Article Figures & Data
Tables
Case Summary U.S. v. Maack (U.S. District Court for the Eastern District of Pennsylvania)33 Richard Maack pled guilty to five counts of mail, wire, and bank fraud. The defense requested a downward departure for diminished mental capacity on the ground of Mr. Maack’s “longstanding compulsive sexual addiction.” Defense expert witnesses, psychiatrist Dr. Turner and internist Dr. Berman, opined that Mr. Maack suffered “from a primary sexual addiction, dating back to adolescence” (Ref. 33, p 451). Psychologist Dr. Cooke testified for the government that Mr. Maack’s behavior did not rise to the level of an addiction over which he lacked control. The court denied Mr. Maack’s motion, holding that even if sexual addiction is legitimate, the defense failed to establish a clear link between the crimes and sexual addiction. U.S. v. Long (U.S. District Court for the District of Columbia)34 Kenneth Long was charged with multiple counts of trafficking minors, possessing sexually explicit depictions of minors, and sexual exploitation of children. Mr. Long requested a downward departure on the ground that he committed the offenses while experiencing a sexual disorder. Forensic psychiatrist Dr. Berlin testified for the defense, diagnosing Mr. Long with “paraphilic disorder not otherwise specified,” noting that he had a “significantly reduced mental capacity, both cognitively and volitionally” (Ref. 34, p 45). The court denied the motion, ruling that “evidence of powerful sexual addiction does not amount to proof that the defendant was without the capacity to decide what course of action to take in order to satisfy his addiction” (Ref. 34, p 47). U.S. v. Lester (U.S. District Court for the Eastern District of Pennsylvania)35 Robert Lester was charged with two counts of sending child pornography to an undercover FBI agent posing as a 12-year-old girl and one count of attempting to entice a minor to engage in sexual activity. The defense requested a downward departure on the grounds of diminished capacity due to OCD and sexual addiction. Psychologist Dr. Cooke testified for the defense that Mr. Lester’s sexual addiction constituted reduced mental capacity. Forensic psychiatrist Dr. Sadoff testified for the government that the term “addiction” did not apply because of the absence of adverse physical response when not engaging in sexual fantasies. He also disagreed with the claim that it constituted a “significant impairment in mental functioning” (Ref. 35, p 519). The court denied the motion, ruling that Mr. Lester did not have an impaired ability to control behaviors he knew were wrong. U.S. v. Boyden (U.S. District Court for the Eastern District of Michigan, Southern Division)36 Robert Boyden was charged with purchasing access to a site providing online child pornography, as well as possession of sexually explicit depictions of minors. Psychologist Dr. Sugrue testified for the defense that Mr. Boyden was not a pedophile and diagnosed him with sexual addiction, characterized by lack of control. Psychologist Dr. Penix testified for the government and agreed that Mr. Boyden posed limited risk of recidivism but did not opine on the diagnosis of sexual addiction. The court cited the expert testimony when sentencing Mr. Boyden to 12 months in prison followed by three years of supervised release and counseling by a registered sex therapist (maximum sentence of 10 years). U.S. v. Irey (U.S. Court of Appeals for the Eleventh Circuit)37 William Irey was charged with one count of transporting sexually explicit material involving minors to the United States. During trial, he admitted to engaging in sexual intercourse with more than 50 underage girls (as young as four years old) in Cambodia. He also admitted to starring in and distributing footage and images of his sexual encounters. Forensic psychiatrist Dr. Berlin testified for the defense that Mr. Irey was unable to “appreciate the extent of his improprieties” (Ref. 37, p 1171). Psychologist Dr. Shaw further testified for the defense that Mr. Irey displayed a “long-standing problem with sexual obsession,” and “something like sexual addiction” (Ref. 37, p 1173). Many of the arguments focused on likelihood of recidivism and relied heavily on expert testimony. Mr. Irey was sentenced to 17.5 years in prison (from range of 15-30 years). On appeal, the U.S. Court of Appeals ruled that this sentence was unreasonable and imposed a 30-year sentence. U.S. v. Wilbur (U.S. District Court for the Middle District of Florida, Tampa Division)38 Preston Wilbur was charged with the possession and distribution of several thousand videos and images of child pornography. Forensic psychiatrist Dr. Saks conducted a psychosexual evaluation of Mr. Wilbur. She concluded that he was seeking treatment and had established “more social support and therapeutic connection” and opined that he “may not regress to Internet sexually compulsive behavior” if he continued treatment for sexual addiction (Ref. 38, p 4). The court imposed a 10-year sentence, followed by 20 years of supervised release (significantly less than advised range of 17.5-20 years), citing his treatment as a mitigating factor. People v. Velasco (Court of Appeal of California, Second Appellate District, Division Eight)39 William Velasco, Jr., was charged with one count of burglary and 14 counts of invasion of privacy for planting a hidden camera in the restroom of a restaurant. Forensic psychiatrist Dr. Lavid testified for the defense that he agreed with Mr. Velasco’s treating clinicians that his sexual addiction was in remission and that his risk of recidivism remained low. The court acknowledged that Mr. Velasco had sought treatment, though stated that there was no guarantee his disorders could be cured, and his risk of recidivism remained higher than zero. The court sentenced Mr. Velasco to four years imprisonment and lifetime registration to the sex offender registry. Case Summary In re: Gole (Supreme Court of Indiana)40 The Indiana Supreme Court Disciplinary Commission charged attorney Richard Gole with two counts of professional misconduct after clients reported that he made sexually explicit remarks to them. The commission and Mr. Gole reached an agreement to impose a six-month suspension from the practice of law with conditional probation. The parties cited Mr. Gole’s diagnosis of sexual addiction as a mitigating factor. They also alluded to his subsequent treatment in a 12-step group and his voluntary participation in a psychiatric evaluation that found him to present a low risk of recidivism. At the commission’s request, Mr. Gole was also evaluated by a psychologist, who determined that his efforts to address his sexual addiction appeared substantial and sincere. The Indiana Supreme Court approved the conditional agreement. In re: Vogel (Supreme Court of Tennessee, At Nashville)41 The Board of Professional Responsibility initiated disciplinary proceedings against attorney Robert Vogel for engaging in sexual intercourse with a client whom he had employed while representing. The Hearing Panel petitioned the court for an order enforcing a suspension from the practice of law for one year, with all but 30 days to be serviced on probation. A psychologist testified that sexual addiction is a treatable condition and is a type of impulse control disorder, which is “recognized in the DSM […] similar to alcoholism” (Ref. 41, p 527). He stated that Mr. Vogel was “compliant with all the elements of the monitoring agreement” and believed it was unlikely Mr. Vogel would engage in similar conduct (Ref. 41, p 528). The Tennessee Supreme Court found the Hearing Panel’s judgment inadequately lenient and moved to impose a 12-month suspension, all of which would be considered active suspension. - Table 3
Most Commonly Used Instruments to Quantify Sexual Addiction (Partly Based on Hook et al., 2010)83
Instrument Type of Questionnaire Scoring and Results Samples Studied Psychometric Properties Comments Sexual Addiction Screening Test (SAST)28,84 Self-Report Checklist (25 questions) Yes/No
Scores 0-25
Cutoff of 13 suggests sexual addictionPsychotherapy patients, college students, community sample, physicians. Mostly heterosexual males. Internal consistency 0.89–0.95
Good evidence of convergent validity (to other questionnaires) and discriminant validity with normal controlsWidely used in practice and research
Validated in heterosexual male samples. Variants for women and gay men lack sufficient evidence.
New version (SAST-R, 2010) has been validated across gender and orientation (N = 1604)84Sexual Compulsivity Scale (SCS)85 Self-Report Rating Scale (10 questions) Likert scales
Scores 10-40
Cutoff of 24 indicates a problem with sexual addictionMore than 30 samples, including community samples, college students, patients with HIV, heterosexual and homosexual male and female samples Internal consistency 0.59-0.92 (mostly above 0.7)
Good evidence of convergent and discriminant validityMost widely used in research Sexual Addiction Scale (SAS) of the Disorder Screening Inventory (SDI)86 Self-Reports Rating Scale (5 questions) Likert scale
Scores 0-20
0-5: Low risk
5-11: Moderate risk
12-20: High risk1 sample of 34 heterosexual male psychotherapy patients Internal Consistency 0.83
Some evidence for discriminant validity with controlsExamines five components of sexual addiction: compulsive use, loss of control, negative consequences, covertness of use, codependent response Sexual Dependence Inventory-Revised (SDI-R, 1998)87 Self-Report Rating Scale (179 questions) Likert scale
Each question has 2 answers:
Frequency (0-5)
Power (0-5)
3 scores:
Total score
2 composite scores
10 subscale scores for subdivisions of sexual addictionMultiple samples including psychotherapy patients, community samples, sex offenders.
Mostly studied in heterosexual males.Internal consistency 0.99 for total scores (Power and Frequency), and 0.9-0.99 for subscale scores
Some evidence for convergent and discriminant validity
Some evidence of criterion-related validityLong, in-depth
10 subscales: fantasy, seductive role playing, voyeurism, exhibitionism, paying for sex, trading sex, pain exchange, intrusive sex, exploitive sex, and anonymous sexCompulsive Sexual Behavior Inventory (CSBI)88 Self-Report Rating Scale (28 questions) Likert scale (1 indicates highest frequency)
Scores 28-140 (28 being most severe)
3 subscale scores:
Loss of control
Violence
AbuseHeterosexual males, heterosexual females, homosexual males, community samples, college students, psychotherapy patients Internal consistency 0.68-0.87
Substantial psychometric support: good convergent and discriminant validityUsed in several studies
Focuses on past abuse and connection to violenceYale-Brown Obsessive-Compulsive Scale— Compulsive Sexual Behavior (YBOCS—CSB)14 Clinician Rating Scale (10 questions) Likert scale
Scores 0-40
Higher scores indicating higher riskSamples of gay and bisexual men Internal consistency 0.66-0.99
Some convergent validity
Sensitive to change over timeLimited initial evidence for reliability and validity
Not studied in other populationsPATHOS89 Self-Report Checklist (6) Yes/No
Scores 0-6
Cutoff of 3 suggests sexual addiction2 Studies done by Carnes et al.(95)
Study 1: Inpatients receiving treatment for sexual addiction N = 1908 (30% females)
Study 2: Outpatients receiving treatment for sexual addiction (N = 646, 86.8% males), college students (N = 203, 23.2% males), inpatients receiving treatment for sexual addiction (N= 64, 100% females)Internal consistency 0.94
Good convergent and discriminant validityQuestions extracted from SAST:PreoccupiedAshamedTreatment soughtHurt othersOut of controlSad as a result
Designed to resemble CAGE questionnaire for alcohol use disorder (desire to Cut down, Annoyed with people’s comments, Guilt about use, Eye-opener drinks)
