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Women in forensic psychiatry making progress but still have ways to go
AUSTIN, TEX. – Women are making progress in equal representation and leadership within the field of forensic psychiatry, but gender parity remains elusive, according to a presentation at the annual meeting of the American Academy of Psychiatry and the Law.
In the presentation, Kelly L. Coffman, MD, MPH, assistant professor of psychiatry and associate program director of the forensic psychiatry fellowship at Emory University, Atlanta, and Helen M. Farrell, MD, a lecturer at Harvard Medical School, Boston, discussed gender bias in the field and in medicine at large.
After reviewing a handful of Supreme Court cases since the 1970s establishing women’s rights to equal opportunities and harassment-free workplaces, Dr. Farrell noted a recent commentary in the New England Journal of Medicine illustrating the challenges women still face. In that commentary, Reshma Jagsi, MD, a professor of radiation oncology at the University of Michigan, Ann Arbor, and director of the Center for Bioethics and Social Sciences in Medicine, shared her own #MeToo experience within the context of such harassment narratives throughout academic medicine (N Engl J Med. 2018;378:209-11).
Harassment found in medicine
Dr. Jagsi had published a study in 2016 on workplace sexual harassment in medicine that surveyed 1,066 recipients of career development grants from the National Institutes of Health (JAMA. 2016;315:2120-1). The average age of respondents was 43 years, and 46% of respondents were women.
While only 22% of men reported perceiving gender bias in their careers, 70% of women reported such bias. Similarly, 66% of women said they had experienced gender bias in their careers, compared with 10% of men (P less than .001). Women also were substantially more likely to have experienced sexual harassment (30% vs. 4%).
Most women (92%) reporting those experiences described sexist remarks or behavior, 41% experienced unwanted sexual advances, and 9% experienced coercive advances.
“Although a lower proportion reported these experiences than in a 1995 sample, the difference appears large given that the women began their careers after the proportion of female medical students exceeded 40%,” Dr. Jagsi and her colleagues reported in the study.
The effects of those experiences were not minor: Among women who reported harassment, 59% said their confidence as professionals took a hit, and 47% said those experiences hurt their career advancement.
Women still underrepresented
One factor in those high rates might be the extent of existing power differentials: Women remain underrepresented in medical leadership despite accounting for more than half of all enrollees in U.S. medical schools in 2017, according to the Association of American Medical Colleges (AAMC). Female enrollment in medical schools hovered around 40% in the mid-90s, yet in 2015, the AAMC reported that women held 37% of all U.S. medical school faculty positions and 20% of full professorships.
“There’s also a large discrepancy in terms of specialties,” said Dr. Farrell, also a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston. “Women tend to go into fields like pediatrics and ob.gyn. at much higher rates than men, and there are very low rates of women going into surgical fields like neurosurgery and orthopedics.”
Dr. Farrell then zeroed in on the field of forensic psychiatry in particular and various ways to consider how gender bias might manifest: opportunities for exposure to forensics in residency; fellowship applications vs. acceptances; experience in court; publications; invitations to present; large- and small-scale organizational leadership representation; and job placement across the settings of clinics, academics, prisons/institutions; and experience in private practice. Then there’s the perception of female forensic psychiatrists in court.
“There’s a really big question about the difference between how men and women are perceived by attorneys who hire us as experts, and by judges and juries in terms of our credibility when we’re testifying,” Dr. Farrell said.
Picking up where Dr. Farrell left off, Dr. Coffman noted that women always have faced an uphill battle – particularly within forensic psychiatry.
“Forensic psychiatry really is the global intersection of medicine, the criminal justice system, and the law – and traditionally, all three of these fields have really been male dominated,” Dr. Coffman said. “We were often told that women should not go into careers like medicine and the law, because if they work too hard, they might ruin their reproductive potential. They were also thought of as being weak and unable to handle seeing blood.”
Fortunately, however, she added: “That’s very different from how we think about things today.” For example,
Gender perceptions matter
Those numbers show progress, though “we’re a little bit behind the trends,” Dr. Coffman said. One reason for this probably is rooted in implicit biases that shape a person’s thinking, without a conscious realization of the sexist ideas about gender roles that have been internalized.
She presented two descriptions of an individual to make her point: one an accomplished scientist, tax attorney, and major political figure, and one a loving parent with a reputation for “always being well-coiffed and tastefully dressed.” Both depictions describe Margaret Thatcher, the first woman to become prime minister of the United Kingdom.
“There’s that real disconnect between the woman and the role, and that that’s where the prejudice lives,” Dr. Coffman said. “The greater the mismatch you see, the greater potential for prejudice.”
Research backs up those assertions. Dr. Coffman shared findings from a study that compared how male and female doctors introduced one another as speakers (J Womens Health [Larchmt]. 2017 May;26[5]:413-9).
Across 321 forms of address, women were more likely to use professional titles when “introducing any speaker during the first form of address, compared with male introducers (96.2% vs. 65.6%).” When the researchers drilled deeper, they found that women introduced others using their professional titles 97.8% of the time (45/46), while men used professional titles to introduce 72.4% of the time (110/152). A disparity was found in mixed-gender introductions: Women used professional titles when introducing men 95% of the time (57/60), but men did the same with women 49.2% of the time (31/63).
Research on perceptions of women as expert witnesses in court is more complicated. In one experiment, for example, mock jurors read a written summary of a civil case where the expert’s opinion was written by either a male or female automobile engineer. The jurors reached the same verdict just as often with female as male engineers – but awarded higher damages when the engineer was a woman.
But that was a written experiment. In similar research where mock jurors viewed video summaries involving cross-examination of a forensic mental health expert, men were found to be more “likable, believable, trustworthy, confident, and credible” than were women.
This and other research underscore a common dilemma for women, Dr. Coffman said: balancing the expectation of being warm and the need to appear competent – both of which can help and harm the way in which women are perceived. But the reality of perception sometimes can surprise.
She pointed to the double-edged sword of eye contact as an example: “If you don’t make eye contact, then you’re perceived as being weak. But if you make too much eye contact, then you’re perceived as being aggressive. So you really can’t win, right?”
Yet the women remained cautiously optimistic, especially noting the large proportion of men attending the session itself.
“It really takes everybody working together to keep the conversation going, finding out where women want to flourish and bloom, and having people to champion us and support that,” Dr. Farrell said.
Dr. Coffman and Dr. Farrell had no relevant conflicts of interest. They will be presenting an expanded version of the presentation at the International Academy of Law and Mental Health meeting in July 2019 in Rome.
AUSTIN, TEX. – Women are making progress in equal representation and leadership within the field of forensic psychiatry, but gender parity remains elusive, according to a presentation at the annual meeting of the American Academy of Psychiatry and the Law.
In the presentation, Kelly L. Coffman, MD, MPH, assistant professor of psychiatry and associate program director of the forensic psychiatry fellowship at Emory University, Atlanta, and Helen M. Farrell, MD, a lecturer at Harvard Medical School, Boston, discussed gender bias in the field and in medicine at large.
After reviewing a handful of Supreme Court cases since the 1970s establishing women’s rights to equal opportunities and harassment-free workplaces, Dr. Farrell noted a recent commentary in the New England Journal of Medicine illustrating the challenges women still face. In that commentary, Reshma Jagsi, MD, a professor of radiation oncology at the University of Michigan, Ann Arbor, and director of the Center for Bioethics and Social Sciences in Medicine, shared her own #MeToo experience within the context of such harassment narratives throughout academic medicine (N Engl J Med. 2018;378:209-11).
Harassment found in medicine
Dr. Jagsi had published a study in 2016 on workplace sexual harassment in medicine that surveyed 1,066 recipients of career development grants from the National Institutes of Health (JAMA. 2016;315:2120-1). The average age of respondents was 43 years, and 46% of respondents were women.
While only 22% of men reported perceiving gender bias in their careers, 70% of women reported such bias. Similarly, 66% of women said they had experienced gender bias in their careers, compared with 10% of men (P less than .001). Women also were substantially more likely to have experienced sexual harassment (30% vs. 4%).
Most women (92%) reporting those experiences described sexist remarks or behavior, 41% experienced unwanted sexual advances, and 9% experienced coercive advances.
“Although a lower proportion reported these experiences than in a 1995 sample, the difference appears large given that the women began their careers after the proportion of female medical students exceeded 40%,” Dr. Jagsi and her colleagues reported in the study.
The effects of those experiences were not minor: Among women who reported harassment, 59% said their confidence as professionals took a hit, and 47% said those experiences hurt their career advancement.
Women still underrepresented
One factor in those high rates might be the extent of existing power differentials: Women remain underrepresented in medical leadership despite accounting for more than half of all enrollees in U.S. medical schools in 2017, according to the Association of American Medical Colleges (AAMC). Female enrollment in medical schools hovered around 40% in the mid-90s, yet in 2015, the AAMC reported that women held 37% of all U.S. medical school faculty positions and 20% of full professorships.
“There’s also a large discrepancy in terms of specialties,” said Dr. Farrell, also a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston. “Women tend to go into fields like pediatrics and ob.gyn. at much higher rates than men, and there are very low rates of women going into surgical fields like neurosurgery and orthopedics.”
Dr. Farrell then zeroed in on the field of forensic psychiatry in particular and various ways to consider how gender bias might manifest: opportunities for exposure to forensics in residency; fellowship applications vs. acceptances; experience in court; publications; invitations to present; large- and small-scale organizational leadership representation; and job placement across the settings of clinics, academics, prisons/institutions; and experience in private practice. Then there’s the perception of female forensic psychiatrists in court.
“There’s a really big question about the difference between how men and women are perceived by attorneys who hire us as experts, and by judges and juries in terms of our credibility when we’re testifying,” Dr. Farrell said.
Picking up where Dr. Farrell left off, Dr. Coffman noted that women always have faced an uphill battle – particularly within forensic psychiatry.
“Forensic psychiatry really is the global intersection of medicine, the criminal justice system, and the law – and traditionally, all three of these fields have really been male dominated,” Dr. Coffman said. “We were often told that women should not go into careers like medicine and the law, because if they work too hard, they might ruin their reproductive potential. They were also thought of as being weak and unable to handle seeing blood.”
Fortunately, however, she added: “That’s very different from how we think about things today.” For example,
Gender perceptions matter
Those numbers show progress, though “we’re a little bit behind the trends,” Dr. Coffman said. One reason for this probably is rooted in implicit biases that shape a person’s thinking, without a conscious realization of the sexist ideas about gender roles that have been internalized.
She presented two descriptions of an individual to make her point: one an accomplished scientist, tax attorney, and major political figure, and one a loving parent with a reputation for “always being well-coiffed and tastefully dressed.” Both depictions describe Margaret Thatcher, the first woman to become prime minister of the United Kingdom.
“There’s that real disconnect between the woman and the role, and that that’s where the prejudice lives,” Dr. Coffman said. “The greater the mismatch you see, the greater potential for prejudice.”
Research backs up those assertions. Dr. Coffman shared findings from a study that compared how male and female doctors introduced one another as speakers (J Womens Health [Larchmt]. 2017 May;26[5]:413-9).
Across 321 forms of address, women were more likely to use professional titles when “introducing any speaker during the first form of address, compared with male introducers (96.2% vs. 65.6%).” When the researchers drilled deeper, they found that women introduced others using their professional titles 97.8% of the time (45/46), while men used professional titles to introduce 72.4% of the time (110/152). A disparity was found in mixed-gender introductions: Women used professional titles when introducing men 95% of the time (57/60), but men did the same with women 49.2% of the time (31/63).
Research on perceptions of women as expert witnesses in court is more complicated. In one experiment, for example, mock jurors read a written summary of a civil case where the expert’s opinion was written by either a male or female automobile engineer. The jurors reached the same verdict just as often with female as male engineers – but awarded higher damages when the engineer was a woman.
But that was a written experiment. In similar research where mock jurors viewed video summaries involving cross-examination of a forensic mental health expert, men were found to be more “likable, believable, trustworthy, confident, and credible” than were women.
This and other research underscore a common dilemma for women, Dr. Coffman said: balancing the expectation of being warm and the need to appear competent – both of which can help and harm the way in which women are perceived. But the reality of perception sometimes can surprise.
She pointed to the double-edged sword of eye contact as an example: “If you don’t make eye contact, then you’re perceived as being weak. But if you make too much eye contact, then you’re perceived as being aggressive. So you really can’t win, right?”
Yet the women remained cautiously optimistic, especially noting the large proportion of men attending the session itself.
“It really takes everybody working together to keep the conversation going, finding out where women want to flourish and bloom, and having people to champion us and support that,” Dr. Farrell said.
Dr. Coffman and Dr. Farrell had no relevant conflicts of interest. They will be presenting an expanded version of the presentation at the International Academy of Law and Mental Health meeting in July 2019 in Rome.
AUSTIN, TEX. – Women are making progress in equal representation and leadership within the field of forensic psychiatry, but gender parity remains elusive, according to a presentation at the annual meeting of the American Academy of Psychiatry and the Law.
In the presentation, Kelly L. Coffman, MD, MPH, assistant professor of psychiatry and associate program director of the forensic psychiatry fellowship at Emory University, Atlanta, and Helen M. Farrell, MD, a lecturer at Harvard Medical School, Boston, discussed gender bias in the field and in medicine at large.
After reviewing a handful of Supreme Court cases since the 1970s establishing women’s rights to equal opportunities and harassment-free workplaces, Dr. Farrell noted a recent commentary in the New England Journal of Medicine illustrating the challenges women still face. In that commentary, Reshma Jagsi, MD, a professor of radiation oncology at the University of Michigan, Ann Arbor, and director of the Center for Bioethics and Social Sciences in Medicine, shared her own #MeToo experience within the context of such harassment narratives throughout academic medicine (N Engl J Med. 2018;378:209-11).
Harassment found in medicine
Dr. Jagsi had published a study in 2016 on workplace sexual harassment in medicine that surveyed 1,066 recipients of career development grants from the National Institutes of Health (JAMA. 2016;315:2120-1). The average age of respondents was 43 years, and 46% of respondents were women.
While only 22% of men reported perceiving gender bias in their careers, 70% of women reported such bias. Similarly, 66% of women said they had experienced gender bias in their careers, compared with 10% of men (P less than .001). Women also were substantially more likely to have experienced sexual harassment (30% vs. 4%).
Most women (92%) reporting those experiences described sexist remarks or behavior, 41% experienced unwanted sexual advances, and 9% experienced coercive advances.
“Although a lower proportion reported these experiences than in a 1995 sample, the difference appears large given that the women began their careers after the proportion of female medical students exceeded 40%,” Dr. Jagsi and her colleagues reported in the study.
The effects of those experiences were not minor: Among women who reported harassment, 59% said their confidence as professionals took a hit, and 47% said those experiences hurt their career advancement.
Women still underrepresented
One factor in those high rates might be the extent of existing power differentials: Women remain underrepresented in medical leadership despite accounting for more than half of all enrollees in U.S. medical schools in 2017, according to the Association of American Medical Colleges (AAMC). Female enrollment in medical schools hovered around 40% in the mid-90s, yet in 2015, the AAMC reported that women held 37% of all U.S. medical school faculty positions and 20% of full professorships.
“There’s also a large discrepancy in terms of specialties,” said Dr. Farrell, also a staff psychiatrist at Beth Israel Deaconess Medical Center, Boston. “Women tend to go into fields like pediatrics and ob.gyn. at much higher rates than men, and there are very low rates of women going into surgical fields like neurosurgery and orthopedics.”
Dr. Farrell then zeroed in on the field of forensic psychiatry in particular and various ways to consider how gender bias might manifest: opportunities for exposure to forensics in residency; fellowship applications vs. acceptances; experience in court; publications; invitations to present; large- and small-scale organizational leadership representation; and job placement across the settings of clinics, academics, prisons/institutions; and experience in private practice. Then there’s the perception of female forensic psychiatrists in court.
“There’s a really big question about the difference between how men and women are perceived by attorneys who hire us as experts, and by judges and juries in terms of our credibility when we’re testifying,” Dr. Farrell said.
Picking up where Dr. Farrell left off, Dr. Coffman noted that women always have faced an uphill battle – particularly within forensic psychiatry.
“Forensic psychiatry really is the global intersection of medicine, the criminal justice system, and the law – and traditionally, all three of these fields have really been male dominated,” Dr. Coffman said. “We were often told that women should not go into careers like medicine and the law, because if they work too hard, they might ruin their reproductive potential. They were also thought of as being weak and unable to handle seeing blood.”
Fortunately, however, she added: “That’s very different from how we think about things today.” For example,
Gender perceptions matter
Those numbers show progress, though “we’re a little bit behind the trends,” Dr. Coffman said. One reason for this probably is rooted in implicit biases that shape a person’s thinking, without a conscious realization of the sexist ideas about gender roles that have been internalized.
She presented two descriptions of an individual to make her point: one an accomplished scientist, tax attorney, and major political figure, and one a loving parent with a reputation for “always being well-coiffed and tastefully dressed.” Both depictions describe Margaret Thatcher, the first woman to become prime minister of the United Kingdom.
“There’s that real disconnect between the woman and the role, and that that’s where the prejudice lives,” Dr. Coffman said. “The greater the mismatch you see, the greater potential for prejudice.”
Research backs up those assertions. Dr. Coffman shared findings from a study that compared how male and female doctors introduced one another as speakers (J Womens Health [Larchmt]. 2017 May;26[5]:413-9).
Across 321 forms of address, women were more likely to use professional titles when “introducing any speaker during the first form of address, compared with male introducers (96.2% vs. 65.6%).” When the researchers drilled deeper, they found that women introduced others using their professional titles 97.8% of the time (45/46), while men used professional titles to introduce 72.4% of the time (110/152). A disparity was found in mixed-gender introductions: Women used professional titles when introducing men 95% of the time (57/60), but men did the same with women 49.2% of the time (31/63).
Research on perceptions of women as expert witnesses in court is more complicated. In one experiment, for example, mock jurors read a written summary of a civil case where the expert’s opinion was written by either a male or female automobile engineer. The jurors reached the same verdict just as often with female as male engineers – but awarded higher damages when the engineer was a woman.
But that was a written experiment. In similar research where mock jurors viewed video summaries involving cross-examination of a forensic mental health expert, men were found to be more “likable, believable, trustworthy, confident, and credible” than were women.
This and other research underscore a common dilemma for women, Dr. Coffman said: balancing the expectation of being warm and the need to appear competent – both of which can help and harm the way in which women are perceived. But the reality of perception sometimes can surprise.
She pointed to the double-edged sword of eye contact as an example: “If you don’t make eye contact, then you’re perceived as being weak. But if you make too much eye contact, then you’re perceived as being aggressive. So you really can’t win, right?”
Yet the women remained cautiously optimistic, especially noting the large proportion of men attending the session itself.
“It really takes everybody working together to keep the conversation going, finding out where women want to flourish and bloom, and having people to champion us and support that,” Dr. Farrell said.
Dr. Coffman and Dr. Farrell had no relevant conflicts of interest. They will be presenting an expanded version of the presentation at the International Academy of Law and Mental Health meeting in July 2019 in Rome.
REPORTING FROM THE AAPL ANNUAL MEETING
Autistic youth face higher risks from online child pornography
Prevention efforts include advising adolescent patients about puberty and sex.
AUSTIN, TEX. – It is important to understand the legislative and social lay of the land for child pornography and related issues, such as sexting and revenge porn, according to Nicole Sussman, MD.
Dr. Sussman of Cambridge (Mass.) Health Alliance provided an overview of the history of child pornography legislation before discussing the current landscape and the unique challenges and risks it presents to autistic youth at the annual meeting of the American Academy of Psychiatry and the Law.
History of U.S. child pornography laws
The Protection of Children Against Sexual Exploitation Act, passed in 1977, criminalized the act of forcing a child to engage in sexual activity. But it wasn’t widely cited. Little awareness existed around the issue until New York v. Ferber in 1982, which upheld a New York statute that outlawed distribution of material depicting children under 16 years of age engaged in sexual acts. The U.S. Supreme Court linked child porn to sexual abuse of a child and determined that the only way to control production of child pornography was to regulate distribution of it.
Shortly thereafter, the Child Protection Act of 1984 limited the production, distribution, and possession of “materials involving the sexual exploitation of minors even if the material is not found to be ‘obscene.’ ” The law also raised the age of a minor for the law’s purposes to anyone younger than age 18 years, removed the requirement that the materials be sold (free distribution was now also regulated), and authorized interception of communications to investigate offenses.
Two years later, the Child Sexual Abuse and Pornography Act and the Child Abuse Victims’ Rights Act strengthened child pornography laws; the first made it a federal offense to advertise “any product depicting sexually explicit conduct with a minor or the opportunity to engage in such conduct with a minor.”
More regulation followed with the Child Protection and Obscenity Enforcement Act of 1988, which added regulation of child pornography on computers, and the Child Pornography Prevention Act of 1996, which regulates all forms of online/virtual child pornography.
The first weakening of these laws came with Ashcroft v. Free Speech Coalition in 2002, which held that the 1996 law was overly broad, with the potential to violate free speech, since prohibition of images that “appear to be” or “convey the impression” of child pornography might not necessarily have actually involved child exploitation.
Finally, the Adam Walsh Child Protection and Safety Act of 2006 established the national sex offender registry and mandated convicted offender requirements for reporting their whereabouts based on the “tier” of their crime.
Today’s landscape: Internet use and pornography
With all that legislation as a backdrop, the intersection of growing use of mobile technology, online pornography and sexting can become thorny.
Recent data show that 95% of teens aged 13-17 years have access to a smartphone – independent of their race, sex, ethnicity, or socioeconomic status. Nearly half of teens (45%) report that they are online nearly constantly, Dr. Sussman said.
And pornography is free and easy to find online. A 2006 survey of New Hampshire college students found that 72% of them had seen porn before age 18 years – and that’s decade-old data.
A 2013-2014 survey of 16- and 17-year-olds in Boston found that about half (51%) reported watching porn at least weekly, and 54% watched porn to learn how to do something. Further, 30% of youth in that survey said porn was their primary source of sexual education, followed by parents, cited by 21%.
Put these realities together, and you encounter sexting, the act of sharing “sexually explicit images, videos, or messages through electronic media.” Research on the prevalence of sexting varies widely, with estimates up to 60% of teens. Though prevalence estimates depend on definitions, recent studies suggest that one in four teens send “sexts” and one in seven teens receive them, Dr. Sussman said.
But these figures should be considered alongside an understanding normal sexual development among adolescents. Sexting might simply represent a normal emerging component of sexual development within the context of today’s society, Dr. Sussman said. Sexting often is viewed by youth as a way to initiate and maintain relationships, she said.
Nevertheless, teens might not be able to fully appreciate the risks associated with sending or receiving sexually explicit texts. One in eight teens report being involved in nonconsensual sexting, whether as recipient of an unsolicited sext or as the subject of one.
Sexting also can take the form of “revenge porn” and “sextortion,” in which sexually explicit electronic images are distributed as a form of revenge or are threatened to be distributed.
Early legislation related to sexting has led to litigation, such as the case of 16-year-old A.H., who was charged with producing child pornography after she emailed her 17-year-old boyfriend images of the two of them engaged in sexual activity. She argued she had a right to privacy. But the court disagreed, finding the state had a compelling interest “in protecting children from sexual exploitation,” regardless of “whether the person sexually exploiting the child is an adult or a minor.”
By 2008-2009, about 4,000 cases involving minors sexting were making their way through the courts, demonstrating a “need for laws to evolve and to consider developmental context,” Dr. Sussman said. Punishment could be severe, including requirements for youth to register in the national sex offender registry. Today, however, 25 states have laws differentiating sexting from child pornography.
Child pornography and autistic youth
Teens with autism spectrum disorder might be particularly at higher risk for accessing child pornography and subsequent conviction. Autistic youth’s weaknesses in social skills make it difficult for them to understand the unwritten rules and subjectivity of dating. While their bodies and hormones are changing, their mental age might lag, and their weak interpersonal skills limit their ability to move a relationship in a romantic direction.
Meanwhile, autistic youth might feel more comfortable interacting with others on their computers. Paired with a difficulty in judging others’ age and a limited awareness or understanding of the potential outcomes of their actions, autistic youth can easily fall into a trap of accessing child pornography.
Porn might become a substitute for human interaction, and the accessibility of porn online makes it easy to discover child pornography whose “mere existence implies legality,” Dr. Sussman said. Further, youth are drawn toward images depicting people they personally identify with in terms of their social or emotional age.
Given that pornography typically is not discussed by parents or in sex education, “there have been some cases where people who have autism spectrum disorders have gotten in trouble,” Dr. Sussman said. Autistic youth also might struggle to make the connection between what’s wrong in real life versus what might appear abstract and more acceptable on a computer.
The realities of this special population have several implications courts should consider, Dr. Sussman said. For one, their actions may be misinterpreted as criminal when they might not pose the same level of danger to society as someone else who accesses child pornography. In general, criminal behavior is statistically lower among autistic individuals, but victimization of them is higher than average.
Yet it might be difficult for courts to perceive deficits in individuals with stronger (“high-functioning”) skills in some areas. Courts also should consider how an autistic person might fare in a correctional facility, where inability to understand and adhere to the prison environment’s social structure could prove fatal.
Autistic individuals might be more inclined to report those who break rules and might have an eagerness to please that makes them easily manipulated. Prison staff might misinterpret their behavior, and autistic inmates might be at risk for higher rates of isolation for their own protection.
Dr. Sussman said. Physicians should provide anticipatory guidance when it comes to puberty, sex, romantic interests, and masturbation, she said, and parents can us parental controls.
Youth, especially autistic youth, should be taught the difference between acceptable (“good”) touch, versus unacceptable (“bad”) touch, respect of personal space, and the difference between public and private behavior. Discussions of reality vs. fantasy – especially considering how unrealistic online porn often is – and the definition of consent are also vital preventive strategies.
Dr. Sussman had no conflicts of interest.
Prevention efforts include advising adolescent patients about puberty and sex.
Prevention efforts include advising adolescent patients about puberty and sex.
AUSTIN, TEX. – It is important to understand the legislative and social lay of the land for child pornography and related issues, such as sexting and revenge porn, according to Nicole Sussman, MD.
Dr. Sussman of Cambridge (Mass.) Health Alliance provided an overview of the history of child pornography legislation before discussing the current landscape and the unique challenges and risks it presents to autistic youth at the annual meeting of the American Academy of Psychiatry and the Law.
History of U.S. child pornography laws
The Protection of Children Against Sexual Exploitation Act, passed in 1977, criminalized the act of forcing a child to engage in sexual activity. But it wasn’t widely cited. Little awareness existed around the issue until New York v. Ferber in 1982, which upheld a New York statute that outlawed distribution of material depicting children under 16 years of age engaged in sexual acts. The U.S. Supreme Court linked child porn to sexual abuse of a child and determined that the only way to control production of child pornography was to regulate distribution of it.
Shortly thereafter, the Child Protection Act of 1984 limited the production, distribution, and possession of “materials involving the sexual exploitation of minors even if the material is not found to be ‘obscene.’ ” The law also raised the age of a minor for the law’s purposes to anyone younger than age 18 years, removed the requirement that the materials be sold (free distribution was now also regulated), and authorized interception of communications to investigate offenses.
Two years later, the Child Sexual Abuse and Pornography Act and the Child Abuse Victims’ Rights Act strengthened child pornography laws; the first made it a federal offense to advertise “any product depicting sexually explicit conduct with a minor or the opportunity to engage in such conduct with a minor.”
More regulation followed with the Child Protection and Obscenity Enforcement Act of 1988, which added regulation of child pornography on computers, and the Child Pornography Prevention Act of 1996, which regulates all forms of online/virtual child pornography.
The first weakening of these laws came with Ashcroft v. Free Speech Coalition in 2002, which held that the 1996 law was overly broad, with the potential to violate free speech, since prohibition of images that “appear to be” or “convey the impression” of child pornography might not necessarily have actually involved child exploitation.
Finally, the Adam Walsh Child Protection and Safety Act of 2006 established the national sex offender registry and mandated convicted offender requirements for reporting their whereabouts based on the “tier” of their crime.
Today’s landscape: Internet use and pornography
With all that legislation as a backdrop, the intersection of growing use of mobile technology, online pornography and sexting can become thorny.
Recent data show that 95% of teens aged 13-17 years have access to a smartphone – independent of their race, sex, ethnicity, or socioeconomic status. Nearly half of teens (45%) report that they are online nearly constantly, Dr. Sussman said.
And pornography is free and easy to find online. A 2006 survey of New Hampshire college students found that 72% of them had seen porn before age 18 years – and that’s decade-old data.
A 2013-2014 survey of 16- and 17-year-olds in Boston found that about half (51%) reported watching porn at least weekly, and 54% watched porn to learn how to do something. Further, 30% of youth in that survey said porn was their primary source of sexual education, followed by parents, cited by 21%.
Put these realities together, and you encounter sexting, the act of sharing “sexually explicit images, videos, or messages through electronic media.” Research on the prevalence of sexting varies widely, with estimates up to 60% of teens. Though prevalence estimates depend on definitions, recent studies suggest that one in four teens send “sexts” and one in seven teens receive them, Dr. Sussman said.
But these figures should be considered alongside an understanding normal sexual development among adolescents. Sexting might simply represent a normal emerging component of sexual development within the context of today’s society, Dr. Sussman said. Sexting often is viewed by youth as a way to initiate and maintain relationships, she said.
Nevertheless, teens might not be able to fully appreciate the risks associated with sending or receiving sexually explicit texts. One in eight teens report being involved in nonconsensual sexting, whether as recipient of an unsolicited sext or as the subject of one.
Sexting also can take the form of “revenge porn” and “sextortion,” in which sexually explicit electronic images are distributed as a form of revenge or are threatened to be distributed.
Early legislation related to sexting has led to litigation, such as the case of 16-year-old A.H., who was charged with producing child pornography after she emailed her 17-year-old boyfriend images of the two of them engaged in sexual activity. She argued she had a right to privacy. But the court disagreed, finding the state had a compelling interest “in protecting children from sexual exploitation,” regardless of “whether the person sexually exploiting the child is an adult or a minor.”
By 2008-2009, about 4,000 cases involving minors sexting were making their way through the courts, demonstrating a “need for laws to evolve and to consider developmental context,” Dr. Sussman said. Punishment could be severe, including requirements for youth to register in the national sex offender registry. Today, however, 25 states have laws differentiating sexting from child pornography.
Child pornography and autistic youth
Teens with autism spectrum disorder might be particularly at higher risk for accessing child pornography and subsequent conviction. Autistic youth’s weaknesses in social skills make it difficult for them to understand the unwritten rules and subjectivity of dating. While their bodies and hormones are changing, their mental age might lag, and their weak interpersonal skills limit their ability to move a relationship in a romantic direction.
Meanwhile, autistic youth might feel more comfortable interacting with others on their computers. Paired with a difficulty in judging others’ age and a limited awareness or understanding of the potential outcomes of their actions, autistic youth can easily fall into a trap of accessing child pornography.
Porn might become a substitute for human interaction, and the accessibility of porn online makes it easy to discover child pornography whose “mere existence implies legality,” Dr. Sussman said. Further, youth are drawn toward images depicting people they personally identify with in terms of their social or emotional age.
Given that pornography typically is not discussed by parents or in sex education, “there have been some cases where people who have autism spectrum disorders have gotten in trouble,” Dr. Sussman said. Autistic youth also might struggle to make the connection between what’s wrong in real life versus what might appear abstract and more acceptable on a computer.
The realities of this special population have several implications courts should consider, Dr. Sussman said. For one, their actions may be misinterpreted as criminal when they might not pose the same level of danger to society as someone else who accesses child pornography. In general, criminal behavior is statistically lower among autistic individuals, but victimization of them is higher than average.
Yet it might be difficult for courts to perceive deficits in individuals with stronger (“high-functioning”) skills in some areas. Courts also should consider how an autistic person might fare in a correctional facility, where inability to understand and adhere to the prison environment’s social structure could prove fatal.
Autistic individuals might be more inclined to report those who break rules and might have an eagerness to please that makes them easily manipulated. Prison staff might misinterpret their behavior, and autistic inmates might be at risk for higher rates of isolation for their own protection.
Dr. Sussman said. Physicians should provide anticipatory guidance when it comes to puberty, sex, romantic interests, and masturbation, she said, and parents can us parental controls.
Youth, especially autistic youth, should be taught the difference between acceptable (“good”) touch, versus unacceptable (“bad”) touch, respect of personal space, and the difference between public and private behavior. Discussions of reality vs. fantasy – especially considering how unrealistic online porn often is – and the definition of consent are also vital preventive strategies.
Dr. Sussman had no conflicts of interest.
AUSTIN, TEX. – It is important to understand the legislative and social lay of the land for child pornography and related issues, such as sexting and revenge porn, according to Nicole Sussman, MD.
Dr. Sussman of Cambridge (Mass.) Health Alliance provided an overview of the history of child pornography legislation before discussing the current landscape and the unique challenges and risks it presents to autistic youth at the annual meeting of the American Academy of Psychiatry and the Law.
History of U.S. child pornography laws
The Protection of Children Against Sexual Exploitation Act, passed in 1977, criminalized the act of forcing a child to engage in sexual activity. But it wasn’t widely cited. Little awareness existed around the issue until New York v. Ferber in 1982, which upheld a New York statute that outlawed distribution of material depicting children under 16 years of age engaged in sexual acts. The U.S. Supreme Court linked child porn to sexual abuse of a child and determined that the only way to control production of child pornography was to regulate distribution of it.
Shortly thereafter, the Child Protection Act of 1984 limited the production, distribution, and possession of “materials involving the sexual exploitation of minors even if the material is not found to be ‘obscene.’ ” The law also raised the age of a minor for the law’s purposes to anyone younger than age 18 years, removed the requirement that the materials be sold (free distribution was now also regulated), and authorized interception of communications to investigate offenses.
Two years later, the Child Sexual Abuse and Pornography Act and the Child Abuse Victims’ Rights Act strengthened child pornography laws; the first made it a federal offense to advertise “any product depicting sexually explicit conduct with a minor or the opportunity to engage in such conduct with a minor.”
More regulation followed with the Child Protection and Obscenity Enforcement Act of 1988, which added regulation of child pornography on computers, and the Child Pornography Prevention Act of 1996, which regulates all forms of online/virtual child pornography.
The first weakening of these laws came with Ashcroft v. Free Speech Coalition in 2002, which held that the 1996 law was overly broad, with the potential to violate free speech, since prohibition of images that “appear to be” or “convey the impression” of child pornography might not necessarily have actually involved child exploitation.
Finally, the Adam Walsh Child Protection and Safety Act of 2006 established the national sex offender registry and mandated convicted offender requirements for reporting their whereabouts based on the “tier” of their crime.
Today’s landscape: Internet use and pornography
With all that legislation as a backdrop, the intersection of growing use of mobile technology, online pornography and sexting can become thorny.
Recent data show that 95% of teens aged 13-17 years have access to a smartphone – independent of their race, sex, ethnicity, or socioeconomic status. Nearly half of teens (45%) report that they are online nearly constantly, Dr. Sussman said.
And pornography is free and easy to find online. A 2006 survey of New Hampshire college students found that 72% of them had seen porn before age 18 years – and that’s decade-old data.
A 2013-2014 survey of 16- and 17-year-olds in Boston found that about half (51%) reported watching porn at least weekly, and 54% watched porn to learn how to do something. Further, 30% of youth in that survey said porn was their primary source of sexual education, followed by parents, cited by 21%.
Put these realities together, and you encounter sexting, the act of sharing “sexually explicit images, videos, or messages through electronic media.” Research on the prevalence of sexting varies widely, with estimates up to 60% of teens. Though prevalence estimates depend on definitions, recent studies suggest that one in four teens send “sexts” and one in seven teens receive them, Dr. Sussman said.
But these figures should be considered alongside an understanding normal sexual development among adolescents. Sexting might simply represent a normal emerging component of sexual development within the context of today’s society, Dr. Sussman said. Sexting often is viewed by youth as a way to initiate and maintain relationships, she said.
Nevertheless, teens might not be able to fully appreciate the risks associated with sending or receiving sexually explicit texts. One in eight teens report being involved in nonconsensual sexting, whether as recipient of an unsolicited sext or as the subject of one.
Sexting also can take the form of “revenge porn” and “sextortion,” in which sexually explicit electronic images are distributed as a form of revenge or are threatened to be distributed.
Early legislation related to sexting has led to litigation, such as the case of 16-year-old A.H., who was charged with producing child pornography after she emailed her 17-year-old boyfriend images of the two of them engaged in sexual activity. She argued she had a right to privacy. But the court disagreed, finding the state had a compelling interest “in protecting children from sexual exploitation,” regardless of “whether the person sexually exploiting the child is an adult or a minor.”
By 2008-2009, about 4,000 cases involving minors sexting were making their way through the courts, demonstrating a “need for laws to evolve and to consider developmental context,” Dr. Sussman said. Punishment could be severe, including requirements for youth to register in the national sex offender registry. Today, however, 25 states have laws differentiating sexting from child pornography.
Child pornography and autistic youth
Teens with autism spectrum disorder might be particularly at higher risk for accessing child pornography and subsequent conviction. Autistic youth’s weaknesses in social skills make it difficult for them to understand the unwritten rules and subjectivity of dating. While their bodies and hormones are changing, their mental age might lag, and their weak interpersonal skills limit their ability to move a relationship in a romantic direction.
Meanwhile, autistic youth might feel more comfortable interacting with others on their computers. Paired with a difficulty in judging others’ age and a limited awareness or understanding of the potential outcomes of their actions, autistic youth can easily fall into a trap of accessing child pornography.
Porn might become a substitute for human interaction, and the accessibility of porn online makes it easy to discover child pornography whose “mere existence implies legality,” Dr. Sussman said. Further, youth are drawn toward images depicting people they personally identify with in terms of their social or emotional age.
Given that pornography typically is not discussed by parents or in sex education, “there have been some cases where people who have autism spectrum disorders have gotten in trouble,” Dr. Sussman said. Autistic youth also might struggle to make the connection between what’s wrong in real life versus what might appear abstract and more acceptable on a computer.
The realities of this special population have several implications courts should consider, Dr. Sussman said. For one, their actions may be misinterpreted as criminal when they might not pose the same level of danger to society as someone else who accesses child pornography. In general, criminal behavior is statistically lower among autistic individuals, but victimization of them is higher than average.
Yet it might be difficult for courts to perceive deficits in individuals with stronger (“high-functioning”) skills in some areas. Courts also should consider how an autistic person might fare in a correctional facility, where inability to understand and adhere to the prison environment’s social structure could prove fatal.
Autistic individuals might be more inclined to report those who break rules and might have an eagerness to please that makes them easily manipulated. Prison staff might misinterpret their behavior, and autistic inmates might be at risk for higher rates of isolation for their own protection.
Dr. Sussman said. Physicians should provide anticipatory guidance when it comes to puberty, sex, romantic interests, and masturbation, she said, and parents can us parental controls.
Youth, especially autistic youth, should be taught the difference between acceptable (“good”) touch, versus unacceptable (“bad”) touch, respect of personal space, and the difference between public and private behavior. Discussions of reality vs. fantasy – especially considering how unrealistic online porn often is – and the definition of consent are also vital preventive strategies.
Dr. Sussman had no conflicts of interest.
REPORTING FROM THE AAPL ANNUAL MEETING
Case shows clinical assessment supersedes psychological screening tools
AUSTIN, TEX. – Using psychological screenings for law enforcement employment decisions can be a worthwhile supplement to more traditional hiring procedures, but such tools should be used with caution, a recent case study suggests.
“Pre-employment psychological evaluations for police officers are increasingly utilizing self-reported personality assessments to identify attributes in candidates that have shown to correlate with job performance outcomes,” Ann Marie Mckenzie Cassidy, DO, of Icahn School of Medicine at Mount Sinai, New York, and her colleagues wrote in an abstract presented at the annual meeting of the American Academy of Psychiatry and the Law.
“As research supporting the predictive power of written self-reported measurements expands, the call for this empirically validated data to be weighted over clinician judgment is becoming more substantive,” the researchers wrote. “The following case exemplifies a psychological evaluation where test results were either inconclusive or strongly conflicted with the clinical picture of the candidate.”
The applicant was a 34-year-old male Army veteran who received an honorable discharge after three deployments. Though he had no relevant medical or formal psychiatric history or drug use, he said he did drink alcohol heavily for a short time after joining the Army. He also had four speeding citations and one drag racing citation.
His personal history revealed several problems, including a military write-up for yelling at a subordinate and a history of difficulties working with his supervisor.
“While working as a car mechanic, he was unable to resolve a conflict with a difficult customer” and quit his job without notice, leading his employer to say he would not hire the applicant again. Yet, the applicant “denied interpersonal issues at work” and said he did not recall the yelling incident. He also said the situation where he quit with only 2 hours’ notice was unfair.
The applicant reported stress, “feeling down and having a diminished interest in activities” following his deployment in Iraq, but he turned down treatment for his stress. He also “used unprofessional language during the examination, and, when asked to refrain from cursing, he did not express concern about this conduct.”
His psychological test results on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), however, suggested “a pattern of positive impression management and defensiveness that is not likely to accurately represent existing psychopathology,” the researchers reported. “Closer review suggests the applicant is apt to see himself as having high moral standards and not having aggressive impulses,” they wrote. Similarly, the applicant’s Sixteen Personality Factor Questionnaire results “reflected an individual who is tough-minded, with low anxiety, who is emotionally stable, deferential, and relaxed.”
These two tools’ findings conflicted with the applicant’s history and presentation, and the examiner deemed him “psychologically unsuitable for hire.”
The researchers said this case reinforces the importance of investigating how empirical data – even with tools such as the MMPI-2, whose predictive power has been validated in several studies – are weighted and used with clinical psychological assessments.
the researchers concluded. “Until there is greater exploration of divergent or complementary testing findings and clinical judgment, test data should not be weighted over clinical judgment in psychological evaluations.”
AUSTIN, TEX. – Using psychological screenings for law enforcement employment decisions can be a worthwhile supplement to more traditional hiring procedures, but such tools should be used with caution, a recent case study suggests.
“Pre-employment psychological evaluations for police officers are increasingly utilizing self-reported personality assessments to identify attributes in candidates that have shown to correlate with job performance outcomes,” Ann Marie Mckenzie Cassidy, DO, of Icahn School of Medicine at Mount Sinai, New York, and her colleagues wrote in an abstract presented at the annual meeting of the American Academy of Psychiatry and the Law.
“As research supporting the predictive power of written self-reported measurements expands, the call for this empirically validated data to be weighted over clinician judgment is becoming more substantive,” the researchers wrote. “The following case exemplifies a psychological evaluation where test results were either inconclusive or strongly conflicted with the clinical picture of the candidate.”
The applicant was a 34-year-old male Army veteran who received an honorable discharge after three deployments. Though he had no relevant medical or formal psychiatric history or drug use, he said he did drink alcohol heavily for a short time after joining the Army. He also had four speeding citations and one drag racing citation.
His personal history revealed several problems, including a military write-up for yelling at a subordinate and a history of difficulties working with his supervisor.
“While working as a car mechanic, he was unable to resolve a conflict with a difficult customer” and quit his job without notice, leading his employer to say he would not hire the applicant again. Yet, the applicant “denied interpersonal issues at work” and said he did not recall the yelling incident. He also said the situation where he quit with only 2 hours’ notice was unfair.
The applicant reported stress, “feeling down and having a diminished interest in activities” following his deployment in Iraq, but he turned down treatment for his stress. He also “used unprofessional language during the examination, and, when asked to refrain from cursing, he did not express concern about this conduct.”
His psychological test results on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), however, suggested “a pattern of positive impression management and defensiveness that is not likely to accurately represent existing psychopathology,” the researchers reported. “Closer review suggests the applicant is apt to see himself as having high moral standards and not having aggressive impulses,” they wrote. Similarly, the applicant’s Sixteen Personality Factor Questionnaire results “reflected an individual who is tough-minded, with low anxiety, who is emotionally stable, deferential, and relaxed.”
These two tools’ findings conflicted with the applicant’s history and presentation, and the examiner deemed him “psychologically unsuitable for hire.”
The researchers said this case reinforces the importance of investigating how empirical data – even with tools such as the MMPI-2, whose predictive power has been validated in several studies – are weighted and used with clinical psychological assessments.
the researchers concluded. “Until there is greater exploration of divergent or complementary testing findings and clinical judgment, test data should not be weighted over clinical judgment in psychological evaluations.”
AUSTIN, TEX. – Using psychological screenings for law enforcement employment decisions can be a worthwhile supplement to more traditional hiring procedures, but such tools should be used with caution, a recent case study suggests.
“Pre-employment psychological evaluations for police officers are increasingly utilizing self-reported personality assessments to identify attributes in candidates that have shown to correlate with job performance outcomes,” Ann Marie Mckenzie Cassidy, DO, of Icahn School of Medicine at Mount Sinai, New York, and her colleagues wrote in an abstract presented at the annual meeting of the American Academy of Psychiatry and the Law.
“As research supporting the predictive power of written self-reported measurements expands, the call for this empirically validated data to be weighted over clinician judgment is becoming more substantive,” the researchers wrote. “The following case exemplifies a psychological evaluation where test results were either inconclusive or strongly conflicted with the clinical picture of the candidate.”
The applicant was a 34-year-old male Army veteran who received an honorable discharge after three deployments. Though he had no relevant medical or formal psychiatric history or drug use, he said he did drink alcohol heavily for a short time after joining the Army. He also had four speeding citations and one drag racing citation.
His personal history revealed several problems, including a military write-up for yelling at a subordinate and a history of difficulties working with his supervisor.
“While working as a car mechanic, he was unable to resolve a conflict with a difficult customer” and quit his job without notice, leading his employer to say he would not hire the applicant again. Yet, the applicant “denied interpersonal issues at work” and said he did not recall the yelling incident. He also said the situation where he quit with only 2 hours’ notice was unfair.
The applicant reported stress, “feeling down and having a diminished interest in activities” following his deployment in Iraq, but he turned down treatment for his stress. He also “used unprofessional language during the examination, and, when asked to refrain from cursing, he did not express concern about this conduct.”
His psychological test results on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), however, suggested “a pattern of positive impression management and defensiveness that is not likely to accurately represent existing psychopathology,” the researchers reported. “Closer review suggests the applicant is apt to see himself as having high moral standards and not having aggressive impulses,” they wrote. Similarly, the applicant’s Sixteen Personality Factor Questionnaire results “reflected an individual who is tough-minded, with low anxiety, who is emotionally stable, deferential, and relaxed.”
These two tools’ findings conflicted with the applicant’s history and presentation, and the examiner deemed him “psychologically unsuitable for hire.”
The researchers said this case reinforces the importance of investigating how empirical data – even with tools such as the MMPI-2, whose predictive power has been validated in several studies – are weighted and used with clinical psychological assessments.
the researchers concluded. “Until there is greater exploration of divergent or complementary testing findings and clinical judgment, test data should not be weighted over clinical judgment in psychological evaluations.”
REPORTING FROM THE AAPL ANNUAL MEETING
Death row executions raise questions about competence
AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.
Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.
The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”
They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.
When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.
They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.
Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.
Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.
Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.
Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.
The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”
No disclosures were reported.
AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.
Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.
The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”
They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.
When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.
They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.
Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.
Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.
Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.
Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.
The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”
No disclosures were reported.
AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.
Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.
The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”
They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.
When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.
They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.
Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.
Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.
Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.
Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.
The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”
No disclosures were reported.
REPORTING FROM THE AAPL ANNUAL MEETING
Substance use increases likelihood of psychiatric hold in pregnancy
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
REPORTING FROM THE AAPL ANNUAL MEETING
Key clinical point: Women are more likely to receive a psychiatric hold if they are pregnant and using a substance.
Major finding: Almost 53% of clinicians would place a suicidal pregnant woman on a psychiatric hold, but 73.6% would do so if she were using methamphetamines.
Study details: The findings are based on an Internet survey of 68 members of the American Academy of Psychiatry and the Law.
Disclosures: No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
Sibling abuse more common than child, domestic abuse combined
AUSTIN, TEX. – Sibling violence is the most common form of family violence – more prevalent than child abuse and domestic abuse combined – according to new research.
A review of the literature shows that it occurs in anywhere from 42% to 80%-90% of families, according to an abstract by Peter S. Martin, MD, MPH, of the University of Buffalo, New York.
Nearly 50% of siblings engaged in severe violence in the past year, though emotional aggression is more common than is physical aggression, Dr. Martin shared at the annual meeting of the American Academy of Psychiatry and the Law.
“Both perpetrators and victims are at risk for poor outcomes,” Dr. Martin wrote, listing distress, low self-esteem, developmental delays, depression, anxiety, posttraumatic stress disorder, substance use disorders, eating disorders, and suicidality, sometimes reaching into adulthood. Those symptoms typically can be as severe as those experienced by victims of peer bullying, he wrote.
Males involved in sibling violence tend to show more aggression and delinquency, while females experience more difficulties with psychological adjustment, he wrote. Sibling violence also is a predictor for college dating violence.
Siblings – whether biological, half, step, adoptive, foster or even fictive (like chosen family) – spend more time with each other than anyone else growing up. Those relationships provide companionship, support, and opportunities for play and engagement against an adversary, but they remain unique from other family relationships.
Healthy sibling relationships are linked to increased social competence, independence, self-control, companionship, general life skills, support, and overall social, cognitive, and emotional growth, Dr. Martin noted in his abstract.
On the flip side, “,” he wrote.
Yet, despite the prevalence of sibling aggression and the commonness of having a sibling in general, studying sibling violence is challenging because neither the academic research nor legal realms have a standardized definition for it.
To better understand the phenomenon, Dr. Martin conduced a literature review using Medline, Web of Sciences, PsycINFO, and Google Scholar. He identified 158 articles from peer-reviewed journals or textbooks.
Dr. Martin described sibling rivalry and sibling aggression and abuse separately, though overlap certainly occurs. Sibling rivalry – conflict over something the other sibling wants or a lack of balance between them – generally stems from resentment related to birth order and competition.
Common sources include favoritism or preferential treatment that one child perceives a parent to grant another sibling, problems with sharing possessions, and “fair” or “even” division of household chores.
“Usually the biggest problems is an impaired sibling relationship,” Dr. Martin wrote. But the experience can contribute to low self-esteem into adulthood if individuals believe themselves to be their parents’ less favored children, and sibling rivalry often can develop into sibling abuse.
Sibling aggression often is unrecognized with poor measures of prevalence, frequently relying on recall from college students. Yet, when paired with peer violence, sibling violence increases the likelihood of worse mental health outcomes, Dr. Martin found. Further, youth who fight with their siblings are 2.5 times more likely to fight with their peers.
The frequency of sibling violence is highest before age 9, but its “severity peaks in adolescence,” Dr. Martin wrote. Clinicians evaluating someone as a perpetrator or victim of sibling violence need to consider perception, intention, and severity in their assessments.
“Psychological aggression is often a precursor to physical aggression and often more damaging,” Dr. Martin wrote. Older siblings are more likely to be the aggressors, and males and females are equally likely to be victims and perpetrators of less severe abuse.
But “presence of a male child increases the likelihood of violence between siblings,” Dr. Martin found, and males are more likely to be perpetrators of more severe abuse – with one exception: Females are more likely to be perpetrators of sexual abuse. Although sexual abuse often is excluded from discussions of sibling violence, it is the most common form of familial sexual abuse.
Many psychological schools of thought can be used to explore causes from a theoretical perspective, but the list of interacting factors is long. It includes factors related to the parent-child relationship as well as individuals and the family as a whole.
Among the parent-child factors Dr. Martin lists are “parental differential treatment (particularly by fathers), active and direct judgmental comparison by parents, negative and conflictual parent-child relationships, lack of parental reinforcement of prosocial behavior, polarized definitions of good and bad children,” and rejecting or overcontrolling mothers. Other factors include coercive parenting, inadequate parental supervision, parental child abuse, parental approval of physical aggression between siblings, and lack of acknowledgment of children’s concerns.
In terms of the family unit, sibling violence is linked to domestic partner violence, marital conflict, poor family cohesion, living with a stepfamily, and lack of family resources and/or “lack of clear and consistent family rules,” Dr. Martin found.
While a “perpetrator’s lack of empathy, low self-esteem, and aggressive temperament” all are risk factors for sibling violence, protective factors include greater warmth in family relationships.
Sibling murder accounts for 1% of all homicide arrests and 8%-10% of all familial murders. The majority of these, about 75%, are brothers killing brothers. The remaining quarter include, in decreasing prevalence, brothers killing sisters, sisters killing brothers, and sisters killing sisters.
Though no evidence-based treatments exist for sibling violence, prevention strategies might include “secondary prevention, including family and individual approaches,” and “primary prevention with parenting programs for those at risk to abuse,” such as Successful Parenting, Systematic Training for Effective Parenting, and Parent Effectiveness Training.
Clinicians also have the option to modify existing tools, address sibling conflict through mediation, work to improve all family members’ communication skills, and establish rules for appropriate behaviors. Other treatment approaches may include “structured family therapy, task-centered approaches, utilizing social learning theory or nonviolent resistance,” Dr. Martin reported.
AUSTIN, TEX. – Sibling violence is the most common form of family violence – more prevalent than child abuse and domestic abuse combined – according to new research.
A review of the literature shows that it occurs in anywhere from 42% to 80%-90% of families, according to an abstract by Peter S. Martin, MD, MPH, of the University of Buffalo, New York.
Nearly 50% of siblings engaged in severe violence in the past year, though emotional aggression is more common than is physical aggression, Dr. Martin shared at the annual meeting of the American Academy of Psychiatry and the Law.
“Both perpetrators and victims are at risk for poor outcomes,” Dr. Martin wrote, listing distress, low self-esteem, developmental delays, depression, anxiety, posttraumatic stress disorder, substance use disorders, eating disorders, and suicidality, sometimes reaching into adulthood. Those symptoms typically can be as severe as those experienced by victims of peer bullying, he wrote.
Males involved in sibling violence tend to show more aggression and delinquency, while females experience more difficulties with psychological adjustment, he wrote. Sibling violence also is a predictor for college dating violence.
Siblings – whether biological, half, step, adoptive, foster or even fictive (like chosen family) – spend more time with each other than anyone else growing up. Those relationships provide companionship, support, and opportunities for play and engagement against an adversary, but they remain unique from other family relationships.
Healthy sibling relationships are linked to increased social competence, independence, self-control, companionship, general life skills, support, and overall social, cognitive, and emotional growth, Dr. Martin noted in his abstract.
On the flip side, “,” he wrote.
Yet, despite the prevalence of sibling aggression and the commonness of having a sibling in general, studying sibling violence is challenging because neither the academic research nor legal realms have a standardized definition for it.
To better understand the phenomenon, Dr. Martin conduced a literature review using Medline, Web of Sciences, PsycINFO, and Google Scholar. He identified 158 articles from peer-reviewed journals or textbooks.
Dr. Martin described sibling rivalry and sibling aggression and abuse separately, though overlap certainly occurs. Sibling rivalry – conflict over something the other sibling wants or a lack of balance between them – generally stems from resentment related to birth order and competition.
Common sources include favoritism or preferential treatment that one child perceives a parent to grant another sibling, problems with sharing possessions, and “fair” or “even” division of household chores.
“Usually the biggest problems is an impaired sibling relationship,” Dr. Martin wrote. But the experience can contribute to low self-esteem into adulthood if individuals believe themselves to be their parents’ less favored children, and sibling rivalry often can develop into sibling abuse.
Sibling aggression often is unrecognized with poor measures of prevalence, frequently relying on recall from college students. Yet, when paired with peer violence, sibling violence increases the likelihood of worse mental health outcomes, Dr. Martin found. Further, youth who fight with their siblings are 2.5 times more likely to fight with their peers.
The frequency of sibling violence is highest before age 9, but its “severity peaks in adolescence,” Dr. Martin wrote. Clinicians evaluating someone as a perpetrator or victim of sibling violence need to consider perception, intention, and severity in their assessments.
“Psychological aggression is often a precursor to physical aggression and often more damaging,” Dr. Martin wrote. Older siblings are more likely to be the aggressors, and males and females are equally likely to be victims and perpetrators of less severe abuse.
But “presence of a male child increases the likelihood of violence between siblings,” Dr. Martin found, and males are more likely to be perpetrators of more severe abuse – with one exception: Females are more likely to be perpetrators of sexual abuse. Although sexual abuse often is excluded from discussions of sibling violence, it is the most common form of familial sexual abuse.
Many psychological schools of thought can be used to explore causes from a theoretical perspective, but the list of interacting factors is long. It includes factors related to the parent-child relationship as well as individuals and the family as a whole.
Among the parent-child factors Dr. Martin lists are “parental differential treatment (particularly by fathers), active and direct judgmental comparison by parents, negative and conflictual parent-child relationships, lack of parental reinforcement of prosocial behavior, polarized definitions of good and bad children,” and rejecting or overcontrolling mothers. Other factors include coercive parenting, inadequate parental supervision, parental child abuse, parental approval of physical aggression between siblings, and lack of acknowledgment of children’s concerns.
In terms of the family unit, sibling violence is linked to domestic partner violence, marital conflict, poor family cohesion, living with a stepfamily, and lack of family resources and/or “lack of clear and consistent family rules,” Dr. Martin found.
While a “perpetrator’s lack of empathy, low self-esteem, and aggressive temperament” all are risk factors for sibling violence, protective factors include greater warmth in family relationships.
Sibling murder accounts for 1% of all homicide arrests and 8%-10% of all familial murders. The majority of these, about 75%, are brothers killing brothers. The remaining quarter include, in decreasing prevalence, brothers killing sisters, sisters killing brothers, and sisters killing sisters.
Though no evidence-based treatments exist for sibling violence, prevention strategies might include “secondary prevention, including family and individual approaches,” and “primary prevention with parenting programs for those at risk to abuse,” such as Successful Parenting, Systematic Training for Effective Parenting, and Parent Effectiveness Training.
Clinicians also have the option to modify existing tools, address sibling conflict through mediation, work to improve all family members’ communication skills, and establish rules for appropriate behaviors. Other treatment approaches may include “structured family therapy, task-centered approaches, utilizing social learning theory or nonviolent resistance,” Dr. Martin reported.
AUSTIN, TEX. – Sibling violence is the most common form of family violence – more prevalent than child abuse and domestic abuse combined – according to new research.
A review of the literature shows that it occurs in anywhere from 42% to 80%-90% of families, according to an abstract by Peter S. Martin, MD, MPH, of the University of Buffalo, New York.
Nearly 50% of siblings engaged in severe violence in the past year, though emotional aggression is more common than is physical aggression, Dr. Martin shared at the annual meeting of the American Academy of Psychiatry and the Law.
“Both perpetrators and victims are at risk for poor outcomes,” Dr. Martin wrote, listing distress, low self-esteem, developmental delays, depression, anxiety, posttraumatic stress disorder, substance use disorders, eating disorders, and suicidality, sometimes reaching into adulthood. Those symptoms typically can be as severe as those experienced by victims of peer bullying, he wrote.
Males involved in sibling violence tend to show more aggression and delinquency, while females experience more difficulties with psychological adjustment, he wrote. Sibling violence also is a predictor for college dating violence.
Siblings – whether biological, half, step, adoptive, foster or even fictive (like chosen family) – spend more time with each other than anyone else growing up. Those relationships provide companionship, support, and opportunities for play and engagement against an adversary, but they remain unique from other family relationships.
Healthy sibling relationships are linked to increased social competence, independence, self-control, companionship, general life skills, support, and overall social, cognitive, and emotional growth, Dr. Martin noted in his abstract.
On the flip side, “,” he wrote.
Yet, despite the prevalence of sibling aggression and the commonness of having a sibling in general, studying sibling violence is challenging because neither the academic research nor legal realms have a standardized definition for it.
To better understand the phenomenon, Dr. Martin conduced a literature review using Medline, Web of Sciences, PsycINFO, and Google Scholar. He identified 158 articles from peer-reviewed journals or textbooks.
Dr. Martin described sibling rivalry and sibling aggression and abuse separately, though overlap certainly occurs. Sibling rivalry – conflict over something the other sibling wants or a lack of balance between them – generally stems from resentment related to birth order and competition.
Common sources include favoritism or preferential treatment that one child perceives a parent to grant another sibling, problems with sharing possessions, and “fair” or “even” division of household chores.
“Usually the biggest problems is an impaired sibling relationship,” Dr. Martin wrote. But the experience can contribute to low self-esteem into adulthood if individuals believe themselves to be their parents’ less favored children, and sibling rivalry often can develop into sibling abuse.
Sibling aggression often is unrecognized with poor measures of prevalence, frequently relying on recall from college students. Yet, when paired with peer violence, sibling violence increases the likelihood of worse mental health outcomes, Dr. Martin found. Further, youth who fight with their siblings are 2.5 times more likely to fight with their peers.
The frequency of sibling violence is highest before age 9, but its “severity peaks in adolescence,” Dr. Martin wrote. Clinicians evaluating someone as a perpetrator or victim of sibling violence need to consider perception, intention, and severity in their assessments.
“Psychological aggression is often a precursor to physical aggression and often more damaging,” Dr. Martin wrote. Older siblings are more likely to be the aggressors, and males and females are equally likely to be victims and perpetrators of less severe abuse.
But “presence of a male child increases the likelihood of violence between siblings,” Dr. Martin found, and males are more likely to be perpetrators of more severe abuse – with one exception: Females are more likely to be perpetrators of sexual abuse. Although sexual abuse often is excluded from discussions of sibling violence, it is the most common form of familial sexual abuse.
Many psychological schools of thought can be used to explore causes from a theoretical perspective, but the list of interacting factors is long. It includes factors related to the parent-child relationship as well as individuals and the family as a whole.
Among the parent-child factors Dr. Martin lists are “parental differential treatment (particularly by fathers), active and direct judgmental comparison by parents, negative and conflictual parent-child relationships, lack of parental reinforcement of prosocial behavior, polarized definitions of good and bad children,” and rejecting or overcontrolling mothers. Other factors include coercive parenting, inadequate parental supervision, parental child abuse, parental approval of physical aggression between siblings, and lack of acknowledgment of children’s concerns.
In terms of the family unit, sibling violence is linked to domestic partner violence, marital conflict, poor family cohesion, living with a stepfamily, and lack of family resources and/or “lack of clear and consistent family rules,” Dr. Martin found.
While a “perpetrator’s lack of empathy, low self-esteem, and aggressive temperament” all are risk factors for sibling violence, protective factors include greater warmth in family relationships.
Sibling murder accounts for 1% of all homicide arrests and 8%-10% of all familial murders. The majority of these, about 75%, are brothers killing brothers. The remaining quarter include, in decreasing prevalence, brothers killing sisters, sisters killing brothers, and sisters killing sisters.
Though no evidence-based treatments exist for sibling violence, prevention strategies might include “secondary prevention, including family and individual approaches,” and “primary prevention with parenting programs for those at risk to abuse,” such as Successful Parenting, Systematic Training for Effective Parenting, and Parent Effectiveness Training.
Clinicians also have the option to modify existing tools, address sibling conflict through mediation, work to improve all family members’ communication skills, and establish rules for appropriate behaviors. Other treatment approaches may include “structured family therapy, task-centered approaches, utilizing social learning theory or nonviolent resistance,” Dr. Martin reported.
REPORTING FROM THE AAPL ANNUAL MEETING
Identifying and stopping a likely mass shooter: A case study
AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.
“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)
It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.
It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.
A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.
Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”
But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”
Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.
But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.
The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.
Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.
The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.
Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.
Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.
On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.
The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.
Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.
The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.
They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.
Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.
Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.
After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.
“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.
“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”
He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.
Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.
Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.
The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”
Dr. Knoll reported no conflicts of interest.
AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.
“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)
It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.
It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.
A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.
Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”
But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”
Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.
But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.
The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.
Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.
The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.
Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.
Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.
On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.
The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.
Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.
The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.
They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.
Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.
Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.
After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.
“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.
“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”
He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.
Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.
Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.
The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”
Dr. Knoll reported no conflicts of interest.
AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.
“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)
It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.
It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.
A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.
Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”
But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”
Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.
But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.
The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.
Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.
The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.
Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.
Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.
On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.
The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.
Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.
The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.
They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.
Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.
Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.
After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.
“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.
“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”
He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.
Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.
Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.
The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”
Dr. Knoll reported no conflicts of interest.
EXPERT ANALYSIS FROM THE AAPL ANNUAL MEETING
Questions about housing transgender inmates remain unresolved
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
AUSTIN, TEX. – The question of where and how to house transgender inmates is a challenging one that involves a range of factors and considerations, according to Ariana Nesbit, MD, a psychiatrist at San Diego Central Jail in California.
The transgender community makes up about 0.1%-0.5% of the U.S. population, but 19%-65% of transgender individuals have been* incarcerated, compared with just 3% of the cisgender U.S. population, she said at the annual meeting of the American Academy of Psychiatry and the Law. (“Cisgender” refers to individuals whose gender identity matches the sex assigned to them at birth.)
The high incarceration rate likely results from the difficult lives these individuals have led: “Pervasive stigma begins early in life,” Dr. Nesbit said.
More than a third (36%) of transgender individuals report having to leave school because of harassment related to their gender identity, and more 90% report experiencing discrimination at work. About one in seven transgender people are unemployed, and 19-30% have histories of homelessness.*
Their social marginalization leads many to seek illegal means of securing income and housing:
“There is a high comorbidity of mental illness and substance use in this population, which confounds the issue because these are also risk factors for incarceration,” Dr. Nesbit explained, though noting that being transgender itself is not a mental illness.
Once incarcerated, transgender people are at much higher risk for victimization because of the hierarchical, hypermasculine culture of the correctional environment, Dr. Nesbit said.
“Inmates rank-order one another based on how masculine they seem, and hypermasculinity is associated with sexual or physical aggression or bias toward women, and transgender people in these facilities are often classified as ‘queens,’ ” Dr. Nesbit said. They experience verbal harassment, beatings, and rape, and they might seek protection from other inmates to survive, she said.
“On the one hand, this may decrease their overall risk of violence,” Dr. Nesbit said. “On the other hand, to maintain this partnership, the transgender inmate is usually forced into subservience to this other partner and that often includes things such as performing sexual favors.”
Correctional staff also can contribute to victimization, by doing mandatory strip searches that humiliate them or placing them in administrative segregation, or ad seg, for protection, which then worsens their mental health, Dr. Nesbit said. Ad seg, also known as “the hole,” is solitary confinement in a tiny cell with little furniture and no windows.
Research also has shown far greater victimization among transgender inmates than the cisgender incarcerated population. A 2007 study involving one-on-one interviews with 322 cisgender and 39 transgender inmates showed that 59% of the transgender inmates had experienced sexual abuse, compared with 4.4% of the cisgender ones.
Similarly, 48% of the transgender respondents had been involved in “reluctant sexual acts,” in which consent was not full, compared with 1.3% of cisgender inmates. And half the transgender inmates had been raped, compared with 3.1% of the cisgender ones.
A similar 2009 study involving 315 interviews with transgender female inmates house in California men’s prisons found that 58% reported sexual abuse by other inmates and 13.6% reported sexual abuse by correctional staff.
This victimization also increases suicidality, as a 2018 study shows: Transgender victimization by another inmate led to a 42% increase in suicide attempts, and victimization by correctional staff led to a 48% increase in suicide attempts (J Correct Health Care. 2018 Apr;24[2]:171-182).
Dr. Nesbit then discussed laws and policies that have attempted to address these problems. Although society historically has “ignored or not cared about harm to inmates,” things began to change when Human Rights Watch came out with its 2001 report, “No Escape: Male Rape in U.S. Prisons.” Among the group’s findings were that certain prisoners targeted for sexual assault were those who were “young, small in size, gay … possessing ‘feminine characteristics,’ such as long hair or high voice.”
The report resulted in a congressional inquiry that led to the unanimously passed Prison Rape Elimination Act (PREA) in 2003, which mandated standards aimed at eliminating sexual assault and regulating detention rules for all state and federal correctional facilities.
Among the requirements were asking about inmates’ gender identity, sexual orientation, gender expression, and safety concerns in a quiet, private place. PREA also prohibited strip searches solely to determine genitalia or gender status and allowed it for a private general medical exam by a medical doctor only.
The act limited residential assignment based on genitalia only and mandated that residential assignments be made on a case-by-case basis, taking into consideration both the inmates’ gender identification and an assessment of their risk. If it were deemed necessary to segregate individuals because of their risk, they “should continue to receive the same opportunities and program access as other units,” Dr. Nesbit said.
Just as PREA’s requirements were being finalized in 2012, the U.S. Federal Bureau of Prisons also issued a Transgender Offender Manual to further clarify policies. Yet, some have contended that little has changed since the “primarily symbolic” PREA and prison manual: Genitalia-based policies still dominate inmate assignments (including at Dr. Nesbit’s facility) and ad seg still is frequently used. The facilities where changes have occurred, however, offer a blueprint on how to move forward. Some prisons have created transgender review committees that include an administrator, PREA coordinators, medical and mental health staff, and transgender advocates or community members. Those committees ask inmates about their housing preferences and make decisions based on individual needs and risks.
An exceptional example of an appropriate policy, though not in the United States, is one in Queensland, Australia. After initial placement in single-occupancy housing, inmate housing is determined by multiple factors:
- The person’s name, because it might pose to safety and security of facility.
- Charges against the inmate.
- The inmate’s personal characteristics.
- Risk to the inmate or other inmates at the facility.
- Hormone status.
- Recommendations by the inmate’s medical doctor.
- The inmate’s preference.
- Any concerns about staff threats to the inmate’s safety.
But it’s unlikely that the United States will see similar policies become widespread under the current administration: The Trump administration made changes in 2018 that mandate officials to “use biological sex as the initial determination” for housing placement decisions and allow consideration of gender identity only in “rare cases,” Dr. Nesbit said.
Despite protests from the National Center for Transgender Equality, which said the change directly defies PREA requirements, Bureau of Prisons spokesperson Nancy Ayers reportedly said that “the manual now addresses and articulates the balance of safety needs of transgender inmates as well as other inmates, including those with histories of trauma, privacy concerns, etc., on a case-by-case basis.” That leaves where to house transgender inmates as an open questions still. No data exist regarding the safest arrangements, and housing based only on genitalia is problematic, Dr. Nesbit said. Placement based on gender identity only is problematic also, since it’s not always the inmate’s preference and violence concerns remain, both for transgender males in male facilities and for transgender females in female facilities.
Though some advocate for placement in separate facilities entirely, which San Francisco does, this is a resource-intensive solution that “may limit access to educational, medical, rehabilitative, and vocational services,” Dr. Nesbit said.
“One-size-fit-all policies that rigidly assign housing do not work,” Dr. Nesbit said, yet no empirical studies exist on individualized approaches. Meanwhile, the best recommendations are to train correctional staff to improve their knowledge about transgender inmates, implement correctional intervention programs that address hypermasculinity, and recognize that transgender incarceration rates and inmate victimization are part of a larger problem of social marginalization, she said.
*Correction, 11/1/2018: An earlier version of this story misstated the timing of transgender individuals' incarceration and homelessness.
REPORTING FROM THE AAPL ANNUAL MEETING
Most profiles of mass shooters do not include mental illness
AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.
Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.
But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.
She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”
Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.
, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.
“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”
Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:
- Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
- Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
- Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).
But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.
Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.
A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).
Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).
Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.
The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).
Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.
“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.
And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).
Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).
Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”
“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”
AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.
Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.
But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.
She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”
Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.
, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.
“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”
Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:
- Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
- Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
- Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).
But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.
Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.
A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).
Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).
Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.
The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).
Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.
“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.
And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).
Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).
Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”
“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”
AUSTIN, TEX. – Mass shootings make up only a tiny percentage of annual gun violence deaths in the United States, but they capture the attention of the nation – and of media that do not always accurately represent their context.
Experts tend to identify the first modern U.S. mass shooting event as the University of Texas Tower shooting in Austin by Charles Whitman in 1966, Corina Freitas, MD, said at the annual meeting of the American Academy of Psychiatry and the Law.
But two previous incidents preceded Whitman’s: Howard Unruh’s 12-minute killing spree in his neighborhood in Camden, N.J., in 1949, and Andrew Kehoe’s 1927 series of bombings that killed 43 people in the Bath School disaster in Michigan. Studies of these events and the hundreds since have led to a better understanding of what motivates mass shooters (or bombers in Kehoe’s case) and how to potentially identify them and prevent such events, said Dr. Freitas, of the department of psychiatry and behavioral sciences at George Washington University in Washington.
Dr. Freitas provided an overview of mass shooting history in the United States before Karen B. Rosenbaum, MD, clinical assistant professor at New York University and clinical instructor at New York Presbyterian–Weill Cornell Medical Center, spoke about the social, political, and legal implications of the intersection between mental illness and mass shootings.
She began by explaining how the FBI’s definition of mass shootings has changed from “four or more people at one location within one event” in 2005 to its redefinition in 2012-2013 to “three or more killings in a single incident and in a place of public use.”
Mass shootings usually are not impulse kills, Dr. Freitas said, noting that 77% of shooters plan their shooting for at least a week, and 46% of people spend about a week preparing. The perpetrators are potentially recognizable, typically displaying four to five concerning behaviors up to 1 year before the shooting, such as talking about their plans or purchasing supplies. But only a minority of people who observe these behaviors ever speak up about them or take any actions, she said.
, but they also display numerous other psychosocial characteristics, such as self-esteem issues, paranoia, narcissism, depression, and suicidality.
“Almost half of them are suicidal, and they actually proclaim it up to 1 year ahead of the shooting,” Dr. Freitas said. “We could catch them if we paid more attention to that.”
Mass killers tend to fall into three categories, as classified by psychiatrist Park Dietz, MD, in 1986:
- Family annihilators, such as George Banks, are typically depressed, paranoid, suicidal older males who might be intoxicated at the time of their attack. Banks shot 13 people, including 5 of his own children and 2 other children and their mothers, in Pennsylvania in 1982.
- Pseudocommandos, such as Charles Whitman, are usually preoccupied with firearms and plan heavily. “They usually end up killing themselves by cop,” Dr. Freitas said.
- Set-and-run killers, the rarest type, include perpetrators like Kehoe; their method of killing gives them an escape (though Kehoe blew himself up as well).
But mental illness is not a major feature of mass killers: Only about a quarter of mass shooters have a diagnosed mental illness, and the illness might not necessarily be related to their crime. Of that quarter, about 75% of mass shooters had a mood disorder, 25% had an anxiety disorder,19% had psychosis, and 1% had the developmental condition, such as autism spectrum disorder.
Yet, as mass shootings have dramatically increased, mental illness has become inextricably associated with these events in the media and popular opinion, Dr. Rosenbaum said. There have been 74 school shootings since the Newtown, Conn., tragedy, and mental illness is repeatedly brought up as a contributor, she said.
A 2014 study that analyzed 25% of a random sample of news stories from 1997 to 2012 on serious mental illness and gun violence (before Newtown) found that most of the coverage occurred after mass shootings and “ ‘dangerous people’ with serious mental illness were more likely to be mentioned than ‘dangerous weapons’ as a cause of gun violence” (Am J Public Health. 2014 Mar;104[3]:406-13).
Yet this association does not reflect reality, Dr. Rosenbaum said. One meta-analysis found that prevention of one stranger homicide by someone with psychosis would require detaining 35,000 people with schizophrenia who had been judged as being at high risk for violence (Schizophr Bull. 2011 May;37[3]:572-9).
Further, the relationship between violence and mental illness is not simple. Complex historical factors are usually involved, including past violence, juvenile detection, physical abuse, substance abuse, age, parental arrest record, and life circumstances – such as a recent divorce, unemployment, or victimization.
The greater danger of a person with mental illness is the harm they will do to themselves, research shows. A study of 255 recently discharged psychiatric patients and 490 matched community residents found that the patients were no more likely to perpetuate violence than were the community members, but they were significantly more likely to report being suicidal (Int J Law Psychiatry. 2018 Jan-Feb;56:44-9).
Rather than mental illness, what is associated with violence is substance use and access to weapons, Dr. Rosenbaum said.
“The United States is one of only three countries in the world with a constitutionally protected right to own firearms,” Dr. Rosenbaum said, citing a 2017 study by John S. Rozel, MD, and Edward P. Mulvey, PhD, (Annu Rev Clin Psychol. 2017 May 8;13:445-9). And the United States has few restrictions on that right. With more than 350 million privately owned firearms – approximately 30% of all privately owned firearms in the world – the U.S. population exceeds all other countries in both per capita and absolute gun ownership.
And research shows that guns don’t make a country safer: Guns per capita are significantly correlated with firearm-related deaths; mental illness is only of borderline significance (Am J Med. 2013 Oct;126[10]:873-6).
Substance use – including use of cocaine, hallucinogens, methamphetamine, ecstasy, and prescription medications – has a stronger correlation with gun-carrying and gun-related behaviors (Inj Prev. 2017 Dec; 23[6]:383-7 and Epidemiol Rev. 2016;38[1]:46-61). Both acute and chronic alcohol misuse also are linked to firearm ownership and violence toward others and one’s self (Prev Med. 2015 Oct;79:15-21).
Yet public misperceptions of mental illness as a contributor to violence persists, research shows (Aust N Z J Psychiatry. 2014 Aug;48[8]:764-71), further stigmatizing people with psychiatric conditions and potentially reducing the likelihood of their seeking treatment. Politicians contribute to these misperceptions; an example is House Speaker Paul Ryan’s comment after the Parkland, Fla., school shooting: “Mental health is often a big problem underlying these tragedies.”
“The media sensationalizes violent crimes committed by people with mental illness, especially after mass shooting, and this societal bias contributes to the stigma that leads to decreased treatment seeking and discrimination,” Dr. Rosenbaum said, citing research from Mohit Varshney, MD, and his associates (J Epidemiol Community Health. 2016 Mar;70[3]:223-5). “It is important to dissociate the concept of mental illness from dangerousness.”
REPORTING FROM THE AAPL ANNUAL MEETING