In 2020, cognitive neuroscientist Itiel Dror developed a cognitive framework to address biases influenced by cognitive processes and external pressures in decisions made by forensic experts. Dror's model highlights how ostensibly objective data, such as toxicology or fingerprints, can be affected by bias driven by contextual, motivational, and organizational factors. Forensic mental health evaluations, often more subjective than physical forensic evidence analysis, are particularly vulnerable to these cognitive biases. Dror identified six expert fallacies, such as the belief that bias only affects unethical or incompetent practitioners, and proposed a pyramidal model showing how biases infiltrate expert decisions. This article adapts Dror's model to forensic mental health, exploring how biases influence data collection and interpretation and proposing mitigation strategies like Linear Sequential Unmasking-Expanded (LSU-E). We emphasize that mitigating cognitive biases requires structured, external strategies, as self-awareness alone is insufficient. By applying Dror's concepts and framework, we offer a practical approach to reduce biases and improve the fairness and accuracy of forensic mental health assessments.

Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision pedophilic disorder is only warranted when the victim is prepubescent (Tanner Stage 1). Broadening pedophilic disorder to include children both prepubertal and pubertal (pedohebephilia) was rejected by the American Psychiatric Association Board of Trustees. Sexual contact with pubertal children is not considered a Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision mental disorder. The rejection of pedohebephilic disorder has had substantial consequences in sex offender risk assessments where a predisposing mental disorder is required to substantiate civil commitment of high-risk sex offenders. The insistence on prepubescence to render the diagnosis ignores research regarding ethnoracial differences in early onset of puberty. This is particularly consequential for young Black girl victims who are more likely than other racial groups to be pubertal by age 8 or 9 (Tanner Stages 2 and 3). Adultification is the perception that children are older than their chronological age and has been identified as a form of racial bias via sexualizing young Black girls. The current pedophilic disorder criteria adultifies young Black girls as nondeviant sexual targets-even, if they are 8 or 9 years old, because of their sexual development. It raises the possibility of greater vulnerability of young Black girls to sexual assault, child sex traffickers, and producers of child sexual materials. Adultification of young Black girls is dehumanizing as they are not viewed as innocent children in need of protection. These points may also be applicable to young Latina girls who reach puberty earlier than White girls. We argue for the revision of pedophilic disorder.

Forensic evaluators may have little experience and knowledge of the political context of Myanmar, the Burmese people, and the refugee crisis. Oppression of several ethnic minority groups has marked Burmese military rule of Myanmar for several decades. Protracted trauma exposure, both pre- and post -migration, among refugee populations increases the risk for mental health disorders, particularly depression, anxiety, alcohol abuse, and posttraumatic stress disorder. These experiences may result in anger and psychiatric manifestations that bring Burmese refugees in conflict with the law in their host country. Culture influences how mental distress is experienced and reported, and it can influence a forensic evaluator's assessment of psychological -legal matters, such as competency to stand trial and asylum evaluations. The salience of cultural competence becomes particularly pressing given the small number of those of Burmese background in the United States. Most evaluations will be performed by forensic mental health professionals who are not Burmese in ethnicity, nor familiar with Burmese culture. In this article, we provide a backdrop of the military suppression of ethnic minorities prior to discussing the integration of cultural matters in forensic assessments of competency to stand trial, competency for extradition, and asylum seekers in Burmese refugees.

The term "dirty work" reflects employment that is distanced from mainstream society. Treating those who commit sex offenses can be a form of dirty work: sex offenders are often persona non grata and reviled by society. The treatment - inpatient and outpatient- tends to be involuntary. It can stigmatize and maligns the clinician even though the work may be required by public policy- as in conditions of probation and parole. Consequently, it can set conditions for moral injury, an overlooked occupational hazard for sex offender treatment providers. Moral injury is distinct from compassion fatigue and burnout. It is painful dissonance a person experiences when they act in ways that transgress deeply held morals and beliefs. Moral injury can be developed when sex offender treatment providers hold a punitive stance toward their clients, that is in direct conflict with professional values to have regard for and not harm their clients. Conversely, moral injury can also arise from helping a population that society tends to loathe. In this paper, we explore some pathways to moral injury and review methods to potentially prevent and mitigate moral injury in the context of sex offender treatment.

Though the U.S. Department of Veterans Affairs (VA) provides housing, residential treatment, and mental health care to justice involved veterans, those with sexual offenses face daunting obstacles to securing such services, including exclusion from housing programs, and lack of mental health services to treat sexual deviancy disorders. The VA's strategy to date may reflect a large system's caution in systematically addressing a problem that involves a population with an even higher degree of stigma than homelessness. Failure to develop strategies to address this problem reflects the need for a VA system-wide, consistent, and effective approach across relevant domains that incorporate the current state of knowledge and practice. Since 2006, the VA's program serving justice system veterans has been highly effective in serving the reentry veteran population. The challenge of serving veterans with sex offenses can and must be met with a similar level of effectiveness. In this commentary, we propose that the VA, beginning with the Secretary, adopt a "reset" policy and programmatic action agenda to enhance access to housing and treatment for sexual deviancy disorders. We offer specific pathways for implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

In recent decades, there has been an evolution in forensic psychiatry and psychology toward closer examination of the professionals' attitudes and intentions in their practice. We theorize that the progressive change reflects increased attention to the experiences of evaluators and evaluees in their social worlds. This cultural focus complements the traditional emphasis on biomedical elements, such as neuropsychiatric disorders. We suggest that sociocultural factors (such as poverty, trauma, and sexual orientation) and ethnocultural factors (such as those related to ethnic status, discrimination, and racialized application of risk assessment) have contributed substantially to these developments in forensic practice. We utilize past and current literature to illustrate the change and to frame it as a way of improving practice. This is a call for forensic practitioners to enhance their awareness of the impact of social and ethnocultural factors. We recommend further examination of these ideas by training programs and broader scholarly discussion in educational forums.

Military veterans with sexual offenses committed after discharge are often eligible for Veterans Affairs (VA) services including health care. There are few, if any, studies of sexual recidivism among military veterans with sexual offense histories to guide clinical management. This study examined diagnostic and postrelease sexual and nonsexual recidivism among military sexual offenders released from California sexually violent predator (SVP) commitment. The sample consisted of 363 males; 131 were identified as military veterans and 232 as civilians. The rates of recidivism were assessed for two follow-up periods: a fixed 5-year and a total 21-year follow-up. Recidivism was operationalized as any new sexual, violent, or general criminal arrest or conviction occurring after discharge to the community in California. We found a low risk for sexual reoffense for both groups. Specific to veterans, the rates for sexual and nonsexual violent recidivism were under 7% for both follow-up periods. Diagnostically, veterans had a significantly higher rate of pedophilic disorder and lower rate of antisocial personality disorder than civilians; neither were predictive of sexual recidivism or any other recidivism. On average, veterans were 61 years old at discharge; and older age at discharge was associated with a significantly lower likelihood of recidivism of any type. A relatively high proportion of veterans had a history of childhood sexual abuse and head trauma. Trauma-informed care may be a particularly valuable treatment approach for veterans with sexual offenses. These data may aid the VA and other providers in forming evidence-based decisions regarding the management of veterans with sexual offenses. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

This brief report estimates the lifetime prevalence of incarceration among U.S. military veterans using data from three nationally representative U.S. samples: the National Health and Resilience in Veterans Study (NHRVS; n = 4069), the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III; n = 3119 veterans, and the National Veteran Homeless and Other Poverty Experiences (NV-HOPE; n = 1004). Across the three surveys, 3.5–10.6

Veterans have higher rates of incarceration for sexual offenses than non-veterans, but little is known about the factors associated with repeat sexual offending among veterans. This study used the Survey of Inmates in State and Federal Correctional Facilities to examine whether the factors associated with repeat sexual offending differ between veterans and non-veterans. In a multivariate logistic regression, there were significant interactions between veteran status and both age and race. Diagnosis of personality disorder and history of violation of conditional release were also associated with repeat offense status. Findings can help inform intervention and risk management with veterans.

Criminal history plays a prominent role in violence risk assessments. For people in nondominant groups, disproportionate criminal justice involvement may unfairly and inaccurately elevate violence risk in evaluations. Criminal justice reports continue to document higher rates of arrest and convictions for those in minoritized racial groups. Bureau of Justice surveys have found that ethnic minorities are more likely to serve time when crime is violent than are Whites. Black males ages 18 and 19 were 12.7 times more likely to be imprisoned than White males of the same ages. In fact, across all age bands, from 18 to 65 and older, Blacks had higher rates of imprisonments than Whites. Racial inequities in incarceration rates can translate into a Black offender receiving higher risk scores on actuarial instruments than a White offender and thus a biased misclassification as high risk. Awareness of the impact of structural biases that may be embedded in violence risk assessments is critical to fair assessments. We highlight sources of potential systemic racial bias embedded within existing violence risk assessment methods and conclude with potential methods to enhance structural competency and reduce the risk of biased assessments.

This study followed 146 sexual offenders released from prison custody for a period of 25-years. Overall, 34% of individuals committed at least one sexual reoffense in the 25 years following release from incarceration. Most sexual recidivism occured within the first 15-years following release. The highest rates of sexual recidivism were observed for individuals under 34 years at release from incarceration, for whom recidivism steadily increased over time before peaking at 42% at 25 years. The mean age at reoffense was 42.51. Age was significantly associated with sexual recidivism at 5 years, but not at subsequent follow-up periods. These findings suggest that long-term patterns of sexual recidivism may be related to age at release. It will be important for future research to explore the characteristics of individuals who commit sexual offenses that may contribute to reoffending risk, and examine the effectiveness of policies and practices designed to mitigate recidivism.

Public Significance Statement Forensic experts opine to the vaguely or undefined threshold of "reasonable degree of certainty" that an individual has a mental disorder requiring indefinite sexually violent predator (SVP) civil commitment. Defining the reasonable degree threshold in line with a clear and convincing level of burden of proof threshold offers a balance between community safety and civil liberties. Sexually violent predator (SVP) hearings represent a unique set of postincarceration civil commitment proceedings, where expert psychological or psychiatric testimony plays a central role in the commitment determinations. Psychologists are often asked to offer their testimony to a recognized professional standard. Courts have a gate-keeping role to exclude unreliable expert testimony, and testifying experts must offer opinions that are relevant and reputable. That standard has been a "reasonable degree of certainty." A review of SVP court cases over almost 25 years demonstrated that testifying experts recite the term but do not define the threshold. This lack of a standard definition has direct implications for determining the diagnoses that are key components in SVP hearings, as the data used by experts represent varying standards of proof. In order to standardize the term and because forensic psychologists are quite familiar with legal thresholds, the legal standards can provide sufficient guidance to define reasonable psychological certainty. The consequential nature of indefinite civil commitment calls for experts to move away from an undefined or vaguely defined threshold of probability to a defined probability. We argue that the threshold should be at the level of a clear and convincing standard.

While military veterans have a lower overall rate of incarceration for criminal offenses than civilians, they have a higher rate of incarceration for violent sexual offenses. Despite military veteran overrepresentation among individuals adjudicated for violent sexual offenses, little is known about their risk factors for sexual offending. This study compared military veterans and civilians who had been involuntarily hospitalized and discharged pursuant to California's Sexually Violent Predator Act. Pedophilic disorder appeared nearly twice as often among veterans than civilians (62.7% vs. 38.7%), whereas antisocial personality disorder was twice as common among civilians compared to veterans (48.1% vs. 23.9%). Consistent with the result for pedophilic disorder, veterans were more likely to target male victims age 13 and below, while civilians tended to target female victims over the age of 13. The results suggest different risk profiles for veterans compared to civilians who have been convicted of sexually violent offenses.

The use of antisocial personality disorder (ASPD) as a qualifying mental disorder for a sexually violent predator (SVP) or a sexually dangerous person (SDP) commitment continues to arouse controversy. Two common questions arise. Is ASPD considered a qualifying mental disorder in statutory or case law definitions? Can ASPD be the sole qualifying mental disorder? We review case law for guidance as to when ASPD may serve as a sole qualifying diagnosis in SVP/SDP evaluations. Other than the federal government and New York, all other jurisdictions with SVP/SDP commitments permit the use of ASPD as a stand-alone diagnosis when it can be linked to sexually violent behavior. ASPD is a viable qualifying disorder when the pattern of offending is atypical, severe, and can be linked to the risk for further sexual offending. ASPD is less viable as a qualifying diagnosis when it is manifested primarily by criminal behavior, the sex crimes are situational in context (e.g., substance abuse, negative peer affiliation), or the disorder cannot be linked to future sexual offending. Case law can provide guidelines, but the forensic clinician as the diagnostic expert bears the responsibility of providing a cogent and sound rationale as to why ASPD drives the risk for sexual reoffense.

The U.S. Supreme Court indicated in Kansas v. Crane that a qualifying mental disorder for Sexually Violent Predator civil commitment must differentiate between the 'dangerous sexual offender' and the 'ordinary criminal recidivist,' an issue of particular relevance when Antisocial Personality Disorder is the diagnosed condition. The DSM-5 categorical framework can be problematic in forensic contexts where the legal definition calls for a complex, layered, and nuanced approach. Dimensional schemes describe personality pathology in a flexible, individualized, and in-depth manner. In this paper we propose the expansion of DSM-5 ASPD criteria through the Alternative Model for Personality Disorders as a dimensional bridge to the SVP legal definition of a mental disorder. To that end, we first explain why a dimensional framework is plausible for the SVP definition of a mental disorder. Next, we review dimensional elements of ASPD impairments that serve to differentiate the sexually dangerous person from the ordinary criminal recidivist. Lastly, we provide a practical model that a forensic evaluator can use to determine whether to accept or reject ASPD as a viable SVP mental disorder.

Sexually violent predator (SVP) statutes are unique in that these laws allow for the indefinite civil psychiatric commitment of sex offenders after their criminal sentences have been served. In addition to the high cost of psychiatric hospitalization, recently observed low base rates of sexual recidivism of sex offenders released from custody suggest that, in select SVP cases, a collaborative justice model of outpatient placement may be feasible in lieu of lengthy and costly placement in state hospitals. Given its position as one of the states with a large number of SVP commitments, California offers an opportunity to implement a collaborative justice model for adult sex offenders found to meet SVP criteria. In this article, a template for such a model is suggested. Admittedly, this model faces multiple obstacles, both within the judicial system and in the public arena. Nonetheless, public concerns may be mitigated through high-control parole plus additional treatment and controls, interim halfway house placement, and community prosocial support systems.

The use of antisocial personality disorder (ASPD) as a qualifying mental disorder for a sexually violent predator (SVP) or a sexually dangerous person (SDP) commitment continues to arouse controversy. Two common questions arise. Is ASPD considered a qualifying mental disorder in statutory or case law definitions? Can ASPD be the sole qualifying mental disorder? We review case law for guidance as to when ASPD may serve as a sole qualifying diagnosis in SVP/SDP evaluations. Other than the federal government and New York, all other jurisdictions with SVP/SDP commitments permit the use of ASPD as a stand-alone diagnosis when it can be linked to sexually violent behavior. ASPD is a viable qualifying disorder when the pattern of offending is atypical, severe, and can be linked to the risk for further sexual offending. ASPD is less viable as a qualifying diagnosis when it is manifested primarily by criminal behavior, the sex crimes are situational in context (e.g., substance abuse, negative peer affiliation), or the disorder cannot be linked to future sexual offending. Case law can provide guidelines, but the forensic clinician as the diagnostic expert bears the responsibility of providing a cogent and sound rationale as to why ASPD drives the risk for sexual reoffense.

Among prison-incarcerated men in the United States, more veterans (35%) have a sexual offense conviction than nonveterans (23%). Limited research has investigated factors explaining the link between military service and sexual offending. Nationally representative data from prison-incarcerated men (n = 14,080) were used to examine the association between veteran status and sexual offenses, adjusting for demographic, childhood, and clinical characteristics. Veterans had 1.35 higher odds (95% confidence interval = [1.12, 1.62], p < .01) of a sexual offense than nonveterans. Among veterans, those who were homeless or taking mental health medications at arrest had lower odds and veterans with a sexual trauma history had higher odds of a sexual offense compared with other offense types. Offering mental health services in correctional and health care settings to address trauma experiences and providing long-term housing options can help veterans with sexual offenses as they transition from prison to their communities.

A common criticism of sexually violent person (SVP) laws is that psychiatric commitment has been co-opted to continue the incarceration of dangerous criminals, not dangerous individuals with mental illness. This opinion may have credence because some forensic clinicians use a "silo" approach (i.e., diagnosing based on historical criminal behavior rather than current symptomatology, and formulating risk for future sexual violence based on actuarial scores rather than characteristics and features of the mental condition). A silo process fosters a missing link; namely, the absence of a nexus between the mental condition and risk. This approach violates the necessary predicate for involuntary civil commitment, that the symptoms of an individual's current mental disorder be linked to and support a present sexual danger to others. In this article, we provide a brief overview of SVP statutes; describe how the silo approach compromises accurate diagnosis and identification of relevant risk factors; and present actual and fictitious cases illustrating the presence and absence of the missing link.