Public opinion on both sides of the Atlantic currently seems to show ‘zero tolerance’ to sex offenders. Meanwhile, behind both determinate and indeterminate sentencing can lie a pretence that treatment is the purpose of confinement.
The American Psychiatric Association task force has endeavoured to question the ‘policing’ role given to psychiatrists, while at the same time educating them about sex offenders and their needs. It also examines the effectiveness of classification and treatment and the impact (or lack of impact) of the latter on recidivism.
Many statistics attempting to determine the prevalence of the different paraphilias are provided. As is often the case in such studies, the descriptions of the different diagnoses far outweigh any attempts to understand why such behaviours occur. Treatment is discussed in chapters on cognitive—behavioural and pharmacological method. Psychodynamic treatments are mentioned only in the chapter on recidivism (with its implication that no treatment cures these problems), which contains a brief reference to the lack of psychodynamic research findings. The task force concludes that psychodynamic treatments are not reported because they are not successful.
This seems to me a simplistic review of a complicated field. There is a substantial international psychoanalytic literature that offers much in the way of understanding sexually deviant behaviour, an understanding that has arisen out of careful treatment. Perhaps it is not accredited because it often describes single cases in detail and does not set out to count successes. The failure to acknowledge this literature is particularly apparent in the same chapter on recidivism, in the section on theoretical explanations. It makes no sense to me for the task force to state that there have been very few recent attempts to conceptualise the theoretical causes of sexual offending. Again, the developmental aspects so important to psychoanalysis are completely missed out. The psychological entity is overlooked in the tendency to create ever-growing descriptive lists.
The final two chapters offer some useful questions and information to encourage the reader to think about the issues involved. For example, various scenarios involving a fictitious John Doe examine what to do when he is accused of abusing his 5-year-old daughter, a 13-year-old boy and a 23-year-old woman. The statement in the section on policy recommendations that “ sexual predator commitment laws represent a serious assault on the integrity of psychiatry” is certainly thought-provoking.
With reservations, the report serves as a review of the current struggle with a very real and complex problem for which there is no simple answer.
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