Forensic criteria, clinical and theoretical issues of the indication of court-ordered treatment: A comparative survey among experts in forensic psychiatry and sentencing judges in France.

Following the French law n° 98-468 of 17 June 1998 relative to the prevention of sexual offenses and the protection of minors, social and judicial follow-up and court-ordered treatment were introduced with the aim of reinforcing the prevention of recidivism. Court-ordered treatment is one of the possible obligatory measures provided for by social and judicial follow-up. However, there is no consensus between the different professionals concerning the criteria of indication and the final purpose of this measure. Most of the few available studies are retrospective. Only rare studies have assessed the influence of criminological factors on the indication of court-ordered treatment. We carried out a nation-wide qualitative comparative study in two populations, psychiatric experts and sentencing judges, by means of e-mail questionnaires. The aim was to determine the criteria for court-ordered treatment according to psychiatric experts and to sentencing judges, to identify the criteria that gave rise to differences in appreciation between these professionals, and to attempt to explain these differences. The secondary aim of the study was to determine the methods and tools used in expert practice to evaluate dangerousness and risk of recidivism. We obtained 20 responses in each of the two populations. The great majority of psychiatric experts and sentencing judges considered that court-ordered treatment was appropriate when the offender presented with psychiatric dangerousness, and so with an underlying mental disorder. When a subject had no identified mental disorder, the psychiatrists were divided in their opinion, whereas the majority of sentencing judges were in favor of court-ordered treatment. Opinions differed particularly significantly between the two populations in four circumstances: a subject with an antisocial/psychopathic personality disorder, a subject who denied the alleged acts, the influence of precarious social circumstances and the influence of instability in intimate relationships. The majority of experts used international classifications (DSM-5 and ICD-10) as a basis for their psychiatric diagnosis. Just under half of those surveyed used structured or semi-structured interview guides and only a few stated that they used standardized actuarial tools to assess risk of recidivism. The concepts of care, dangerousness and mental disorder are associated with multiple representations that certainly play a part in the disagreements between the different professionals. It is of prime importance to define these concepts more clearly in order to encourage the use of a common language and to clarify the indications and purpose of court-ordered treatment. We also hypothesize that disagreements between professionals regarding the criteria for court-ordered treatment may be related to certain difficulties raised by the management of the convicted person. The development of guidelines that could be used by all professionals would help to reduce some of these difficulties. Psychiatric experts remain attached to clinical evaluation. Their limited use of assessment tools may relate to the material constraints and time constraints involved. The issue at stake in court-ordered treatment and social and judicial follow-up is to promote cooperation between the various professionals by creating a space for exchange of ideas where the fundamental questions raised by these measures can be discussed, fears shared and knowledge pooled.

Psychiatric disorders and management of sexual offenders in the prison psychiatric consultation unit of Marseille.

Since 2017, complaints of sexual violence have increased in France. At the same time, the management of sexual offenders has been at the center of international public health policies. The prevalence of mental disorders among sexual offenders is an essential field of research. There are some published studies on the prevalence of psychiatric disorders in sexual offenders in detention, but there are few recent published studies among French individuals who were detained. Our objectives were to determine the prevalence of psychiatric disorders among persons detained for sexual offenses and the level of care received according to their diagnosis. For this purpose, we carried out a retrospective observational study from January 2017 to October 2021 of all adult sexual offenders, whether accused or convicted, who were seen in the psychiatric consultation unit of Les Baumettes prison, Marseille, France. The primary outcome measure was the psychiatric diagnosis entered in the medical records. One hundred forty-two patients were included in analysis. All patients were men, and the majority (n = 97, 68.3%) of these patients presented with at least one psychiatric disorder, principally a personality disorder (31.7%). 10.6% presented with a schizophrenic disorder, 4.9% a bipolar disorder, 3.5% a depressive disorder, 5.6% pedophilic paraphilia, and 25.4% an addictive disorder. Their management and comorbid addictions were analyzed in subgroups for each psychiatric disorder. Patients appeared to receive an appropriate level of care for their diagnosed disorder. It seems important to develop structured assessment of recidivism risk for better management of sexual offenders.