The Clinical Angle - Mark A. Ruiz
Forced Intimacy: An argument for increasing an interpersonal focus for understanding sexual offending
Mark A. Ruiz, PhD ABPP (Forensic)
James A. Haley Veterans Hospital/University of South Florida
A few years ago I started getting requests to do risk assessments for individuals who had offended sexually. Various attorneys and agencies sought me out as there were not many people conducting these types of evaluations in my area. Naively, I focused on the business opportunity that these requests presented and did not reflect on why so many well-trained psychologists were not doing this work. I eventually found out how challenging these evaluations could be due to the interpersonal pathology of these patients.
Sex offending is a significant clinical and public health issue. According to the Federal Bureau of Investigation (FBI; 2013), there were an estimated 79,770 forcible rapes in the United States in 2013. This number is almost certainly an underestimate as it only includes those assaults reported to law enforcement and often fails to capture sexual assaults against children, sexual violence within the home, and sexual assaults involving homicide (which are classified as homicides). Meta analytical work has also found that many individuals who are convicted of sex offenses have a re-offending rate around 13-15%, a rate derived primarily from known instances of offending (Hanson & Morton-Bourgon, 2005).
Individuals who offend sexually are a unique and heterogeneous population. This is understandable, as there is a wide range of behaviors (e.g., exhibitionism, sexual battery) that can be classified as a sexual crime. Sexual offending also overlaps with deviant sexuality that is non-criminal (bondage-discipline between consenting adults) and compulsive sexual behavior. Recent conceptual models have emphasized the role of impulse control problems in sexual offending (see Stinson, Sales, & Becker, 2008). Indeed, sexual offending is often conceptualized and treated in a manner similar to drug addiction. Triggers, learned association networks, and cognitive distortions supporting offense behaviors are primary targets in many treatment approaches. Individuals who offend sexually often respond positively to treatment interventions used with other addictive disorders, leading some to postulate the presence of a dysfunctional reward system underlying all appetitive disorders (see Raymond & Grant, 2010). However, this conceptualization often fails to capture important interpersonal processes that are occurring in the lives of these patients.
Conceptualizing sex offending as similar to drug addiction has limitations. Sexual behavior is fundamentally interpersonal. At its best, sex should be an activity that brings two people closer. Building on the work of Dr. Alfred C. Kinsey, a healthy sexual relationship between consenting adults should increase emotional intimacy and create a special physical bond. The process of sharing a sexual experience should build trust and warmth, while also leaving each party vulnerable in a way that emphasizes the importance of the human need for other people. Interpersonally, sex creates a connection of warmth and a sense of vulnerability. Each person also exerts some degree of control. It is this feature of sex, with each partner giving and receiving pleasure, that creates the conditions for intimacy and union. Interpersonal complementarity forms the basis of each successful exchange. Again, this is sex at its best. Most couples approximate this ideal, to varying degrees, over the course of their relationship. However, interpersonal processes associated with sexual offending are different.
Guided by my clinical experience and review of the scientific literature, I have come to focus on the interpersonal behavior of individuals who offend sexually. Hostile dominance seemed to be an obvious starting point given the association between these tendencies and antisocial personality disorder (e.g., Wiggins & Pincus, 1989). However, I encountered interpersonal processes that were more complicated than hostile dominant tendencies. Below are descriptions from some of my observations.
1. Disintegrated Sexuality: In my non-forensic work with couples and individuals I have come to see that healthy functioning often involves some degree of integration between the conception of self and the expression of sexuality. Although it is normal to have some separation between intimate and public life, I have seen that many individuals who offend sexually present with a marked lack of integration between these life areas. They often relate to others in a submissive and detached manner. Various concepts have been proposed to describe these processes, including intimacy deficits or romantic dating skill deficits. It is thought that these individuals cannot get their needs for physical and emotional intimacy met in a normal manner and therefore offend. But why, then, does the offending behavior often exert dramatic levels of hostility and control? What process transforms fairly common frustrations (who has not had ‘intimacy issues’ in life?) to behaviors which are widely held as the heinous type of offending?
2. Forced Intimacy: Despite being a middle age man who frequently does not fit the victim profile (e.g., women, children) of the forensic patients I evaluate, I was taken aback by the level of attempted boundary violations I encountered during risk assessment evaluations. I frequently encountered inappropriately personal questions, requests for physical contact (e.g., hugs), and comments of my personal appearance. Some individuals I evaluated did extensive internet research on me and, in one case, actually made a ‘field trip’ to my residence. In my treatment work a ‘maintenance of appropriate boundaries’ is an ongoing treatment issue. This is in contrast to my experience with violent or drug-involved clients who approached the evaluation in an appropriately formal manner. I discussed my concerns with my wife in a general manner and she commented ‘they are forcing intimacy on you.’ This observation opened my mind to the interpersonal process within the evaluation room. Normal intimacy involves a reciprocal process. Individuals who offend sexually, however, are either unaware or choose to ignore this process. I had not considered this before. The concept of forced intimacy was a useful ideal in these evaluations. What was most striking was that many of these folks had the capacity for normal relating as evidenced by marriage, long-term friendships, and successful careers. For some reason, they chose to force intimacy when such force was far from the only option.
3. Driven from Society: Almost nobody wants to work with individuals who offend sexually. Community notification laws, registration requirements, and local housing restrictions guarantee a life of hardship for anyone convicted of a serious sex offense. Any given person is just as likely, if not more (depending on where you live) likely, to be injured by an intoxicated driver with a prior DUI than get sexually assaulted by someone previously convicted of a sex offense. However, there is no DUI registry or DUI community notification laws. Why? Individuals who offend sexually are treated in a way that is unique in the criminal justice system, often out of proportion to the actual risk they pose to society. Why is that the case? This aversion is also seen among clinicians. Professionally, almost none of my forensically-trained colleagues are willing to work with these individuals. Violent offenders? No problem. Someone convicted of drug trafficking? No problem. Sex offenders? No way! Most clinicians are highly experienced in working with individuals who are the victims of sexual offending, but work with perpetrators is an entirely different manner. It would be important to understand the interpersonal factors that drive this aversion. The problem is far from academic as the lack of appropriate services, particularly preventive services, often increases the risk of offending.
4. The Worst of the Worst: There is a certain type of individual who has fused sexuality and aggression is a primitive way. This concept is hardly new; sexually sadistic psychopaths are well-described in the literature. Although I recognize the ethical and legal dilemmas that do emerge with civil commitment laws for sexually violent predators, I have evaluated a select few patients that are (in my opinion) truly dangerous to society. Sexual homicides and violent sexual assault seem to represent a degree of interpersonal sickness that goes beyond simple violence. Theories of crime or addiction fall short when trying to understand this pathology. Typically, I view the offending behavior as a product of an omnipotent self-object relating to a devalued other within the context of anger/rage. However, this conceptualization is hardly novel and provides little insight regarding etiology. Kernberg’s (1993) concept of malignant narcissism has been helpful in understanding these men (they have been all men), but are there additional insights that can be gleaned from interpersonal theory?
I have found that interpersonal process area rich, yet poorly understood, area for understanding individuals who offend sexually. Hopefully, my clinical observations will promote further interpersonal research in the area.
Federal Bureau of Investigation (2013). Crime in the United States,2013. Accessed at http:www/fbi.gov on March 16, 2015.
Hanson, R. K., & Morton-Bourgon, K. E. (2005). The characteristics of persistent sexual offenders: A meta-analysis of recidivism studies. Journal of Consulting and Clinical Psychology, 73, 1153-1163.
Kernberg, O. K. (1993). Severe personality disorders: Psychotherapuetic strategies. Yale University Press: New Haven, Conneticuit.
Raymond, N. C., & Grant, J. E. (2010). Augmentation with naltrexone to treatment compulsive sexual behavior: A case series. Archives of Clinical Psychiatry, 22, 56-62.
Stinson, J. D., Sales, B. D., & Becker, J. V. (2008). Sex offending: Causal theories to inform research, prevention, and treatment. American Psychological Association: Washington, D.C.
Wiggins, J.S., & Pincus, A.L. (1989). Conceptions of personality disorders and dimensions of personality. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 305-316.