Data on the effectiveness of psychiatric treatments for sexual offenders
are scarce, and what few data there are show mixed results. Despite the lack
of information, however, states continue to enact laws allowing them to
involuntarily commit sexually violent predators to psychiatric facilities once
they have completed prison
Steven Hoge, M.D. (right), comments during an annual meeting workshop on
psychiatric commitment of sexual offenders. Looking on are Paul Appelbaum,
M.D. (left), and Howard Zonana, M.D. All three are members of APA's Council on
Psychiatry and Law.
Credit: David Hathcox
The issue stems from the 1997 U.S. Supreme Court ruling in Kansas v.
Hendricks that states have a right to confine potentially dangerous sex
ual offenders in psychiatric hospitals once they are released from prison. In
2002 the Court issued a follow-up ruling to clarify the criteria under which
sexual offenders released from prison can be committed (Psychiatric
News, March 1, 2002).
Supporters of commitment laws for sexually violent predators maintain that
offenders who have completed their sentences but continue to display violent
tendencies can benefit from treatment in psychiatric facilities. But
significant disagreement exists over the effectiveness of treatment for these
"Diagnostically they are a problem, and clinically they are a
problem," said Howard Zonana, M.D., a member of APA's Council on
Psychiatry and Law, during a workshop at APA's 2007 annual meeting in San
Diego in May.
Zonana said the research data on the effectiveness of long-term treatments
remain "very mixed." He noted that there are no data showing the
effectiveness of one of the key outcomes of treatment for these
patients—admitting all past crimes.
Despite a lack of comprehensive study, some research has indicated that
recidivism among sexual offenders who want treatment may be reduced from 17
percent to 10 percent. However, no comparative research has pinpointed which
treatments are most likely to be effective, Zonana said.
Although APA has opposed laws that commit sexually violent offenders to
psychiatric facilities after they complete prison sentences, psychiatrists
still have a duty to these patients. APA's Task Force on Sexually Dangerous
Offenders recommended in its 1999 report that once such patients have been
placed in a psychiatric facility, psychiatrists should provide any effective
treatments available to those committed and diagnosed with paraphilias. Zonana
said the need for more research to guide psychiatrists in treating violent
sexual offenders is crucial.
"The issue we're struggling with now as more states adopt sexually
violent predators laws is how do we as a profession respond to the
situation?" Zonana said.
One response has been lobbying by psychiatrists before state legislatures.
A recent "success" in this area was enactment of a "hybrid
law" in Connecticut, which includes psychiatrist interviews of sexually
violent offenders to ensure that only those with serious mental illness are
committed to psychiatric hospitals. That has resulted in a smaller number of
such commitments than in other states.
"The irony is these people are coming into our facilities, [while]
our usual patients go untreated, get arrested, and are thrown into
jail," Zonana said.
Another complication is that states continue to expand the numbers of
crimes that qualify inmates for psychiatric commitment under violent
sexual-offender laws, he noted. Those expansions include, for example,
counting an offender's childhood convictions in cases in which multiple
convictions qualify offenders as sexually violent predators.
The newest legal maneuver that states use on convicted sexual offenders is
the imposition of residency restrictions, which limit how close they can live
to schools or day-care facilities. The practical effect is that there are a
growing number of cities where sexual offenders cannot legally live. This
results in a higher likelihood that states will commit them to psychiatric
The impact of these laws on psychiatrists is increased pressure to identify
sexually violent predators, which Zonana said is an unrealistic expectation
that ignores the fact that most sexual assaults occur between people who are"
known and intimate." ▪