An interesting issue . . .

of the British Medical Journal, that is. It's actually worth a few posts here.

I'll start with a troubling problem we have discussed here a few times, one which inspires tremendous political passions, that is how to deal with sex offenders. There is a general perception, although the empirical evidence is weak and conflicting, that at least some categories of sex offenders are less susceptible to reform and more likely to re-offend than other criminals. And, people find sexual offenses, particularly against children or involving high degrees of violence and coercion, particularly reprehensible. Hence we have civil commitment procedures for people who have completed their criminal sentences, offender registration programs, restrictions on where offenders can live, etc.

These measures are very popular but they present ethical and practical difficulties. Can we really justify restricting the liberties, and even continuing to incarcerate people, who have discharged their debt to society, based only on what we think they might do in the future? Why do we treat sex offenders in this way, and not bank robbers? Ex-offenders have to be able to work and live with dignity, or else their risk of re-offending may be higher. (I don't know of quantitative research that shows this, but it's widely accepted among psychologists.) And of course, as a practical matter, we can scarcely afford to lock up large numbers of people forever. Sex offenses obviously vary in severity, and no doubt offenders vary in their likelihood of re-offending and subsceptibility to rehabilitation depending on their personalities, motives, nature of their offenses, age, intelligence, and other factors. Some degree of balance, and the ability to make distinctions, is obviously necessary. But we don't have a lot of good information to go on.

A technical fix that would help greatly to untangle this knot would be proof of effective treatment. Unfortunately, according to a review by Belinda Brooks-Gordon and Charlotte Bilby (BMJ 1 July, 2006), the existing evidence is weak and often conflicting. They found nine randomised controlled trials with a total of 567 male offenders, 231 of them followed for at least ten years. That's not a lot to go on to begin with.

In the ten-year trial, men convicted of pedophilia, exhibitionism or sexual assault were assigned to psychodynamic group therapy or no therapy. Alas, a higher proportion of the men in therapy were re-arrested -- although re-arrest is not, of course, the same thing as re-offending, and they weren't necessarily arrested for sex offenses. In general, completion of therapy is associated with lower rates of recidivism, but it's hard to know whether that's because the therapy is effective, or because more motivated people stay in therapy. Prospective, randomized controlled trials are nearly impossible to do, because allocation to treatment depends on decisions made in the criminal justice system, not random selection. Outcomes are hard to measure because we don't usually know whether people are committing offenses, but only whether they are caught.

My view is that there is a compelling social need for better information about this problem. But it doesn't get a lot of funding. People don't have much sympathy for sex offenders, most voters instinctively favor a punitive approach and just want these people removed from their community. But that is not an answer. It is better for all of us to have some degree of compassion even for the most despised, and to approach problems rationally, no matter how emotionally inflammatory. Many specialists have strong opinions about recidivism among sex offenders -- and it is probably lower than most people think, for most kinds of offenses -- but we don't have answers about how to reduce it further, or how to predict who is and is not likely to re-offend. We need to get those answers.

Update: Here's an article from the WAPO about castration as a solution. Somehow doesn't feel right, but some offenders actually desire it as an escape from their compulsions. The story of one guy who took matters into his own hands is astonishing. I don't have a snap opinion on this.