Psychosis and Sexual Offending: A Review of Current Literature
| Published date | 01 August 2018 |
| DOI | 10.1177/0306624X17740016 |
| Author | E. Thomas Lewis,R. Gregg Dwyer |
| Date | 01 August 2018 |
| Subject Matter | Articles |
research-article2017
Article
International Journal of
Offender Therapy and
Psychosis and Sexual
Comparative Criminology
2018, Vol. 62(11) 3372 –3384
Offending: A Review of
© The Author(s) 2017
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Current Literature
https://doi.org/10.1177/0306624X17740016
DOI: 10.1177/0306624X17740016
journals.sagepub.com/home/ijo
E. Thomas Lewis III, MD1
and R. Gregg Dwyer, MD, EdD1
Abstract
Sexual offending is a public health concern and societal risk requiring a multi-
disciplinary approach. While current data give an indication of the frequency of sexual
victimization, these figures likely underestimate the severity of the concern as many
of these incidents go unreported. And while sex offender research has increased over
the past several decades, particular attention to those offenders with severe mental
illness remains limited. In this descriptive review, literature describing sex offenders
with psychotic disorders is explored with a focus on recent research. Important
considerations are described, including theories surrounding psychosis and sexual
offending, hospitalization rates, recidivism, not guilty by reason of insanity (NGRI),
female offenders, and treatment considerations. By exploring these important aspects
of sex offenders with psychosis, conclusions are drawn and future directions are
proposed, with a particular emphasis on clinical application for the mental health
treatment provider.
Keywords
sex offending, psychosis
Introduction
Sexual offending is a significant public health and societal concern. Data from the
National Intimate Partner and Sexual Violence Victimization Survey (NISVS) indicate
that nearly one in five women in the United States have been raped and nearly one in
1Medical University of South Carolina, Charleston, USA
Corresponding Author:
E. Thomas Lewis III, MD, Medical University of South Carolina, 29-C Leinbach Drive, Charleston,
SC 29407, USA.
Email: Lewiset@musc.edu
Lewis and Dwyer
3373
two women have experienced some form of sexual violence victimization (M. C.
Black et al., 2011). In 2012 in the United States, there were 346,830 rapes and sexual
assaults including verbal threats of each according to the U.S. Department of Justice
(DOJ; Federal Bureau of Investigation, 2012). While data collected through DOJ pro-
vide insight, these statistics likely represent considerable under-reporting of actual
rates of sexual assaults (Kilpatrick & McCauley, 2009). Victims of sexual assault are
at an increased risk of mental health sequelae; they are 3 times more likely to suffer
from depression, 6 times more likely to suffer from posttraumatic stress disorder, 13
times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times
more likely to contemplate suicide (Rape, Abuse, and Incest National Network, 2009).
Through a better understanding of sexual offenders, there is potential to increase com-
munity safety, lower sexual recidivism, and develop strategies for prevention of sexual
violence (Association for the Treatment of Sexual Abusers, 2015).
Building evidence in the scientific literature suggests a high prevalence of psychi-
atric comorbidities within the sex offender population. Substance use disorders, per-
sonality disorders, paraphilic disorders, and mood disorders are frequently cited as
important psychiatric comorbidities requiring further investigation among sex offend-
ers (Booth & Gulati, 2014; Dunsieth et al., 2004). For instance, with regard to sub-
stance usage, it has been shown that a history of substance abuse increases recidivism
rates among sex offenders (Peugh & Belenko, 2001). Furthermore, in Abracen,
Looman, DiFazio, Kelly, and Stirpe (2006), sex offenders with a history of alcohol
abuse who completed both substance use treatment and sex offender treatment exhib-
ited lower recidivism rates than those who only completed sexual offender treatment
(Abracen et al., 2006). Better understanding of the specific relationship between an
individual’s sex offending behavior and particular psychiatric comorbidities has the
potential to influence evaluation, treatment, risk assessment, and prevention (Fazel,
Sjostedt, Langstrom, & Grann, 2007). And despite expanding attention to psychiatric
comorbidities in the sex offender literature, there remains a paucity of data surround-
ing those offenders with severe mental illness (Stinson & Becker, 2011).
Sexual offenders with comorbid psychosis are a distinct group of individuals
requiring further study and attention in the sexual offending and general medical lit-
erature (Booth & Gulati, 2014; Craig, 2011; Craissati & Hodes, 1992; Drake & Pathe,
2004; Murrey, Briggs, & Davis, 1992; Sahota & Chesterman, 1998; Smith & Taylor,
1999; Stinson & Becker, 2011; Wallace, Mullen, & Burgess, 2004; Wallace et al.,
1998). Among samples of sex offenders, rates of psychotic spectrum disorder diagno-
ses range from 5% to 10%, while in more specialized forensic sex offender treatment
units, as many as 16% of patients have been reported to have a psychotic disorder
(Booth & Gulati, 2014; Stinson & Becker, 2011). In comparison, lifetime prevalence
of psychotic disorders among the general population is approximately 3%, with the
Centers for Disease Control and Prevention (CDC; 2011) reporting prevalence of
schizophrenia at 1% (Perala et al., 2007).
When comparing sex offenders with nonsex offender groups, male sex offenders
are 5 times more likely than nonsex offenders to be diagnosed with a psychotic disor-
der. Considering the higher occurrence of psychosis among sex offenders, better
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International Journal of Offender Therapy and Comparative Criminology 62(11)
understanding of the mechanisms surrounding this correlation and potential treatment
implications is imperative for evidence-based assessment and treatment (Drake &
Pathe, 2004). In this descriptive review, the relationship between psychosis and sexual
offending is highlighted with particular attention given to theories of etiology, recidi-
vism, and treatment considerations. In addition, further information is reviewed
regarding female offenders and those individuals found not guilty by reason of insan-
ity (NGRI; Novak, McDermott, Scott, & Guillory, 2007).
The topical areas were selected based on a review of literature on sex offenders
with psychosis, with a particular aim to provide practical review of relevant topics in
this area for evaluators working with sex offenders with psychosis. Theories of the
relationships between sexual offending and psychosis will facilitate creating models of
thinking and provide a framework for subsequent findings included in the review. A
brief discussion of hospitalization among sex offenders with psychosis is provided, as
there are several studies with large samples that provide helpful insight into this impor-
tant aspect of an offender’s history. Next, reviews of other important topics including
NGRI, recidivism, and female offenders will help to further establish the complex
relationship between psychosis and sexual offending. Finally, treatment consider-
ations, conclusions, and future directions will aim to provide practical information for
those in the position of evaluating or providing treatment for this particular subset of
individuals within the sex offender population.
Method
A PubMed query was conducted by searching for manuscripts containing the key
words “sexual offending” and “psychosis” within the title. This yielded 28 articles of
which six were included in this article. Articles from this search were excluded primar-
ily if they did not contain specific information regarding sexual offending or sexually
aggressive behavior. In addition, a medical subject heading (MESH) search was con-
ducted using the terms “sex offenses” and “psychotic disorders” which yielded 144
results, of which three articles were included for review. Similarly, exclusion criteria
included articles that did not address the specific relationship between sexual offend-
ing and psychosis.
Next, a broader review of the literature included studies that addressed psychiatric
comorbidities of sex offenders. A PubMed search of “mental illness” and “sex offend-
ing” yielded 361 results, of which 10 were included. Specific inclusion criteria for this
review were English language, published in 1980 or later, adult populations, and content
that specifically addressed psychosis among sex offenders. Both data driven and review
articles were included. Of note, articles retrieved from these searches were also utilized
to find additional literature on this topic area, yielding...
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