Definitions of offences

It is generally recognized that there is a difficulty in delineating sexual offences because there can be a sexual motive to almost any offence.

Murder may have an overt or hidden sexual motive, ranging from the common case of jealousy or the desire to be rid of a sexual partner to the uncommon case of the necrophiliac...A fetishist may steal a sexual object...A peeper may enter a garden to spy on females undressing in a bedroom. He commits no offence, but by misunderstanding of his motives he may find himself charged with being on enclosed premises. (P

A paraphilia is defined in DSM-IV as 'when the behaviour is judged to cause clinically significant distress or impairment or involves children or non-consenting adults.' By comparison, a sexual offence is defined as an act which contravenes the law of that country—in the United Kingdom this is defined by Acts of Parliament (which include Section 31 of the Criminal Justice Act 1991, the Sexual Offences Act 1956, the Indecency with Children Act 1960, the Sexual Offences Act 1967, Section 54 of the Criminal Law Act 1977, the Protection of Children Act 1978, the Telecommunications Act 1984, and the Public Order Act 1986).

T§ble..,.1, sets out the clinical diagnosis according to DSM-IV and, where relevant, the corresponding offences under English law ( Table..,!).

Table 1 Clinical diagnosis according to DSM-IV and the corresponding offences under English law

From this table it will be seen that there is not a clear equivalence between diagnosis and the definition of an offence. This represents different categories of thinking and conceptual frameworks between lawyers and psychiatrists; this is a conflict which the psychiatrist has to accommodate frequently during treatment and an easy correspondence cannot be made.

This chapter considers the understanding of paraphilias by reviewing their interaction with psychiatric services in a chronological sequence. Committing the offence, arrest, and charge

Most sex offenders are dealt with solely through the criminal justice system. On certain occasions psychiatrists and other mental health professionals become involved in the assessment and management, including court disposal issues. Rarely, such offenders approach psychiatric services before being apprehended, i.e. they recognize that they need treatment for a compulsive action which they know to be illegal but for which they have not yet been caught; the motivation may be either the recognition of the compulsive nature of their acts, which causes subjective distress, or the fear of being caught. This latter form of presentation can be genuine or can serve as an 'insurance policy' for evidence of remorse should legal proceedings subsequently ensue. Here, as throughout, the clinician must be alive to the admixture of motives, both genuine and corrupt.

The psychiatrist's intervention may be requested by the police, prisons, or the patient's legal advocate because of concerns over the mental state in the period immediately following arrest. The concern is usually over the patient's suicidal intent which is supported by the very high instance of suicide by those held in prison on remand.(2)

It should always be borne in mind that a sexual offence may be a presentation of severe psychotic or organic illness rather than evidence of a paraphilia perse. Under these circumstances it is the psychiatrist's role to establish the presence of such illness and to arrange appropriate disposal under the Mental Health Act 1983 and/or treatment. For example, a person with incipient dementia who is charged with indecent exposure may well have the charges dropped against him or her as a result of prompt psychiatric intervention.

The majority of sex offenders are not acutely psychiatrically ill and thus are dealt with by the criminal justice system, as any other defendant. Figure 1 illustrates this process. Some of the details apply only to England and Wales, but the general features apply more widely.

Fig. 1 Pathways illustrating when psychiatric services can become involved in legal proceedings for sex offenders: CJS, criminal justice system.

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