|
 
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| CASE REPORT |
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| Year : 2017 | Volume
: 22
| Issue : 1 | Page : 63-68 |
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A case series of five individuals with asperger syndrome and sexual criminality
Shankar Kumar, Yamini Devendran, Amrtavarshini Radhakrishna, Varsha Karanth, Chandrashekar Hongally
Department of Psychiatry, Victoria Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| Date of Web Publication | 14-Jul-2017 |
Correspondence Address:
Shankar Kumar
Department of Psychiatry, Victoria Hospital, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-8990.210703
The prevalence of autism spectrum disorders has increased in recent years and so has the focus on high functioning autism and Asperger syndrome. A subset of Asperger individuals appears to have a propensity to engage in acts of violence, particularly sexual crimes, which may best be attributed to the core features of their pathology such as “mind-blindness” and paucity of central coherence. This paper is an account on five such cases encountered in our hospital for whom various assessments were done including Mini International Neuropsychiatric Interview, intelligence quotient assessment by Binet Kamat test of intelligence, Montreal Cognitive Assessment, Ritvo Asperger's and Autism Diagnostic Scale, and Gillberg's criteria for diagnosis. These cases gained legal attention and “undeserved” outcomes. By drawing parallels from other countries, a few suggestions have been highlighted in the paper that can be considered to discard glaring deficits in the criminal law system in India in this context. Keywords: Asperger syndrome, autism spectrum disorder, criminal behavior, intellectual disability, paraphilic disorders
How to cite this article:
Kumar S, Devendran Y, Radhakrishna A, Karanth V, Hongally C. A case series of five individuals with asperger syndrome and sexual criminality. J Mental Health Hum Behav 2017;22:63-8 |
How to cite this URL:
Kumar S, Devendran Y, Radhakrishna A, Karanth V, Hongally C. A case series of five individuals with asperger syndrome and sexual criminality. J Mental Health Hum Behav [serial online] 2017 [cited 2023 Jun 4];22:63-8. Available from: https://www.jmhhb.org/text.asp?2017/22/1/63/210703 |
| Introduction | |  |
Asperger syndrome (AS), subsumed under autism spectrum disorders (ASDs), is a condition, in which features of autism exist, in a person who is of average intelligence. AS is characterized by a triad of impairments such as deficient reciprocal social behavior including deficits in communication which are both verbal and nonverbal and abnormalities of flexible imaginative activities.[1] The syndrome is sometimes synonymously also referred to as high functioning autism (HFA), but subtle differences exist between HFA and AS. These include the presence of pragmatic communication deficits and motor clumsiness seen in AS along with relative preservation of “linguistic and cognitive abilities.” Pragmatic communication deficits described in AS include inappropriate use of gestures, topic selection, and difficulty in recognizing humor, irony, or sarcasm. Pedantic and monotonic speech has been described, but no clinically significant delay in language is seen. What is also to be noted is that while some traits associated with autism may ameliorate with age, social dysfunction appears to persist.[2],[3],[4],[5]
A number of case reports published during the past three decades suggest that AS at times has been associated with criminal behavior.[6],[7],[8],[9],[10],[11],[12],[13],[14] Multiple factors could contribute to offensive behavior which apparently is also reflected in their attempts at courtship and sexual advances. This, despite the fact that their sexual desires and fantasies are similar to those found in general population, in that they are neither reduced nor deviant.[15],[16],[17],[18]
Primarily, the reasons for their apparent criminal behavior include poor impulse control, lack of empathy and social understanding, having a tendency of obsessionality in the pursuit of their special interests, and failing to recognize implications of their behavior.
Epidemiology of high functioning autism and criminality
Early studies reveal a prevalence of ASDs of about 0.05%.[19] However, recent surveys suggest a prevalence of all ASDs of 0.60%. The prevalence rate for pervasive developmental disorder (PDD)-not otherwise specified is 0.31% and that for AS is 0.095%.[20]
The prevalence of ASDs including AS among offenders was about 1.5% in specialized psychiatric settings dealing which was higher compared to general population (0.36% as described by Gillberg and Gillberg, 1989).[21] In another literature review of the 132 published cases of AS, only 3 (2.27%) had a history of offense as compared to 6–7% in the general population.
Asperger syndrome individuals accused of crimes
Those with AS may sometimes engage in apparent antisocial behavior leading to entanglement with criminal justice system, but a serious look at such cases would reveal a lack of subjective understanding of the act's inherent impropriety by the AS individual or the misinterpretation of their behavior by others, and not as a result of a criminal mind-set. What appears as malicious intent is often the manifestation of the ASD person's social misunderstandings.[22]
Indulging in personal, telephone, or internet stalking, downloading child pornography, and touching or kissing a stranger have been noted in the offenders. Sexual crimes by individuals with HFA can also include other paraphilic behaviors [6],[7],[8],[9],[10],[11],[14],[23],[24] such as fetishism,[25],[26] a process of eroticization of nonliving objects and/or body parts for sexual gratification.[27] Murrie et al.[11] noted a case, wherein an individual believed he could attract sexual partners by engaging in public performance of bizarre sex acts with an inflatable doll. Jeffrey Dahmer, the sexual serial killer's acts,[24] involved repetitive dehumanization of people – resulting in victim mutilation, similar to the deconstruction of any object, probably suffering from a difficulty to distinguish people from objects.[28],[29]
| Case Report | | |
We hereby describe the clinical presentations, assessments, legal proceedings, and possible factors associated with offending of five individuals with AS, who presented with a history of abnormal sexual behaviors which led to legal cognizance. The cases reported were brought to our notice as a part of the legal consequences for the inappropriate sexual behavior, and we would discuss the probable mechanisms through which symptoms of PDDs (and in particular AD) can place individuals at risk to engage in sexually inappropriate behaviors.
The following assessments were done in the patients:
- Mini International Neuropsychiatric Interview [30] – To rule out psychosis, mood disorder, and obsessive–compulsive disorder
- Intelligence quotient assessment was done using Binet Kamat test of intelligence [31] – To rule out significant intellectual impairment
- Montreal Cognitive Assessment [32] – To rule out major neurocognitive impairment
- Ritvo Asperger's and Autism Diagnostic Scale (RAADS)[33] – Self-rated scale to aid in the diagnosis of AS and autism and has 78 questions to assess dimensions of social relatedness, language and communication, sensorimotor, and stereotypies. A cutoff of 77 or more is taken as highly suggestive
- Gillberg criteria [34] – All of the following must be met for confirmation of diagnosis: (1) Severe impairment in reciprocal social interaction, (2) All-absorbing narrow interest, (3) Imposition of routines and interests, (4) Speech and language problems, (5) Nonverbal communication problems, (6) Motor clumsiness: Poor performance on neurodevelopmental examination. MoCA: Montreal Cognitive Assessment, RAADS: Ritvo Asperger's and Autism Diagnostic Scale, BKT: Binet Kamat test, MINI: Mini International Neuropsychiatric Interview, OCD: Obsessive-compulsive disorder.
The rating scales are available in English language only. RAADS was completed with assistance by a psychiatrist by patient P and patient M. For patients K, N, and S, the scale was administered by a psychiatrist. The scale is not validated in Indian population.
- Mr. S – A middle-aged male was brought to the hospital with a history of undressing and masturbating in front of unknown women when they are alone despite being warned by his family and the frequent police arrests for the same. Mr. S did not have any remorse or embarrassment for his behavior. His other peculiar sexual behavior was that of conversations involving sexual content with his wife and forcing her to have repeated sexual intercourse with him unmindful of her wishes or needs. She was assaulted if she refused and had to repeatedly concede to his demands irrespective of the place they were in or presence of people around them
As a child, there was a history of mild delay in speech as compared to the other siblings and also had stuttering. As per his mother, Mr. S was cold, aloof, had no peers, and did not have any wishes or demands from the family. He was keen to attend school regularly in spite of being punished severely for not completing assignments. As an adult, he did not allow his family to spend his money nor did he spend it for himself. He gave no reason for the same. - Mr. N – A 26-year-old male was brought with complaints of cross-dressing though he did not identify himself with the opposite gender nor had an interest in heterosexual contact. He was beaten up for this behavior but continued with the same. He had a habit of eating outside home, especially at marriages or parties without intimating anyone and claiming that home food is sober and not enjoyable. This was usually followed by indigestion and stomach upset for which he took over-the-counter drugs but continued with this eating routine. He also had a habit of collecting unwanted objects which he would not use and getting angry if not let to do so (absence of ego-dystonicity). Mother reported of him being a loner with minimal interactions with family and had no peers. He rarely expressed emotions while nonverbal communication was also poor. He spoke only if he was interested to speak. He had monotonous pedantic speech with minimal prosody
- Ms.P – A 15-year-old girl from an orthodox Hindu family brought for psychiatric evaluation. She would befriend boys and call them home and would request sexual activity with them, much to their surprise, many of whom ran out of the house embarrassed.
She would also talk about the same to her relatives and was unmindful of their reaction.
Although she never had sex with anyone, she described that she “liked calling them up and asking them.” She would remember contact numbers of most of them.
There was a lack of sustained social relationships since childhood though she described all routine acquaintances as friends. In fact, these people would laugh at her since she would talk at length about discrete issues and would not notice the displeasure of others. She would talk to strangers, smile inappropriately, much to their disgust. In fact, when her grandma, whom she was “most attached to” since childhood, died, she did not show any signs of grief and asked if she could have her jewels.
She had otherwise normal intelligence.
She was started on fluoxetine 20 mg then increased to 40 mg + valproate 500 mg. Her sexual repetitive behavior decreased. However, the patient was lost on follow-up subsequently.
- Mr. K – A 35-year-old male was referred by the Neurology Department (working as an attender there) for psychiatric evaluation as he would inappropriately “grope” female patients and was reprimanded multiple times. Previously diagnosis of mood disorder/antisocial personality disorder was made. He appeared cold and unremorseful for his acts.
He would say that he had multiple friends, but his colleagues would laugh at him as his communication was loosely organized, without coming to the topic, would incessantly talk without understanding that the listener was disinterested or embarrassed, and would inappropriately smile. Family reported of him having difficulties in making friends throughout his life. No core mood or psychotic symptoms. He said he would take great care of his child but in fact would grab eatables from the child and would appear to be unmoved even if the child cried inconsolably. He said he had a good sexual life, but his wife described that many of his behaviors caused physical pain to her. Irrespective of circumstance, he demanded sexual intercourse daily.
- Mr. M – A 38-year-old male working in an autism school as a volunteer was referred for psychiatric evaluation from the Central Jail. Patient was facing trial for misbehavior with a girl child in the neighborhood. Although married for 8 years, he neither had an intimate relationship with his wife nor expressed any sexual interest in other woman. His mother gave a history of him being ridiculed for his peculiar handshakes and hugs while greeting people, especially with females. He spoke for long hours not acknowledging that it annoyed people in the conversation. He did not understand social cues and facial expressions were minimal. There was a history of playing video games for long hours. He insisted that things always be in the order that he likes, else would get annoyed and anxious. He had a history of mild delay in motor and language milestones. Details of initial assessments, mental status examination, previous diagnosis and treatments and reasons for the same, have been highlighted in [Table 1] and [Table 2].
 | Table 2: Initial mental status examination, past diagnosis and treatment, reasons for initial consultation
Click here to view |
| Discussion | | |
Clinical presentation and possible factors associated with offending
AS individuals desire intimate relationships, but yet experience problematic relations with the opposite sex because of the difficulty in indicating interest toward another person in a socially acceptable manner. Mr. M was convicted for sexual abuse as he had kissed a girl child's hand to greet her. Behavioral abnormalities associated with “mind-blindness” which is commonly seen in AS were reflected in his inability to appreciate how his over-familiar behavior with strangers, especially girls, would be perceived both by children and by others in his environment such as the mother in this case.
AS individuals have also been known to have sexually inappropriate behaviors such as undressing in public, touching others, and relentlessly following a romantic interest. Mr. S used to undress in front of females when they were alone. Those with AS cannot understand social prohibitions or mores that are naturally inculcated in most neurotypical individuals. Mr. S, Mr. N, and Mr. M had been brought for their involvement in the legal repercussion for their inappropriate sexual behavior.
Another extremely useful way to conceptualize this phenomenon is in terms of “counterfeit deviance” as was seen in Mr. S who engaged in behavior that superficially looked like a paraphilia but lacked the pathological use of sexual fantasies, urges, or behavior.”[35] Instead, the behavior is explained by “experiential, environmental, or medical factors rather than of a paraphilia due to lack of information about sexual expression, poorly developed social skills, lack of assertiveness, and a limited opportunity for sanctioned age-mate relationships.”
Ms.P compulsively and indiscriminately solicited sexual contact from generally hostile but nevertheless potential partners, reflecting theory of mind (ToM) deficits associated with the circumstances of her solicitation. ToM (or mentalization) refers to the ability to estimate the cognitive, perceptual, and affective lives of others as well as of the self.[23],[36] This relative inability to utilize ToM abilities has been termed “mind-blindness” as mentioned above.[37] Mr. K and Mr. M may suffer from an inability to read the necessary interpersonal cues telling the perpetrator to disengage from a social encounter. All the cases presented with a history of poor socialization skills and no friends, consistent with deficits in social reciprocity.
Frith [23] has introduced the concept of central coherence. Individuals with deficits in central coherence have excessive preoccupation with highly focused internal interests while ignoring social consequences including legal sanctions. Silva et al.[38] have recently proposed that deficits in central coherence and associated compartmentalizing characteristics nurture the growth of inner preoccupations. Such fixations, if left unchecked by normal awareness of social constraints, may lead to maladaptive fantasies.
An interesting finding by Wahlund and Kristiansson [39] mentions that violent HFA criminals are substantially different in both psychosocial functioning and crime scene characteristics from psychopathic violent criminals [40],[41] with predatory violence (as against impulsive violence) being more defining of antisocial personality disordered criminals and absent among criminals with HFAs. Note: These illnesses may not always be mutually exclusive.
Legal outcomes of reported cases
Mr. S. had several cases of sexual misconduct for outraging modesty of women, pending in court, at a time when his wife lodged a complaint in a Women' Protection Cell Nongovernmental Organization (NGO) for coerced sexual intercourses. The treating doctors liaised with the NGO, gave a report of possible social-perceptive deficits as a part AS diagnosis. Despite these efforts, Mr. S. was convicted under Section 376A for 2 years of imprisonment.
Mr. K's deviant behavior beckoned the medical college to constitute a committee to look into the complaints of alleged sexual impropriety committed by him on the pretext of physical examination. Following evaluation, a probable diagnosis of PDD was made, and change in the place of work was suggested. This expert evaluation, however, was not sufficient to deter the arrest of Mr. K by the city police later.
Mr. M was convicted for his sexual digressions and was later granted bail by the court.
Asperger syndrome and criminal responsibility
For convicting an individual with a crime, the prosecution must prove the existence of two components: unlawful act (actus reus) and intent to cause harm or a guilty state of mind (mens rea). The defense of mental illness in most British-American jurisdictions is based on the M'Naghten Rules established in 1800s: “A person is not responsible for criminal conduct if at the time of the act he was laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong.”[42]
To add to this, in Israel, there was a 1994 amendment of the law with an additional criterion for incapacity, namely the offender's inability to control his or her behavior to avoid the criminal act. This is termed the volitional test.[43]
In the United States since 2008, the state legislative and the judiciary have considered the presence of an HFA diagnosis as a factor in making guilt and competency determinations.
Not guilty by reason of insanity
The not guilty by reason of insanity (NGRI) verdict exists in the United States. As described in the Model Penal Code,[44] the NGRI verdict includes provisions for cognitive impairment, or the inability to appreciate that a given act is wrong, and volitional impairment, or the inability to refrain from a given act.[45]
Some changes brought into the judicial circuit have been evident over the years in the United States.
In State versus Burr,[46] the New Jersey Supreme Court heard and ordered a new trial on an assault convict after determining that the defendant's AS diagnosis was relevant to his defense and improperly excluded at trial.
The Missouri Court of Appeals overturned a circuit court opinion that had prevented a defendant charged with murder from presenting evidence that he had Asperger's disorder, including expert testimony from three psychologists.
California and Florida have criminal law referencing an autism diagnosis as grounds for incompetency to stand trial.[47],[48]
The New Jersey law further mandates experts to produce a report with specific training recommendations that would allow the defendant to attain competency.
Future directions
Preliminary findings indicate that HFAs are over-represented in criminal populations relative to their prevalence in the general population. This is why more comprehensive studies are needed in this regard.
Speaking about AS teens, it is necessary that they be taught “public versus private behavior,” “good touch versus bad touch,” “reality versus fantasy,” and the definitions of sexual consent and laws regarding sexuality.[49] Murrie suggests that though the patients may continue to appear socially awkward, by providing education, they may be less likely to violate boundaries and harm others.[50]
In forensic contexts, intellectual disability and [51] HFAs share important similarities in terms of being developmental disabilities, standing at risk for false confessions and manipulation during interrogation, and may provide questionable testimony while disposing before courts. So, why not treat HFAs on the same footing as intellectual disability in trials for crime? An expert who can interpret and testify in court may be needed. Furthermore, it is known that displaying remorse for a criminal act has a favorable impact on legal sentencing. Unfortunately, here, the person's courtroom displays of laughing or giggling, loud vocal tone, and aloof body language (inherent to the condition of AS) can lead judges to conclude that this is a guilty and remorseless person and may thus warrant an adverse sentence.
HFAs would find it difficult in understanding legal monologues or questioning. A pen and paper would come in handy to write them down. As it is known that their visual skills are marginally stronger than their auditory skills, penning down the questions can help as writing and reading it over will give them more time to ponder and process what has been said.
In ideal circumstances, HFA offenders should be assessed to see if they understand the difference between good and bad acts and the need for good acts to be rewarded and bad acts to be punished. Moral reasoning for different types of aggression (e.g., physical and relational) can be judged. The legal determinations in some countries highlight the pressing need for policy recommendations for considering criminal behavior in HFA individuals in India.
The case series has also attempted to highlight the importance of considering AS as a differential diagnosis when an adult psychiatrist encounters such deviant behaviors as it is often overlooked or misdiagnosed. An interesting point to note is that preventive interventions can not only prevent offense but also prevent abuse, as in the case of the Asperger adolescent girl. Many a time, the victims are children.
In a country like ours, intervention modules consisting of management programs for AS sex offenders in community supervision must include cognitive-behavioral therapies and psychopharmacological treatments aimed at diminishing obsessive behavioral and cognitive preoccupations, and improving intimacy, empathy, social skills, and social/emotional reciprocity deficits in all of which mental health professionals can play a direct role.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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