The Journal of Forensic Psychiatry & Psychology,

December 2007; 18(4): 494 – 506

Forensic inpatient male sexual offenders:

The impact of personality disorder and
childhood sexual abuse

MANUELA DUDECK*, CARSTEN SPITZER*,

MALTE STOPSACK, HARALD J. FREYBERGER, &
SVEN BARNOW

Ernst-Moritz-Arndt University, Greifs-wald/Stralsund, Germany

Abstract
Given the great epidemiological, social, and psychological importance of sexual
offences, and their deleterious consequences for victims, it seems vital to focus on
potential risk factors for becoming a sexual offender. Our study aims to contribute to
a better understanding of specific risk factors for sexual offenders by including a
number of potentially important variables: biographical, clinical, and forensic. The
sample consisted of 51 male inpatients at two maximum security forensic hospitals
in Germany. The 19 sexual offenders were compared to the 32 non-sexual
offenders. Personality disorder diagnoses and childhood maltreatment were assessed
by experts; current psychopathology and interpersonal problems were measured
using self-report questionnaires. Narcissistic personality disorders were significantly
more frequent in sexual offenders than in the comparison group. Moreover, sexual
offenders had been sexually abused as children significantly more often than the
non-sexual offenders. Our findings indicate that sexual victimization in childhood
might be an important risk factor for sexual offending in later life. Therapeutic
interventions for offenders focusing on their childhood sexual abuse might improve
their psychosocial well-being and functioning, and their criminal prognosis.

Keywords: Sexual offenders, risk factors, childhood sexual abuse, narcissistic

personality disorder, forensic psychiatry, cycle of violence

Introduction
Sexual offences impose a major burden on society in general and on the
individuals concerned (Ward, Polaschek, & Beech, 2005). For example,

Correspondence: Manuela Dudeck, Department of Psychiatry and Psychotherapy, Ernst-Moritz-Arndt-

University Greifswald, Rostocker Chaussee 70, D-18437 Stralsund, Germany.
E-mail: manuela.dudeck@uni-greifswald.de
*The first two authors contributed equally to this manuscript.

ISSN 1478-9949 print/ISSN 1478-9957 online ª 2007 Taylor & Francis

DOI: 10.1080/14789940701491495
 Male sexual offenders 495
the German Federal Bureau of Criminal Investigation registered 57,306
sexual offences in 2004 (Bundesministerium des Innern, 2004): the actual
levels may be much higher, as many such offences may go unreported.
The short- and long-term consequences for victims are dramatic,
including mental disorders such as posttraumatic stress disorder and major
depression (Cheasty, Clare, & Collins, 1998; McCauley et al., 1997). In
order to conceptualize and establish rational and efficient preventive
programs, it is essential to identify the risk factors for becoming a sexual
offender.
The relationship between childhood maltreatment and later criminal
behaviour, particularly sexual offending, is receiving increased scientific
attention. There is converging evidence that maltreated children are signi-
ficantly more aggressive than those who have not been exposed to mal-
treatment (Barnow & Freyberger, 2003; Barnow, Lucht, & Freyberger,
2001, 2005; Stein & Lewis, 1992). In one comparative study of 16 sexual
and 16 violent offenders, the sexual offenders had experienced significantly
more child abuse – verbal, physical, and sexual (Haapasalo & Kankkonen,
1997). Rates of early childhood sexual abuse in sexual offenders have been
estimated at 12 – 35% (Burton, Miller, & Shill, 2002; English, Jones,
Patrick, & Pasini-Hill, 2003; Glasser et al., 2001; Salter et al., 2003). In
addition to childhood sexual abuse, emotional abuse and familial dys-
function have emerged as risk factors for paedophilia, exhibitionism,
and other types of deviant sexual behaviour (Lee, Jackson, Pattison, &
Ward, 2002). Lee et al. (2002) found that early childhood sexual abuse
appears to be a strong predictor of subsequent paedophilia. Correspond-
ingly, another study of 70 male juvenile sexual offenders indicated that
abnormal sexual experiences in early developmental stages increase the risk
for criminal deviance in later sexual behaviour (Kenny, Keogh, & Seidler,
2001).
Most recently, several investigations have reported that a personality
disorder (PD) diagnosis might be associated with sexual offence. For
example, a study of 47 mentally ill sexual offenders found that 72% showed
at least one PD (as assessed by the SCID-II), with cluster B having the
highest prevalence – 40% were diagnosed as suffering from antisocial PD
(Borchard, Gnoth, & Schulz, 2003). Another investigation of background
data on the psychosocial characteristics of sexual offenders found that the
most frequent psychiatric diagnosis was PD (Curtin & Niveau, 1998).
Based on clinical observations of male inpatients in a maximum security
hospital in California, Murphy and Vess (2003) suggested four possible
subtypes of psychopathy: narcissistic, borderline, sadistic, and antisocial.
In a sample of almost 2,500 sexual offenders in the United States, 75% met
the diagnostic criteria for a PD (Fitch, 2003).
In addition to Axis II disorders (i.e., PD), there is a growing interest in
Axis I disorders and psychopathological distress in general among sexual
496 M. Dudeck et al.
offenders (Leue, Borchard, & Hoyer, 2004). For example, high lifetime and
point prevalence of social phobia has been reported among paraphilic
sexual offenders (Hoyer, Kunst, & Schmidt, 2001). In a sample of 55 sexual
offenders in forensic inpatient treatment, anxiety and mood disorders,
particularly major depression, and substance use disorders were very
common (Leue et al., 2004). Another empirical investigation found that
sexual offenders scored significantly more highly than violent offenders on
social isolation, interpersonal sensitivity, and anger (Gudjonsson &
Sigurdsson, 2000). In line with these findings, several studies have indi-
cated significant differences between sexual and violent offenders with
regard to introversion and emotional problems such as anxiety and
depression (Ahlmeyer, Kleinsasser, Stoner, & Retzlaff, 2003; MacMillan
et al., 2001; Valliant & Bergeron, 1997).
Five out of six studies of dissociative symptoms and disorders in the
context of sexual offending reported significantly higher dissociation scores
in sexual offenders than in the general population (Bliss & Larson, 1985;
Ellason & Ross, 1999; Graham, 1993, 1996; Hulnick, 1996; Spitzer et al.,
2003). Of 70 sexual offenders in one study, 14.3% met the DSM-IV
diagnostic criteria for a dissociative disorder; in contrast, in the control
group of 47 psychiatric inpatients only 4.2% were diagnosed as suffering
from a dissociative disorder (Friedrich et al., 2001). Generally speaking,
sexual offenders show significantly more psychopathological impairment
than psychiatric patients, and the degree of sexual deviance corresponds
with the degree of psychopathological distress (Herkov, Gynther,
Thomas, & Myers, 1996).
In summary, despite the multitude of findings, little is known about the
specific characteristics of sexual offenders. A review of the literature
revealed that no study has analysed psychopathology, dissociation,
personality disorder, and childhood maltreatment simultaneously in sexual
offenders. Thus, the aim of the present study was to investigate the impact
of childhood trauma (particularly sexual trauma), personality disorders,
and psychopathology on later sexual offending, and to answer the following
questions:

1. Do sexual and non-sexual offenders differ with respect to

type of childhood victimization and frequency of exposure to
maltreatment?
2. Is there a relationship between childhood maltreatment, particularly a
history of childhood sexual abuse, and the later form of criminal
offending?
3. Is there an association between personality disorders and sexual
offending?
4. Do sexual offenders have significantly more general and dissociative
psychopathology than non-sexual offenders?
 Male sexual offenders 497
Method
Study design and participants
The study was conducted at the forensic hospitals of Ueckermünde and
Stralsund, two maximum security facilities in Pomerania (the north-eastern
region of Germany). The selection criteria were: male sex, age between
18 and 65 years, no organic mental disorder, no mental retardation, and
engagement in the interview and the self-report questionnaires. Potential
participants were informed about the purpose and the procedure of the
investigation. They were not promised any kind of incentive, and they were
assured that a decision not to participate would not influence their
treatment.
At the time of the study, a total of 113 male inpatients were hospitalized
in the two institutions. The inclusion criteria were met by 55 subjects
(48.6%); only four refused to participate. The mean age of the remaining 51
subjects was 32.4 years (SD ¼ 8.8; range 18 – 55). Only four participants
(7.8%) were in a partnership that had lasted for more than one year; the
majority (n ¼ 36; 70.6%) were single. As regards education: 18 participants
(35.3%) had finished secondary school (10th grade), 15 (29.4%) had
completed extended elementary school (eighth grade), and 18 (35.3%) had
an educational level lower than eighth grade. As regards work/training: the
majority (n ¼ 30; 58.8%) had learned a skilled trade, two (3.9%) were
salaried employees, and 18 (35.3%) had not completed any vocational
training.
In the sample of 51 subjects, 30 (58.8%) were detained under
the German Penal Code section 63, which is applicable in case of
diminished responsibility due to mental illness, profound disturbance of
consciousness, mental retardation, or other serious mental abnormality;
if the individual is judged to be still dangerous, he/she can be
hospitalized in a forensic inpatient facility for unlimited treatment, by
order of the court. The remaining 21 subjects (41.2%) were detained
under section 64 of the German Penal Code, which is similar to section
63 but refers to inpatient treatment for persons with substance use
disorders.
Patients were assigned either to the index sample of sexual offenders
(n ¼ 19: paedophilia n ¼ 12, 63%; rape n ¼ 7, 37%) or to the comparison
group of non-sexual offenders (n ¼ 32: murder/homicide n ¼ 12, 38%;
serious bodily injury n ¼ 20, 62%). Information was gathered on the
psychiatric diagnoses offered by experienced forensic psychiatrists in
court. Data on adverse and traumatic childhood experiences were
gathered in a semi-structured interview following the ICD-10, particularly
chapters XIX (T74 ‘maltreatment syndromes’), XXI (Z61.x ‘problems
related to negative life events in childhood’), and Z62.x (‘other problems
related to upbringing’; World Health Organization, 1991). Finally,
498 M. Dudeck et al.
participants were asked to complete the self-report measures described
below.

Materials
The revised version of the Symptom Check List-90 (SCL-90-R) is a
90-item, self-report clinical rating scale widely used to measure current
psychopathology (Derogatis, 1983). In addition to a global rating (Global
Severity Index, GSI), it comprises nine subscales: somatization, obsessional
compulsion, interpersonal sensitivity, depression, anxiety, anger-hostility,
phobic anxiety, paranoid ideation, and psychoticism. The reliability and
validity of the German version of the SCL-90-R is similar to that of the
original version (Franke, 2002).
The Dissociative Experiences Scale (DES) is a 28-item, self-administered
questionnaire with good reliability and validity (Bernstein & Putnam, 1986).
Factor analysis yields three subscales representing dissociative amnesia,
absorption/imaginative involvement, and derealization/depersonalization
(Carlson & Putnam, 1993). In the German adaptation of the DES, 16 items
have been added to assess dissociative phenomena included in the ICD-10,
mainly pseudoneurological conversion symptoms. The psychometric
properties of the German version, the Fragebogen zu Dissoziativen
Symptomen (FDS), are almost identical to the original version (Spitzer,
Stieglitz, & Freyberger, 2005).
The Inventory of Interpersonal Problems (IIP; Horowitz, Alden,
Wiggins, & Pincus, 2000) is based on Leary’s (1957) interpersonal cir-
cumplex theory. In this general model, two bipolar axes of interpersonal
functioning, friendliness – hostility and dominance – submission, define a
two-dimensional circular space, which can be divided into eight octants
reflecting different combinations of the two personality axes, also regarded
as interpersonal style. The eight types – domineering, vindictive, cold,
socially avoidant, non-assertive, exploitable, overly nurturant, and intru-
sive – are arranged in order around the circumplex, starting from dominant,
then moving round to hostile (cold), submissive (non-assertive), and
friendly (overly nurturant). The IIP assesses the nature of dysfunctional
interpersonal patterns and provides a total score indicating the general
degree of interpersonal problems. The psychometric properties of the
German version of the IIP are very similar to those of the original version
(Horowitz, Strauß, & Kordy, 1994).

Statistical analysis
Data were analysed using SPSS Version 11.5. We applied the w2 test or
Fisher’s exact test when required. For between-group comparison, we used
the t test and analyses of variance. In cases lacking normal distribution,
 Male sexual offenders 499
results were cross-checked using non-parametric procedures. The sig-
nificance level was set at p 5 .05.

Results
As can been seen in Table I, a narcissistic personality disorder had been
diagnosed in 7 of the 19 sexual offenders (36.8%), but in only 3 of the 32
non-sexual offenders (9.4%; p ¼ .028). The odds of having a narcissistic
personality disorder were 5.64 higher in sexual offenders than in non-
sexual offenders (95% CI: 1.25 – 25.54). There were no differences in
the distribution of the other personality disorder diagnoses across the
groups.
Most traumatic and negative childhood experiences did not differ
between the groups, but a significant difference emerged with respect to
sexual abuse, which was more frequent in the sexual offenders (26.3%) than

Table I. Frequency (in %) of personality disorders and negative childhood experiences in the
index sample of sexual offenders and the control group of non-sexual offenders.

Non-sexual Sexual
offenders offenders
(n ¼ 32) (n ¼ 19) w2 p OR (95% CI)

Personality disorders (PD)

Antisocial PD 37.5 26.3 0.41 .413 0.60 (0.17 – 2.07)
a
Narcissistic PD 9.4 36.8 .028 5.64 (1.25 – 25.54)
a
Borderline PD 12.5 5.3 .639 0.39 (0.04 – 3.76)
a
Other PD 9.4 15.8 .659 1.18 (0.33 – 10.05)
Negative and traumatic experiences in childhood (ICD-10 T74.x, Z61.0 – 62.9)
Emotional neglect 43.8 57.9 0.95 .329 1.77 (0.56 – 3.57)
Physical abuse 59.4 47.4 0.69 .405 0.62 (0.20 – 1.93)
a
Sexual abuse 3.1 26.3 .022 11.07 (1.18 – 103.78)
Loss of a love relationship 53.1 36.8 1.27 .260 0.52 (0.16 – 1.65)
Removal from home 25.0 36.8 0.81 .370 1.75 (0.51 – 5.98)
a
Events resulting in loss 15.6 0.0 .143 –
of self-esteem
a
Personal frightening 12.5 10.5 .832 0.82 (0.14 – 4.99)
experience
a
Other negative life 28.1 10.5 .176 0.30 (0.06 – 1.57)
events in childhood
a
Inadequate parental 9.4 10.5 1.00 1.14 (0.17 – 7.50)
supervision/control
a
Parental overprotection 3.1 10.5 .547 3.65 (0.31 – 43.22)
a
Institutional upbringing 25.0 15.8 .505 0.56 (0.13 – 2.45)
a
Other problems related 6.3 15.8 .348 2.81 (0.43 – 18.60)
to neglect in upbringing
a
Fisher’s exact test.
500 M. Dudeck et al.
in the non-sexual offenders (3.1%). The odds of having been sexually
abused in childhood were 11 times higher in sexual offenders than in non-
sexual offenders (OR ¼ 11.1; 95% CI: 1.2 – 103.8; see Table I).
As depicted in Table II, the sexual offenders did not differ from the non-
sexual offenders in terms of current psychopathological distress (SCL-90-R),
dissociative psychopathology (FDS), or interpersonal problems (IIP).

Discussion
The main finding of our study was that significantly more sexual offenders
than non-sexual offenders had experienced childhood sexual abuse
(26.3% compared to 3.1%). This result is in line with other studies indi-
cating that the rate of sexual abuse in childhood among juvenile delinquents
is 39 – 49% (Johnson, 1988; Williams & Finkelhor, 1990).
The ‘cycle of violence’ (Widom, 1989b) – the transmission of violence
achieved by changing one’s role from early victim to later perpetrator – has

Table II. Comparison of psychopathology (SCL-90-R) scores, dissociative experience (FDS)

scores, and interpersonal problem (IIP) scores between sexual and non-sexual offenders.

Non-sexual Sexual
Offenders (n ¼ 32) offenders (n ¼ 19) F p

Psychopathology (SCL-90-R)
Somatization .51 (.54) .53 (.52) .01 .931
Obsessional compulsion .91 (.75) .82 (.51) .23 .634
Interpersonal sensitivity .97 (.76) 1.01 (.75) .02 .878
Depression .97 (.74) 1.20 (.95) .95 .334
Anxiety .72 (.72) .98 (.71) 1.65 .206
Anger-hostility .91 (.93) .93 (.67) .01 .940
Phobic anxiety .34 (.68) .38 (.46) .03 .856
Paranoid ideation 1.09 (.79) 1.17 (.65) .13 .719
Psychoticism .50 (.46) .81 (.66) 3.86 .055
Dissociative experiences (FDS)
Amnesia 10.0 (8.4) 10.1 (11.5) .01 .992
Absorption 19.3 (15.4) 17.8 (16.8) .10 .748
Derealization 6.4 (8.9) 7.4 (14.9) .09 .761
Conversion 5.5 (7.1) 7.3 (8.5) .68 .413
Interpersonal problems (IIP)
Domineering 10.6 (4.5) 12.7 (5.8) 2.13 .151
Vindictive 12.1 (4.7) 14.0 (5.2) 1.73 .195
Cold 10.9 (6.2) 13.4 (6.7) 1.87 .178
Socially avoidant 13.1 (7.4) 14.2 (7.7) .26 .609
Non-assertive 11.1 (7.0) 12.6 (8.4) .44 .508
Exploitable 12.2 (6.4) 11.6 (4.1) .10 .750
Overly nurturant 15.4 (6.6) 14.7 (5.4) .13 .723
Intrusive 11.7 (5.0) 11.3 (4.7) .09 .767
 Male sexual offenders 501
received increasing clinical and scientific attention in the last three decades
(Goodwin, McCarthy, & DiVasto, 1981; Starr, MacLean, & Keating, 1991;
Widom, 1989a, 1989b), particularly as regards sexual victimization and
sexual offence (Glasser et al., 2001). The likelihood of the transmission of
maltreatment, abuse, and neglect in adolescence has been estimated at 26%
(Widom, 1989a, 1989b). Although the psychological and neurobiological
mechanisms underlying this transmission process are not yet entirely
understood, there is no doubt about the essential role of social learning
(Bandura, 1977; Burton et al., 2002), the aversive emotional experiences
associated with various types of maltreatment (e.g., total helplessness and
despair), and aberrant conditioning (Dudeck & Freyberger, in press;
Glasser et al., 2001). For example, in a comparative investigation of delin-
quents with and without a history of sexual abuse, exposure to longlasting
sexual abuse in childhood emerged as a strong predictor of later becoming a
sexual offender (Haapasalo & Kankkonen, 1997). Other studies have
indicated an association between the repetition rate as well as the intensity
of the sexual abuse and the likelihood of the former victim becoming a
sexual offender later in life (Burton et al., 2002; Glasser et al., 2001). On an
emotional level, sexual abuse is linked with the later development of intense
feelings of anger and hostility, which themselves play an important role in
sexual offending (Lee et al., 2002; Malamuth, Sockloskie, Koss, & Tanaka,
1991; Marshall & Barbaree, 1999).
Another important result was that sexual offenders frequently suffer from
a narcissistic personality disorder. We found that 36.8% of the sexual
offenders had a narcissistic PD, as compared to 9.4% in the control group
of non-sexual offenders. The main characteristic of narcissistic PD is
difficulty in interpersonal interactions. Those with narcissistic PD are
incapable of loving care for others and exhibit a lack of empathy, resulting
in a failure to develop stable object relations (Kernberg, 1998; Livesley,
2001). Their grandiose sense of self-importance, their conviction that they
are in the right, and their unwillingness to respect the needs of others may
explain why they have an increased risk of committing sexual offences
which might be understood as vindictive rage in response to personal insults
and as an almost obsessive desire to make sexual conquests without
recognizing and respecting the feelings and needs of potential partners
(Kernberg, 1998; Livesley, 2001).
Futhermore, the interaction between narcissistic PD and exposure to
childhood sexual abuse has to be taken into account (Dudeck, Liß,
Spitzer, & Freyberger, 2004). Within the index group of the sexual
offenders, 40% of those with a narcissistic PD had been sexually abused as
children, compared to 5% of those without a narcissistic PD. Feelings of
worthlessness, the unconscious basis of narcissistic self-grandiosity, in
combination with experiences of powerlessness associated with childhood
sexual abuse, might explain the drive to dominate victims sexually.
502 M. Dudeck et al.
Subjectively, the perpetrator experiences power, domination, and a sense of
being in control during the sexual offence which may – partially –
compensate for his feelings of worthlessness and powerlessness. From the
perspective of social learning theory, the abused child realizes that
his perpetrator enjoys his power and lacks signs of anxiety, and thus
learns that sexual abuse offers the opportunity for the perpetrator to control
others and to feel good and comfortable at the same time (Burton et al.,
2002).
We did not find any differences between the sexual offenders and the
non-sexual offenders in terms of general psychopathological impairment,
which stands in contrast to other studies reporting more symptoms of
social phobia and depression in sexual offenders (Ahlmeyer et al., 2003;
Hoyer et al., 2001). However, we must recall that the degree of psy-
chopathology is not only associated with sexual offence, but also linked with
sexual deviance (Herkov et al., 1996). Thus, psychopathological distress
appears to be quite unspecific in predicting the type of delinquency; rather,
it is associated with delinquency in general (Fazal & Danesh, 2002; Kashani
et al., 1992).
Sexual offenders did not differ from the non-sexual offending control
group in terms of dissociative experiences and interpersonal problems.
This is in line with a previous investigation that failed to find differences in
dissociative symptoms and disorders between sexual offenders, a general
population sample, and another control group comprising subjects falsely
accused of sexual offence (Dwyer, Rosser, & Sawyer, 1992). In contrast,
other studies have reported an association between dissociation and sexual
offending (Friedrich et al., 2001). The participants in our study had been
exposed to traumatic events; thus, one might argue that the dissociation
level was elevated in both the index and the control groups, possibly
blurring true differences. Finally, there is a lack of studies of dissociation
and interpersonal problems in jail inmates which might help to elucidate the
relationship between these phenomena and type of delinquency.
In sum, our findings indicate that a diagnosis of narcissistic PD and
exposure to childhood sexual abuse are significantly more frequent in
sexual offenders than in non-sexual offenders. The fact that 26% of these
sexual offenders had been sexually abused in childhood supports the idea
that early traumatic experiences can be reproduced with a reversal of roles:
the former victim becomes the perpetrator. These individuals might benefit
from a treatment program combining trauma-based therapy approaches
with victim-specific empathy-enhancing approaches (Marshall, Fernandez,
Hudson, & Ward, 1998; Marshall et al., 2005; Webster, Bowers, Mann, &
Marshall, 2005). Therapeutic interventions for PD might also be
helpful, such as dialectical behaviour therapy (DBT; Linehan, 1993) or
transference-focused psychotherapy (TFP; Clarkin, Kernberg, & Yeomans,
1999). Furthermore, there is a need for studies evaluating trauma-based
 Male sexual offenders 503
treatment approaches for mentally ill offenders, particularly with respect to
their well-being, their psychosocial functioning, and their legal prognosis.
Finally, a note of caution is necessary due to some methodological
limitations. Due to the relatively small size of the study population,
statistical power was limited and the precision of the risk estimates was
sometimes low, reducing the generalizability of our findings beyond this
study population. Furthermore, although we used semi-structured inter-
views to assess childhood victimization, this procedure relies on subjects’
free recall and it is likely that there were some recall failures in respondent
reports which might have been overcome by recall-enhancing procedures
(e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Moreover,
differing individual perceptions of stressful events as traumatic can
influence reported trauma rates. For example, in one study 41% of male
inmates meeting the standard criteria for childhood sexual abuse did not
consider themselves to have been abused (Fondacaro, Holt, & Powell,
1999). Presumably this also applies to other forms of interpersonal trauma-
tization. Altogether, our findings may underestimate the true frequency of
childhood maltreatment in forensic patients. In any case, we are in need of
further studies overcoming these limitations. Furthermore, future investi-
gations should focus on specific types of sexual offence – for example, they
should differentiate between paedophilia and rape. Finally, longitudinal
studies on children at high risk of maltreatment will help to elucidate the
complex interactions between childhood victimization, personality dis-
order, and later sexual offending (Salter et al., 2003).

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