Sexual assault in the inpatient psychiatric setting.

Sexual assault in the inpatient psychiatric setting is a significant problem with serious, lasting consequences. It is important for psychiatric providers to appreciate the nature and magnitude of this problem to be able to provide an appropriate response when faced with these challenging scenarios, as well as to advocate for the implementation of preventive measures. This article provides a review of the existing literature regarding sexual behavior in the inpatient psychiatric unit, describing the epidemiology of sexual assaults in these settings, and exploring the characteristics of both victims and perpetrators, with a particular focus on factors of relevance to the inpatient psychiatric patient population. Inappropriate sexual behavior in inpatient psychiatric settings is common, however the varying definition of such throughout the literature serves as a challenge to clearly identifying the frequency of specific behaviors. The existing literature does not identify a way to reliably predict which patients are most likely to engage in sexually inappropriate behaviors on an inpatient psychiatric unit. The medical, ethical, and legal challenges that such cases present are defined, followed by a review of current management and prevention strategies, and suggested future directions for research.

Legal Dilemmas when Victims of Sexual Assault are Voluntarily Intoxicated.

This issue of The Journal includes an article that brings to the forefront legal challenges that arise in prosecuting sexual assault cases in which the victim is voluntarily intoxicated. As we move as a society away from victim blaming and closer to an objective, nonjudgmental approach to victims of sexual assault, the law too has to evolve. In this commentary, we review how laws have generally approached intoxication in the contexts of criminal defenses, sexual consent, and other decisional capacities related to voluntary intoxication. We explore Teravskis and colleagues' findings and conclude with an exploration of possible implications for defendants and considerations for forensic psychiatrists working in this area.

Ending the Cycle of Abuse in Battered Women Defenses.

Intimate partner violence (IPV) is a public health concern, and multiple types of IPV have been described. Women, like men, have various motives for committing intimate partner homicide. This issue of The Journal includes an article reviewing the use of a Battered Woman Syndrome (BWS) defense in American courts. The time was right for a BWS defense a generation ago when there was a lack of understanding of the reasonableness of a woman's action, but not at present. We review the inherent problems of having a gendered law, looking to infanticide acts, as examples. We discuss the validity of BWS considering the DSM and the ICD-10. We explore the role of a forensic psychiatrist in these evaluations, particularly given the lack of a diagnostic, scientific basis for BWS, and consider the similarities with sexually violent predator hearings. In conclusion, we outline considerations for forensic psychiatrists when conducting these examinations. This includes awareness of potential gender bias, recognizing clinical and scientific challenges in the legal diagnosis of BWS, and consideration of the role of posttraumatic stress disorder.

Occupational Hazards versus Professional Duty in Reviewing Potentially Traumatizing Evidence.

Electronic evidence, including real-time recordings of crimes by police cameras and smart phones, is becoming increasingly relevant to the practice of forensic psychiatry. A developing literature in fields parallel to our own has described vicarious trauma experienced by mental health and legal professionals exposed to traumatic material in the line of duty. The impact of potentially traumatizing media on the forensic psychiatric evaluation and on the individual forensic psychiatrist is unknown. Calling upon the research and practices of adjacent fields, as well as the personal experience of the authors, this article outlines the benefits and hazards of examining graphic media, addresses potential strategies to mitigate its traumatogenic potential (including among trainees), and suggests how future scholarship may improve understanding of these hazards and inform strategies to prevent them.

Forensic Evaluation of Sexsomnia.

Sexsomnia is a non-rapid eye movement parasomnic behavior characterized by sexual activity during sleep. Recognized in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Sleep Disorders, sexsomnia is likely to arise with increasing frequency in court as a potential explanation for sexual offending. The forensic psychiatrist has a unique role in the evaluation and management of sexsomnia. The psychosexual evaluation may elucidate the presence or absence of paraphilias and paraphilic disorders and identify any overlap between the alleged sexsomnic behavior and paraphilic interest. In addition, forensic psychiatrists may assess for malingered sexsomnia, provide an opinion regarding criminal responsibility, or evaluate the risk for committing future sexual offenses. Forensic psychiatrists should therefore understand basic information regarding the disorder, as well as how to conduct a psychosexual evaluation effectively in cases of alleged sexsomnia. This article describes the various considerations involved in the forensic evaluation of sexsomnia.

The myth of school shooters and psychotropic medications.

There has been an assertion in certain parts of the media, especially social media, that the majority of individuals who have engaged in a school shooting were prescribed psychotropic medications prior to the event. To determine if there is any validity to this assertion, the authors of this article reviewed publicly available information regarding individuals involved in "educational shootings" per FBI publications for active shooters from 2000 to 2017. Sources of information included news reports with official citations, official reports regarding events, available court records, and FBI Freedom of Information Act requests. Secondary data-points were also collected, such as location, number of weapons used, number of victims, legal outcome, and whether the shooter committed suicide. From the information obtained, it appears that most school shooters were not previously treated with psychotropic medications - and even when they were, no direct or causal association was found.

Voting by People with Mental Illness.

While voting laws trend toward universal suffrage, there are still some who encounter barriers in exercising the right to vote. Citizens with mental illness or cognitive and emotional impairments are especially vulnerable to exclusion from the political process, contributing to disenfranchisement. Facilitating the process for hospitalized patients to vote can increase their agency and amplify their voices and concerns. Through exercising their civic responsibility, psychiatric patients can have a hand in shaping a community in which they feel valued. In this article we will review the literature about voting, the current voting laws, and our lessons learned facilitating voting by proxy at Cambridge Hospital in the 2016 U.S. Presidential election, as well as the obstacles encountered. We will also propose methods to improve implementation of voting by hospitalized psychiatric patients for upcoming elections.

Bestiality: An introduction for legal and mental health professionals.

Bestiality, or human-animal intercourse, has been a concern of the legal and mental health communities for many years. Ancient legal codes delineated punishments for those who engaged in the behavior, denoting a moral and general societal concern surrounding bestiality dating to ancient times. Despite this longstanding interest in and legal efforts to punish humans for having sex with animals, there has been little research on the behavior. Current available research has largely been siloed based on the populations studied, making it difficult to render any firm conclusions about bestiality's prevalence, frequency, and the risk posed by those who have sex with animals. It is important for clinicians to know the legal status of the behavior in their jurisdictions, to understand possible medical and psychiatric complications and comorbidities, and to know how to evaluate and treat individuals who engage in bestiality or have the related diagnosis of zoophilic disorder. This article provides an overview of the terminology and research pertaining to bestiality, summarizes legal and ethical considerations, and describes clinically relevant information for the evaluation and management of individuals engaged in sex with animals.

Involuntary Treatment of Psychosis in Pregnancy.

When a patient with acute psychosis refuses antipsychotic medication despite a clear need for treatment, involuntary medication is often considered. When the patient is both pregnant and acutely unwell, an additional layer of analysis enters the picture. This analysis then also includes the health of the mother and fetus, rights of the mother and fetus, and whose rights take precedence when choosing treatment options in event of a conflict. Antipsychotic agents are frequently the medications prescribed as involuntary treatment. Typical and atypical antipsychotic agents are often used in both emergent and nonemergent situations during pregnancy. Despite a lack of randomized, double-blind, controlled, prospective studies in pregnancy, available data regarding the safety of antipsychotic agents in pregnancy are relatively reassuring. At the same time, the risks of untreated psychosis, for both the mother and the fetus, are not negligible. Such cases merit ethics-related and legal analyses. Forensic psychiatrists involved in such cases need to consider the patient's capacity to make medical decisions and be able to discuss the potential risks, benefits, and alternatives with patients and in court, as part of initiation of involuntary treatment.

The Transgender Bathroom Debate at the Intersection of Politics, Law, Ethics, and Science.

The debate over whether transgender individuals should be allowed to use the public restrooms (including locker rooms and changing rooms) that correspond to their currently expressed gender rather than their biological sex has been of recent interest nationally. The first state law addressing transgender access to restrooms was in North Carolina in 2016. This law prohibited transgender individuals from using the restroom that corresponded to their gender. The terms used in the bill and other legal documents caused it to be referred to as the "bathroom bill." Shortly thereafter, such bills were proposed in many states. Proponents of the bills identify the need to protect public safety by mandating that individuals use the facility that corresponds to their biological sex. Opponents describe such bills as discriminatory. The debate about these bills incorporates ethics-related, legal, and biological arguments. In this commentary, we review the history of such bills in the United States as well as the ethics-related, legal, and evidence-based arguments raised in the debate.

Trouble at teens' fingertips: Youth sexting and the law.

The last decade has seen a rapid increase in the use of smartphones among young children and adolescents. One consequence of this phenomenon is sexting. Although researchers of sexting have yet to arrive at a single, cohesive definition for the behavior, it generally involves the transmission of text, pictures, or videos containing sexual material. Different definitions of the behavior have led to widely varying estimates of its prevalence, although some studies have documented relatively high rates of sexting among teenagers. As adolescence is the time period in people's lives where the psychological tasks of identity consolidation and the development of intimate relationships become primary, it is not surprising that many teens utilize sexting as one way of practicing skills associated with successful completion of these tasks. The criminal prosecution of sexting cases, then, raises many legal and ethical questions. Offenders may be prosecuted under state or federal child pornography laws or state-specific sexting laws. Sexting laws, particularly in instances of consensual sext exchange, call into question who they are meant to protect and from what. In this article we review the research on teen sexting, its prevalence, and its association with mental health problems; summarize legal responses to the behavior in the United States; and identify considerations for prosecutors and legal decision-makers facing sexting cases.

Stalking and Violence.

The three widely known stalker classifications assist in categorizing stalkers, which allows for better management of violence risk. Although 80% of stalking is done by men, women also engage in stalking, and their violence risk should not be underestimated. Juvenile stalkers do exist and juvenile stalking is also associated with violence. Clinicians can become a victim of stalking and may become victims of stalking by proxy, a special type of stalking behavior where the stalker involves other people or agencies to communicate with or track their victim. A careful stalking violence risk assessment is essential in the intervention and risk management process.

Gender Considerations in Violence.

The role of gender in violence is poorly understood. Research has shown that gender has an important and, at times, distinct role in the prediction of violence. However, this gender disparity diminishes in the setting of mental illness. The risk assessment of violence in women is largely based on research in violent men. There are distinct characteristics in female violence compared with male violence. Attention to these characteristics may lead to the development of gender-dependent tools that can be used to evaluate violence risk.

Commentary: women, violence, and insanity.

There is less research about homicidal women than about their male counterparts. Women are often considered the gentler sex, and their risk of perpetrating violent acts is underestimated. In attempts to understand violence by women with mental illness, female homicide offenders found not guilty by reason of insanity (NGRI) are an important subpopulation. Understanding common factors in this subpopulation (such as psychosis with religious delusions) may help in preventing severe violence perpetrated by women with mental illness. However, as with other crimes, those with mental illness who commit homicide may often have rational, nonpsychotic motives (such as anger, jealousy, self-defense, money, or criminal intent) and would not be captured in a study of those found NGRI. Further, caution must be used when studying an NGRI population, as there are potential gender biases in findings of insanity.

Commentary: postpartum psychosis, infanticide, and insanity--implications for forensic psychiatry.

Two dozen nations have infanticide laws that decrease the penalty for mothers who kill their children of up to one year of age. The United States does not have such a law, but mentally ill mothers may plead not guilty by reason of insanity. As in other crimes, in addition to the diagnosis of a mental disorder, other factors, such as knowledge of wrongfulness and motive, are critical to the assessment. Postpartum psychosis has been described for 2,000 years and modern science supports a genetic component to the risk. Yet, the Diagnostic and Statistical Manual of Mental Disorders does not include it as a diagnosis, leading to difficulty in testimony. In this article, we discuss postpartum psychosis, infanticide law, and research regarding mothers who kill, and we make recommendations to forensic psychiatrists.

Psychiatrists' knowledge about maternal filicidal thoughts.

OBJECTIVE: Child murder by mentally ill mothers is an important public health and psychiatric concern. However, the authors' clinical and forensic experience has been that psychiatrists often do not inquire about maternal thoughts of harming their children. This study sought to elucidate the perceptions of psychiatrists and psychiatric residents regarding the frequency of such thoughts, and to clarify whether they inquire specifically about maternal filicidal thoughts. Psychiatrists were expected to underestimate the prevalence maternal thoughts of harming their children. It was hypothesized that psychiatrists often do not ask their patients about these thoughts. METHODS: This study surveyed psychiatrists and psychiatric residents at 2 academic institutions. Respondents were asked whether they routinely query women about motherhood, to estimate the frequency of thoughts of child harm, and whether they inquire about filicidal thoughts in psychotic or suicidal mothers. RESULTS: Two hundred twenty surveys (67%) were returned. Most psychiatrists underestimated the frequency of depressed mothers who experienced thoughts of harming their young children. Almost one half indicated that they do not ask specifically about filicidal ideation but rather ask about general homicidal thoughts only. CONCLUSIONS: Psychiatrists should have further education about the prevalence of filicidal thoughts and more frequently inquire about them.