Thursday, July 19, 2018

Is there such thing as “sexual harm” or is it always Abuse or Trauma?

Danielle Arlanda Harris, PhD, Deputy Director Research, Griffith Youth Forensic Service, Griffith Criminology Institute, Griffith University
Toni Cash, Manager, Practice Advice and Support Team*
Kerri Wyeth, Manager, Practice Response Team*
Kieran McCartan, PhD, Professor, University of the West of England-Bristol

(*Both teams located within Practice Connect under the Queensland Department of Child Safety, Youth, and Women).

The #metoo movement has been called a watershed moment in the way that we think about, respond to, and prevent sexual abuse and harassment. People are talking, which is fabulous. We want people to talk, but language matters, and we need to use the right words.

The Weinstein “event” has led to an increasing number of “brave men and women” coming forth to share their stories. Those stories have been differentially described as revelations, allegations, accusations, disclosures, and delusions. Similarly, the responses by those alleged to have abused have included denials, excuses, justifications, apologies, lies, and responsibility taking. Individuals have been named, shamed, fired, silenced, and “tried by twitter.”

Talking heads are now engaging in nuanced public discussions about the difference between sexual abuse, sexual assault, sexual exploitation, and sexual harassment. These are not the same thing, they do not have the same consequences, or carry the same penalties, and should not be viewed similarly. We have discussed the semantics of sexual abuse, harassment and the #metoo movement on the ATSA blog before. Here, we consider the specific phrase of “sexual harm.” It is challenging to expect members of the public or non-related professions to understand as well as use terminology correctly when even those in the field struggle with language.

We acknowledge the need to use person first language (Willis, 2018) and are beginning to opt for the apparently clunkier “person convicted of a sexual offense” rather than the more pejorative “sex offender” (or worse “predator”). As Nicole Pittman reminded us recently (ATSA conference, 2017): “they’re worth the extra words.” As we continue to negotiate our use of language, it goes without saying we must navigate both legislation and legal jargon as it is used across numerous jurisdictions in multiple countries but also the most sensitive of topics where euphemisms are rife.

ATSA is an international community. Many of us work and travel abroad often.  One can always get mileage out of the flip flop/thong/g-string situation. Since returning to Australia for example, Danielle has had to relearn the language—both legal and practical—to engage in respectful discourse. It was during this process that she came to learn of the challenges and, in some sectors, very strong views about the use of the phrase “sexual harm.”

“Sexual harm” is frequently used as a catchall phrase intended to include various types of violence, abuse, assault, and harm that results from sexual abuse or violence of a sexual nature. The idea of harm—as opposed to other language (i.e., abuse, trauma, etc.)—comes from the field of Zemiology, based on the idea that “harm” is more proactive and adaptive than other terms. It is thought that it is therefore more helpful for people who have experienced sexual abuse or assault and people who have sexually abused others and/or committed sexual offences to move on. However, the word “harm” is divisive in the field of sexual abuse, especially from the perspectives of criminal justice and victim advocacy groups who argue that “harm” lessens the impact and consequences of exactly what a person experiences as a result of sexual abuse.

According to the Queensland Department of Child Safety, Youth, and Women, the harm that a person experiences as a result of sexual abuse is either:

(1) Emotional/psychological harm,

(2) Physical harm or,

(3) Both emotional/psychological and physical harm.

By way of example,

-       If a 16 year old girl reports to her Child Safety Officer that her arm was broken three years ago during an argument with her stepfather, she would be referred to a medical practitioner to ensure that the arm was set properly and the break has healed (thus treating the physical harm) and would likely also be referred to a counsellor to attend to the emotional stress and trauma caused by the same incident (thus treating the psychological harm).

-       If a 16 year old girl reports to her Child Safety Officer that she was vaginally penetrated three years ago by her stepfather, she should similarly be referred to a medical practitioner for an internal exam to ensure that there is no lasting damage, that her vagina has healed (thus treating the physical harm) and would also be referred to a counsellor to attend to the emotional stress and trauma caused by the same incident (thus treating the psychological harm).

Basically, if we understand the harm to be physical then we can target our intervention to the physical harm. Examples include getting medical treatment for damage to the child’s genitals or anus, or diagnosis and appropriate medication for the sexually transmitted infection that the child has contracted. 

Likewise, if we understand the harm to be emotional then we can target our intervention to the emotional harm. Examples here include providing counselling to help the child understand that it was not their fault that the sexual abuse happened to them; or offering assistance that might also focus on the potential risk that the young person poses to others, including safety planning and counselling. 

To be clear, “sexual violence” describes the behaviour that someone is responsible for committing. The “harm” is the resulting impact on the person who has experienced the sexual violence. Quite simply, when someone experiences violence, their resulting physical harm can be treated by a medical doctor and their resulting emotional harm can be treated by a counsellor. The challenge with the use of the phrase “sexual harm” is that it can lead to confusion over how best to help the actual harm that the person has experienced. By observing the presence of the resulting physical and emotional harm that results from the commission of sexual violence we can offer a clear direction for interventions that best cater to the needs of the individual and the actual harm they have experienced.




Friday, July 13, 2018

Toxic Masculinity and How It Can Inform Treatment with Black Boys

By Tyffani Dent, Psy.D.

I work with adolescents who have engaged in problematic sexual behavior. Many of the clients with whom I work are males. Being that within our juvenile justice system there is an over-representation of those who come from marginalized communities, specifically Black and Brown ones---with many explanations for this given from over-policing, racial profiling, poverty not permitting access to services expect through “systems”, etc.---it is not surprising that a significant portion of those I serve are Black. Taking into consideration that the large majority of sexual offenses committed by juveniles are committed by males (Finkelhor, Ormrod, & Chaffin, 2009) it does not surprise me when clients I serve are overwhelmingly black boys, due to a skewed engagement with the juvenile justice system.

When addressing problematic sexual decisions with the boys I counsel, oftentimes the topic of their own early sexual experiences emerges. In these conversations, there are times when they report initiation to sexual behavior occurring at the hands of much older adolescent or adult females and in some cases, male caregivers. Yet, in these discussions, many of them do not view such interactions as sexual abuse or sexually inappropriate, in part, because my community does not often “permit” our boys access to the concept of it being acceptable to not want sexual contact.

Recently, Terry Crews, a famous Black actor, came out and discussed his own #MeToo moment. He disclosed his own experiences with sexual victimization. While some praised him, others including the Rapper 50 Cent, in a tweet, and Senator Feinstein, in a congressional hearing, gave a response with which I am more familiar with--- 50 Cent viewing Mr. Crews’s victimization as discounting his manhood and Senator Feinstein questioning why a big male such as Mr. Crews did not fight back.   This toxic masculinity, which is the push towards hypermasculinity and belief in traditional male stereotypes, is prevalent within our Black and Brown communities in part because of the historical emasculation of Black males since slavery into Jim Crow. The current climate which we live in continues to downplay options for healthy development of a male identity within the Black and Brown communities due to mass incarceration. Such ingrained hypermasculinity impacts not only the starting point in which one engages with Black boys related to what healthy sexual decisions look like, but also in reframing  discriminatory selection of sexual partners as being empowering instead of a sign of “weakness”.

How should the knowledge of toxic masculinity impact our work with especially Black boys who have engaged in problematic sexual behavior?

  1. Explore early sexual experiences-address and normalize feelings of discomfort around sexual contacts with those who were much older and provide them the language to describe it as unwanted and problematic. Allow them the safe space to process this.

  1. Assist in examining how they define manhood. Where did the definitions come from? How do they inform their views of sex and sexuality? The Young Men’s Work curriculum and the book Dare to Be King offer great resources on beginning this discussion from a gender and a racial context.

  1. Reframe masculinity as being an advocate for healthy relationships and being a catalyst for assisting other males in doing the same.

  1. Examine how (if applicable) these boys own problematic sexual decisions were informed by toxic masculinity/hypermasculinity.

  1. When possible, engage other Black men in their lives who can serve as a model for healthy masculinity. When not readily available, identify movies, books, and other mediums in which there are positive portrayals of black manhood. Interwoven in this should also be those stories of black men and boys who have experienced victimization, struggles with their own identifies, and other traumas---which can provide a framework for further exploration of the impact of trauma and how it may play out uniquely for black boys.



Thursday, July 5, 2018

The assessment and treatment of sex offenders with intellectual disabilities: A work in progress.

By Prof. Kasia Uzieblo & Marije Keulen-de Vos, PhD. (Dutch Chapter of the ATSA, NL-ATSA)
On June 11th NL-ATSA, the Dutch Chapter of ATSA, organized a masterclass on the assessment and treatment of sex offenders with intellectual conjunction with the International Forensic Mental Health Services at the IAFMHS conference 2018 in Antwerp (Belgium).  
A considerable number of sex offenders exhibit intellectual disabilities (ID). These offenders require bespoke assessment, support, and treatment. However, in practice ID and its role in sexual deviant behavior are not always fully recognized nor well understood. To enhance the effectiveness of support and treatment programs for sex offenders with ID, it is of great importance for professionals to be aware of the presence of the ID’s, to understand its influence on (sexual) behavior, and to have knowledge of effective treatment programs.
By organizing this masterclass, we also wanted to honor the works of Prof. William R. Lindsay who unfortunately has passed away in March 2017. William Lindsay had dedicated his career to further our understanding of offending behavior among people with ID and to improve assessment and treatment tools in these offenders. He was mainly passionate about identifying the pathways into forensic services of ID offenders, developing adequate assessment tools and establishing effective, evidence-based treatment programs for these offenders. Notwithstanding his very busy research agenda, he also found sufficient time throughout his career to acquire extensive clinical experience with ID offenders: To honor his invaluable work, the masterclass gave ample attention to Prof. Lindsay’s research throughout all sessions. In order to ensure that in-depth insights into Prof. Lindsay’s views and work would be shared, only presenters who had collaborated with Prof. Lindsay in terms of education and/or research were included in the program.
The presenters of the first session, Prof. Kasia Uzieblo (Thomas More and Ghent University, Belgium) and Dr. Petra Habets (OPZC Rekem, Belgium), focused on the assessment of ID in offenders, a topic that even in books on (sex) offenders with ID is often being overlooked. Given the important consequences of an ID diagnosis in offenders, this observation is rather striking. There is ample evidence showing that the assessment of ID in both research and practice comprise several substantial problems and limitations and does not sufficiently adapt to significant evolutions in intelligence research. The convergent validity of the current measures for IQ (e.g., the Wechsler Scales and the Raven’s Progressive Matrices) exhibits substantial problems. For instance, a study by Habets, Jeandarme, Uzieblo, Oei, and Bogaerts (2014) showed that despite positive correlations among intelligence measures, differences between scores on repeated and different IQ measures of 10 points and more occur far too often. In addition, current intelligence measures seem to not sufficiently tap into the various intellectual abilities as described in current theoretical frameworks of intelligence, including the Cattell-Horn-Carroll Model (CHC-model). Another assessment problem arises when taking into account the second diagnostic criterion of ID, i.e. deficits in adaptive functioning. In contrast to previous editions, the fifth version of the Diagnostic and Statistical Manual for Mental Disorders as well as the upcoming 11th edition of the International Classification of Diseases (ICD-11) underline that it is not the IQ score but rather the level of adaptive functioning that determines the level of support needed. Hence, a reliable assessment of adaptive functioning on the conceptual, social and practical domain becomes of utter importance. However, adaptive functioning is often neglected in the assessment procedures or is not sufficiently taken into account when diagnosing ID. This problem might be intertwined with another issue: There is a lack of reliable, valid, and comprehensive measures for adaptive functioning. Unfortunately, this is not all. Many additional problems, including the lack of culturally fair assessment practices and the effect of comorbid psychiatric disorders on ID assessment, merit attention. In sum, Uzieblo and Habets highlighted the need for adequate, comprehensive assessment procedures for ID that align with the most recent theoretical frameworks of intelligence.
The second presenter, Prof. Leam A. Craig (University of Birmingham, UK), focused on the prevalence of ID in sex offenders, etiological explanations of sexual offending behavior in ID offenders, treatment effects, and risk assessment. Prevalence rates of sex offenders with ID typically range from 21 to 50%. However, we have no way of knowing how accurate these percentages actually are. Prof. Craig offered several etiological explanations of sexual offending in offenders with ID. Some studies on sexual abuse in people with ID suggest that behavioral problems (i.e., sexual inhibition) are a consequence of sexual abuse but not of physical abuse. Another hypothesis is that sex offenders with ID are more impulsive than their non-disabled counterparts, although findings on grooming suggest that individuals with ID do demonstrate delayed gratification. One of the most influential explanations is the counterfeit-deviance hypothesis which assumes that sexual deviant behavior is precipitated by a lack of sexual knowledge, poor social skills, limited opportunities, and sexual naivety rather than deviant sexual interests. However, several studies contradict this assumption. In sum, the developmental pathways into sexual offending in people with ID are not well understood yet. With regard to treatment programs for sex offenders with ID, CBT principles are the most commonly applied in these programs. But two problems occur. These programs are typically based on existing non-ID programs. And there is empirical support for their effectiveness. The latter is partly due to methodological problems, such as few randomized clinical trials and the fact that comparison groups are often not available. Next, Prof. Craig provided an overview of commonly used risk methodologies and instruments. Often, the same instruments are used in offenders with ID and non-ID offenders, such as the SVR-20, Static-99, and the Risk Matrix-2000. The ARMIDILLO-S is an instrument specifically developed for sex offenders with ID. Because of the extensive use of risk assessment within the management and treatment of sexual offenders with ID, the accuracy of predictions is of utmost importance. Prediction, however, remains a tricky thing. We have to be aware of what we are actually predicting. Also, the predictive value of risk offender instruments is dependent on definitions of sexual deviant behavior, sex offender ID characteristics (e.g., higher incidence of family psychopathology, behavioral disturbances at school, sexual naivety, and poor impulse control) and base rates. Given the variation in base rates and recidivism rates across risk categories
in samples of sexual offenders with ID, it appears that it is more helpful to report relative levels of risk rather than absolute rates of recidivism.

In the final presentation, Prof. John Taylor (Northumbria University, UK) discussed several tools for practice. He specifically focused on the added value of Finkelhor’s precondition offending model as a shared multidisciplinary and valuable approach. In this approach, the motivation to sexually offend is dissected in four stages. Stage 1 focuses on aspects that influence motivation, such as sexual arousal to inappropriate stimuli and experience of abuse. Stage 2 addresses overcoming self-control. More specifically, cognitive distortions, stress, drug/alcohol abuse and organic factors may lead to disinhibition. Stage 3 emphasizes external control. For example, external factors such as social isolation, discontinuation of supervision or structure, and unusual living/sleeping arrangement may increase the risk of offending. Finally, stage 4 focuses on overcoming victim resistance. Different influencing factors may be prominent in different offenders. Based on these factors, an individualized risk management plan including the level of risk, probability of risk, clinical interventions and management strategies can be developed. In the Northgate Sex Offender Treatment Program (Northumberland, Tyne & Wear NHS Foundation Trust) patients are encouraged to work through three developmental levels over the course of 12-24 months. First (phase 1, pre-treatment group) patients are desensitized to working in a group setting. Next (phase 2, intermediate group, patients are encouraged to discuss more personal issues, emotional difficulties and other things they would like to change. Finally (phase 3, is the offence related group), patients are encouraged to consider behavior related to their offences.

Several discussions with the participants during the masterclass indicated that many practitioners are struggling with the assessment in and treatment of ID offenders. There is clearly an urgent need to share best practices and to develop evidence-based assessment and treatment tools for practice. Since Prof. Lindsay has highlighted these necessities in his first studies, this field has moved forward, mainly thanks to his work. But we are obviously not there yet, as was made very clear throughout the presentations. Hence, it is of vital importance that experts, including Leam Craig, John Taylor and many others working with ID offenders, will proceed with their invaluable work in research and practice. We should also remain working on that two-way bridge between research and practice that Prof. Lindsay had been striving for. Maybe it is utopian to think that we will ever find a solution for all the problems we encounter when working with ID offenders. But nevertheless, we should follow in the footsteps of William Lindsay, and at least aspire to reach this destination.

Want to know more about the aforementioned topics? Some good reads:

Craig, L. A. (2010). Controversies in assessing risk and deviancy in sex offenders with intellectual disabilities. Psychology, Crime & Law, 16(1-2), 75-101.

Craig, L. A., & Lindsay, W. R (2010) Sexual offenders with intellectual disabilities: Characteristics and prevalence. In, L. A. Craig., W. R. Lindsay., & K. D. Browne, (Eds.), Assessment and Treatment of Sexual Offenders with Intellectual Disabilities: A Handbook. (pp. 13-36). Wiley-Blackwell.
Craig, L.A., Stringer, I., & Moss T. (2006). Treating sexual offenders with learning disabilities in the community: a critical review. International Journal of Offender Therapy and Comparative Criminology, 50(4), 369-390.

Habets, P., Jeandarme, I., Uzieblo, K., Oei, K., & Bogaerts, S. (2015). Intelligence is in the eye of the beholder: investigating repeated IQ-measurements in forensic psychiatry. Journal of Applied Research In Intellectual Disabilities, 28(3), 182–192.

Lindsay, W.R., & Taylor, J.L. (2018). Offenders with Intellectual and Developmental Disabilities. Research, Training, and Practice. John Wiley & Sons Inc.

Taylor, J.L., & Halstead, S. (2001). Clinical Risk Assessment for People with Learning Disabilities who Offend. The British Journal of Forensic Practice, 3(1), 22-32.

Uzieblo, K., Winter, J., Vanderfaeillie, J., Rossi, G., & Magez, W. (2012). Intelligent diagnosing of intellectual disabilities in offenders: food for thought. Behavioral Sciences & the Law, 30(1), 28–48.