India has a major problem with sexual crimes against women, which is on the rise rapidly (NCRB 2013) [Figure 1].
It ranks in the bottom five nations globally when it comes to safety of women according to a recent Gallup poll (www.gallup.com). Much soul searching has occurred following the horrific sexual homicide of a woman in New Delhi that focusses the spotlight on sexual offences generally and rape in particular. The Verma commission, created swiftly to address deficits in the management of rape and other sexual offences, recommended widespread changes. Sadly, it focussed only on criminal justice issues of defining laws, enhancing processes, and increasing punishments but remained silent on the slew of health approaches that have been used in the west and increasingly closer to home (e.g., Singapore) in the management of sex offenders. This article would aim to provide a brief overview of mental health literature relevant to theories, taxonomy, assessment, and diagnosis for the complex set of thoughts, feelings, attitude, and behaviours that lead to the offence of rape.
This article focusses only on gender-specific rape (crimes committed by males on adult females; its understanding, assessment, and diagnosis. It does not address other factors-criminological, societal, and cultural-that facilitate and maintain the commission of this offence. Neither does it deal with other sexual offences such as exhibitionism, paedophilia, and others, nor does it discuss treatment options and strategies due to constraints of space. Finally, victim issues such as trauma and other psychiatric morbidity are not dealt with as trauma services exist in India. The paper focuses squarely on perpetrators of the offence of rape and makes the argument that while anguish at their actions; it does nothing to address what are often serious mental health issues that underpin such offendces. It ends with a section on the ethical issues relevant to this area of practice.
In law, rape is defined as vaginal or anal penetration in the absence of lawful consent. However, the source of penetration (e.g., penis, finger, or objects), object of penetration (e.g., vagina, anal, or oral), gender of perpetrator, and victim and definition of consent varies greatly across jurisdictions. Rape is considered to have occurred when her consent has been obtained by (i) putting her (or any person in whom she is interested, e.g., children, close relatives) in fear of death or of hurt, (ii) the administration by him personally or through another of any stupefying or unwholesome substance (so-called “date-rape”), or (iii) when the age of the victim is below 16 years. Moreover, Indian law (section 375 of Indian Penal Code) specifically states that if a woman consents to sex, that consent is invalid and rape is still considered to have taken place if the woman is suffering from “unsoundness of mind or intoxication” so that she is unable to understand the nature and consequence of that to which she gives consent.
There are several types of rape that exist in law
- Penetrative rape: The vagina is penetrated by penis, finger, or other objects
- Statutory rape: The penis is touched on vagina but no penetration takes place. This type of rape does not exist in Indian statutes yet
- Marital rape: When rape occurs within a marriage. This is not yet recognized in Indian law
- Date rape: When rape occurs during an exploratory platonic romantic meeting between a man and a woman, where often an intoxicating agent is mixed in the food or drink of the victim
- Gang rape: When more than one person rapes the victim
- Male rape: When man on man rape takes place.
Since events in late December 2013 which has sparked a wave of soul-searching, several narratives of what rape is all about has emerged from various people - in public offices, religious communities, and special interest groups - plugged on mainstream media. Some of these discourses have merely rehashed what are known to be myths. Some of these myths are: (a) women ask for sex by the way they dress and behave, (b) they enjoy being raped, (c) women are raped only by strangers, (d) women could avoid being raped if they really wanted to, (e) women cry rape for revenge on powerful men, (f) rapists are crazy or psychotic (“animals” is a word that is often used), and (g) most rapists are “different”, “not like us.” None of the above are generically true even if there may be some truth in some rare individual cases.
WHY MENTAL HEALTH?
Extensive research over the past 3 decades (and more) suggests that several mental health issues underlie sexual violence and offending, particularly rape. Much of this research comes from the west and the lack of meaningful research on rapists in India highlights a serious lacunae in knowledge and skills required to manage mental health factors that underlie criminal activities, a role that forensic psychiatrists generally play.
Rape may a be associated with organic brain damage and learning disability, disorders associated with congenital or acquired brain damage. Marshall and Barbaree proposed that a critical developmental task for adolescent males involves learning to distinguish between aggressive and sexual impulses, as this has consequences for their ability to control aggressive tendencies during sexual experiences and activities. They argue that both types of impulses - violent and sexual - originate from the same brain structures. For vulnerable individuals with adverse early developmental experiences, differences in hormonal functioning will make this task even more difficult. Rapists were found to have head injuries (3.9%) in a large sample in Sweden, and sadistic rapists have shown abnormalities within the temporal horn, although the clinical significance of these findings remain unknown at the present time. For an excellent review of neurobiological factors underlying sexual offending, the reader is directed to a paper by Bradford.
Most rapists are not mentally disordered. People with schizophrenia or related psychoses may often commit rape or show abnormal sexual behavior which is related either directly to the psychosis or indirectly to disinhibition. Similarly, patients with hypomania and mania become sexually disinhibited leading to such offences. It has been reported that those diagnosed with schizophrenia are four times more likely to have been convicted of a serious sexual offence than those without mental illness. It has been proposed that schizophrenia patients who engage in sexually offensive activities (not just rape) fall into four broad groups: (1) Those with pre-existing paraphilias, (2) whose deviant sexuality arises in the context of illness and/or its treatment, (3) whose deviant sexuality is one manifestation of a more generalized antisocial behaviour, and (4) other factors such as dementia, head injury, or substance misuse. In terms of incidence, Langstrom et al., carried out the most extensive study in which they retrospectively analyzed psychiatric diagnoses in an in-patient Swedish sample of 535 rape offenders discharged from Swedish prisons. The most prevalent diagnoses were alchohol abuse or dependence (9.3%), drug abuse (3.9%), personality disorder (2.6%), and psychosis (1.7%).
In Diagnostic and Statistical Manual, 4th edition (DSM-IV), paraphilias are defined in the following terms: (a) At least a 6-month period of recurrent, intense, sexually arousing fantasies, or sexual urges involving specific paraphilic behaviour, and that the fantasies, sexual urges, or behaviors; (b) cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the year 2000, DSM-IV-TR added that this diagnosis could be made in certain cases where individuals, even though not personally distressed or impaired in their functioning, had acted out the urge and carried out the behaviors with a nonconsenting party. In International Classification of Diseases, 10th revision (ICD-10), paraphilas are described, much as in DSM-IV-TR, as being carried out to gain sexual excitement and gratification. In ICD-10, sadism and masochism are combined in one category, whereas they form two categories in DSM-IV-TR.
Rape as a behavioral disorder has been excluded even though pedophilia (sex with underage children), sadomasochism, and exhibitionism are included. One possible reason could be that rape as a behavior seems so similar to other criminal offences and rapists so similar to property or violent offenders that it was not considered to be related to deviant sexual arousal, which pedophilia, exhibitionism, and sadomasochism undoubtedly are. Consequently, the DSM mentions rape only under the diagnosis of sexual sadism (although sadism incorporates only 5-10% of all rape cases). The ICD-10 does not consider rape to be a disorder and there is no mention even within the disorder of sadomasochism. However, as the subsequent material would reveal, rape offenders experience many of the deficits and dysfunctions that other mentally disordered individuals do.
Several studies show that rapists experienced multiple early life adversities such as sexual abuse, physical abuse, and dysfunctional family relations, which are likely to affect their capacities for secure attachments and developing healthy adult relationships. Such experiences create deficits of intimacy with insensitive and aloof interpersonal styles and dismissive attachment characterized by hostility to, suspicion of, and unempathic and callous attitudes toward attachment figures.
Cognitive distortions or CD are errors in cognitions that allow the offender to rationalize and minimize the perceptions and judgements used by the sex offender to justify his molestation behavior. It is said that men hold implicit theories about the nature of the world which underlie their distorted beliefs which often drive and justify their rape behavior. The implicit theories proposed for rapists are listed below and research has found evidence for such beliefs:
- Women are unknowable: Rapists believe that women are fundamentally different from me and, therefore, cannot be understood. Encounters with women will, therefore, be adversarial and women will be deceptive about what they really want. An example of such a CD might be ”…she is dressed in hot pants and her cleavage is visible. This means she wants sex and it is okay for me to have sex with her” when she says “no” she actually wants to turn me on further.”
- Women are sex objects: The CD is that women are constantly receptive to men's sexual needs but are not necessarily always conscious of this. Their body language is more important than what they say and women cannot be hurt by sexual activity unless they are physically harmed, that is beaten or punched. An example of this might be ”…when she looks furtively at me when I make lewd comments, she is actually interested in me. So when she says “no” she is actually playing with me to turn me on further.
- Male sex drive is uncontrollable: Men's sexual energies can build up to dangerous levels if women do not provide them with sexual opportunities and once aroused it is difficult not to progress to orgasm. In India, with its culture-bound syndromes of “male sexual weakness” or dhat syndrome, one manifestation of such a CD might be “… I am going to become weak if my “dhat” (semen) flows out (premature ejaculation while molesting or sexually harassing a woman) and a woman does not offer herself to me.”
- Entitlement: Men's needs, which include sexual needs, should be met on demand by women. In a nation like India with major gender-based inequalities, such CDs of male entitlement, especially if the victim is from lower status for whatever reason (socioeconomics, caste, etc.) can lead to marital rape (recommended to be considered a crime in the Verma Commission report).
- Dangerous world: The world is a hostile and threatening place and people need to be on their guard, but there is no safe haven. An example is “…. I have been wronged in many ways, and so it is not wrong for me to do wrongs to others.”
THEORIES OF RAPE
Just as a diabetic man may be a rapist, similarly psychiatric diagnosis may coexist in a rape offender. It is risky at least and downright negligent and harmful at worst to assume a causal link between a psychiatric disorder and rape, that is, the rape was the direct outcome of someone's psychosis, bipolar disorder, depression, or any other psychiatric disorder, unless there is clear evidence that the rape was directly caused by severe symptoms which the offender could not control at all. This is often only possible and plausible in cases of severe psychosis or in individuals with serious organic brain disorders or severe learning disability. In most cases, there is multifactorial causation of the offence rather than any one specific cause (like psychosis for example). In order to assist optimal assessment and treatment of rapists, a comprehensive understanding of the range of aetiological theories available to explain sexual aggression is required. This is necessary in order to develop case formulations which are theoretically driven conceptual models that represent offenders’ various difficulties, the hypothesized underlying mechanisms, and their inter-relationships which give rise to symptoms or problems. A case formulation provides a rational basis for determining treatment needs that are used to tailor interventions with offenders.
Sexual offending literature consists of three main types of theories: Single-factor, multifactor, and microtheories.
- Single-factor theories: These refer to theories that attempt to explain a single unifying underlying cause of sexual aggression, e.g., psychodynamic, evolutionary, cultural, or sociocognitive theories. While in and of themselves single-factor theories cannot explain causally many of the rape cases, they contribute in generating good multifactor theories.
- Multifactor theories: These combine a number of single factor theories into a comprehensive explanation of interactions and causal relationships that go to create a favorable environment for rape to occur, e.g., confluence model, integrated theory, quadripartite theory, and an unification of all these theories into one metatheory - integrated theory of sexual offending. Such theories are useful in developing risk assessment and intervention strategies for groups of offenders.
- Microtheories: These are essentially descriptive theories developed from an analysis of the offence data and offenders’ accounts of their behavior. They specify how offending occurs in terms of core cognitive, behavioral, affective, volitional, and contextual factors and provide excellent shared relapse prevention plans for offenders and their therapists/supervisors.
For reasons of brevity and parsimony, details of the theories underlying sexual aggression are not provided here but the interested reader can read the original works cited.
TAXONOMY OF RAPISTS
There is no one homogenous group of rapist population, as there are multifactorial causative factors posited by theories of differing persuasions. This is not dissimilar to other complex behavioral problems with multiple underlying motivations within a context of varied mental disorders, for example, self-harm (Sarkar 2011). One way of attempting to reduce the heterogeneity is to produce smaller descriptive categories (or taxonomies) that could be used to guide treatment decisions. There are many taxonomies available but one of the most robust, widely used, and methodologically sound typological systems to date is the Massachusetts Treatment Centre Rapist Typology: Version 3 (MTC:R3) which uses both theory and empirical data. This model uses motivating dimensions to describe six different types of rapists, which is as follows:
- Opportunistic rapist: Offences are unplanned and impulsive and immediate sexual gratification is sought, with force used as necessary. Offences are driven largely by immediate antecedent events (situational factors) rather than personal psychopathology, for example, late night, lone isolated female, no witnesses around. Sexual assault is one of many instances of poor impulse control.
- Anger rapist: His offence is driven by extreme gratuitous aggression, severe violence, and a history of previous antisocial offending, serious physical injury to the victim is caused.
- Sexual rapist: He is driven by preoccupation with sexual fantasies and urges and is best captured by the diagnosis of Paraphillia – Not otherwise specified (DSM-IV-TR)
- Sexually nonsadistic rapist: He is driven by sexual fantasies and urges too, but the sexual arousal is inappropriate in nature (e.g., fetish), there are offence supportive beliefs and feelings of inadequacy regarding masculinity and sex.
- Sexually sadistic rapist: The motivation for this rapist is not sexual but fantasies of degradation and humiliation of and power and control over the victim, best captured by the diagnosis of sexual sadism in the DSM-IV-TR.
- Vindictive rapist: His drive is predominantly anger, but unlike the angry rapist, his anger and aggression is focussed exclusively on women. His behavior is intended to humiliate and degrade victims with little/no evidence of eroticised aggression and low levels of impulsivity.
Some of these typologies include further subdivisions in terms of high or low social competence and the offence being sadistic in overt or muted manner.
It is highly unlikely, well-nigh impossible, that a man will voluntarily admit to rape and subject himself to a psychiatric evaluation as he runs the risk of being apprehended and prosecuted. He is, therefore, different from most other individuals who seek assessment. They are a difficult group to assess compared to individuals who are not facing charges of crime or even in comparison with violent offenders for reasons of deception and denial that often characterize their presentation during an assessment. Being sent for mandatory assessments by criminal justice agencies, coupled with shame of what they are alleged to have done, are two of the many factors that make such assessments difficult. Consequently, it is important to have clear process (structure), knowledge (of sexual and criminogenic issues), and techniques (skills) rather than theories and experience (of carrying out assessment for non-offenders or offenders with violent crimes) when it comes to assessing sex offenders. The focus of a psychiatric evaluation is as much about the “what” of the behavior, as well as the “how” that behavior is assessed. The following section is written based on a fictional subject who is being assessed on request of criminal justice agencies (police, prison, probation, etc.) or courts. It is of course applicable to those voluntarily seeking help.
Usually, the subject is likely to be very anxious at the beginning of the interview in addition to being keen to present himself in the best possible light. This may present as hostility, evasiveness, or in some other way. It is important not to become authoritarian or dismissive in a reaction to this presentation. The assessor must lay down “ground rules” from the outset, being clear about how many times you are likely to meet, what will be asked, the lack of confidentiality rules that govern usual doctor-patient interactions, what will happen to the information from interview. You must clarify what your role is and what information you already have access to. Establishing this framework allows the interviewee a greater sense of containment and help to establish a rapport that is based on honesty. Care must be taken to maintain a less threatening atmosphere in the interview and it is helpful to begin with more basic information and build up to more complex and detailed information. Features in the assessor that is related to positive outcomes are listed in Table 1.
The interview should include information that allows a building-up of picture of the person rather than a truncated mental state evaluation alone. Some of the topics to cover in the clinical interview are given below.
- Early life experiences: Details of any conflict experienced as a child and how this was managed, family history of mental illness, drug abuse and criminality, details of how women/children were treated in the family home and how this may have shaped subsequent attitudes and behaviour
- Education history: Details of bullying (victim or perpetrator) and conflict with authority figures, their ability to form and sustain relationships
- Occupational history: Information about any conflict with employers and colleagues, any indication of sexualized behaviors at place of work, how long they spent in job/s and why they left
- Psychosexual history: This must be assessed in great detail and is summarized in Appendix 1
- Hobbies/interests/friends/skills: These provide a glimpse into healthier aspects of one's life
- Previous forensic history: Nonsexual offending history, specific information sought about what, when, who, and so on in order develop understanding of the pattern of offending
- Offence analysis: This must be done in great detail and a recommended approach is summarised in Appendix 2
- Previous and current psychiatric issues: Record age of onset both of mental disorder and sexually inappropriate (even if not rape) as this will provide clues to links between the two; assess presence of fantasies, urges, and sexual preoccupations and ruminations that may become uncontrollable under certain situations; assess if deviant fantasies occurred before, during, or after onset of any axis I disorder; association of alchohol or drug use in relation to rape.
- Personality: Usual patterns of stress-coping-social support available, attitudes, self-image, and so on.
- Barriers to treatment: Motivation to change, guilt, denial, practical difficulties, and so on.
Rapists are well-known to be very defensive about their actions and engage in denial that range from slight minimization to outright denial. It is important to accept this as part of the assessment and to ignore answers that you know to be untruthful, at least in the early stages of the interview, in order to maintain rapport and to facilitate disclosure of sensitive material. It is thought denial is the only means a person has to cope with the shame they may feel by their behavior. It is known that anxiety and guilt increase shame and, hence, the interviewer should take every sensible step to minimize and moderate the amount of anxiety that the person experiences during the interview.
Motivational interviewing is an approach designed to reduce the need for defensiveness, hostility, and anxiety in a self-protective interviewee. Derived from the transtheoretical model of motivation for problem drinkers to facilitate engagement in treatment program, the model helps the individual to move through various stages. These include the stages of precontemplation (denial of the problem), to contemplation (accepting there is a problem but ambivalent about change), to determination (decides change is necessary), to action (engaging in treatment), to maintenance (remaining free of relapse). Sexual offending has been considered to be an “addiction” in terms of being repetitive, self-reinforcing behavior often used to counter a negative mood state.
Understanding the psychological characteristics of an offender and making risk assessments of future offending behavior are major elements of any sex offender treatment program. Several types of risk assessments are carried out. These will not be described in any length but the following section will provide a brief summary of the types of instruments that are routinely used in this type of work. Two types of risks are assessed-static and dynamic risks. Static risk factors refer to those factors that are unchangeable, for example, historical facts such as number of previous convictions. Dynamic risk relate to those risk factors that are susceptible to change with treatment and that can be used as markers of treatment response and further risk prediction. There are two types of dynamic factors: Stable and acute. Stable risk factors relate to personality characteristics and learned behavior that may be changed through interventions. Finally, acute risk factors are those short-term or temporary factors which can change rapidly and are implicated in relapse prevention. To illustrate it with an example from cardiology, static risk corresponds to genetic vulnerability (long-term risk), stable risk corresponds with characteristics such as blood pressure, cholesterol levels (targets for treatment), and acute factors correspond with immediate behaviors of concern such as smoking, diet, and lack of exercise (monitoring and supervision).
One of the better and commonly used static risk assessment instruments is the Risk Matrix. It uses information such as age, number of appearances in court for sexual and criminal (nonsexual) offences, gender of victim (if male, then more risky), stranger victims, if perpetrator is single (implies intimacy deficits) and noncontact sexual offences (exhibitionism, sexual harassment, etc.).
Thornton also provides the structured assessment of risks and needs which assesses various dynamic risk factors and categorises them into four risk domains. Summated score on each domain allow treatment to be targeted to those domains with monitoring of risk scores (alongside clinical evidence) used to measure change. These four domains are as follows:
- Sexual interests-includes sexual preoccupation, sexual preference (for children or violence), and so on.
- Distorted attitudes and beliefs-CDs and offence-supportive beliefs, etc.
- Socio-affective management-emotional regulation, intimacy deficits, and so on.
- Self-management-poor problem-solving skills, lifestyle impulsiveness, and so on.
Some of the other well-validated instruments used for risk assessments include sex offender risk appraisal guide, Static-99, sexual violence risk. There are many others which cannot be described here but the moot point is that structured risk assessments are an integral part of sex offender treatment and even if they may not predict risks with fool-proof accuracy, they incrementally add to the risk predictions as determined by reconviction data.
A battery of tests are used to measure constructs relevant to rape such as emotional loneliness, social competence, deficits in empathy, CDs, personality assessment, impulsivity scale, deception scale, and others. These appear to distinguish those who benefit from treatment from those who have not.
Phallometry or measurements involving the phallus is used in the assessment and monitoring of sex offenders as it deals with some of difficulties associated with psychometric measures. These difficulties include limited discriminate or predictive validity, self-report bias, and limitation of deception scales. One of the most common methods is penile plethysmography (PPG), which determines sexual arousal by measuring increases in penile tumescence (volume or circumference) or blood flow in response to visual (still or moving), auditory (scripted stories) imaginal and olfactory stimuli. As sexual arousal cannot be directly observed, PPG offers a direct physiological, albeit intrusive method of assessing what causes sexual arousal in rapists. It is not without criticism as some argue that the stimuli used to generate arousal amounts of showing pornographic material to offenders. Other concerns relate to lack of standardization of methodology, limited control data for normal populations, and the ability of people taking the test to fake non-arousal by various means. Nevertheless, when used within an array of other tests, phallometry can provide very useful information in terms of identifying focus for treatment.
As discussed earlier, rape is not a mental disorder by itself. As a psychiatric diagnosis is a prerequisite for civil and criminal commitment, forensic mental health clinicians have tended to use the paraphillia-not otherwise specified (PNOS) diagnosis. Controversy exists around using such as “rag-tag” diagnosis for commitment of rapists under the sexually violent person or sexually dangerous predator laws in United States to detain high-risk rapists in secure conditions beyond their terms of imprisonment. The interested reader is directed to an excellent review of a proponent's and an opponent's view on this matter.
There is, however, a larger ethical issue beyond the various arguments that experts may offer and clinical diagnostic criteria. Psychiatrists are first and foremost doctors and should work within the ethical principles of “beneficence” and “nonmaleficence,” that is doing good and avoiding harm. However, their involvement can be ethically justified by arguing that by detaining and treating the patient (no longer considered just a “bad guy” who needs only punishment), the psychiatrist is helping the person, which otherwise would not have been possible. The Royal College report suggests that there are potentially four ways in which this question can be answered and ethical justifications are provided for each of the positions adopted.
Do psychiatrists have a duty to get involved in crime management and prevention by the law enforcement agencies, even if some offenders may suffer from mental disorder, if psychiatric involvement may lead to uncovering of more offending behavior, presence of severe antisocial personality disorder, or longer than normal time in detention? There are four possible ethical positions that a psychiatrist can take. S/he can adopt the traditional medical ethics model of beneficence and nonmaleficence as one extreme stance and refuse to be involved in even assessing individuals, unless there is a “welfare” disposal, that is, there is some scintilla of benefit to the individual. A further extension of this position is to only act for the defence when the assessment is clearly within a framework of potential benefit to the person. At the other extreme, the psychiatrist can become involved as a pure “forensicist,” that is, in doing so they are not acting as a doctor but a risk specialist who can give evidence that could lead to enhanced punishment. In between these poles, the psychiatrist can choose to operate from the framework of justice ethics, that is, it is in everybody's interests that there is good-quality evidence available to the court in relation to making just decisions.
However, there is a bigger question when such issues are considered with regards to India. It has been lamented elsewhere that forensic psychiatry, the profession that is directly implicated in the type of work described in this paper, does not exist as a specialty in India even though some general psychiatrists in various institutions deal with the courts and police. As such many might regard the content of this paper with alarm as it puts the psychiatrist in the gaze of media and legal spotlight with its own disadvantages if one gets it wrong. It is, therefore, essential that the Indian psychiatric society and the law and home ministries of the nation consider what contribution and impact mental health professionals can make in crime prevention and its management. It is imperative that individuals do not jump into the field without proper training and experience as the field can be quite challenging and can often spell the doom for unsuspecting doctors if she gets it wrong.
The recent surge in sexual violence towards women in India require a multi-pronged response that should involve not just organised and non-organized sectors, but also individuals as members of that society as perpetrators of rape often have mental health and psychosocial risk factors that trigger, maintain and perpetuate the offence. Psychiatry can play a constructive and educative role in assisting criminal justice agencies in managing this scourge. For the discipline to do so, it requires leadership and vision in developing the neglected field of forensic mental health. National mental health planning must include centres that can train the next generation of professional in the assessment and management of offending behaviours such as rape. In doing so, the discipline and its practitioners must be cognizant of the ethical and moral principles that govern their actions as doctors and as carers of individuals with mental health professionals and protect themselves from excessive and unjust demands from others as well as act to reduce the stigma associated with being consumers of mental health services (Sarkar 2011).
1. Sarkar J, Dutt AB. Forensic psychiatry in India: Time to wake up J Forensic Psychiatr Psychol. 2006;17:121–30
2. Gordon H, Grubin D. Psychiatric aspects of the assessment and treatment of sex offenders
Adv Psychiatr Treat. 2004;10:73–80
3. Marshall W, Barbaree HMarshall W, Laws D, Barbaree H. An integrated theory of sexual offending Handbook of Sexual Assaults: Issues, Theories and Treatment of the Offender. 1990 New York Plenum:363–85
4. Langstrom N, Sjostedt G, Grann M. Psychiatric disorders and recidividsm in sexual offenders Sex Abuse. 2004;16:139–50
5. Aigner M, Eher R, Fruehwald S, Frottier P, Gattirez-Lobos K, Dwyer S. Brain abnormalities and violent behaviour J Psychol Human Sex. 2000;11:57–64
6. Wright P, Nobrega J, Langevin R, Wortzman G. Brain density and summetry in paeedophillic and sexually aggressve men Ann Sex Res. 1990;3:319–28
7. Bradford JM. The neurobiology, neuropharmacology and pharmacological treatment of the paraphilias and compulsive sexual behaviour Can J Psychiatry. 2001;46:26–34
8. Grubin D, Gunn J. The Imprisoned Rapist and Rape 1991 London Her Majesty's Stationery Office
9. Smith AD, Taylor PJ. Serious sex offending against women by men with schizophrenia. Relationship of illness and psychtic symptoms to offending Br J Psychiatry. 1999;174:233–7
10. Green THouston J, Galloway S. Clinical assessment and formulation Sexual Offending and Mental Health: Multi-Disciplinary Management in the Community. 2008 London Jessica Kingsley
11. Drake CR, Pathe M. Understanding sexual offending in schizophrenia Crim Behav Ment Health. 2004;14:108–20
12. . American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 19944th ed Washington DC American Psychiatric Association
13. Craissati J. Sexual violence against women: A psychological approach to the assessment and management of rapists in the community Probat J. 2005;52:401–22
14. . World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic guidelines 1992 Geneva WHO
15. Alder C. The convicted rapist: A sexual or violent offender? Crim Justice Behav. 1984;11:157–77
16. Craissati J, Falla S, McClurg G, Beech A. Risk, reconviction rates and pro-offending attitudes for child molesters in a complete geographical area of London J Sex Aggress. 2002;8:22–38
17. Dhawan S, Marshall W. Sexual abuse histories of sexual offenders Sex Abuse. 1996;8:7–15
18. Beech A, Fisher D, Ward T. Sexual murders’ implicit theories J Interpers Violence. 2005;20:1366–89
19. Smallbone S, Dadds R. Childhood attachment and adult attachment in incarcerated adult male sex offenders
J Interpersonal Violence. 1998;13:555–73
20. Stirpe T, Abracen J, Stermac L, Wilson R. Sexual offenders’ state-of-mind regarding hildhood attachment: A controlled investigation Sex Abuse. 2006;18:289–302
21. Polaschek D, Ward T. The implicit theories of potential rapists. What our questionnaires tell us Aggress Violent Behav. 2002;7:385–406
22. Beech AR, Ward T. The integration of etiology and risk in sex offenders
: A theoretical model Aggress Violent Behav. 2004;10:31–63
23. Gannon T, Collie RM, Ward T, Thakker J. Rape: Psychopathology, theory and treatment Clin Psychol Rev. 2008;28:982–1008
24. Ward T, Hudson S. A model of the relapse process in sexual offenders J Interpersonal Violence. 1998;13:700–25
25. Malamuth NM. Predictors of naturalistic sexual aggression J Pers Soc Psychol. 1986;50:953–62
26. Malamuth NBuss D, Malamuth N. Sex, Power and Conflict: Evolutionary and Feminist Perspectives Sex, Power and Conflict: Evolutionary and Feminist Perspectives. 1996 New York Oxford University Press:269–95
27. Hall GC, Hirschmann R. Toward a theory of sexual aggression: A quadripartite model J Consult Clin Psychol. 1991;59:662–9
28. Ward T, Polascheck D, Beech A. Theories of Sexual Offending Chichester Wiley
29. Sarkar J, Beeley C. Developing an algorithm of short-term and immediate responsein the management of repetitive self-harm in women with severe personality disorders inmedium security J Forensic Psychiatr Psychol. 2012;22:845–62
30. Sarkar J. Short-term management of self-harm in secure services Adv Psychiatr Treat. 2011;17:435–46
31. Marshall W, Laws D, Barbaree H, Knight Prentky R. Classifying sexual offenders: The development and corroboration of taxonomic models Handbook of Sexual Assaults: Issues, Theories and Treatment of the Offender. 1990 NY Plenum:23–52
32. Knight RASchlank A. Typologies for rapists: The generation of a new structural model The Sexual Predator. 2009;4 New York Civic Research Institute:1–28
33. Marshall W, Anderson L, Fernandez Y. Cognitive behavioural treatment of sexual offenders 1999 Chichester Wiley
34. Mann R, Shingler JMarshall W, Fernandez Y, Marshall L, Serran G. Schema-driven cognition in sexual offenders: Theory, assessment and treatment Sexual Offender Treatment: Controversial Issues. 2006 Chichester Wiley:173–85
35. Thornton D, Mann R, Webster S, Blud L, Travers R, Friendship C, et al Distinguishing and combining risks for sexual and violent recidivism Ann N Y Acad Sci. 2003;989:225–35
36. Thornton D. Constructing and testing a framework for dynamic risk assessment Sex Abuse. 2002;14:137–51
37. Quinsey V, Harris G, Rice M, Cormier C. Violent offenders: Appraising and managing risk 1998 Washinton DC American Psychology Association
38. Hanson RK, Thornton D. Static-99: Improving actuarial risk assessments for sex offenders
User Report 99-02. 1999 Ottawa Department of the Solicitor General of Canada
39. Boer D, Wilson R, Gauthier C, Hart SWebster C, Jackson M. Assessing risk of sexual violence: guideline for clinical practice Impulsivity: Theory, Assessment and Treatment. 1997 New York The Guildford Press:326–42
40. Craig L, Beech A, Browne KD. Evaluating the predictive accuracy of se offender risk assessment measures on UK samples: A cross validation of the risk matrix 2000 scales Sex Offender Treat. 2006;1:1–15
41. Beech A, Friendship C, Erikson M, Hanson RK. The relationship between static and dynamic risk factors and reconviction in a sample of UK child abusers Sex Abuse. 2002;14:155–67
42. Barker J, Howell RJ. The plethysmograph: A review of recent literature Bull Am Acad Psychiatry Law. 1992;20:13–25
43. Simon WT, Schouten PG. The plethysmograph reconsidered: Comments on Barker and Howell Bull Am Acad Psychiatry Law. 1993;21:505–12
44. Launay G. The phallometric assessment of sex offenders
: An update Crim Behav Ment Health. 1999;9:254–74
45. Frances A, Sreenivasan S, Weinberger LE. Defining mental disorder when it really counts: DSM-IV-TR and SVP/SDP statutes J Am Acad Psychiatry Law. 2008;36:375–84
46. Doren D. Evaluating sex offenders
: A manual for civil commitments and beyond 2002 Thousand Oaks Sage Publishers
47. Zander T. Commentary: Inventing diagnosis for civil commitment for rapists J Am Acad Psychiatry Law. 2008;36:459–69
48. Weinstock R, Gold LSimon R, Gold L. Ethics in Forensic Psychiatry Forensic Psychiatry: The Clinician's Guide. 2004 Washington DC American Psychaitric Publishing:91–115
49. Stone AA. The ethical boundaries of forensic psychiatry: A view from the ivory tower Bull Am Acad Psychiatry Law. 1984;12:209–19
50. Sarkar JAgrawal N, Bolton J, Gaind R. Public health psychiatry in criminal justice states Current Themes in Psychiatry: In Theory and Practice: In Theory and Practice. 2011 London Palgrave Macmillan:18–36
Source of Support: Nil
Conflict of Interest: None declared