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Ethical Treatment of Sex Offenders: A Hypocrite s Oath Renee Sorrentino, MD Institute for Sexual Wellness Instructor, Harvard Medical School www ... – PowerPoint PPT presentation

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Title: Renee Sorrentino, MD

Ethical Treatment of Sex Offenders A Hypocrites
Renee Sorrentino, MD Institute for Sexual
Wellness Instructor, Harvard Medical
Survey of Audience
  • Treating sex offenders is unethical under the
    standard professional guidelines for clinicians
  • Treating sex offenders is ethical under the
    standard professional guidelines for clinicians

  1. Review of the Ethical Principles of Medicine
  2. Beneficence
  3. Confidentiality and privilege
  4. Informed consent
  5. Involuntary treatment
  6. Right to refuse treatment
  7. Application of Ethical Principles to Sex
  8. Case Studies
  9. Conclusion

Code of Medical Ethics
  • Beneficence
  • Welfare of the patient is paramount
  • Non-maleficence
  • Avoiding harm
  • Respect for autonomy
  • Informed consent
  • Justice
  • Patient is treated fairly, equitably, and in
    accordance with his rights and entitlement

Hippocratic Oath
  • I SWEAR by Apollo the physician, AEsculapius, and
    Health, and All-heal, and all the gods and
    goddesses, that, according to my ability and
    judgment, I will keep this Oath and this
  • I WILL FOLLOW that system of regimen which,
    according to my ability and judgment, I consider
    for the benefit of my patients, and abstain from
    whatever is deleterious and mischievous.

  • WHATEVER, IN CONNECTION with my professional
    practice or not, in connection with it, I see or
    hear, in the life of men, which ought not to be
    spoken of abroad, I will not divulge, as
    reckoning that all such should be kept secret.
  • WHILE I CONTINUE to keep this Oath unviolated,
    may it be granted to me to enjoy life and the
    practice of the art, respected by all men, in all
    times! But should I trespass and violate this
    Oath, may the reverse be my lot!

Hippocratic Oath
Duty of Confidentiality
  • You have a duty as a clinician to respect the
    patient's trust and keep this information
  • This requires the clinician to respect the
    patient's privacy by restricting access of others
    to that information.
  • Such a duty facilitates a trusting environment by
    respecting patient privacy thereby encouraging
    the patient to be honest.

Exceptions to Confidentiality
  • Concern for the safety of other specific persons
  • Legal
  • Abuse (child or elder)
  • Therapeutic privilege

  • Respect for the individuals right of privacy
    and the maintenance of confidentiality are major
    concernsthe psychiatrist maintains
    confidentiality to the extent possible given the
    legal context.
  • Forensic evaluations are exceptions to the rules
    of confidentiality.
  • AAPL Ethical Guidelines

Confidentiality Sex Offender
  • Confidentiality is not maintained in sex offender
  • Individuals are asked to consent to limited
    confidentiality upon entry into treatment.
  • Individuals may be denied treatment if they do
    not consent to limited confidentiality.

Confidentiality Sex Offender
  • What happened to beneficence and the Hippocratic
  • Effective treatment requires confidentiality be
  • Effective treatment requires clinicians to
    corroborate with corrections officers, family,
    and parole officers.

Confidentiality Sex Offender
  • Is the clinician a treatment provider or public
  • Is the primary role of treatment to benefit the
    patient or to protect the public?
  • Both are required, and therefore clinical input
    will usually be most effective when delivered as
    part of a team approach.

Case Confidentiality
  • Mr. Father is a 24 yo married man who lives with
    his wife in the community.
  • Mr. Father served 5 for Indecent Assault and
    Battery on A Minor.
  • Mr. Father is currently attending sex offender
    treatment as a condition of his probation.
  • Mr. Father agrees with the diagnosis of
    pedophilia (sexual interest in preschool girls).

Case Confidentiality
  • Mr. Father has been a model patient.
  • Mr. Father reports a significant reduction in
    deviant sexual fantasies as a result of therapy.
  • Mr. Father and his wife have decided to have a
  • You discuss with both Mr. Father and his wife
    your concerns regarding their decision to have a

Case Confidentiality
  • Mr. Fathers case is not one of the exceptions to
  • Breaching confidentiality violates the
    non-maleficence code of ethics (i.e. avoiding
    harm to the patient).
  • Therefore it would be unethical to breach
  • Is it ethical to terminate with Mr. Father?

Yes, especially if you have strong
countertransferential feelings. You have an
obligation to refer him to a competent clinician.
Case Confidentiality
  • You are one of three psychiatrists in the state
    that treats sex offenders
  • Your colleagues (the other 2) are not accepting
    new patients
  • Is it ethical to terminate with Mr. Father?

Yes. You must refer him to another competent
Informed Consent
  • Informed consent is the process by which a fully
    informed patient can participate in choices about
    his health care.
  • Originates from
  • legal and ethical right the patient has to direct
    what happens to his body
  • the ethical duty of the physician to involve the
    patient in his health care

Elements of Informed Consent
  • Informational
  • the nature of the decision/procedure
  • reasonable alternatives to the proposed
  • the relevant risks, benefits, and uncertainties
    related to each alternative
  • Competent
  • Manipulation of information
  • Voluntary
  • Reliable

Case Informed Consent
  • Mr. Release is a 38 yo single, man who pled
    guilty to Rape Of A Child.
  • Mr. Release is currently incarcerated but
    eligible for parole in 3 months.
  • Mr. Release is requesting Lupron treatment to
    decrease his pedophilic urges.
  • Mr. Release refused Lupron treatment when offered
    in the past (while in the community).

Case Informed Consent
  • Mr. Release is evaluated for his capacity to
    provide informed consent for treatment
  • Mr. Release understands the treatment, including
    the risks and benefits of treatment vs.
  • When asked why he wants Lupron treatment, Mr.
    Release stated to get the hell out of here and
    never come back. Ive been asking for it for the
    past 6 months.

Case Informed Consent
  • You ask Mr. Release why he refused Lupron in the
    community. He states, I wouldnt take it if I
    didnt have to. That stuff is risky. I just
    want to get paroled.
  • You ask Mr. Release if he would accept Lupron if
    it did not relate to his possible parole. He
    states, Check my past. That will tell you how I

Case Informed Consent
  • Does Mr. Release demonstrate the capacity to give
    informed consent regarding Lupron treatment?
  • Does he understand the proposed treatment? Risk
    and benefits of treatment and withholding
    treatment? Alternative treatments?
  • Is his decision consistent and reliable?
  • Is his decision voluntary, free of coercion?

No. Mr. Release is choosing Lupron treatment
because he thinks it will be viewed positively by
the parole board.
Case Informed Consent
  • You contact Mr. Release attorney to share your
    opinion that Mr. Release cannot give informed
  • The attorney tells you the only chance this man
    has to get out of here is with Lupron. Its not
    ethical of you to deprive him of his right to be
    a free man.
  • You agree with the attorneys statement that Mr.
    Release release is influenced by his decision to
    accept Lupron.

Case Informed Consent
  • Is it ethical to refuse to treat Mr. Release on
    the basis that you would deprive him of a
    reasonable chance of release (freedom)?

No, it is unethical to prescribe to an individual
who cannot give informed consent. You could allow
the Judge to decide by presenting all the data.
In the absence of informed consent, the Judge may
use substituted judgment.
Chemical Castration
Voluntary Treatment
  • Based on respect for individuals autonomy
  • Founded in constitutional rights
  • Individuals can choose to pursue or reject

History of Chemical Castration
  • By
  • Sara Moore, M.A.
  • Massachusetts School of Professional Psychology

Keeper of the Bed
  • Eunuchs have been in existence since the 9th
    Century BC.
  • Castrated men in China were in high demand to
    guard the grand palace and royal quarters.
  • In 1996, the last noble servant passed away at
    the age of 94.

  • India is the only country where castration is
    still practiced.
  • No one in the community wants to be accosted by
    one of them for fear of a curse however, they
    are invited to bless childbirths, weddings,
    housewarmings, and other occasions.

  • During the 18th Century, young males who sang in
    the choir were castrated to prevent the onset of
  • Churches used prepubescent boys to sing the
    soprano sections and those displaying a voice fit
    for the opera were selected and castrated.

Social Control
Chemical Castration and the 20th Century
  • The first reported use of hormonotherapy to
    reduce recidivism was in 1944. Men were
    prescribed medicine to lower their testosterone.
  • In 1960s, German physicians prescribed
    antiandrogens to limit male paraphilic behavior.

In the US
  • In 1966, researcher John Money because the first
    to use medroxyprogesterone acetate (MPA) in the
    treatment sexual offenders.
  • He administered the drug to a bisexual
    transvestite who was in therapy for pedophilic
    behavior with his six-year-old son.

State Laws
  • Some states authorize castration for certain
    sexual offenders who are being released back into
    the community.
  • The two forms of castration are either surgical
    castration or chemical.
  • Surgical Castration the removal of the testes
    in an effort to reduce the available androgen
  • Chemical Castration prescribing either an
    antiandrogen or hormonal medication to decrease
    testosterone production

Which States?The following states offer some
form of castration
  • California either chemical or surgical
  • Florida either chemical or surgical castration
  • Iowa either chemical or surgical castration
  • Louisiana either chemical or surgical castration
  • Georgia chemical castration
  • Montana chemical castration
  • Oregon chemical castration
  • Wisconsin chemical castration
  • Texas voluntary surgical castration

Ethical Considerations
  • 1) The states do not agree on what chemical
    agents should be used for treatment.
  • 7 states identify the use of MPA as a treatment
  • 7 permit the use of use of MPA plus other
    pharmaceutical agents
  • 2) Requirement of a medical or psychiatric
    evaluation differs among the nine states.
  • California is the only state that does not
    require an evaluation of any kind prior to

Ethical Considerations
  • 3) How the states address informed consent.
  • Iowa, Florida, and Oregon do not address
  • Five states require that that the offender be
    informed of the side effects and of those five,
    three states require the offender to acknowledge
    receipt of this information.
  • Texas requires the most for obtaining informed
    consent for treatment.
  • 1) the offender must be 21 years or older
  • 2) the offender must meet with a psychiatrist or
  • 3) the offender is then monitored by someone to
    ensure the offenders consent is informed and
  • 4) the offender must request surgical castration
    in writing
  • 5) the offender has the right to change his mind
    at any time
  • 6) should the offender withdraw his request, he
    is no longer eligible for surgical castration in
    the future

Ethical Considerations
  • 4) Whether or not psychological treatment is
  • Seven of the nine states do not require
    additional therapy other than some form of
  • 5) The specific length of chemical treatment
    required by the 8 states.
  • To stop treatment 6 of the 8 states require that
    the state or offender demonstrate that chemical
    castration is no longer necessary.
  • 6) The last component deals with liability
  • 6 of the 9 statutes do not state whether the
    treatment providers are held liable if following
    the standards of the law in their state.

Forensic Implications
  • Infringement on the sexual offenders First
    Amendment right
  • Violation of the Eighth Amendment
  • A challenge to the Fourteen Amendment

The First Amendment
  • The First Amendment protects a persons freedom
    of speech, which the Supreme Court has generally
    held to include the right to generate ideas,
    regardless of their social worth.
  • Opponents argue that castration reduces or
    eliminates deviant sexual thoughts and fantasies
    and therefore violates the sexual offenders
    right to entertain sexual fantasies.
  • Proponents challenge this argument by noting that
    sexual offenders have demonstrated their
    inability to control their fantasies and as a
    result have committed a sex crime.

The Eighth Amendment
  • The Eighth Amendment bans the use of cruel and
    unusual punishment.
  • The Supreme Court assesses three questions when
    determining if the punishment violates the Eighth
  • 1) Is the punishment inherently cruel or
  • 2) Is the punishment or condition proportional to
    the crime?
  • 3) Can the state achieve its goal through less
    intrusive means?

The Eighth Amendment
  • Opponents argue that the laws are vindictive in
    nature and intend to inflict the same type of
    sexual brutality on the offender that he
    inflicted on his victim.
  • Proponents do not consider the use of
    antiandrogens as cruel since the treatment
    decreases the likelihood of further crimes/future
    punishments and permits the offender to have
    increased freedom as a result of the treatment.

The Fourteenth Amendment
  • Fourteenth Amendment protects the individuals
    life, liberty, or property from the state
    without due process of the law.
  • The U.S. Supreme Court analyzes four general
    considerations when an inmate refuses treatment.
  • 1) It must be determined that the inmate suffers
    from a mental illness or abnormality.
  • 2) Treatment proposed must be in the inmates
    medical interest.
  • 3) Must consider the safety of the inmate and
    the safety of others.
  • 4) There cannot be any less intrusive
    alternatives to treatment.

The Fourteenth Amendment
  • Opponents argue that committing a sex offense
    does not necessarily indicate the existence of a
    mental disease or abnormality and may not be in
    the inmates best medical interest.
  • Proponents argue that requiring a dangerous sex
    offender to be castrated as a condition of
    release serves an important interest in
    preventing that individual from committing
    another sex crime.
  • Surgical chemical castration treatment prevents
    further victimization and is a less restrictive
    means for the government to accomplish its goal.

  • Eunuchs Indias third gender (2002). Things
    Asian. Retrieved March 13, 2010 from
  • La Fond, J. Q. (2005). Should sex offenders be
    castrated Preventing sexual violence How
    society should cope with sex offenders (pp.
    167-200) Washington, DC American Psychological
  • Scott, C. L. Holmberg, T. ( 2003). Castration
    of sex offenders Prisoners rights versus
    public safety. Sexual Abuse The Journal of the
    American Academy of Psychiatry and Law, 314,
  • Sorrentino, R. (2008). Legal and privacy issues
    surrounding sexual disorders. In D. L. Rowland
    L Incrocci (Eds.), Handbook of Sexual and Gender
    Identity Disorders (pp. 603-621) Hoboken, NJ
    John Wiley Sons, Inc.
  • Sorrentino, R. (2008). Paraphilias. In B.
    Sadock, V. Sadock, P. Ruiz (Eds.), Kaplan and
    Sadock (pp. 2090-2102) New York, NY Lippincott
    Williams Wilkins.

Voluntary Treatment Sex Offenders
  • Voluntary treatment is rarely free of coercion
  • Refusal to choose treatment may affect
  • Parole decisions
  • Limitations in visits
  • Reduction of good time credits
  • Restriction from lower security placement
  • Referral to a denial phase of treatment

Case Involuntary Treatment
  • Mr. Down has been court ordered to participate in
    sex offender treatment.
  • Mr. Down accepted a plea bargain, pleading guilty
    to Lewd and Lascivious Behavior relating to his
    masturbating in front of a 10 yo neighbor girl.
  • Mr. Down stated that he was masturbating in his
    bathroom when his 10 yo neighbor girl opened the

Case Involuntary Treatment
  • Mr. Down does not have a history of sex offenses.
  • Mr. Down completed a comprehensive sex offender
    evaluation which revealed a negative PPG, ABEL
    and polygraphy.
  • You have determined that Mr. Down does not have a
    paraphilia or problematic sexual behavior.
  • You have determined, however, that Mr. Down
    suffers from depression. You treat Mr. Down for

Case Involuntary Treatment
  • You routinely provide letters to the Probation
    Officer that Mr. Down is compliant with
  • 3 months later, Mr. Downs probation officer
    calls for a detailed update.
  • You inform the probation officer that Mr. Down is
    not in sex offender treatment but is receiving
    treatment for depression.
  • The probation officer violates Mr. Downs as
    noncompliant with sex offender treatment.

Case Involuntary Treatment
  • Was your treatment of Mr. Down ethical?

Case Involuntary Treatment
  • Was your treatment of Mr. Down ethical?
  • No. Mr. Down was referred to you for sex
    offender treatment. You choose to provide him
    with treatment for depression.
  • You do not have the ability to authorize
    treatment changes without the courts approval.
  • If you did not agree with sex offender
    treatments, you should have informed the courts

Right to Refuse Treatment
  • The right of a patient to refuse treatment is
    based upon five constitutional protections
  • 8th amendments protection against cruel and
    unusual punishment
  • 1st amendments protection of free speech
  • the 1st amendments protection of freedom of
  • the more broadly interpreted right to privacy
  • the 14th amendments protection of liberty (the
    right to be free from unjustified intrusions on
    personal security)

Right to Refuse Treatment
  • Sex offenders may be court order to treatment
  • As such, offenders do not have a right to refuse
  • Sex offenders are a distinct group in that they
    are not allowed to refuse treatment

Challenges to Treatment Ethics
  • Treatment is offered as a component of punishment
  • DOC programs, probation/parole conditions
  • Beneficence is incompatible with punishment

Mr. Lee
  • Referred to sex offender therapy as a condition
    of his probation.
  • 34 yo man, born and raised in China. He is a
    Buddhist and opposed to western medicine.
  • Requested an individual therapist who is
    knowledgeable about his culture.
  • Mr. Lees request was denied by the court.

Case Right to Refuse Treatment
  • Does Mr. Lee have a right to chose his treatment
  • Does Mr. Lee have a right to engage in and to
    terminate professional relationships?
  • Does the therapist have an ethical duty to
    promote the offenders right to
  • Is it ethical to force patients to adopt specific
    attitudes, values, and behaviors determined
    largely by the therapist?

Case Right to Refuse Treatment
  • Is it ethical to force patients to adopt specific
    attitudes, values, and behaviors determined
    largely by the therapist?
  • Mr. Lees treatment will be influenced by the
    therapists attitude and values.
  • What about therapeutic alliance?
  • Effects whether the patient advances or fails
    treatment by setting up goals which may not be
    relevant and

Case Right to Refuse Treatment
  • Is it ethical to force patients to adopt specific
    attitudes, values, and behaviors determined
    largely by the therapist?
  • If Mr. Lee is competent, he can chose the
    treatment/treater of his choice except in the are
    of sex offender treatment.
  • Sex offenders do not have a choice about
    treatment or treaters regardless of competency.

Case Right to Refuse Treatment
  • Mr. Eskimo has been court mandated to receive
    Lupron treatment as part of his probation.
  • Mr. Eskimo has been diagnosed with Klinefelters
    syndrome (genetic disorder), pedophilia and
    sexual sadism.
  • He requested data about the efficacy of Lupron in
    Eskimos with Klinefelters syndrome and
  • You tell Mr. Eskimo that there is no data for
    this patient population.

Case Right to Refuse Treatment
  • Mr. Eskimo asks your medical opinion about the
    efficacy and safety of Lupron in his case?
  • You tell Mr. Eskimo you can only theorize and do
    not have evidence to support you theory?
  • Is it ethical to prescribe Lupron in this case?
  • Mr. Eskimo cannot give informed consent since the
    efficacy of Lupron in his case are not known.

Case Surgical Castration
  • Mr. Cutit is a 30 yo man who is on parole, living
    in the community.
  • Mr. Cutit served 10 years for Rape of a Child.
  • Mr. Cutit has been attending a sex offender
    program since release.
  • Mr. Cutit has been a model patient.
  • Despite Mr. Cutits participation in treatment,
    he still experiences recurrent pedophilic urges.

Case Surgical Castration
  • Mr. Cutit is requesting surgical castration to
    diminish his pedophilic urges.
  • Mr. Cutit has failed treatment with multiple SSRI
  • Mr. Cutit states, I am tormented by these
    thoughts and I just want them to go away
  • Mr. Cutit refused hormonal agents stating, I
    want to absolute treatment. I dont want to take
    a medication.

Case Surgical Castration
  • Mr. Cutit has been provided literature about
    chemical castration. He continues to refuse
    chemical castration complaining of possible side
    effects and his determination for absolute
  • Mr. Cutit understands the indication,
    risks/benefits of surgical castration, possible
    alternatives. He demonstrates a consistent,
    voluntary decision to choose surgical castration.

Case Surgical Castration
  • Mr. Cutit demonstrates the capacity to provide
    informed consent for surgical castration.
  • Is it ethical to treat Mr. Cutit with surgical

Is surgical castration a reasonable
treatment? The treatment (castration) exceeds the
cure (decreased sex drive) Chemical castration is
equally efficacious and reversible There is no
scientific rationale for surgical castration
Case Chemical Castration
  • Mr. Opportunity is a 38 yo single man who served
    8 years for Indecent Assault and Battery on a
  • Mr. Opportunity is living in the community and
    attends sex offender therapy groups on a
    voluntary basis.
  • When he was incarcerated he learned that some sex
    offenders are court mandated to have chemical

Case Chemical Castration
  • Mr. Opportunity attended groups while
    incarcerated with individuals who received court
    ordered chemical castration.
  • Mr. Opportunity is requesting chemical castration
    as he believes it will decrease his sexual urges.
  • Mr. Opportunity demonstrates the capacity to make
    informed decisions regarding chemical castration.

Case Chemical Castration
  • Mr. Opportunity has been informed there are no
    community psychiatrists willing to provide
    chemical castration.
  • Mr. Opportunity contacted the DOC to inquire
    about psychiatrists who provide chemical
  • The DOC told him that psychiatrists are available
    only to SVPs

Case Chemical Castration
  • Is it ethical to offer treatment to SVPs and not
    community placed offenders?
  • Medical treatment should be available for all
  • An individual should be given the chance to
    participate in a treatment that has been shown to
    decrease sexually deviant thoughts.
  • If a medication reduces sexually deviant
    thoughts, it should be available to all who want
    and desire it.

Case Chemical Castration
  • In Paoli v. Gailey (MD)
  • DOC were told that they could not refuse to give
    MPA to an inmate who requested the treatment and
    was medically appropriate
  • McDonald v. Warden State Prison (CT)
  • DOC backed down in its refusal to supply an
    inmate with MPS when it hand no evidence to
    support why they denied it
  • Ohlinger v. Watson (9th Circuit)
  • Offender is entitled to the best opportunity for
    rehabilitation, regardless of cost, staff
    availability or facilities.

Case Mr. Gee
  • Mr. Gee is a 28 yo single, man with a 10 yr
    history of exhibitionism.
  • He has been incarcerated 4 times for this
  • Mr. Gee has been unsuccessfully treated with
  • Mr. Gee is requesting Lupron treatment for his
    uncontrollable urges to expose.

Case Off Label Use
  • Mr. Gee demonstrates the capacity to provide
    informed consent regarding the use of Lupron
  • Mr. Gee has been reading about Lupron and asks
    you for a reference regarding the use of Lupron
    for exhibitionism.
  • You tell Mr. Gee that there are research papers
    supporting this indication but no FDA approval.

Case Off Label Use
  • Mr. Gee looks worried and states Im taking a
    drug with serious adverse side effects that has
    not been FDA approved?
  • You tell Mr. Gee that Lupron has been FDA
    approved for other disorders but not for
  • Is it ethical to prescribe Lupron for an off
    label indication?

Are Ethical Codes Necessary?
Are Ethical Codes Necessary?
  • Ethical codes establish standards of conduct
  • Protection and promotion of particular
    professional groups
  • Establish a public commitment by a professional
    group to a particular set of standards and rules

Adopting a Framework
  • Conceptualize society as the patient
  • The ethical principles apply to the societal
  • The primary measure of treatment success is the
    protection of society
  • (not amelioration of the individuals condition)

Adapting a Framework
  • Paternalism
  • Provides a way for clinicians to adopt
    traditional codes of ethics
  • Specifics of the situation justify the dominance
    of one particular principle
  • Ultimately interested in the welfare of the
  • Promoted increased long-term autonomy

Adapting a Framework
  • Paternalism
  • Teach offenders to understand their patterns of
    behavior and to recognize the consequences
    thereby ultimately increasing the offenders
    capacity to make informed and rational life
  • I know whats best for you.

Adopting a Framework
  • ATSA has recognized the need for special ethical
    considerations when working with sex offenders
  • 1993 first developed guidelines
  • Endorses standards of professional conduct that
    represent a public commitment to clients and
    society toward the goal of preventing sexual

Evidence Based Arguments
  • Is compliance affected by informed consent?
  • Are voluntary patients more likely to comply with
    treatment compared with involuntary patients?

Evidence Based Arguments
  • Some studies (Maletzky, 1980) show that there is
    little difference in compliance between voluntary
    and involuntary patients
  • Does it matter whether we obtain informed consent
    if the outcome is the same?

  • The ethical issues that arise in the treatment of
    sex offenders are unique to this patient
  • The traditional codes of confidentiality,
    informed consent, beneficence, and justice are
    not applicable to the treatment of sex offenders
  • The ethical treatment of sex offenders requires a
    re-framing of traditional medical/therapist

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