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A Clinical Evaluation of Possible Sex Offenders - Part II
By Gene G. Abel, MD
This monograph was developed after a l985 training institute, "The Incest Offender, The
Victim, The Family: New Treatment Approaches" sponsored by MHA. As noted in the
introduction to the monograph, the articles by Dr. Abel and Dr. Groth "provide the reader
with syntheses of two different perspectives about the nature of the disorder and suggest
solutions for treating the offender." These articles present their thinking and practice as
of l985. Times and practice change and these articles do not necessarily reflect best
practice in 2002. We will post a discussion of these articles written from the perspective
of current practice. This monograph is presented now for its historical value, to raise
awareness of these important issues and hopefully to stimulate discussion among
interested individuals.
Interviewer Focus on What Others Have Said About the Patient
If the patient denies any paraphiliac interests or behavior, the interviewer should focus on what others have said that he did. With a child molester,
the clinician should ask him what the police report said or what the victims family described. Once this information is established, the interviewer
should ask questions that do not challenge the offender as to whether he actually engaged in these behaviors, but instead, ask for clarification about
the behavior. If accused of molesting of a boy while the patient served as a camp counselor during the summer the interviewer might ask, "What
kind of initiation (of behavior) did the boy make towards you?" "How often has the boy approached you like this in the past?" "When do you
spend time together?" When the patient begins to describe the relationship between him and the boy, this should be elaborated on, with greater
references to the extent of their sexual involvement.
If the patient denies any involvement whatsoever in the reported deviant behavior, the interviewer should not schedule numerous appointments in
the future, in an attempt to establish a "relationship" with the patient, so that he will report what has happened. This is a time consuming
procedure that will not necessarily lead to valid reporting by the patient. It would also be extensive time to pass without the patient receiving
treatment, therefore placing further individuals at risk for victimization. Instead, the clinician should ask the patient for permission to contact his
family, his lawyer, the protective services agencies, and/or any other parties involved. If permission is granted, telephone calls should be made
from the interviewer's office with the patient present. After brief discussion about the reasons for the call,- the phone is handed over to the patient
for him to give his consent to the third party. The clinician should never reveal any of the details he has obtained during the interview to the third
party (to preserve confidentiality). The offender should be asked to step out, while the interviewer gains further history regarding the particulars
of the alleged sexual crimes.
Sending release of information forms to these parties tends to impede the progress of finding out what actually happened. These releases take time
and therefore place further individuals at risk for victimization.
Physiologic Testing-Psychophysiologic Assessment
Paper and pencil testing is not particularly helpful in working with alleged sex offenders because these instruments have not been designed
specifically for sex offenders. We cannot expect precise questions to be answerable from tests designed to identify general characteristics.
A cardsort administered early in the evaluation process might be the exception. Cardsorts to evaluate paraphilias include one or two sentence
scenes of various types of paraphiliac arousal listed in DSM Ill. Each sentence is rated by the patient on a seven-point scale, from -3 (sexually
repulsive) through +3 (highly sexually arousing). A card for a rapist might read, "I have pinned a 25 year old woman to the ground; she is really
terrified; I am completely in control of her; I'm going to rape her."
The advantage of such a cardsort, especially when administered early in the evaluation process, is that some of the offenders are willing to validly
report their arousal patterns. The greater time that elapsed with the offender denying any deviant behavior, the less likely such paper and pencil
techniques (or interviews themselves) are to be valid assessors of the patient's true arousal pattern. It appears that the longer he has maintained the
position that he is not involved in deviant behavior, the more difficult it is for him to change that story.
Psychophysiologic Measurement
A major breakthrough in the assessment of paraphiliac arousal has been the use of psychophysiologic measurement. This method involves direct
measurement of the patient's penis size while presenting him stimuli (audio tape descriptions, slides, video tapes) depicting various paraphiliac
stimuli. Of greatest help has been the use of this measurement technique while recording erection responses beyond the patient's awareness,
generally response changes of less than 5% of a full erection. For example, slide depictions of various deviant behaviors are presented for 7
seconds. The patient's erection responses are recorded during the 7 seconds and for an additional 14-seconds after the slide is turned off. Since
many paraphiliacs have a variety of paraphiliac interests, the stimuli presented should include a broad range of paraphiliac interests. Of course, it
is essential to gain informed consent before such measurement, and a critical aspect of that informed consent is to clarify to the patient that the
measurement procedure is frequently beyond his awareness. It should also be clarified that his responses to psychophysiologic testing will be used
to determine his need for treatment and the type of treatment(s) that should be offered him.
The greatest validity of psychophysiologic assessment, is not in failure of the offender to respond to paraphiliac stimuli, but instead, is in the
presence of an erection response to the paraphiliac stimuli. The reason that validity is low when the offender fails to respond, is that erection
measures are in part under the voluntary control of the offender. Therefore, failure to respond to such cues is of limited value, whereas the
presence of erection response to a paraphiliac cue has much higher validity.
To investigate the validity of such measurement, 24 non-coerced, outpatient, suspected paraphiliacs were assessed using extensive confidentiality
procedures. Clinical interviews were obtained and patients were then evaluated using psychophysiologic assessment to determine the presence or
absence of paraphiliac arousal. The results of their psychophysiologic assessment were explained to each offender and their histories were
elaborated on as a consequence of this "confrontation". In 30% of cases there was complete agreement between the clinical history and the
psychophysiologic measurement. In 70% of cases there was disparity between the psychophysiologic measurement (showing paraphiliac arousal
patterns) and the previously obtained clinical interview. When these positive erection responses were shown to the patients, 70% of these
individuals admitted to further deviant behavior. These results show that psychophysiologic assessment can aid disclosure of to paraphiliac
arousal in 50% of patients coming for the initial interview.
Psychophysiologic Assessment Effective in Separating Rapists from Non-Rapists
Psychophysiologic assessment has demonstrated its effectiveness at separating rapists from non-rapists, child molesters from non-child molesters
and has been able to identify a variety of exotic arousal patterns that patients either could not or would not report. In view of the high validity of
this procedure, interviewers not incorporating psychophysiologic assessment into their evaluation of potential sex offenders are severely limiting
their ability to help clients, since it is well known that many offenders either cannot or will not self-report their true arousal pattern. With the use
of psychophysiologic assessments, the interviewer is able to (1) add additional information to his clinical interview, (2) more easily motivated the
patient for treatment and (3) more accurately tailor the therapy for the paraphiliac's specific arousal pattern(s).
Sex offenders in general have repeatedly practiced concealing the true nature of their arousal from their family, friends, sexual partners,
investigative agents, therapists and from themselves. This strategy of concealment has served them well, in that they are infrequently arrested and
others are generally totally unaware of the magnitude of their behavior. Throughout the clinical interview, psychological testing and
psychophysiologic assessment, the clinician's position should be that he or she is attempting to learn exactly what kind of problem the patient
might have so that if he needs help, it can be provided. Therapists should take the position of working with the patient to uncover possible
difficulties. The clinician should avoid allowing the patient to thrust him into the position of either agreeing with the patient's self report or
viewing him as a liar before assessment results have been obtained.
In interpreting the results of assessment this same "working with" strategy should be continued. Where deviant arousal has been identified it
needs to be pointed out to the patient in a non-judgmental fashion and in a manner so as not to get in a confrontational position with him. Two
factors appear especially helpful during feedback to the patient regarding his evaluation. The communications should , first of all be relatively one
sided from the therapist to the patient. The importance of this one sided communication is that if the offender is allowed to immediately take a
position oppositional to the results of the assessment and commits himself to that position, it is difficult for him to later change that story and back
down from that position. That being the case it is helpful for the clinician to "put his cards on the table" first. Say, "Wait a minute George, let me
fill you in on all the details of the results before we discuss them". All the information that supports findings of paraphiliac arousal should be
discussed, before progressing with the interpretation of what these results mean.
Continuing First Article, A Clinical Evaulation of Possible Sex Offenders
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