Hospital or Prison? Psychiatric Care For the Sexual Offender

Recently a convicted sexual offender was committed to a state psychiatric hospital in Rhode Island after his prison term ended (see story on page 1). This commitment was ordered by the governor of Rhode Island over the objections of the chief of the hospital psychiatric services, Dr. Brandon Krupp, and a forensic specialist at the hospital. As a result, Dr. Krupp resigned from his position after 12 years in protest to what he saw as the need for doctors to oversee the medical facility without political interference. Citing what he described as “cynical abuse of the state's mental health law and practice,” Dr. Krupp noted further, “Doctors aren't jailers, and hospitals aren't prisons” shortly after leaving his post in November.

The transinstitutionalization of sexual offenders by state officials from criminal to psychiatric facilities is not limited to Rhode Island. This past fall, New York Gov. Pataki ordered two dozen sexual offenders who were about to be released from prison committed to state psychiatric hospitals using existing state laws. A heated argument ensued in the New York state legislature, and the issue has yet to be resolved.

The question of how best to continue to treat sexual offenders once their prison sentence has expired is not an easy one. These are individuals who may pose a danger to society and for whom there is no clearly effective treatment but who have served their time in the criminal justice system. Many of these individuals have a mental illness in addition to the pedophilia or antisocial behavior that is related to their sexual offense. The sexual offender in the Rhode Island case has schizophrenia; however, his schizophrenia is under control and was not a valid reason for continued hospitalization.

To date 16 states and the District of Columbia have passed civil confinement laws for sexual offenders once their prison terms have ended. Of these states, 13 have passed amendments about how and when the civil confinement can be used, and many of these states have been sued by civil libertarians in relation to these efforts. During the 1990s, most states focused on increasing sentences in the criminal justice system and in imposing close supervision of offenders at the end of their prison terms.

Civil commitment is based on the premise of forced confinement to a hospital that must offer treatment, not just containment or punishment. For that reason, APA has opposed civil commitment programs for sexual offenders. Our guidelines indicate that an involuntary hospital stay must include that the person be mentally ill, that the person is dangerous because of his or her illness, and the person is capable of being treated. Many sexual offenders do not have clear-cut illnesses that can be improved with psychiatric treatment, and to use the hospital for an extension of a prison term is not only a violation of civil liberties, it seems to me, but also a distortion of the purpose of the psychiatric hospital. Hospitals are there to provide care for patients, not to incarcerate or punish.

As a medical specialty, we are part of an ethical tradition to put our patients first and to do no harm. Although psychiatric care often deals with issues of public safety and social control, the use of psychiatric hospitals as jails has no place within our professional purview. The sexual offender whose prison term is up is a problem for our legal system, not the mental health system. ▪