When medicine reaches a dead end

Psychiatrists are thinking of classifying habitual rapists as victims of Paraphilic Coercive Disorder. This doesn't even help the criminals. 
Theron Bowers | Apr 23 2010 | comment  

from New York Times

How many psychiatrists does it take to change a light bulb?
One, but only if the light bulb wants to change.

Money, either the love of it or the lack of it, is the modern explanation for evil. Eliminating poverty will solve both terrorism and muggings. But sex crimes defy a materialist’s universal financial fix. Even Marx couldn’t argue that men who molest children are simply trying to feed their family.

It was Sigmund Freud who provided the beginning of a “scientific” solution for evil. He argued that all of human behaviour ultimately had a sexual explanation. Alfred Kinsey’s popular -- but later discredited --work was an application of this insight which developed into a “scientific” discipline of sexology. The correct kind of sex therapy, he contended, could amend deviant and criminal sexual behaviour.

There are few crimes which are more evil than rape. But now the American Psychiatric Association (APA) is trying to decide whether rapists are evil or sick. The upcoming Diagnostic and Statistical Manual (DSM-5), psychiatry’s lexicon of mental disorders, may list a compulsive desire to rape as a mental illness. It would be called Paraphilic Coercive Disorder.

Is giving rape a fancy label the best way for society to deal with the problem of sexual violence? I would say No, for several reasons.

First of all, even though the number of sexual illnesses in the psychiatric handbooks has grown, therapy has proven unsuccessful. For several decades, until the 1990s, therapists used Freudian, psychoanalytic or behavioral techniques. Doctors pronounced that criminals were cured and encouraged them to return to their communities.

Unhappily, when researchers got around to evaluating these therapies, no one could demonstrate that they had succeeded. The same doctors who had proclaimed that sex offenders could be cured then announced that sex offenders couldn’t be cured. Dr Fred Berlin, the founder of the Sexual Disorders Clinic at John Hopkins University, even made a public apology for claiming cures. Berlin went on to write a letter to the American Psychiatric Association arguing that an offender’s proclivities, including pedophilia, were simply sexual orientations which cannot be changed.

Second, treating rape (and other sexual crimes) as medical problems means that you have to place the patients in hospitals. Except that they have to be special hospitals, jail-lite institutions called civil commitment. This is an alternative in about 20 US states. Offenders who are unable to control their impulses live in a pleasant environment with paintings and pool tables and TV where they can get “relapse prevention treatment” -- training offenders to recognize triggers which cause the behavior and how to avoid bad thoughts and habits. Since 1990, 3,000 sex offenders have been committed for treatment in the US.

The problem is that only a few of the offenders have ever been released. Since 1994, sex offenders can be treated for life under civil commitment statutes. In 1994, the Supreme Court ruled that indefinite commitment for sex offenders was constitutional. Three years ago, the New York Times reviewed the policy of civil commitment for sexual predators. It found that it was expensive and ineffective. Civil commitment programs cost about four times (US$100,000 annually) as much as incarceration ($25,000 annually).

Octogenarian sex offenders rolling in wheelchairs on oxygen are kept in civil commitment or prison well beyond the time that they pose a threat or danger to anyone.

The programs are a bizarre combination of prison, psychiatric hospital and nursing home. The Times illustrated a chaotic environment at some centers, where custodians ignore rule-breaking prisoners and female employees are merely quietly dismissed after having had sex with inmates.

Legal risks are a barrier to treatment. Most of the patients under civil commitment refuse to attend therapy groups under the advice of their attorneys who are concerned that any revelations in therapy may result in longer jail time.

Furthermore, even an A+ student can flunk the exam outside of prison. The New York Times reviewed treatment for sex crimes and reported on the disturbing case of Michael Renaud Jackson, a felon who had spent 12 years in prison and 5 years in civil commitment. Jackson, who had reached the highest level of the relapse prevention program, raped and killed a young woman 2 years after his release.

Third, a taste for sexual crimes is not like a disease. People want to be cured of diseases. This is not necessarily true of sex offenders. Often therapists are only assuming that the patient (aka the criminal) believes that he is ill and wants treatment. Their tragic patient is like the mythical wolf-man, dangerous and passion-driven but tortured. His deep guilt has made him ready make any sacrifice, even death for a cure. “Who in their right mind would be sexually attracted to young children?” asks Fred Berlin in USA Today.

Well, the numbers of such people are not high, but they are sane enough to form groups like the North American Man Boy Love Association.

While Dr. Berlin believes that child molesters are obviously sick, the pedophile may not agree. When I was starting my career, I consulted for a program which treated recently released drug addicts and sex offenders. One parolee looked like a very ordinary guy. Jim (not his real name) was a slender middle-aged Caucasian with a few brown strands of hair covering his bald dome. He lacked the usual adornment of five tattoos and earrings. Jim could have easily been the checker at my local grocery store or a shoe salesman.

Most child molesters are not paedophiles (adults sexually attracted to prepubescent children) but older men seeking teenagers. Jim was a paedophile and defended paedophilia to me very cogently. In professorial tones he contended that unlike Europeans, Americans were unenlightened. Children were better treated by the molesters than by their parents. The trauma was entirely due to the legal system. He even told me that 5-year-old children could consent to sexual activity.

Can self-deception be treated with medication? With counselling? With discussion groups?

Finally, there’s a practical problem with a diagnosis of Paraphilic Coercive Disorder. To demonstrate that he has it, a patient must have committed three acts of rape. Being sick may keep him out of jail for ten years but it could put him in a civil commitment facility for life. It is the psychiatric equivalent of the Three Strike laws common in many states for habitual criminals. Writing in the Psychiatric Times, Dr Allen Frances, the architect behind the last DSM, doubts that any rapist would be crazy enough to admit to more rapes and subject themselves to the limbo of civil commitment.

It’s about time that the psychiatric profession recognizes that ultimately evil is beyond its powers to treat. Evil may co-exist with treatable mental illness but only spiritual remedies are capable of redeeming people from a will with unspeakable cravings. Dr Matthew Carroll, a psychiatrist who evaluated John Gardner, the recently confessed killer of 17-year-old California girl Chelsea King, several years ago reported that the felon “would not be amenable to treatment.”

Carroll’s assessment was not based on sophisticated medical technology or preternatural psychiatric insights. Instead, he pointed out what is blindingly obvious, “There is no known treatment for a person who sexually assaults girls and does not admit to it.” Gardner, he said, was “simply a bad guy who is inordinately interested in young girls.”

Sexual predators are like other criminals. They are responsible for their actions. They can’t be cured but they can change. Medicine will never have the silver bullet to change a soul. Hopefully, the APA will recognize the limits of psychiatry and not misdiagnose another crime as a disease.

Theron Bowers MD is a Texas psychiatrist.

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