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.