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The Health Agenda, Volume 3. Issue 2. April, 2015

EDITORIAL Psychosocial intervention of sexual offenders Authors: Prakash B Behere, Akshata N Mulmule, Shib Sekhar Datta Corresponding author: Dr. Prakash P Behere Professor and Head, Dept. of Psychiatry Jawaharlal Nehru Medical College Wardha, Maharashtra, India - 442004 Mail ID: [email protected] ABSTRACT Extensive research over the past many years suggests that several mental health issues underlie sexual violence and offending. Sexual offences are on the rise and recent media-hyped occurrences have shifted the focus on them; with the government, the law makers, the victims and their kin as well as the public at large seeking a comprehensive way to tackle the problem by minimizing its occurrence as well as punishing and/or committing to treat and change the offenders. Sexual offences range from rapes to different paraphilias, although represent a group of similar offences, but even minor differences in them warrant a separate look at each one of them. They can neither be collectively subjected to a generalized punishment nor to any form of treatment in particular. The offenders are often the victims themselves of mental illnesses, mental retardation or are suffering from certain organic disorders impairing their judgment. Some of them are suffering from sexual perversions. Also, recidivism is another problem that needs to be looked at separately. Indicators of recidivism have been studied and we need to implement these research findings while addressing the problem of sexual offenders. Here, we reflect at these various issues and comment on the Indian scenario. Key words: Prevention, Psychosocial Intervention, Sex offenders INTRODUCTION What is perceived as a sexual assault varies with culture and is influenced by the relationship between the victim and the perpetrator. (1) Rape in broad sense has been defined as forced sexual intercourse including both psychological coercion as well as physical force. Forced sexual intercourse means penetration by the offender. It includes attempted rapes, male as well as female victims, both heterosexual and homosexual rape. Attempted rape includes verbal threats of rape. ‘Sexual assault’ is a broader term and is defined as a wide range of victimizations, separate from rape or attempted rape. These crimes include attacks or attempted attacks generally involving unwanted sexual contact between victim and offender. Sexual assaults may or may not involve force and include such things as grabbing or fondling and also includes verbal threats. (2)

Not only has defining sexual offences been controversial, but also, dealing with sexual offenders has been a debatable issue. There are people demanding outright punishments for these offenders while others are of the opinion that they should be instead be referred for compulsory treatment. This leads to the need for standardized assessments of these offenders. The current laws in India lack such provisions. Here, we highlight few suggestions regarding same and how to prevent further sex offences. Current Indian Scenario Rape is defined according to Section 375 of the IPC. Before 3 February 2013, it was considered that penetration is sufficient to constitute the sexual intercourse necessary to the offence of rape. Exception to this is sexual intercourse by a man with his wife, who is not under fifteen years of age, is not considered as rape. It also fails to take same sex crimes under consideration. (3) Page | 30

The Health Agenda, Online ISSN No: 2320-3749

Behere PB, Mulmule AN, Datta SS: Psychosocial intervention of sexual offenders However, after 3 February 2013, the definition was expanded to include same sex crimes and raised the age of consent to age 18 years. Thus, rape is now included as a crime of sexual assault, which is currently defined for the purposes of Indian penal code (IPC) as: A person is said to commit ‘sexual assault’ if that person; (a) penetrates his penis, to any extent, into the vagina, mouth, urethra or anus of another person or makes the person to do so with him or any other person; or (b) inserts, to any extent, any object or a part of the body, not being the penis, into the vagina, the urethra or anus of another person or makes the person to do so with him or any other person; or (c) manipulates any part of the body of another person so as to cause penetration into the vagina, urethra, anus or any part of body of such person or makes the person to do so with him or any other person; or (d) applies his mouth to the penis, vagina, anus, urethra of another person or makes such person to do so with him or any other person; (e) touches the vagina, penis, anus or breast of the person or makes the person touch the vagina, penis, anus or breast of that person or any other person, except where such penetration or touching is carried out for proper hygienic or medical purposes under the circumstances falling under any of the following seven descriptions; 1. against the other person's will, 2. without the other person's consent. 3. with the other person's consent when such consent has been obtained by putting such other person or any person in whom such other person is interested, in fear of death or of hurt, 4. when the person assaulted is a female, with her consent, when the man knows that he is not her husband and that her consent is given because she believes that he is another man to whom she is or believes to be lawfully married, 5. with the consent of the other person when, at the time of giving such consent, by reason of unsoundness of mind or intoxication or the administration by that person personally or through another of any stupefying or unwholesome substance, the other person is unable to understand the nature and consequences of that action to which such other

person gives consent, 6. with or without the other person's consent, when such other person is under eighteen years of age, 7. when the person is unable to communicate consent. It was mentioned under law that penetration to any extent is ‘penetration’ for the purposes of this section; for the purposes of this section, ‘vagina’ shall also include labia majora; ‘consent’ means an unequivocal voluntary agreement when the person by words, gestures or any form of nonverbal communication, communicates willingness to participate in the specific act; provided that, a person who does not physically resist to the act of penetration shall not by the reason only of that fact, be regarded as consenting to the sexual activity, sexual intercourse or sexual acts by a man with his own wife, the wife not being under sixteen years of age, is not sexual assault. (4) Except in certain aggravated situation the punishment will be imprisonment not less than seven years but which may extend to imprisonment for life, and shall also be liable to fine. In aggravated situations, punishment will be rigorous imprisonment for a term which shall not be less than ten years but which may extend to imprisonment for life, and shall also be liable to fine. A new section, 376A has been added which states that if a person committing the offence of sexual assault, ‘inflicts an injury which causes the death of the person or causes the person to be in a persistent vegetative state, shall be punished with rigorous imprisonment for a term which shall not be less than twenty years, but which may extend to imprisonment for life, which shall mean the remainder of that person’s natural life, or with death. In the case of ‘gang rape’, persons involved regardless of their gender shall be punished with rigorous imprisonment for a term which shall not be less than twenty years, but which may extend to life and shall pay compensation to the victim, which shall be reasonable to meet the medical expenses and rehabilitation of the victim. (5) The rate of rape in India as per the recent crime census was 2.0% which amounts to a staggering 24,206 incidents of the heinous crime in the country. (6) Moreover, lack of specific data for the Page | 31

The Health Agenda, Volume 3. Issue 2. April, 2015 recidivism regarding sexual offences points towards the attitude of the judiciary, lacking the right insight in the nature of these crimes and ignoring the fact that whether the punishments being meted out are succeeding or failing in preventing the criminal from re-committing it either voluntarily or by virtue of any of his illnesses. There exist no concrete mechanisms for such cases who are habitual offenders and only difference noted in their proceedings is a harsher punishment than a first time offender. Recent interview by BBC Channel 4 of one of the sex offenders of Delhi ‘Nirbharya’ case of December 16, 2012 outraged Government of India and public. Role of mental health in sexual offences in India There is a big question when issues regarding sexual offences are considered with regards to India. It has been lamented that forensic psychiatry, the profession that is directly implicated in this type of work, does not exist as a specialty in India. (7) However, some general psychiatrists in various institutions deal with the courts and police. 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 he gets it wrong.

sexual recidivism while controlling for overall risk. (8) A diagnosis of sadism in sexual offenders is commonly regarded as indicative of high risk for violent reoffending. The overall risk of sadists compared with non-sadists with respect to violent (including sexual contact) reoffending was slightly elevated, yet not significantly increased. Similarly, the risk of sexual reoffending among sadists was slightly, but not significantly, higher than among non-sadists. Only a measure of sadistic behavior, not the clinical diagnosis, was associated with violent reoffending. A clinical diagnosis of sexual sadism and behavioral measures of sadism are related to the risk of violent reoffending in sexual offenders. At the individual level, the risk for future violence in sadists can therefore be adequately described by customary risk assessment instruments. (9) Sexual recidivism occurred significantly later in the case of released offenders with aftercare treatment compared to those without. Moreover, for the duration of aftercare treatment the general risk of recidivism was approximately 85% lower; however, after termination of treatment the recidivism rates of both samples converged to almost the same level. Individually adapted measures should be maintained after finishing aftercare treatment; however, because prisoners released from prison are frequently less prepared than patients from forensic psychiatric hospitals, the therapeutic work often reaches its limits in these cases. Therefore, social work should be taken into account right from the start. (10)

Psychosocial intervention for offenders

2. Assessment of offenders

1. Recidivism and its prevention

Sexual offenders are often referred by courts for assessment to a psychiatrist. Assessment of the sexual offenders requires the psychiatrist to have been specially trained for the purpose. In India, however, there is no special training available at present but psychiatrists attached to public and general hospitals continue to deal with the perpetrators albeit in a self-designed way. The tools available for the assessment of these offenders are many, but their validation for the Indian scenario still remains a challenge.

Habitual or repetitive sexual offenders are seen all over but there exists no mechanism to have a check on such individuals in India. Risk assessments of all offenders in this regard might prove beneficial. Self-perceived protective strengths were significantly valid predictors for sexual, violent and general recidivism. In regression analyses, protective strengths accounted for a unique portion of the variance in

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Behere PB, Mulmule AN, Datta SS: Psychosocial intervention of sexual offenders The offenders of sexual assaults are as expected guarded and refuse the charges completely. They may present as non-cooperative, hostile, disinterested, anxious or intimidated at the initial assessment. The assessor’s job is to break the ice with a combination of unconditional positive regard, definition of the framework he will be adopting in the assessment, his role, the extent of information that has already been provided by the court, the absence of the usual confidentiality ethics and other such queries that may arise and thus try to establish rapport on the foundation of honesty. Nothing can substitute a good clinical interview for establishing the basic facts and to engage a patient into further assessments using questionnaires and some invasive procedures. The assessment should include risk assessments. The ‘Risk Matrix’ is the usually used tool for this purpose. (11) Some of the other well-validated instruments used for risk assessments include sex offender risk appraisal guide (12), Static-99, (13) and sexual violence risk. (14) Besides these, psychological tests are commonly done to assess the static as well as the dynamic risk factors in the offenders. Invasive tests like penile plethysmography have been a subject of debate, but their use is increasing all over to assess the arousal of the offenders to various sexual stimuli. (15) 3. Suggestions for handling sexual offenders Those charged with sexual offences should be handled in courts by a slightly different procedure from the one which is used for other accused persons, in view of the discussed medical and psychiatric aspects. In regard to sexual offenders, punishment without treatment is not likely to have any beneficial effect; indeed, it can make these offenders even worse and thus increase the rates of recidivism. Thus, the ill effects of not treating these offenders might be then born by both the individual as well as more so by the

community at large. Sexual offences lead to a deep rooted psychological trauma to the victims and this may not be apparent at the outset. So the gravity of the trauma caused both physical as well as psychological may be underestimated and the offenders might be treated in a lenient way. Hence, dealing with the offenders from a remedial point of view is essential. The recent rise in sexual offences in our country has made it a need of the hour to approach this problem collectively and from all directions. This requires concentrated efforts not only from institutions and organizations, but also from individuals as members of that society, as sexual offenders often have mental-health and psychosocial risk factors that incite, maintain and perpetuate the offence. Psychiatry can play both a constructive and educative role as well as assist the criminal justice agencies in managing this mammoth issue. 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. (14) In doing so, the discipline and its practitioners must be aware of the ethical and moral principles that govern their actions as doctors and as careers 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. (16) Psychiatrists are first and foremost doctors and should work within the ethical principles of ‘beneficence’ and ‘nonmaleficence’, which is doing good and avoiding harm. (17) However, their involvement can be ethically justified by arguing that by detaining and treating the patient, the psychiatrist is helping the person, which otherwise would not have been possible.

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The Health Agenda, Volume 3. Issue 2. April, 2015 REFERENCES 1.

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13. Hanson RK, Thornton D. Static-99: Improving actuarial risk assessments for sex offenders, User Report 99-02. Ottawa: Department of the Solicitor General of Canada; 1999. 14. Sarkar J. Mental health assessment of rape offenders. Indian J Psychiatry. 2013;55(3): 235-43. 15. Boer D, Wilson R, Gauthier C, Hart S. Assessing risk of sexual violence: Guideline for clinical practice. In: Webster C, Jackson M, editors. Impulsivity: Theory, assessment and treatment. New York: The Guildford Press; 1997. 326-42. 16. Sarkar J. Short-term management of self-harm in secure services. Adv Psychiatr Treat. 2011;17(6):435-46. 17. Weinstock R, Gold L. Ethics in Forensic Psychiatry. In: Simon R, Gold L, editors. Forensic Psychiatry: The Clinician's Guide. Washington DC: American Psychiatric Publishing; 2004. 91-115.

Particulars of authors: Dr. Prakash P Behere, recipient of Dr. B. C. Roy National Award, is Director (Research and Development) at Jawaharlal Nehru Medical College, Wardha; visiting Professor at University of Chester, UK; adjunct Faculty, Georgia Southern University, USA; and Chairman, Rehabilitation Psychiatry and Indian Psychiatric Society. Dr. Akshata N Mulmule; Resident, Dept. of Psychiatry, Jawaharlal Nehru Medical College, Wardha. Dr. Shib Sekhar Datta; Associate Professor, Dept. of Community Medicine, Tripura Medical College and Dr. BRAM Teaching Hospital, Agartala, Tripura and Chief Editor, The Health Agenda journal. Page | 34