Assessing sexual violence

Melissa M. SiscoUniversity of Arizona

Overview

Assessment in general health settings Definitions of sexual violence Methods of assessment Key areas Important considerations Wrap up Question/answer period

Assessment in general health settings

Pool of sex offendersOffenders seen in medical setting

Contact with medical providers

Pool of sex offendersCourt contact

Contact with the court

Pool of sex offendersVictims seen in medical setting

Contact with medical providers

Court contact

Lifetime prevalence rates

FEMALE MALE

IN GENERAL 15% to 54% (sexual abuse)

3 to 16% (sexual abuse)

MILITARY 46 - 55% (sexual abuse)42 - 45% (rape)

???Bachman, 2000; Beebe et al., 1994, Bernhard, 2000; Cameron et al., 1996; Coxell et al 1999; Coyle et al., 1996; Fisher et al., 2003; Finkelhor et al., 1990; Merrill et al., 1998; Sorenson et al., 1987)

The danger from within

The majority of victims (79%) know their offender well (Harned, 2004)

The majority of women who are physically abused by an intimate partner are also sexually abused (Tjaden & Thoennes, 2000) – 7.7% only spousal sexual abuse– 22.1% solely physical assault– 24.8% both during the lifetime

“Who else would know?”

95% of crimes come to the attention of the police through direct citizen report as opposed to police contact (Fisher , Daigle, Cullen, & Turner, 2003)

2 out of 3 sexual assaults go unreported to authorities (BJS, 1998)

70% of victims report sexual assaults to trusted friends or loved ones (as opposed to 6% who report to police) (Harned, 2004)

Studies documenting the benefit of general assessment.

Though no comparative studies were found regarding sexual violence…

In a pediatric setting, when a physician began actively asking all parents to fill out a questionnaire regarding child abuse, reports increased 1500% in just 1 year (Sisk, 2002)

Defining sexual violence

“What is sexual violence?”

Reprehensible- Joking, harassing, lying to or pressuring a person into engaging in sexual forum or behaviors after the person expressed objection

Prosecutable- Any sexually motivated act that involve a person who is unwilling or unable to consent due to intoxication, covert drugging, state of awareness, age/maturity or physical force

Levels of sexual violence

There are many dimensions to consider:– Level of contact– Relation to the victim– Prior history of criminal activity– Legal offense description– Strategy of offense– Motives– Comorbidity with other disorders

Think about how these would infer different treatment implications

Sexual violence and mental health

Possible connections between sexual violence and mental illness:(1) a disorder may decrease the person’s ability to decipher social cues (e.g. autism)(2) sexual violence may be a marker for a disorder (e.g. antisocial personality disorder)(3) a disorder can drive the offensive behavior (e.g. delusional states) (Chesire, 2004)

Methods of assessment

Assessment purposes

Ensuring current victim, providers, and offender safety

Detecting acts of sexual violence Judging the likelihood of re-offense Exploring treatment effectiveness

4 assessment tools

Self-report questionnaires Guided clinical interviews Unstructured clinical interviews Physiological response tests

*Note: The assessments that will be discussed focus on evaluation of offenders.

Self-report questionnaires

Description: Paper or computer based questions that ask for self-report on personal behavior or attitudes.

Sample item: Please indicate your stance on a scale of 1 (disagree strongly) to 5 (agree strongly)… “A woman in a short skirt is asking for it” (Burt, 1980)

Benefits: The same for all, cost-effective, quick, can be scientifically validated and ‘normed’.

Draw-backs: Educational/reading level required, ‘lying’, only self-report (no family/friends feelings about the respondent), lack of clinical judgment

Key term description

‘Norm’ – 1,000s of sex offenders respond to a series of items.

Their responses are analyzed to determine if there are common underlying characteristics of their answering styles. These answering patterns are called ‘norms’ which are described in mathematical statements giving ‘weight’ to the strongest factors.

– New respondent’s answers are statistically compared to the offenders patterned ‘norms’ to test for similarity.

– Highly similar answers suggest further assessment is necessary and the probability of offense may be likely

Structured clinical interviews

Description: A manual that trained clinicians use to loosely guide the areas that should be addressed in a forensic interview. Use requires specified training

Sample item: A general topic with suggested questions. Benefits: Based on actuarial ‘norms’ while allowing

clinician to use some clinical judgment and to tailor the language to the respondent

Draw-backs: Costly, restricted to use by trained forensic professionals, not a perfect predictor of future behavior, not perfectly similar for all respondents

Unstructured clinical interviews

Description: A free-flowing conversational interview guided solely by clinical judgment

Benefits: Very tailored to each client, common to most health appointments, good preliminary investigation

Draw-backs: Studies have shown that clinical judgment alone functions only slightly better than chance at predicting future criminal behaviors

Physiological response test

Description: Scientific apparatus that monitors the physiological arousal in response to certain stimuli

Examples: The polygraph or the plethysmograph Benefits: Concrete output, possible treatment

benefits (“Get it all out, I’ll know if you are lying”) Draw-backs: Costly, can be fooled by trained

individuals, and can give false impressions regarding physiological arousal (response to normative stimuli can be misinterpreted)

Key areas of assessment

Static, stable-dynamic and acute-changing factors

Preparation

Information is obtained before an interview We typically use multiple sources: corroborative

interviews with providers/friends/family, review of treatment notes, police reports, victim reports, investigational materials, psychiatric evaluations, psychological testing, children’s agency reports, and recorded testimony (Maletsky, 1997)

3 main topic areas in assessment

Static factors Stable-dynamic factors Acute changing factors

Static factors

A static risk factor is a permanent fact that makes a person more likely to be in danger of sexually offending. Static factors are the personal experiences someone uses to evaluate how they should act.

– E.g. Life history, experiences, past behaviors– Developed from weighted norms– Common to structured clinical interviews

Must use multiple informants

Commonly assessed static factors

Family violence^ (a) severity (b) age of onset Physical/sexual abuse^ (a) force used (b) degree of penetration (c)

relation to perpetrator, (d) age of onset, (e) duration Prior sexual offenses* (a) age at offense, (b) victim age/sex (c)

undue force used (d) degree of penetration (e) setting Prior violent acts* (a) age at offense, (b) victim age/sex (c) undue

force used (d) degree of penetration (e) setting Prior criminal record* (a) incarceration record (b) prior delinquency Life stability* (a) married (b) employment (c) education (d) social

network (e) family support Demographics* (a) culture/race, (b) age, (d) socio-economic status*Included in almost every static risk assessment tool ^Shown to be a significant predictor of sexual offense in juveniles, but

not directly tied to adult offenders

Prediction based on static factors

Problems: (1) not case specific, (2) lack of clinical judgment, and (3) although there is high sensitivity, i.e. catching 80-90% of reoffenders, there is low specificity, i.e. wrongly accusing 40-70% of non-reoffenders

Benefit: IDing high-risk individuals Use: An initial risk indicator ranking a person as “Low”,

“Medium”, or “High” risk for the purpose of initial assignment to a supervision group

Frequency: Since these factors do not change, one might only evaluate these initially and as warranted

Stable-dynamic factors

Stable-dynamic factors are sets of semi-permanent factors that treatment aims to correct. These systems are basically our values– E.g. attitudes, cognitive distortions, and preferred

coping skills– Mostly developed through fiat– Questionnaires and interviews

Commonly assessed stable-dynamic factors

Attitudes towards women (a) hostile masculinity (b) masculine role stress (c) attitudes towards women (d) traditional patriarchal beliefs (e) rape myth beliefs (f) societal norms (g) family norms

Personal/social adjustment (a) isolation (b) pathological deceitfulness (c) coping strategy / present stress (d) life/social functioning skills

Personality (a) psychopathy (b) impulsivity (c) emotional detachment (d) antisociality (e) free-floating aggression (f) controlling demeanor

Sexual belief / knowledge (a) experience (promiscuity, impersonal sex, sexual appropriateness beliefs), (b) fantasy (deviance or preoccupation), (c) sexual education, (d) functioning (compulsivity, fixation, preoccupation, physiological ability)

Intimacy belief / knowledge (a) perception of intimacy (b) dating script knowledge (c) interpretation of sexual cues (d) empathy

Prediction based on stable-dynamic factors

Problems: Not the most commonly used marker of recidivism and due to the large variation among sex offender etiology, no universal set of dynamic risk factors

Benefits: The specificity and sensitivity are weaker than the stable factor structure’s, i.e. about 50-70% of real reoffenders and nonoffenders are identified

Use: As a compliment to original static assessment Frequency: They should be re-assessed periodically

throughout treatment to indicate progress

Acute changing factors

Acute changing variables are the constantly changing situations that make a person more inclined to act in a certain fashion. Although ‘triggers’ cannot be eliminated, the offender can learn how to recognize, avoid or cope with them.

– E.g. emotional states, intoxication, environments high in temptation, distressing events, etc.

– Common in all forensic interviews– No specified list of acute changing factors, case by case

assessment.

Prediction based on acute changing factors

Problems: New method, no normative data exists Benefits: In a Thornton study, offenders who attended

treatment that focused on the “bad decision” that led to the crime as opposed to the sexual crime itself were less likely to reoffend

Use: In conjunction with the other batteries, this should be explored extensively asking for a description of all ‘bad decisions’ and used to guide treatment and forensic recommendation of terms of sentence

– Later in treatment, the clinician should bring these factors to the clients attention and help train the client to identify and get out of these risky situations

Frequency: Extensively initially and rechecked throughout treatment

Important considerations

Incorporating screening into your practice

Be sensitive to situations in which there seem to be signs of distress (extreme couple conflict, physical signs of abuse, history of domestic violence, drug/alcohol abuse, or violent propensity)

Have crisis and treatment information on hand. Ask questions: “You won’t know if you don’t ask.” Use precaution in the types of questions asked… know

your clinical boundaries Be ready to refer

“Not another Inquisition”

Be reluctant to jump to conclusions… people devote careers to the assessment of sexual violence

An assessment instrument cannot definitively indicate that a person has or will sexually offended

Professionals typically use a calculated assortment of assessment tools and clinical judgments relying on multiple sources to make predictions of possibilities of offenses

Mandatory reporting procedure

In most service fields, acts of suspected child abuse and sexual violence must be immediately reported to law enforcement authorities. Know the limits of confidentiality and legal obligations of your field!– Exemptions: Clergy and lawyers

Safety of disclosure

Inform all respondents about the limits of your confidentiality / reporting duties

Screen possible victims in environments where an offender is not likely to be present, like a medical office or school (AAPCCAN, 1998)

Language choices

Avoid loaded language Terms with negative connotations are likely

to evoke a defensive response– Behavior (penetration when…) vs. label (rape)

Use language that is appropriate to the respondent’s educational level

Use caution to avoid the discomfort or offense of the respondent

Cognitive distortions

Most offenders have an intricate system of distorted justifications for their actions. Many are not able to consciously understand that these values are incorrect because this would mean that they had done ‘wrong’.

Example: “She wanted it, she was dressed for sex” or “She didn’t say no and she kissed me first, so she really meant yes”

Social desirability

People have a tendency to gloss over personal flaws and focus on positive features

Not as much a concern if the respondent has a high level of cognitive distortions and does not feel judged by the clinician but…

Some questionnaires use lie scales to measure this tendency

Clinicians must constantly consider this issue

Acting within your professional limits

Get informed: consult with a fellow mental health professional who is more specialized or refer to educational resources (see appendix)

Connect the client to a specialized provider: If the situation arises, referrals are common and welcome

Brief wrap up: The 3 Ws

What?

Different types of sexual violence– Reprehensible vs. illegal– Level of contact– Relation to the victim– Prior history of criminal activity– Legal offense description– Strategy of offense– Reason for actions– Comorbidity with other disorders

Why?

Reasons for assessment in general settings– Link between mental health and sexual violence– Underreporting issues– Promising increase seen in universal screening

How?

Methods of assessment– Questionnaires, unstructured interviews, structured

interviews, physiological response measurement Key questions

– Static, stable-dynamic, and acute changing factors Important considerations

– Multiple sources to assess, mandatory reporting laws, safety of disclosure, language choice, cognitive distortion, social desirability, and professional limits

Questions or comments?

Thank you for your time! For more information feel free to contact me at sisco@u.arizona.edu

References

American Academy of Pediatrics Committee on Child Abuse and Neglect (AAPCCAN) (1998). The role of the pediatrician in recognizing and intervening on behalf of abused women. Pediatrics, 101, 1091-1092.

Bachman, R. (2000). A comparison of annual incidence rates and contextual characteristics of intimate partner violence. Violence Against Women, 6(8), 839-867.

Beebe, D. K., Gulledge, K. M., Lee, C. M., and Replogle, W. (1994). Prevalence of sexual assault among women patients seen in family practice clinics. Family Practice Research Journal, 14(3), 223-228.

Bernhard, L. A. (2000). Physical and sexual violence experienced by lesbian and heterosexual women. Violence Against Women, 6(1), 68-79.

Burt, M.R. (1980). Cultural myths and support for rape. Journal of Personality and Social Psychology, 38, 217-230.

References

Bureau of Justice Statistics (December 1998). National Crime Victimization Survey. Washington, DC: U.S. Department of Justice.

Cameron, P., Proctor, K., Coburn, W.J., Forde, N., Larson, H., and Cameron, K. (1986). Child molestation and homosexuality. Psychology Report, 58, 327-337.

Coxell, A., King, M., Mezey, G., and Gordon, D. (1999). Lifetime prevalence, characteristics and associated problems of non-consensual sex in men: Cross sectional survey. British Medical Journal, 318, 846-850.

Coyle, B. S., Wolan, D. L., and Van Horn, A. S. (1996). The prevalence of physical and sexual abuse in women veterans seeking care at a veteran’s affairs medical center. Military Medicine, 161(10), 588-593.

Finkelhor, D., Hotaling, G., Lewis, I.A., and Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19-28.

Fisher, B.S., Daigle, L.E., Cullen, F.T., and Turner, M.G. (2003). Reporting sexual victimization to the police and others: Results from a national-level study of college women. Criminal justice and behavior, 30(1), 6-38.

References

Harned, M.S. (2004). Does it matter what you call it? The relationship between labeling unwanted sexual experiences and distress. Journal of Consulting and Clinical Psychology, 72(6), 1090-1099.

Maletsky, B.M. (1997). Exhibitionism: Assessment and treatment. In D.R. Laws and W. O’Donahue (Eds.), Sexual deviance: Theory, assessment, and treatment, (pp.40-74).

Merrill, L. L., Hervig, L. K., Newell, C. E., Gold, S. R., Milner, J. S., and Rosswork, S. G. (1998). Prevalence of premilitary adult sexual victimization and aggression in a Navy recruit sample. Military Medicine, 163(4), 209-212.

Sisk, D. (2002, June 4). Domestic violence screening in a pediatric clinic. Arizona’s Child Abuse Infocenter. Retrieved April 4, 2004 from http://www.ahsc.arizona.edu/acainfo/index2.htm .

Sorenson, S.B., Stein, J.A., Siegel, J.M., Golding, J.M., and Burnam, M.A. (1987). The prevalence of adult sexual assault. The Los Angeles Epidemiologic Catchment Area Project. American Journal of Epidemiology, 126, 1154-1164.

Tjaden, P., & Thoennes, N. (2000). Full report of the prevalence, incidence, and consequences of violence against women (Rep. No. NCJ 183781). Rockville, MD: Office of Justice Programs, National Institute of Justice.

Resources- Local contacts

Southern Arizona Center Against Sexual Assault www.sacasa.org or 327-1171

Brewster Center Domestic Violence Services www.thebrewstercenter.org or

Pima County Attorney’s Office www.pcao.pima.gov or 740-5600

Resources- Hotlines

Hotlines– Rape, abuse, and incest national network (RAINN) 24 hr.

free, anonymous crisis line 1.800.656.HOPE   – Southern Arizona Center Against Sexual Assault 24 hr. free,

anonymous crisis line (520) 327-7273 or (800) 400-1001 (what to do after a sexual assault- http://www.sacasa.org/)

– Brewster Center Domestic Violence Crisis Line: (520) 622-6347 or (877) 472-1717

– National Hopeline 24 hr. free anonymous suicide intervention 1-800-SUICIDE (1-800-784-2433)

Resources- Online background checks

Pima county court criminal and civil search by name or case number: http://jp.co.pima.az.us/casesearch/index.php

Tucson City Court case look up (including superior court): http://www.supreme.state.az.us/publicaccess

Registered sex offender search (AZ) by name or near location: http://az.gov/webapp/offender/main.do

Resources- Research cites

Arizona Rape Prevention and Education Program: http://www.azrapeprevention.org/

– Feature: Articles on offenders and victims, sponsored by the CDC and U of A, this site also gives direct access to current sexual violence assessment questionnaires and state of the art articles

Rape, Abuse, and Incest National Network: www.rainn.org – Feature: Victim oriented information in a user friendly format

National Center on Domestic and Sexual Violence: www.ncdsv.org – Feature: Links specifically regarding military issues, very nice treatment

ideas and materials in the resource section Center for Sex Offender Management: www.csom.org

– Feature: Articles, assessment info, and funding opportunities regarding sexual offender treatment

Association for the Treatment of Sex Abusers: www.atsa.org – Feature: Articles, links, employment/funding opportunity