Forensic assessment and treatment of sex offenders

There is a fairly widespread notion associated with sexual offenses that their perpetrators are generally deranged and abnormal people. This leads to the consideration of unconditionally handing over all such offenders to doctors to recognize, name and, if possible, eliminate the mental disorder. Among sex offenders undoubtedly there is a psychopathologically motivated or sexually deviant subgroup. This subgroup is different in number for different crimes. Its existence justifies medical intervention in the treatment of offenders. However, medicalization of the entire field of sexual delinquency is not and cannot be our program. The majority of perpetrators of sexual offenses do not act out of either psychopathological or sexually deviant motivation. After all, medicine is not only concerned with the care of criminals. Victims of sexual offenses also require medical treatment and counseling.

The diagnosis of sexual deviation is not always easy. Perpetrators of sexual offenses are among those investigated who have little sharing and are often negativistic. Their sexual history is typically hypernormal. It is not easy for a sex offender to admit that they suffer from sexual deviance. Repeat offenders, whose deviant motivations are beyond doubt, often resist such a designation.

Where the examinee cooperates and is willing to provide valuable information, the diagnosis of deviance is easy. Key to it are subjective preferences, problems with conventional sexuality, erotic dreams and fantasies. Psychological screening tests can help. A phalloplethysmographic examination (PPG) has a specific price. However, this requires at least the passive cooperation of the subject. If such minimal cooperation cannot be ensured, the phallographic examination is worthless. The PPG examination is particularly useful in the detection of sexual orientation disorders. In the case of sex offenders, it is sometimes appropriate to objectify the reported homosexuality or heterosexuality. Also, the degree of erotic attractiveness of prepubertal children is of great value when assessing the specific dangerousness of a pedophile offender tort into the future.

Psychopathological findings in sex offenders rarely indicate more serious mental disorders. Psychosis and dementia are very rare in these men. The finding of a personality disorder and a mild mental defect is more common. The more aggressive the sexual offense, the more frequent the finding of a psychopathological structure of the offender's personality. The influence of alcohol is applied differently in different crimes. Sexual aggressors are most often under the influence of alcohol at the time of the crime (up to 50%).

Sex offender treatment concepts
Treatment for sex offenders is rarely initiated at their own request. These men seek the consultation of a sexologist, as a rule, under pressure from the environment. Most often, however, it is a forced protective treatment ordered by the court. A smaller proportion of this clientele is forced to undergo examinations by family members or local authorities who have learned of their offences.

Our concept of treating sex offenders is based on the classic idea of ​​adaptation treatment, which was defined years ago by Karel Nedoma, a worker at the Prague Institute of Sexology. The goal of the entire treatment process is to achieve the best possible sexual adaptation. The paraphilic sex offender first gets the best possible insight into his sexual motivation. Furthermore, it is necessary to consider how he can adapt to his sexual behavior did not lead to a violation of social norms. The most common and also the most reliable way of adaptation is the establishment and consumption of a valuable partner relationship. Mostly heterosexual, although homosexual partnerships cannot be underestimated either. If the shortcomings in this area are greater, then a valuable partnership remains only an unattainable goal or ideal. The individual is only capable of occasional partnerships, or does not even have the basic prerequisites for them. Then it is possible that autoerotics serve for sexual adaptation. The patient should be systematically guided to it. Masturbation is a very important adaptation phenomenon. It should also bridge the current rise of sexually deviant tendencies.

It follows from the above that psychotherapy is of fundamental importance in our treatment scheme. Adaptation treatment is understood as a synthesis of psychotherapy, sociotherapy and possibly also biological treatments. Neither psychotherapy nor hormonal suppression treatment with anti-androgens, brain surgery and castration can change pedophilic, fetishistic or even homosexual preferences. Even a castrated pedophile remains a pedophile. Only his sexual spontaneity is reduced to a minimum.

Biological treatment of sex offenders
In the first plan, the meaning of biological treatment is clear. It is an effort to reduce sexual activity. It is assumed that if the urgency of sexual needs can be suppressed, then it is easier for the patient to resist the realization of sexually deviant acts. Antiandrogens can mainly be used to suppress a man's sexual activity. Of these, gestagen medications cyproterone acetate (Androcur) or medroxyprogesterone acetate (Provera) are available today. In recent years, GnRH (gonadoliberin) analogues such as goserelin, leuprorelin and triptorelin have also become available.

In cases where it is appropriate to suppress a man's sexual activity permanently, the patient can request castration. The performance must be approved by the expert committee. Surgical removal of the gonads can be done with a modified surgical procedure, a "testicular pulpectomy". In this procedure, the entire testicles are not removed, but only their hormonally active medulla, leaving the fibrous sheaths of the testicles in the scrotum. A better cosmetic effect can of course be achieved by sewing suitable acrylic or silicone testicle substitutes into the scrotum. In our experience, the results of correctly indicated castration are generally very good. The reduction of sexual activity is absolutely reliable. However, castration cannot change the sexual preference of the operated man. Castrated sex offenders show very low specific recidivism. In large sets, after years of follow-up, there is no more than 2.5% recidivism of sexual offenses.