Counterpoint: Flaws in the sexual addiction model
“That but a moment’s thought is passion’s passing bell.” – John Keats, Lamia Part II: 39.
It is naïve to think that psychiatry is generally accepted in the treatment of problematic sexual behaviors. Although some might think that psychiatry has a “liberated” view of sexuality born of Freud’s Oedipus, the psychiatrist’s involvement in managing sexual behavior, especially within the criminal justice system, is controversial rather than “celebrated.”
Although some such as Dr. Mahorney may assert an addiction model for problem sexual behavior, that model is seriously flawed. Parallels do exist between problem sexual behavior and other addictive behaviors. Within the broad range of sexual behaviors, however, the line between “addictive” and “alternative” cannot be finely drawn. For example:
- Certain advocacy groups such as the North American Man-Boy Love Association (NAMBLA) believe in legalized pederasty and have exerted a lobby to affect rulings on freedom of expression in “virtual” child pornography over the Internet.
- Representatives of the U.S. Catholic church have publicly “mitigated” the controversy over some priests’ sexually inappropriate behavior by stating that the offenders were “not pedophiles” because their victims were over the arbitrary age of 13.
This discussion might easily encompass the controversial “cures” for homosexuality that were quashed in the late 1960s. How also might we classify the consenting masochist or the philanderer?
Finally, there is the forensic question: Do we allow “mental illness” to “excuse” one’s willful sexual behavior by giving it a label or a treatment?
Sexual offense vs. mental illness
Part of the problem with defining sexual “addiction” is that one first needs to define sexual “normalcy.” No such definition exists. Even so, adding a “sexual addiction” diagnosis to the next Diagnostic and Statistical Manual (DSM) would likely be met with indifference or active denial from the psychiatric community, based solely on its legal ramifications. Attorneys would perceive that an official DSM diagnosis could open the door to acquittal on the basis of insanity for sexually motivated crimes in certain states that retain a “product rule.” It might even exonerate individuals in restrictive states that follow the more cognitive M’Naughten standard (Box).
INSANITY PLEA: TWO STANDARDS FOR ACQUITTAL
The “product rule” asserts that a person is not responsible for his or her acts if they were a product of mental illness. The M’Naughten rule holds that a person is not responsible if, by virtue of a mental illness, that person does not understand the wrongfulness of the act.
Assailant John Hinckley Jr. was acquitted on the basis of an insanity plea under the “product rule” in the attempted assassination of President Reagan on March 30, 1981, outside a hotel in Washington, DC. Hinckley, who was obsessed with actress Jodie Foster, shot and wounded Reagan, press secretary James Brady, a Secret Service agent, and a police officer. After Hinckley’s acquittal, most states adopted the more stringent M’Naughten standard.
A number of forensic mental health issues such as sexual predator classifications and sex offender civil commitment have placed professional societies at odds with one another over sexual behavior and mental illness. Mental health organizations such as the National Association of State Mental Health Program Directors and the American Psychiatric Association argue that most sex offenders do not suffer from a mental illness. Translation: “We don’t want to be responsible for handling sex offenders.”
This distinction between sexual offenses and mental illness contrasts with the laws of several states that broadly define mental illness to include mental conditions that result in dangerous and “uncontrollable” behavior. Translation: “We want to keep sex offenders controlled or away from the community.” There has been no rational support for either of these positions, only data that have been loosely contrived to justify one or the other.
Res ipsum loquitur: the thing defines itself
Many “experts” have conjectured about the nature of sex-offending behavior and the phenomenon of “sexual addiction” without subjecting their conclusions to scientific scrutiny. Agendas have abounded, and countertransference rather than objectivity has driven many perceptions within the field. Treatments have often been theory-based rather than tested. The universal problem has been that many providers have invented solutions without defining the problems. Indeed, the problems have been multifaceted.
There has been little reliable outcome data to demonstrate the success in any given treatment, although a few notable exceptions stand out. Medical interventions with hormonal compounds like medroxyprogesterone and cyproterone have reduced recidivism. 1 According to the Task Force Report on Sexually Dangerous Offenders, however, psychodynamic treatments in general have been ineffective.1 Most of the supportable psychological treatments have emerged since 1980 and have centered on a cognitive model of relapse prevention.2
The Minnesota Sex Offender Program has been the gold standard as a cognitive-based relapse prevention model for sex offenders.3 The program was developed as an inpatient program with a structured level system and topic-specific modules. It has focused on a relapse prevention cycle that teaches strategies to recognize and avoid cognitive distortions and maladaptive coping responses that eventually lead to re-offense.
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.
COMMON AXIS I DIAGNOSES IN 113 CONVICTED SEX OFFENDERS WITH AND WITHOUT PARAPHILIAS*
Mood disorders (any)
Substance abuse (any)
Anxiety disorders (any)
Eating disorders (any)
Impulse control disorders (any)
* 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.
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
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.
1. Zonana H, (chairperson). Dangerous sex offenders. A task force report of the American Psychiatric Association. Washington, DC: American Psychiatric Association Press, 1999.
2. Hanson RK, Gordon A, Harris AJ, et al. First report of the collaborative outcome data project on the effectiveness of psychological treatment for sex offenders. Sex Abuse 2002;14(2):169-94.
3. Schlank A, Cohen F. The sexual predator: law, policy, evaluation, and treatment. Kingston, NJ: Civic Research Institute, 1999.
4. McElroy SL, Soutullo CA, Taylor P, et al. Psychiatric features of 36 persons convicted of sexual offenses. J Clin Psychiatry 1999;60(6):414-22(update by Dunsieth N, et al with data from 113 subjects in progress).
5. Raymond N, Coleman E, Ohlerking F, Christenson GA, Miner M. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry 1999;156:786-8.
6. Kafka MP, Hennen J. Psychostimulant augmentation during treatment with selective serotonin reuptake inhibitors in men with paraphilias and paraphilia-related disorders: a case series. J Clin Psychiatry 2000;61(9):664-70.
7. Nelson E, et al. Data unpublished from the University of Cincinnati Biological Psychiatry Program (paper in progress).