uit, Central Criminal, and Special Criminal Courts. Supreme Court the Court of Criminal App eal. Legally quali \201 ed justices; summary (up to 6mths \200\231 Cases heard by judge and jury; indictable cases and Cases heard by High Court judge Only scheduled offenses (mainly terrorist cases); Chief Justice and High Court justices hear appeals from 1 Grounds A (1995) The criminal justice system. In Chiswick D and Cope R (eds), Seminars in practical forensic psychiatry. London: Gaskell. 2 Bailey S (1990) Lawyers, legislation, th e administration of the law and legal aid. In Bluglass R and Bowden P (eds), Principles and practice of forensic psychiatry. Edinburgh: Churchill Livingstone 3 Nicholson G (1990) T he courts and law in Scotland. In Bluglass R and Bowden P (eds), Principles and practice of forensic psychiatry. Edinburgh: Churchill Livingstone. 17_Semple_Chap17.indd 673 12/7/2012 3:49:44 PM CHAPTER 17 Forensic psychiatry 674 Crime A crime is an act that is capable of being followed by criminal proceedings. It is a man-made concept de \201 ned by the rules of the state and modi- \201 ed by legislation, therefore there are differences between countries and across time in the same country. Age of criminal responsibility: England and Wales, and NI \200\22410yrs; Scotland \200\22412yr s; RoI \200\2247yrs. Classi \201 cation of crime \200 Crimes against the person assault, homicide; sexual offenses: indecent exposure, rape; robb ery Crimes of dishonesty and forgery Criminal damage Car crime Drug crime Other Offenses of interpersonal violence: minor Burglary; theft and handling stolen goods; fraud \200 \200 \200 Property damage; arson Use, possession, supplying Crime rates Table 17.2 shows the annual number of of \201 cially recorded crimes in the co untries of the British Isles. From the British Crime Survey only about half of crime is rep orted to the police (and of \201 cially recorded), of which between 25 and 50% is cleared up by the police (conviction rates for sexual offenses are signi \201 cantly lower at 6 \200\2238%). \200 \200 Theft, burglary, criminal damage, and car crime are the most common. Violent crimes are unc ommon; sex offenses and robbery are rare. Who commits crimes? Young males aged 10 \200\22320yrs account for 50% of crime. Females 720 % of offenders. Peak age: males 14 \200\22317yrs; females 12 \200\22315yrs. What are the \200\230causes \200\231 of crime? The following factors are associated with offending. They interact, and causality cannot be assumed. \200 Genetic factors recorded and self-reported offending. In adoption studies children are more similar to biological than adoptive parents. Intelligence Personality Family supervision, erratic/harsh discipline, marital disharmony and parental separation, parental rejection, l ow parental involvement, antisocial parents, and large family size. Offenders who marry non -offending spouses reduce their rate of offending. Peers others versus alone decreases with age. Close relationship between delinquent activities of friends. Offenders are unpopular in non- offending groups, but popular in offending groups. Schools The following are not re lated to delinquency rates: age and state of buildings, number of children, amount of space , pupil/teacher ratio, academic emphasis, teacher turnover, number of outings. High punishm ent and low praise associated with delinquency \200\224but is this cause or effect? Alterna tive placements and approaches to disruptive MZ more concordant than DZ twins for of \201 cially \200 \200 Low intelligence associated with offending. Impulsivity and lack of empathy with victims. Childhood factors linked to later offending: poor parental Most delinquent acts are committed with others. Offending with No clear evidence that school factors in \202 uence offending. 17_Semple_Chap17.indd 674 12/7/2012 3:49:44 PM CRIME 675 and delinquent pupils may reduce delinquency compared with mainstream education. Socio-econ omic deprivation with later offending. Employment protective. Ethnicity males. Lower rates in Asian males. Is association due to socio- economic deprivation, discrimination, differen t rates of arrest? Alcohol and substance misuse impulsivity, poor behavior control, and dir ectly to criminal acts (e.g. acquisitive crime to fund habit). Major indicator of risk in f orensic populations. Poverty and poor housing associated Higher rates of offending in Afro-Caribbean than in white Linked with antisocial behavior, Table 17.2 Crime statistics for the British Isles The following table is based on offenses of \201 cially recorded by the police for 2001 (S cotland and RoI) and 2001 \200\2232 (England and Wales and NI). Different jurisdictions use different categories and de \201 nitions so compari-sons between jurisdictions should be made very cautiously. Numbers of crimes with percentage of total for that jurisdiction in p arentheses. England and Wales Scotland NI RoI 650154 (11.7) 19523 (4.6) 26104 (18.8) 3876 (4.5) Violence against the person Sexual offenses 49612 (0.9) 5987 (1.4) 1431 (1.0) 1939 (2.2) Robbery 121375 (2.2) 4228 (1.0) 2222 (1.6) 2880 (3.3) Theft 2267055 (41.0) 169454 (40.0) 41720 (30.0) 45652 (52.7) Burglary 878535 (15.9) 44868 (10.7) 17143 (12.4) 24015 (27.7) Fraud and forgery 317399 (5.7) 17410 (4.1) 8619 (6.2) 3492 (4.0) Criminal damage 1064470 (19.3) 94924 (22.5) 39953 (28.8) 1407 (1.6)* Drug offenses 121332 (2.2) 36175 (8.6) 1108 (0.8) 2380 (2.7) Total 5527082 (100.0) 421093 (100.0) 138786 (100.0) 86663 (100.0) Only arson for RoI 17_Semple_Chap17.indd 675 12/7/2012 3:49:45 PM CHAPTER 17 Forensic psychiatry 676 Homicide De \201 nition Homicide is the killing of a person by another. Types of homicide Legal classi \201 cation: \200 \200 \200\230Lawful \200\231: \200\230Unlawful \200\231: homicide \200\224discretion in senten cing (imprisonment, community, mental health disposal, discharge); infanticide \200\224(not in Scotland) sentencing as for manslaughter; death by dangerous driving. Justi \201 able (e.g. on behalf of State); excusable (e.g. accident). Murder \200\224manda tory life sentence; manslaughter/culpable The traditional \200\230psychiatric \200\231 classi \201 cation: \200\230 \200 Normal \200\231 homicides \200\224no psychiatric disorder \200\230 \200 Abnormal \200\231 homici des \200\224psychiatric disorder However, this is determined by whether the individual was found insane, convicted of infanticide, or found to be of diminished responsibility \200 \224 therefore it is really a legal classi \201 cation (Box 17.1). Homicide rates 882 recorded homicides in England and Wales in 2001 \200\223 2,106 in Scotla nd (2001), 55 in NI (2001 \200\2232), 74 in RoI (2001). Rates per million population/yr for 1997 \200\2239: England and Wales 15, Scotland 20, NI 31, RoI 13.5, European Union average 17.0, USA 62.6, South Africa 564.9. Victims of homicide Usually male (70%); 60 \200\22380% known to offender; 30 \200\22350% re lated or partner; 15% children (highest risk under 1-yr-old) usu- ally killed by parent (75 %); less than 5% parent (matricide > patricide); 40 \200\22350% of females killed by partne r or ex-partner; males more commonly killed by acquaintances (25% England and Wales, 60% Sc otland) and stran- gers (37% England and Wales, 20% Scotland). Perpetrators of homicide Predominantly male (80 \200\22390%); using sharp imple- ment (most common 30 \200\22340%), kicking/punching, strangulation (more com- mon with female victims ), or blunt force; anger, jealousy, revenge, or threat of separation are usual motives; oft en involving alcohol, or sometimes drugs. Mental disorder and homicide Minority of homicide offenders are men- tally disordered. Alco hol and drug dependence most common, then per- sonality disorder. Schizophrenia, delusional disorder, and depression may be relevant in a few cases. England and Wales: 5 \200\22310% of cases result in diminished responsibility, infanticide, or insanity; half of these resul t in a hospital disposal. Scotland: 4% of cases result in hospital disposal. Psychiatric assessment in homicide cases As with other offenses need to assess mental state both currently and at time of offense. In most jurisdic- tions murder carries a mandatory punishment (life imprisonment in the main jurisdictions of the British Isles). To achieve a hospital disposal the offender has to be found insane or of diminished responsibility (doe s not apply in Ireland). See b p. 722. Homicide inquiries In England and Wales independent inquiries following homicides committed by people in contact with mental health services ha ve been mandatory since 1994. They have been criticized for being 17_Semple_Chap17.indd 676 12/7/2012 3:49:45 PM HOMICIDE 677 inef \201 cient, costly, misleading, unsystematic, and unjust. A systematic national appro ach has been made in the National Con \201 dential Inquiry.1 The main issues to be highlig hted include: need for training in risk assess- ment and management; better means of docume ntation and recording, particularly risk information; addressing non-compliance and disenga ge- ment from services; managing comorbid alcohol and drug misuse; access to help for famil ies at times of concern; appropriate use of mental health legislation; policies on manageme nt of personality disorder; addressing stigma; culture of blame. Box 17.1 Legal aspects of homicide in different jurisdictions England and Wales Murder Offender of sound mind and discretion, and had malice afore- thought (intent to caus e death or grievous bodily harm). Intent assumed if reckless, knowing that death or serious harm was virtual certainty. Manslaughter Homicide unlawful, but circumstances do not meet full criteria for murder or t here are certain mitigating factors, such as: (1) immediate severe provocation (2) abnormal ity of mind (diminished responsibility under section 2 (1) Homicide Act 1957; see b p. 723) (3) suicide pact (section 4 (1) Homicide Act 1957). Infanticide (see b p. 722) Scotland Murder Homicide committed with wicked recklessness or intent. Culpable homicide Equivalent of manslaughter. Provocation, diminished responsibility are re cognized, but no legal category for suicide pacts. No of \201 cially recognized crime of infanticide, such cases are usually pros- ecuted as culpable homicide. NI Murder, manslaughter, infanticide \200\224as for England and Wales. RoI Murder de \201 ned as an intentional act to kill (narrower than England and Wales de \201 nition). The concept of diminished responsibility was intro- duced into Irish law under th e Criminal Law (Insanity) Bill 2002. Manslaughter, infanticide \200\224as for England and Wales. 1 Appleby L (2000) Safer services: conclusions from the report of the National Con \201 de ntial Inquiry. Adv Psychiat Treat 6: 5 \200\22315. 17_Semple_Chap17.indd 677 12/7/2012 3:49:45 PM CHAPTER 17 Forensic psychiatry 678 Violence 1: theoretical background1,2 De \201 nition Violence is an act that causes injury or harm. The term may cover a range of acts from the killing of another person to verbal a buse, and may also be used to cover acts causing damage to property includ- ing arson. In t his section the focus is on acts of physical assault on oth- ers. Property damage and arson are considered on b p. 688, and sexual offenses on b p. 682. Types of aggression Various t ypes have been described in terms of the determinants, biological substrate, goals, and cha racteristics of the aggres- sive act. Broadly they fall into three groups: \200 Instrumental aggression usually planned and not associated with increased arousal (e.g. vio lence used to carry out a robbery or control the victim of a sexual assault). A related ter m from animal studies is predatory aggression \200\224aggression used by predatory animals when hunting food (aka interspeci \201 c aggression). Sadistic aggression is a form of ins trumental aggression used to achieve sexual and/or emotional pleasure through control and/o r in \202 icting harm on a victim. Expressive aggression (aka affective aggression, reacti ve aggression, hostile aggression, angry aggression, fear-induced aggression, irritable agg ression, indiscriminate aggression). Aggression with the primary goal of harming the victim in response to feelings of hostility towards the victim; emotional arousal in the perpetra tor (due to fear, frustration, anger, resentment) and usually impulsive (although may be pl anned) (e.g. violence in response to discovery of in \201 delity or in response to being t hreatened). A related term from animal studies is defensive aggression \200\224aggression u sed when threatened. Aggression seen in social interactions aggression, aka intraspeci \201 c aggression) e.g. intermale aggression, territorial aggression, and maternal aggressi on. Aggression as a means to attain a goal, (a form of expressive Although some acts of aggression clearly fall into one of these, many com- bine features of both, e.g. aggression may be used to subdue the victim of a sexual assault (instrumental) and also as an angry reaction to the victim striking back (expressive). Theories of aggression \200 Biological functions to ensure population control, selection of the strongest for reproduct ion and social organization; low levels of 5-HT activity and cholesterol associated with ag gression; modest genetic contribution; limbic and frontal areas important in determining ag gression; testosterone may facilitate aggression. Psychodynamic frustration, later as an in stinct; hostile character traits may be caused by \201 xation at/regression to oral or an al stage. Ego psychologists: aggressive instinct needs to be sublimated or displaced. Neo-F reudians: emphasized sociocultural origins of aggression. Attachment theory: emphasizes ear ly relationships and the impact of their disruption on adult interaction. Ethological studies of lower animals suggest aggression Freud: aggression initially seen as response to 17_Semple_Chap17.indd 678 12/7/2012 3:49:45 PM VIOLENCE 1: THEORETICAL BACKGROUND 679 Learning theory leading to the development and maintenance of aggressive responses to certa in stimuli or in order to attain goal (material gain, escape from aversive stimulus). Frust ration aggression hypothesis: frustration leads to aggression depending on the perceived va lue of the blocked goal and the degree of frustration (depends on degree of prior reinforce ment or punishment); punishment may inhibit aggression, but may itself be frustrating or pr ovide model for aggression. Observational learning (modeling). Cognitive Learning theories seen as too simple and cognition important; cognitive distortions about victims may facilit ate aggressive behavior; appraisal of arousal and context important in determining occurren ce of aggression; causal attributions and moral evaluations of self and others may facilita te or reduce aggression. Social Social structure theory: poor socio-economic standing sti \202 es pursuit of \201 nancial and social success, so seek success through deviant metho ds. Social process theory: socialization process through contact with institutions and soci al organizations steers individual towards violence. Neutralization theory: neutralization of personal beliefs and values as person drifts between conventional and offending behavior . Social control theory: direct (e.g. through punishment) and indirect (e.g. through social af \201 liation) control prevents violence. Labeling theory: an original deviant act (pri mary deviance) results in stigmatization and labeling, leading to hostility, alienation, an d resentment in the individual and further deviant behavior (secondary deviance). Rewarding/reinforcing contingencies important, 1 Mackintosh J (1990) Theories of violence. In Bluglass R and Bowden P (eds), Principles an d practice of forensic psychiatry, Edinburgh: Churchill Livingstone. 2 Gunn J (1993) Non-ps ychotic violence. In Gunn J and Taylor P (eds), Forensic psychiatry: clinical, legal and et hical issues. Oxford: Butterworth-Heinemann. 17_Semple_Chap17.indd 679 12/7/2012 3:49:45 PM CHAPTER 17 Forensic psychiatry 680 Violence 21,2 Causes of a violent act Violent acts involve a perpetrator, a victim, and con textual factors. There will usually be an interplay between factors related to these three. Many of the background factors associated with offending generally (see b p. 674) are asso ciated with violence, although violent offenders are usually young adults rather than teena gers. The speci \201 c factors of importance in deter- mining the occurrence of aggressive acts are the same as those needing to be considered in assessing the risk of violence (see b p. 692). Types of violent offenses The range of recognized violent offenses (excluding sexual offens es) is shown in Box 17.2. The seriousness of an assault may be determined by chance factors such as the availability of medical care and the physical health of the victim. Other ways of categorizing violent offenses are in terms of the victims and circumstances: domestic/s pousal abuse, child abuse (see b p. 663), elder abuse. Rates of violence Per 10 000 of the adult population there were 676 assaults and 84 rob- be ries in England and Wales compared with 458 assaults and 54 robber- ies in Scotland in 1999 as estimated from the British Crime Survey 2000 (i.e. number of actual incidents, rather t han number of of \201 cially recorded offenses). The total numbers of of \201 cially reco rded violent offenses are shown in Box 17.2. Psychiatric assessment and management The clinical assessment of a person who has been viol ent or who appears to be at risk of violence involves a thorough psychiatric history and me ntal state examination and an assessment of risk (see b p. 692). If the person is fac- ing criminal charges then a report may have to be prepared considering the issues set out on b p. 706. Management of risk is described on b p. 693. The acute management of violent patien ts is described on b p. 988. Domestic violence 1 in 4 women experience domestic violence during their lifetimes. Women a re victims of 70% of domestic violence. In over 10% of cases serious inju- ries occur (e.g. broken bones, loss of consciousness). May be a contribu- tory factor in 25% of suicide att empts and in 75% of cases children witness the violence. Accounts for 25% of violent crime in Britain (which will be an underestimate). Elder abuse Prevalence (from US \201 gures): 3 \200\2235% of the elderly subject to viole nce, neglect, or emotional abuse, particularly females. Perpetrators are usually son or dau ghter, perhaps under stress, with alcohol or drug problems and unable to cope with looking after victim. 17_Semple_Chap17.indd 680 12/7/2012 3:49:45 PM VIOLENCE 2 681 Box 17.2 Recorded violent offenses The following \201 gures are the violent offenses recorded by the police in each of the j urisdictions in the British Isles in 2001 (Scotland and RoI) or 2001 \200\2232 (England and Wales and NI). Note that different jurisdictions have different ways of de \201 ning and classifying violent offenses. England and Wales (2001 \200\2232) Homicide Attempted murder Threat or conspiracy to murder Child destruction Causing death with vehicle Wounding Endangering railroad passenger or li fe at sea Other wounding Possession of weapons Harassment Cruelty to or neglect of children Abandoning child under 2 Child abduction Procuring illegal abortion Concealment of birth A ssault on a constable Common assault Total violence against the person Robbery* Scotland (2 001) Serious assault (includes homicide) Handling an offensive weapon Robbery Other Total n on-sexual crimes of violence Petty assault* NI (2001 \200\2232) Homicide * Indicates offens es not of \201 cially categorized as violent offenses in the relevant jurisdiction. 164 740 Attempted murder Threat or conspiracy to murder Causing death with vehicle Wounding/assault occasioning actual bodily harm Aggravated assault Common assault Police assault Total viol ence against the person Robbery* RoI (2001) Homicide Murder Murder \200\224attempt Abortion Manslaughter Infanticide Murder \200\224threats Procuring or assisting abortion Total homi cide Assaults: Assault causing harm Coercion Harassment Poisoning Assault/obstruction/ resi sting police of \201 cer Endangerment False imprisonment Abduction Total assaults Robbery* 886 858 13648 23 6507 0 407 16537 18 941 13971 1563 212059 28740 113677 3048 26104 222 52 2 0 6 0 14 49 583 6 3 30010 231625 650154 0 74 3114 4 276 4 121375 7296 8671 236 41 46 81 3082 2880 4228 3556 23751 54870 55 1 Cordess C (1995) Crime and mental disorder I. Criminal behavior. In Chiswick D and Cope R (eds). Seminars in practical forensic psychiatry. London: Gaskell. 2 Gunn J (1993) Non-psy chotic violence. In Gunn J and Taylor P (eds), Forensic psychiatry: clinical, legal and eth ical issues. Oxford: Butterworth-Heinemann. 17_Semple_Chap17.indd 681 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 682 Sexual offenses 1 Offenses range from prostitution and indecent exposure to rape. Other typ es of offenses (e.g. homicide, assault, robbery, theft, and burglary) may have a sexual com ponent. Sex offending, sexual deviation (b p. 480), and inappropriate sexual behavior (a ra nge of sexual behaviors which cause offense and/or harm to others) are overlapping but dist inct con- cepts. A man who commits a sexual offense against a child may or may not be a ped ophile and a man who exposes himself may or may not be an exhibitionist. A 17-yr-old male w ho has sexual intercourse with his 15-yr- old girlfriend is committing a sexual offense, bu t will probably not have a sexual deviation. Here the focus will be on indecent exposure an d contact sexual offenses against adults and children. Types of sexual offenses and offende rs The range of of \201 cially rec- ognized sexual offenses is set out in Box 17.3. Legal classi \201 cations change and a legal label says little about the nature of the actual in cident. Various typologies (based on the nature of the act, the motivation of the offender, the characteristics of the offender, and the characteristics of the victim) lack validity, reliability, and practical utility. Indecent exposure The most common sexual offense. Classi \201 cation: \200 Exhibitionists with sudden powerful urge to display genitals, who make little attempt to av oid capture and who make no further erotic or obscene gestures/ attempt any contact with vi ctim. Disinhibited Aggressive, impulsive, and antisocial Inhibited men, often previous unremarkable character, \200 \200\224by alcohol, stress, or psychiatric disorder. \200\224a small minority. Most do not reoffend. A small number may progress to more serious sexual offenses. Rates of further indecent exposure: \201 rst-time offend- ers \200\22420%, previous sexual offens es \200\22460%, previous sexual and non-sexual offenses \200\22470%. Rape and other sexual assaults on adults Usually perpetrated by men against women and, less often, other men. Fem ale perpetrators uncommon. Typologies lack validity, but may be classi \201 ed as: aggress ive, sexual, or sadistic. Most rapists are young males from poor social and educational bac kgrounds who have a history of other offending. A small number of these offenders are sexua l sadists. Sadistic fantasy is common in men, but sadistic sexual offending is rare \200 \224features which may be associ- ated with acting out sadistic fantasies are social isolat ion, coexisting other paraphilias, lack of empathy, disinhibition (by alcohol, drugs, stres s, or psychiatric disorder). 15% of rapists reoffend sexually and 20% go on to commit non-s exual violent offenses. 17_Semple_Chap17.indd 682 12/7/2012 3:49:46 PM SEXUAL offenses 1 683 Rape and other sexual assaults on children Female children are victimized more than males. \200 Intra-familial abuse (incest) fathers against daughters. Family pathology (dysfuncti onal families with generational blurring) often mixed with pathology in the perpetrator (al cohol misuse, personality disorder, pedophilia \200\224but only in a minority). Extra-famil ial with poor social skills, physical unattractiveness, and isolation from peers. Adult off enders are more likely to have paedophilic sexual fantasies than adolescent offenders and i ntra-familial offenders. In some cases offending against children re \202 ects general ant isocial tendencies or the expression of repressed paedophilic impulses in susceptible men d isinhibited (by alcohol, stress, or psychiatric disorder). Many offenders become skilled at targeting and grooming victims to gain their trust. A very rare minority have sadistic pae dophilic fantasies. Cases of sexually motivated killing of children are extremely rare. is usually perpetrated by fathers or step- abuse is less common. Adolescent offending is associated Rates of sexual offenses Rates of recorded sexual offenses are shown on b p. 685. Many sexu al offenses are not reported. Rates of sexual reoffending Extra-familial child offenders > offenders against adults > incest offenders. Internet offenses A growing concern over the l ast two decades has been the role of the Internet in providing a method of distribution of obscene and/or unlawful sexual material (particularly images of children). The fast rate of technological developments and the global reach of the Internet, crossing legal jurisdicti ons, has left the police and legal authori- ties in many countries struggling to keep pace and the law in this area is still developing. The recently adopted Section 63 of the Crimin al Justice and Immigration Act 2008 (in England and Wales) and Section 42 of the Criminal J ustice and Licensing (Scotland) Act 2010 (in Scotland) criminalize possession of what it re fers to as \200\230extreme pornographic images \200\231. 17_Semple_Chap17.indd 683 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 684 Sexual offenses 2 Characteristics of sex offenders A heterogeneous group \200\224possible r elevant factors: deviant sexual fantasy, sexual dysfunction, abnormal per- sonality (impuls ivity, lack of empathy, inhibition, social anxiety), relation- ship dif \201 culties (poor social skills, social isolation), alcohol or drug misuse, denial and minimization of offen ding, cognitive distortions (regarding sex, women, or children), problems with assertivenes s and control of anger, previous histories of victimization. Mental disorder and sex offend ing The most common mental dis- orders found in sex offenders: personality disorder, paraph ilias, alcohol and substance misuse; severe mental illness is rare. Sex offenders with psyc hosis share many of the features of other sex offenders and offending is rarely due to spec i \201 c psychotic symptoms. Disinhibition due to mania or organic disorders may lead to, usually minor, sexual offenses. Most sex offenses committed by people with LD are associate d with lack of sexual knowledge, poor social skills, and inability to express a normal sex drive appropriately. A few more serious and persistent LD offenders may share characteristi cs of other sex offenders. Assessment of sex offenders Full psychiatric history and MSE \200\224 emphasis on the nature of the incident(s), psychosexual history, and previ- ous of fenses, utilizing sources of information other than the accused. It may be dif \201 cult t o build up a full picture of a person \200\231s sexual fantasies and activi- ties. Some cen ters (mainly in North America) use penile plethysmography (measuring the extent of penile e rection in response to various stimuli). Risk assessment (b p. 692) Consider the following factors: sexual devi- ation; personality disorder; mental illness; substance misuse; relati onship problems; employment problems; previous offenses (sexual and non-sex- ual); previous supervision failure; frequency, types, and escalation in sexual offending; physical harm t o victims and use of weapons; denial/minimization and cognitive distortions; future plans a nd attitudes towards intervention. Management of sex offenders Some mentally disordered off enders require treatment in hospital (esp. those with mental illness or marked LD). In psyc hotic sex offenders it is usually important to address fac- tors common to other sex offend ers. Those with personality disorders, paraphilias, and substance misuse are normally deale d with by the crimi- nal justice system. Within the criminal justice system, both in prison and the community, group CBT programs have been developed. A small number of sex offenders receive psychodynamic treatment at specialist clinics. Medications such as anti-androgens, anti-gonadotrophins, and SSRIs may be used in a few offenders. Speci \201 c legal provisi ons The Sex Offenders Act 1997 requires sex offenders to register their address with the po lice. The Crime and Disorder Act 1998 enables courts to impose Sex Offender Orders on convi cted sex offenders who are not registered under the Sex Offender Act and whose behavior giv es cause for concern. The order requires the offender to register with the police and to de sist from behavior that has been identi \201 ed as indicative of future risk. The same Act allows courts to impose extended sentences on sex offenders. The extended sentence compris es a custodial element with an \200\230extended \200\231 period of supervision 17_Semple_Chap17.indd 684 12/7/2012 3:49:46 PM SEXUAL offenses 2 685 post-release for up to 10yrs. Amendments to the Sexual Offenses Act 2003 allow courts to ap ply a \200\230Sexual Offenses Prevention Order \200\231 (SOPO) even for offenses not prima rily sexual in nature. Offenders issued with a SOPO are added to the sex offenders \200\231 register and are barred from speci- \201 ed behaviors. The \200\230Protection of Childr en and Prevention of Sexual Offenses (Scotland) Act 2005 allows for the application of the similar \200\230Risk of Sexual Harm Order \200\231 (ROSHO) to offenders in Scotland. Box 17.3 Recorded sexual offenses Sexual offenses recorded by the police in each of the jurisdictions in the British Isles in 2001 or 2001 \200\2232. Note that different jurisdictions have different ways of de \201 ning and classifying sexual offenses. England and Wales (2001 \200\2232) Buggery Indecent assault on a male Gross indecency betwe en males Rape of a female Rape of a male Indecent assault of a female Unlawful sexual inter course with a girl Unlawful sexual intercourse with a girl <16 Incest Procuration Abduction Bigamy Soliciting or importuning by a man Abuse of position of trust Gross indecency with a child Total offenses Indecent exposure (recorded with other offenses Scotland (2001) Rape Assault with intent to rape Indecent assault Lewd and libidinous practices Indecent exposu re Incest Homosexual acts Sexual intercourse with a girl <16 Prostitution offenses Other cr imes of indecency Total crimes NI (2001 \200\2232) Rape Attempted rape Buggery Indecent assault of female Indecent assault of female child Indecent assault of male Indecent assault of male child Homosexual acts In decent exposure Indecent conduct towards a child Other sexual offenses Total offenses 354 3613 163 252 40 27 286 308 9008 735 21765 170 34 55 1336 5 333 23 93 130 263 74 1648 32 1431 RoI (2001) Sexual assault Sexual offense involving mentally impaired person Gross indecency Buggery Unlawful carnal knowledge Rape (section 4) Bestiality Aggravated sexual assault In decency Rape of a female Incest Brothel keeping Prostitution Total offenses 408 1665 41425 8187 1048 10 33 36 78 66 2 18 150 335 16 5 142 1939 589 164 1154 1557 808 34 133 179 1328 41 5987 17_Semple_Chap17.indd 685 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 686