Читать книгу Social Work with Sex Offenders - Cowburn Malcolm - Страница 37

Medical understandings of sex crimes are rooted in a socio-biological understanding of human behaviour. This generally assumes an evolutionary perspective that locates sex crimes within a context of the survival of the species. Notions of ‘natural selection’ predominate (see Thornhill and Palmer, 2001), and aggressive sexual conduct is seen as an evolutionary adaptation to ensure the continuation of the species (for a fuller exploration of this perspective, see Thornhill and Palmer, 2000; for feminist critiques of the evolutionary perspective, see Travis, 2003).

The medical perspectives of the 19th and 20th centuries were initially informed by the work of Freud, and the sexologists Krafft-Ebing and Havelock-Ellis (but also later by the work of Kinsey, Masters and Johnson). The sexologists adopted an evolutionary perspective of human sexual behaviour. Krafft-Ebing’s work Psychopathia Sexualis (2011/1886) was first published in 1886 and the 12th and final edition (written by Krafft-Ebing) was published in 1903. The book was influential in both the legal and medical professions, and it established the framework through which sexual behaviours (and sex crimes) were interpreted (for bibliographic information, see Ooesterhuis, 2012). Ooesterhuis (2012, p 134) describes the changing focus of European psychiatry at the end of the 19th century:

[the] main thrust was that in many cases, irregular sexual behaviour should not be regarded as sin and crime but as symptoms of pathology. Since mental and nervous disorders often diminished responsibility, most sex offenders should not be punished but treated as patients.

Figure 2.2: Flow of sexual offence cases from victimisation to conviction

With this shift, Oosterhuis (2012, p 134) notes the growth of diagnostic terminology: ‘homosexual’ and ‘heterosexual’ preceded more specialist terms such as ‘exhibitionism’, ‘voyeurism’, ‘fetishism’, ‘paedophilia’, ‘bestiality’, ‘sadism’ and ‘masochism’; however, ‘paraphilia’ is a key catch-all term. The Oxford English Dictionary (OED, 2015) defines ‘paraphilia’ as ‘Sexual desires regarded as perverted or irregular; spec. attraction to unusual or abnormal sexual objects or practices; an instance of this’. The words ‘perverted’, ‘irregular’, ‘unusual’ and ‘abnormal’ clearly establish the nature of paraphilia against an implied (heterosexual) norm; moreover, this exceptional character is compounded by the word ‘disorder’. The naming of ‘paraphilic disorders’ is, however, in some cases, a controversial process.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published in 1952. Now in its fifth iteration (APA, 2013), it is the diagnostic ‘manual’ for psychiatry in North America, and is influential across the ‘Western’ world. DSM 5 identifies eight paraphilic disorders: exhibitionistic disorder; fetishistic disorder; frotteuristic disorder; paedophilic disorder; sexual masochism disorder; sexual sadism disorder; transvestic disorder; and voyeuristic disorder. Tosh (2011) outlines the debates about whether to include acts of sexual coercion in the DSM. She notes that rape as a symptom of psychiatric illness has a long history dating back to the early 20th century. Rape and sexual assault were included in the first DSM in 1952 under the ‘vague’ diagnosis of ‘sexual deviance’, which included the subcategory of ‘sexual sadism’, which seems to be a ‘catch-all’ for rape and many other sex offences (Tosh, 2011, p 2). Tosh (2011, pp 3–4) raises concerns about the ‘medicalisation’ of rape. Frances and First (2011, pp 558–9) similarly express concerns about the attempts of the US legal system to use the medicalisation of rape as a justification for the extended incarceration of rapists; they note that ‘the act of being a rapist is almost always an aspect of simple criminality, and that rapists need to receive longer prison sentences not psychiatric hospitalizations’.

Medical treatments are available for sex offenders – primarily in the form of anti-libidinal medication – which are usually combined with some form of ‘talking’ therapy. The evidence for the effectiveness of this treatment is inconclusive, although there are concerns about the long-term side effects of medication (Basdekis-Jozsa et al, 2013). However, medical understandings and responses to sex offending highlight a central issue for (medical) practitioners: ‘as long as paraphilias are regarded as a disorder, sexual offenders with paraphilias have to be seen as patients first and not (only) as perpetrators’ (Basdekis-Jozsa et al, 2013, p 314). The majority of medical theorising and treatments are focused on male offenders; there does not appear to be a significant body of literature that addresses biological perspectives directly relating to female offenders.