¹Institute of Psychiatry, Federal University of Rio de Janeiro, Federal Fluminense University, Brazil
²Institute of Psychiatry, Federal University of Rio de Janeiro, Federal Fluminense University, Brazil
³Department of Molecular Medicine, Federal University of Minas Gerais, Brazil. University of Porto, Portugal
⁴Institute of Psychiatry, Federal University of Rio de Janeiro, Brazil
⁵Hospital of Clinics - Federal University of Pernambuco, Brazil
⁶Institute of Social Medicine and Criminology- São Paulo-Brazil
⁷Hospital of Clinics- Porto Alegre, Federal University of Rio Grande do Sul, Brazil

*Address for Correspondence: Alexandre Martins Valença, Institute of Psychiatry, Federal University of Rio de Janeiro, Federal Fluminense University, Brazil Email: avalen@uol.com.br

Submission: 28 February, 2024 Accepted: 18 March, 2024 Published: 20 March, 2024

Copyright:© 2024 Valença AM, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Keywords: Schizophrenia; Psychosis; Sex crime; Sexual offense

Abstract: The article presents the case of an individual with diagnosis of schizophrenia who committed a sexual offense and underwent forensic psychiatric examination to assess criminal liability, being considered not guilty by reason of insanity. The authors discuss factors that can potentially contribute to such crimes in individuals with psychotic disorders.

Sexual violence is a global phenomenon, considered a serious social and public health problem. In Brazil, an estimated 822 thousand cases of rape occur each year, or approximately two cases per minute [1]. However, the real numbers may be even higher due to underreporting of cases by law enforcement and health services.

Considering the high prevalence of sexual offenses in Brazil, the identification of the principal characteristics of this type of perpetrator is essential for both the legal and scientific fields. A growing number of scientific studies have attempted to elucidate the relationship between sexual violence and mental disorders[2,3].

Sex offenders with comorbid psychotic disorders represent a heterogeneous group that requires more studies and attention from the medical and scientific community. Data suggest that approximately 5-10% of sex offenders present some psychotic disorder. The rate may reach 16% in forensic psychiatric hospitals [4-6]. Alden et al. [6] assessed the association between psychotic disorders and sex offenses in individuals born in Denmark from 1944 to 1947. In the sample of 173,559 males, 1.1% were imprisoned for sexual violence, while 2.2% were hospitalized due to psychotic disorders (schizophrenia, organic mental disorders, affective psychosis, or other psychotic disorders). Of these, 8.4% were involved in physically aggressive sexual violence and 9% in non-physically aggressive sexual violence. Individuals that were hospitalized for psychotic disorders showed higher odds of being arrested for non-physically aggressive sexual violence when compared to the general population.

A recent systematic review [7] found that individuals with diagnosis of schizophrenia spectrum disorder committed more sex offenses when compared to healthy community controls.

The current study aims to present the case of an individual diagnosed with paranoid schizophrenia who committed a sex crime and underwent forensic psychiatric examination to assess criminal liability at a public facility in Rio de Janeiro, Brazil.

M., male, 44 years old, born in Rio de Janeiro, married (currently separated), with complete primary schooling. According to information from the forensic examination, M. was accused of raping his ex-wife, with whom he had been married for 12 years.

M. had initiated psychiatric treatment several years before committing the offense,with the report of one admission to a psychiatric hospital. The patient under examination did not use psychiatric medication after the hospital discharge. During most of the examination, M. displayed an extremely suspicious attitude, looking over his shoulder several times and remaining hyper-alert to every movement around him. M. stated that“in everything I do, I’m being persecuted... I’m suffering demoniacal, spiritual, and material persecution.” He added, “I hear voices talking about me, as if I were at home hearing things from the barracks... the spirits want to destroy my life... I have the revelation of things from God and the devil.”

When asked about the rape charge, M. said, “I was under stress, so I grabbed her by the arm and took her to the motel for us to talk... I wanted her to be open with me... I hear people conspiring against me, to kill me spiritually.” He added, “My wife turned information about me over to them... I’d like to know who this so-called B. is, because she [the wife] mentioned this guy’s name at the motel... one day they entered my house and put cocaine in my coffee.”

The forensic psychiatric examination revealed hallucinatory delusional symptoms, with auditory-verbal hallucinations, jealous, mystical and persecutory hallucinations, impaired reality judgment, and a suspicious and hypervigilant attitude. According to information provided by the victim, there had been a radical change in her husband’s behavior two years before the alleged facts,when he believed that the wife’s lovers were intruding their home. The forensic psychiatric examination concluded that M. met sufficient ICD-10 criteria for the diagnosis of paranoid schizophrenia. The individual presented total adherence of his personality to the psychotic symptoms and was deemed not liable on grounds of insanity [8].

Many theories have been proposed to explain the relationship between psychosis and sexual violence.A literature review on the topic found that psychosis may contribute directly or indirectly to sexual violence [9]. Command hallucinations or those with sexual content and/or delusional beliefs may, in rare cases, result directly in a sexual offense. Meanwhile, over-arousal, disorganized thinking, and impaired social functioning can contribute indirectly to sexual offenses.In addition, substance use by sex offenders with schizophrenia also may contribute to inadequate sexual behavior, through disinhibition and impaired interpersonal relations, or by reducing adequate social and sexual behaviors [10].

A review study by Moulden & Marshall [11] identified four factors that can explain the phenomenon of sexual violence in individuals with severe mental disorders (including schizophrenia): (1) preexisting paraphilia; (2) violence regulated directly by symptoms (3) comorbid personality disorder; and (4) neurological impairment and/or other factors. Either the preexisting paraphilia can motivate the violence, or the acute decompensation of some mental disorder may decrease the strategies for inhibition of sexual impulses.

A retrospective study by Alish et al. [12], compared three different groups of men: sex offenders with schizophrenia, non-sexual offenders with schizophrenia, and sex offenders without schizophrenia. Of the 36 cases of sexual violence, only one was related directly to classical psychotic symptoms such as hallucinations, paranoia, and delusions of reference. The study found that sexual violence committed by individuals with schizophrenia displays similar nature and context to the crimes committed by the group of sex offenders without schizophrenia. The two groups of sex offenders had similar rates of paraphilia, suggesting that the diagnosis is not necessarily related to psychotic syndromes and may represent a subset of criminal sexual behavior.

Further according to data from the same study, the group of sex offenders with schizophrenia showed the same marriage and employment rates, which may indicate that such individuals display better social functioning than the other subgroups [12]. The data suggest that victims of sex offenders with schizophrenia tend to be females, while victims of sex offenders without schizophrenia tend to be males, mainly children and adolescents.

In their analysis of 68 sex offenders considered not criminally liable at a forensic psychiatric hospital in California, Holoyda et al.[13] found that the majority had a diagnosis of primary psychotic disorder, associated with high rates of substance abuse, personality disorders, and paraphilic disorders. Comparing such individuals to others considered not criminally liable and who had not committed sexual violence, the authors found lower rates of prior convictions and later first incarceration. Although these differences are not completely elucidated, it is assumed that the non-criminally liable sex offenders present fewer antisocial characteristics than the noncriminally liable individuals who had committed non-sexual offenses.

The role of mental disorders in the risk of sexual violence is still unknown. Some studies suggest that comorbid mental disorders may increase criminal recidivism and reincarceration[14]. In a study conducted in Sweden[15] reviewing the records of 1,000 prisoners convicted of sex crimes, the group of individuals with psychotic disorders showed 5.1 higher odds of repeat offenses when compared to individuals without psychosis, with mean follow-up of 5.7 years. However, further studies are needed to further understand the relationship between criminal recidivism and individuals with psychosis.

The most important part of psychiatric forensic examination in the Brazilian legal system is the assessment of the criminal responsibility of the offender. The evaluation of criminal responsibility, according to the Brazilian Penal Code[16], is based on a biopsychological concept. This implies that full penal responsibility can only excluded if the offender was, at the time of the criminal deed(s), suffering from a mental disorder (biological component) and, as a result, was completely incapable of understanding the unlawful nature of his/her act(s) or to restrain him/herself from committing it (them) (psychological component). The existence of a causal link between the mental disorder and the criminal deed(s) must be established beyond doubt. The possibility of cases with limited criminal responsibility, which result from partial impairment of cognitive or volitional functions, is also acknowledged. Those who are deemed not responsible for their unlawful acts are committed to involuntary treatment in forensic mental hospitals. In cases of limited responsibility, compulsory treatment may also be imposed by the court.

In case of doubt as to the individual’s mental sanity in these cases, it is essential to perform a forensic psychiatric assessment of criminal liability, to determine the appropriate penal and correctional measures for each case. Forensics should check carefully for violent ideation and behavior in clinical high-risk patients, as these have predictive value for conversion to psychosis and likelihood of violence in the future. Patients at elevated risk for violence might benefit from closer monitoring by mental health professionals and rapid treatment interventions.

In the case of M., the psychotic symptoms had a direct influence on his criminal behavior. At the time of the crime, M. presented acute decompensation of his psychiatric condition, with hallucinatory experiences, delusional beliefs (mainly jealous delusions toward the victim), significantly impaired critical judgement, and disinhibition of impulse control. Therefore, the accused did not meet the conditions to be held criminally accountable for the offense, and he was considered not criminally liable.

Sexual violence committed by individuals with psychotic disorders is a challenging phenomenon that draws considerable clinical and forensic attention, but it has still received little study by the scientific community. Data have suggested that the psychotic syndrome can bear a direct relationship to sexual violence or may be associated with other psychiatric diagnoses, especially substance use and paraphilias. Forensic psychiatric examination is essential for the diagnosis and adequate treatment of individuals with mental disorders who commit sex offenses, thus reaching clinical stability and possibly decreasing the criminal recidivism rates in this group.