‘Counterfeit Deviance’ Revisited
Abstract
Background
The field has seen a renewed interest in exploring the theory of ‘counterfeit deviance’ for persons with intellectual disability who sexually offend. The term was first presented in 1991 by Hingsburger, Griffiths and Quinsey as a means to differentiate in clinical assessment a subgroup of persons with intellectual disability whose behaviours appeared like paraphilia but served a function that was not related to paraphilia sexual urges or fantasies. Case observations were put forward to provide differential diagnosis of paraphilia in persons with intellectual disabilities compared to those with counterfeit deviance. The brief paper was published in a journal that is no longer available and as such much of what is currently written on the topic is based on secondary sources.
Method
The current paper presents a theoretical piece to revisit the original counterfeit deviance theory to clarify the myths and misconceptions that have arisen and evaluate the theory based on additional research and clinical findings. The authors also propose areas where there may be a basis for expansion of the theory.
Results
The theory of counterfeit deviance still has relevance as a consideration for clinicians when assessing the nature of a sexual offence committed by a person with an intellectual disability. Clinical differentiation of paraphilia from counterfeit deviance provides a foundation for intervention that is designed to specifically treat the underlying factors that contributed to the offence for a given individual.
Discussion
Counterfeit deviance is a concept that continues to provide areas for consideration for clinicians regarding the assessment and treatment of an individual with an intellectual disability who has sexually offended. It is not and never was an explanation for all sexually offending behavior among persons with intellectual disabilities.
Introduction
Early on, Murphy & Haynes (1983) noted a paucity of options and urged for clinical treatment of individuals with intellectual disabilities who offended sexually. In 1985, Griffiths, Hingsburger and Christian described a community programme in the article, Treating Developmentally Handicapped Sexual Offenders. A literature review conducted at the programme's inception revealed that challenging sexual behaviours of persons with intellectual disabilities had been largely unresearched and that those treatment options that existed were typically intrusive (i.e. Paul & Miller 1971; Foxx 1976).
In the 1989 book ‘Changing Sexually Inappropriate Behaviour’, Griffiths, Hingsburger and Quinsey elaborated on the community-based model for treatment and relapse prevention, outlining the need for evaluation of the individual's history and circumstances of the offence, the nature of the living and working/school environment, socio-sexual knowledge, social skills, coping skills, relationships, knowledge of responsibility and assessment of sexual preference and arousal. After evaluation, each individual had a personalized programme to both enhance skills and provide coping strategies for deviant arousal or problematic behaviour patterns. They noted that some of the individuals presented with behaviours that were consistent with the Diagnostic and Statistical Criteria of paraphilia at the time (American Psychiatric Association 1987) involving arousal to unusual or intrusive sexualized images and fantasies, however some did not.
Using the data from more than 10 years of work with individuals referred for sexual offences (ranging from exposure to child molestation), the authors noted that some individuals presented differently than anticipated for someone with paraphilia. On examination, it was noted that the presenting behaviours, although inappropriate, were the product of different diagnostically significant factors. These factors were noted to influence the commission of sexually inappropriate behaviour. It was this observation that lead to the concept of ‘counterfeit deviance.’
The theory of ‘counterfeit deviance’
The theory of ‘counterfeit deviance’ never denied paraphilia in persons with intellectual disabilities. The article stated that some individuals with intellectual disabilities, as with the typical population, develop sexualized interests that meet the diagnostic criteria of paraphilia. However, the authors cautioned against assumptions of paraphilia based solely upon behaviour. Assessment, it was cautioned, was required to ensure that deviance was present, not assumed.
In the article, paraphilia was described as three types: benign, offensive or hypersexualized. Benign included situations where diagnostically significant fetishes or images, although unusual, posed no danger. Often, these behaviours were noticed in persons with intellectual disabilities because of clustered living environments where their behaviours were easily observed by care providers who deemed them problematic. Typically developing individuals might have similar fetishes but have opportunities for privacy.
Offensive paraphilia involved individuals showing arousal to children or situations involving violence. This paraphilia presented similarly to the nondisabled population.
Lastly, hypersexuality was noted in some individuals. In these cases, the individuals were obsessed or controlled by sexual thoughts. As with the nondisabled, this was often a manifestation of obsessive compulsive behaviour or even mania. Individuals with intellectual disabilities presenting as described as benign, offensive or hypersexual met the diagnostic criteria of paraphilia. However, for sexualized behaviours that masquerade as paraphilia without the underlying urges, the authors posited eleven hypotheses to explain inappropriate sexual behaviour in some individuals.
These hypotheses aimed at understanding both the individual and the system in which they lived. People with intellectual disabilities often lived in atypical situations that could lead to atypical behaviour. ‘Counterfeit deviance’ suggested that individuals be understood in the context of lives lived resulting from attitudes, practices and protocols. Policies denying appropriate sexual behaviours could possibly render any sexual behaviour problematic or deviant. The theory clarified that people needed to have treatment adapted because of the disability and that assessment needed to consider environmental factors unique to people with intellectual disabilities.
What ‘counterfeit deviance’ did not do was suggest that any of the hypotheses was predictive of individual behaviour or was characteristic of ‘sex offenders with intellectual disabilities.’ For example, one hypothesis is ‘sexual knowledge.’
- That all sex offenders with intellectual disabilities had poor sexual knowledge.
- That someone with an intellectual disability with poor sexual knowledge will sexually offend.
- A sexual offence could possibly occur because of poor sexual knowledge.
- It was possible to have deviant arousal and good sexual knowledge. Hence, a lack of sexual knowledge is not a definitive path to sex offending, rather an area worth exploring when determining treatment.
It is important to understand that these hypotheses only assist a clinician in determining appropriate treatment regardless of the existence of paraphilia. It was also possible, according to ‘counterfeit deviance,’ for an individual with a disability to have a paraphilia that was exacerbated by the presence of another hypothesis.
The eleven original hypotheses in counterfeit deviance are elaborated below:
The structural hypothesis: some with intellectual disabilities have lived or continue to live in environments where appropriate sexuality was restricted. Therefore, individuals expressed sexuality in ways to avoid sanctioning, such as engaging in sex in public but out of sight of care-providers.
The modelling hypothesis: some inappropriate expressions were modelled on staff or others behaviour. In environments that did not model appropriate privacy when providing personal care, individuals may have replicated touching without respect for boundaries.
The behavioural hypothesis: inappropriate sexual behaviour may be highly functional in either garnering attention or allowing the individual to escape or delay an undesired situation.
The partner selection hypothesis: many individuals exist in a socio-sexual ‘peer-void’ because they lacked opportunity or social skills to develop relationships. The relationship vacuum could produce situations where the individual attempted relationships with care-providers, children or others.
The inappropriate courtship hypothesis: lack of opportunities and education may have led to a lack of courtship skills resulting in blunt, often aggressive attempts at courtship.
The sexual knowledge hypothesis: a lack of appropriate and comprehensive sexual knowledge was sometimes the cause of inappropriate sexual behaviour.
The perpetual arousal hypothesis: a chronic state of sexual arousal, engaging in repeated masturbation due to inability to masturbate to completion. Causes varied from medication, lack of privacy or stimulation; a history of punishment; or lack of physical ability.
The learning history hypothesis: the relationship between the experience of both sexual abuse and a lifetime of receiving harsh negative sexual messages. This was compounded by other life experiences often associated with life in multibed facilities such as being witness to a sexualized culture neither appropriate nor legal.
The situation above led into the moral vacuum hypothesis. Given the experiences of many with intellectual disabilities, the values held in society regarding sexuality may not have developed standards on which to judge their own behaviour or that of others.
The last two hypotheses were based on medical observations. The medical hypothesis was noted for individuals who were experiencing a medical problem such as touching genitals in public when experiencing a rash. The medication side effect hypothesis was generated based on cases where individuals were reacting with frustration in an attempt to gain sexual satisfaction when a medication has altered their sexual functioning.
Research related to ‘counterfeit deviance’
Research into the specific hypotheses that fall within ‘counterfeit deviance’ has been rare. Despite markedly differing living environments and social learning histories of people with intellectual disabilities, few researchers have explored the prospect of alternate motivations and causes of deviant sexual behaviour. However, research does exist examining the hypotheses in tangential ways. The following will discuss each of the hypotheses, alone or clustered, based on the existing literature. There may be methodological limitations or inconclusive results, which will be addressed.
Structural hypothesis and moral vacuum hypothesis
As discussed, the living situations and culture of the intellectually disabled population are vastly different from the typical population. There are often sexually restrictive environments (structural hypothesis) and environments with different social norms and moralities (moral vacuum). Many individuals with intellectual disabilities grew up in institutions. These settings often featured rows and rows of beds affording little or no privacy. Private activities such as changing, undressing and masturbation were made public by the constant presence of staff and co-residents regardless of gender.
After deinstitutionalization, many community agencies had policies forbidding consenting relationships and enforcement meant punishment. If appropriate sexuality was forbidden, individuals might seek inappropriate sexual outlets.
In a study on Australian deinstitutionalization, Young et al. (1998) looked at 289 individuals with intellectual disability and found that of those who had lived in institutions, most had lived in them from 8 to 9 years (p. 162). This amount of time is sufficient to make claims regarding the effects of institutionalization. Thirteen studies were reviewed to determine the effects of deinstitutionalization across a variety of domains. While adaptive behaviour improved, none showed improvements in problematic behaviour when entering into community settings. Particularly, health and morality were reviewed in three studies, and with no changes reported in any when individuals were transferred to community settings, attempts to acclimatize individuals to community mores were only partially successful. Behaviours such as aggression and attitudes like morality did not conclusively improve, which indicated that old cultural norms persist after deinstitutionalization.
Institutional life had been studied based on the possible effects and increased risk associated with individuals in prison. Like institutions, prisons have unique social mores, sex offences being so common to be ‘dismissed by prison administrators as behaviours that are unique to the prison environment or a result of deprivation and not indicative of risk in the community’ (Heil et al. 2009; p. 893). Heil et al. (2009) studied a group of 3169 male offenders who had completed prison sentences. They studied three groups: sex offenders who committed crimes in the community, those who committed sex crimes only in prison and those who committed sex crimes in both prison and the community looking at rates of recidivism of sexual offending behaviour at 1-year and 5-year intervals. They found that at 1 year, the sex crime in prison-only group was less likely to commit a hands-off sexual offence. At 5 years, those with sex crimes prior to prison were most likely to be charged after 5 years with another sex crime. Although there was insufficient data on new sex offences for the prison-only group, at 1 year, only 33.3% of sex crimes were hands-on, but at 5 year this number jumped to 80% hands-on offences (Heil et al. 2009).
Thus, life in a prison or institutional setting appears to have some impact on individuals and may generate new behaviours that were not present previously. Individuals without sex offences engaged in sexual assault while in prison, and administrators tacitly condoned these assaults. A portion of these continued sexual offending when out of prison and the intensity of the behaviour grew dramatically over time. Drawing an analogy to similar environments and attitudes in institutions, it is reasonable to include structure and environment as a factor contributing to sexual offences where deviance may not be the primary function.
Society's mores and values were not explored in the original article because of its brevity and the time in which it was written. Lindsay (2009) noted based on his research (Lindsay et al. 2008) that an expansion of the ‘counterfeit deviance’ theory on moral vacuum should be considered. He noted that individuals with intellectual disabilities, while not being ‘completely naïve about the fact that their behaviour is inappropriate, they have not internalized the extent to which it is against the conventions of society (p. 98)’. He suggested that some individuals with intellectual disabilities have learned neither the appreciation for self-control with regard to their sexual behaviour nor the importance of developing appropriate relationships fitting societal mores. His research and observations would indicate a need to evaluate the understanding that the individual has to laws and societal rules as part of the assessment process.
Modelling hypothesis and learning history hypothesis
Hingsburger in 1989 published a case study of coprophilic behaviour in an institutionalized person with an intellectual disability whose learning history led to unusual ways to achieve sexual pleasure. This predated and presaged the development of counterfeit deviance as a theory. An earlier paper (Hingsburger 1985) also suggested that the restrictions and experiences of institutionalization were an alternative explanation for inappropriate behaviour. Also, the cycle of abuse theory posits that history of abuse may serve as a model to later offending (modelling), which is compounded by the lack of normative sexual experiences (learning history).
Individuals with intellectual disabilities have been frequent targets of sexual abuse. Statistics vary, but it has been reported that 61% of women and 25% of men have been sexually abused in their lifetimes (McCarthy & Thompson 1997). An almost uniform finding is that sexual abuse is overrepresented in this population. In drawing a correlation between abuse history and offending, Lindsay et al. (2001) compared the sexual abuse histories of sexual and non-sexual offenders with intellectual disabilities. There were 46 sexual offending participants and 48 non-sexual offending participants; they theorized that the sexual offending participants would have sexual abuse histories, while the non-sexual offending participants would have histories of physical abuse. The results showed a significant difference in sexual abuse histories between the two groups, with 38% of the sexual offenders being abused and 12.7% of the non-sexual offenders being abused. The authors concluded that an abuse history may lead to a replication of abusive behaviour. Further validated in a study by Lindsay et al. (2011) where similar differential abuse types and rates were found between sexual and non-sexual offenders. In this study, 32.6% of male sex offenders were sexually abused, against 17.8% of non-sexual offenders. A similar correlation was found when looking at non-accidental injury, with reports of 32.5% of non-sexual offenders compared with only 16% of sexual offenders.
These results, although not conclusive, lend credence to ‘counterfeit deviance.’ Given the sexual abuse rates within the intellectually disabled population, exposure to and experience with deviant sexual behaviour is significantly greater than in the typical population. In the light of this increased abuse, the study by Lindsay et al. (2001) demonstrates a correlation between sexual abuse and nature of offence. Evidence suggests that previous experience with sexual abuse could serve as a model influencing future behaviour.
Behavioural
There are numerous potential functions for problematic behaviour. ‘Counterfeit deviance’ posits the possibility of alternate behavioural functions for deviant behaviour. For the purposes of this paper, only attention and sensory functions will be discussed.
The use of applied behaviour analysis for sexually offending behaviour is still in its infancy. However, there are studies that have used behaviour analysis for sexual offending behaviour in other populations, and findings will be extrapolated with caution.
In 2009, a study by Alderman, Knight and Birkett Swan looked at the current technology available on sexually offending behaviour, notably with individuals with acquired brain injuries (ABI). They developed the St. Andrew's Sexual Behaviour Assessment (SASBA) to record and track inappropriate sexual behaviour (ISB) including details such as setting events, antecedents and interventions. Using this tool, they looked at 91 individuals with ABI and assessed their ISB over a period of three months.
They found that ISBs were less likely to occur in noisy environments and when individuals were involved in rehabilitation. A significant portion of the time (64%) behaviours occurred with no obvious antecedent, but the authors theorized that less structured activities played a role. The most common intervention utilized was ignoring, which occurred 70.4% of the time, and while talking to individuals, which occurred after 21% of the behaviours. However, they felt that ‘ISB may provide…contact with staff at times when reduced opportunities for social engagement increase the likelihood of expression of sexual needs’ (Alderman et al. 2009, p. 217). Additionally, they highlighted the stark difference between ignoring as a response and attending to behaviours, suggesting that attention was intermittently reinforcing ISBs.
A single case study was conducted by Fyffe et al. (2004) using a functional analysis on the inappropriate sexual behaviour of a 9-year-old male with a traumatic brain injury. They found that the behaviour was being maintained by social attention from adults. Furthermore, interventions based on this analysis included functional communication training, which reduced the behaviour by 94%.
Although it is difficult to make conclusive statements, there is some evidence to suggest the possibility that some or part of the sexually offending behaviour in the above studies was mitigated by non-deviant factors and served alternate functions.
Partner selection and inappropriate courtship
Many individuals with intellectual disabilities lack the opportunity and skills to develop normative relationships. In a 1999 study, McCabe found that individuals with intellectual disabilities had less sexual experience than those with physical disabilities or the typical population. While the desire for sexual experience and relationships may be appropriate, the object (partner selection) and means (inappropriate courtship) may not be. The romantic or sexual pursuit is not deviant, but the means may be inappropriate.
Some literature supports the theory that unmet sexual and intimacy needs contribute to sexual offending. Lockhart et al. (2010) measured the sexual knowledge, experience and needs of 600 adults and youth with intellectual disabilities. They were divided into three groups: sexualized challenging behaviour, non-sexualized challenging behaviour and no challenging behaviour. The sexualized challenging behaviour group showed greater needs in the areas of dating and intimacy than the non-sexualized challenging behaviour group, which ‘lends some empirical support to opinion in the literature that the problematic sexual behaviour of individuals with ID represents an effort to meet these needs in inappropriate way’ (Lockhart et al. 2010, p. 128). This difference was not seen with the non-challenging behaviour group, which makes it difficult to establish strong conclusions.
In 1989, Marshall concluded the following: ‘treatment and assessment programs should include as targets, attachment and intimacy as well as the experience of loneliness’ (p. 497). Similarly, he discussed the role of intimacy needs and loneliness and argued for ‘the inclusion of these issues in the functional analysis of sexual offending [which] will expand behavioral theories and treatments of these problems to the greater benefit of patients and to the proper protection of society’ (Marshall, 1989, p. 500).
One treatment approach for sexual offenders, The Good Lives Model, lists nine primary treatment goals that reflect what most humans try to achieve including life, friendship and happiness. Sexual needs are fundamental to humanity, and appropriately fulfilling them is a primary goal according to the Good Lives Model. The theory behind the Good Lives Model is that these goals are not deviant but their pursuit can lead to deviant methods of attainment (Ward & Stewart 2003).
Individuals with intellectual disabilities that sexually offend appear to have greater unmet sexual needs than individuals with other problematic behaviours. Although there is no direct evidence that these needs lead to sexual offending, there is some research to suggest that unmet sexual interests can lead to behaviour that appears deviant. Inappropriate courtship and partner selection have both some empirical and clinical underpinnings as potential contributors to sexually inappropriate behaviour.
Sexual knowledge
Sex education often comes from formal teaching, but it appears that there is an overall reluctance to provide this education to those with intellectual disabilities. This deficit was noted by McCabe (1999); who found that ‘in all areas of sexuality assessed in this study, people with intellectual disability demonstrated lower levels of knowledge than people with physical disability, who in turn demonstrated lower levels of knowledge than people from the general population’ (p. 166). Sexual knowledge is the most researched and possibly most controversial topic in ‘counterfeit deviance.’ In recent years, researchers have examined the socio-sexual knowledge of sexual offenders who have intellectual disabilities and concluded that offenders with intellectual disabilities do not have less knowledge than non-offenders (Talbot & Langdon 2006) and indeed that persons with intellectual disabilities who sexually offend demonstrate significantly more sexual knowledge than a control group (Michie et al. 2006). Although the findings from the above articles at first appear to dispute the theory of ‘counterfeit deviance’ in that the persons with intellectual disabilities did not offend because of a lack of sexual knowledge, their findings are not inconsistent with the theory.
This was illustrated by Lunsky et al. (2007) who reported similar results when they measured the knowledge and attitudes of 48 male individuals with an intellectual disability who also had sexual offence histories to a matched control sample group. However, when the authors split the sex offending participants into one of two groups, type 1 offenders were described as, ‘paedophiles, rapists or as having engaged in repeated or forced sexual assaults’ (Lunsky et al. 2007, p. 76) and type 2 offenders had engaged in ‘ina-ppropriate touching, public exhibitionism or public masturbation’ (p. 76). The authors found that not only did type 1 offenders have more sexual knowledge than non-offenders but also that type 2 offenders showed no significant difference in knowledge compared with the non-offender group. Lockhart et al. (2010) whose study found similar results concluded that ‘in relation to sexual knowledge, the current study did not uphold the hypothesis that individuals with sexualized challenging behaviour would have the lowest levels of sexual knowledge’ (p. 127). However, given the dynamic relationship between knowledge and offending, it is important to note that while lack of knowledge does not necessarily lead directly to offending, it may be a contributing factor in the type 2 subgroup whose behaviours are inappropriate rather than offending.
The distinctions between offenders raised by Hingsburger et al. (1991) and supported by Lunsky et al. (2007) are consistent with Day's (1994) suggestion that there are two types of offenders with intellectual disabilities. Day (1994) noted that sexual offences committed by persons with intellectual disabilities are typically more ‘minor or nuisance offences’ (p. 279). He suggests that many of the offences, such as indecent exposure, represent an inappropriate expression of sexual feelings rather than a sexual deviance (Day 1994). Day (1994) similarly does not deny the existence of paraphilia within the population of intellectual disabilities, rather cautions for differentiation.
According to the ideas behind ‘counterfeit deviance,’ the wrong question is often asked in research and practice. The question is not ‘Do persons with intellectual disabilities offend sexually because of a lack of sexual knowledge?’ but ‘Has a lack of sexual knowledge resulted in or contributed to this particular individual acting in a sexually inappropriate way?’
Perhaps, one of the benefits of the theory of ‘counterfeit deviance’ is that the issue of sex education became discussed and researched at all! The original paper preceded this research by many years and may have been an impetus in organizations, treatment and residential, in ensuring that sex education was more readily available for people with intellectual disabilities.
Medical, medication and perpetual arousal
Another ‘counterfeit deviance’ hypothesis is the existence of medical issues or medication side effects that influence inappropriate sexual behaviour. There is a heightened prevalence of mental health issues within the intellectually disabled population. It is difficult to pinpoint an exact rate; however, approximately 30% of individuals with an intellectual disability will have a mental health concern (Ministry of Health & Long-Term Care & Ministry of Community & Social Services 2008). Based on this prevalence, it is assumed that a disproportionate amount of medications will be prescribed.
Among the most commonly prescribed medications for the intellectual disability population are selective serotonin reuptake inhibitors (SSRIs) (Matson et al. 2009). These drugs, used for a variety of concerns, increase the amount of serotonin left in the system. If this medication and medical side effects are a potential contributing factor of sexually offending behaviour, it would be assumed that any medication commonly prescribed would lead to hypersexuality. However, sexual dysfunction is one of the most prevalent side effects associated with this class of drugs. For example, Montejo-Gonzalez et al. (1997) found that 200 of 344 (or 58%) patients reported sexual dysfunction after using SSRIs. Additionally, a wide difference (43.94%) was found between using spontaneous reporting and questionnaire as data collection methods. As a result, sexual dysfunction in many studies may be underreported. In line with Kafka's (2003) theory that serotonin plays a factor in suppressing testosterone, common current treatment practice recommends prescribing SSRIs to reduce sexually offending behaviour (Adi et al. 2004). In conclusion, commonly prescribed medications, notably SSRIs, likely play a role in reducing sexual arousal patterns and not increasing them. Given their usage to treat sexual offending behaviour, it is unlikely that they increase libido or sexual desire.
Although clinically observed and inherently logical, at present, there is little empirical research supporting the medical/medication hypothesis of counterfeit deviance. More structured research needs to be carried out on the topic.
Expansion of the theory of ‘counterfeit deviance’
The theory of ‘counterfeit deviance’ was updated in ‘The Key: A community approach to assessment, treatment and support for people with intellectual disabilities’ (Hingsburger et al. 2010), in which the hypotheses were added to and grouped into four differing types. Several new hypotheses were added under the following categories: Historical and Environmental; Abuse Related; Medical and Psychiatric; and Deviance. The hypotheses were grouped thus to ensure that readers understood that ‘counterfeit deviance’ did not mean that deviance was not possible. The grouping was also to help clinicians in their assessment process to ensure that questions be asked that covered all four possible areas from which ‘counterfeit deviance’ might arise.
The updated list of possible hypotheses shows growing understanding of the lives of people with disabilities. Since the original article, there has been significant research into the abuse of people with intellectual disabilities; therefore, most of the new hypotheses are abuse related. With new research comes new areas of questioning. Further, as people with disabilities return home to the community from institutions and as young people with disabilities are not institutionalized, there are hypotheses that are linked to community living – and indeed there are.
Here are two examples of new hypotheses:
The Behavioural Reporting of Abuse: people with disabilities re-enact their abusive history as an attempt to display what happened to them. Historically, people with disabilities who verbally reported abuse received little in the way of support or counselling, let alone believe that their stories were true.
Malicious Peer Pressure: people with intellectual disabilities will be used as dupes by their non-disabled peers as a joke. Desperate for ‘friends’ and ‘approval’ and without ability to recognize manipulation, people with disabilities are vulnerable to engaging in behaviour for social acceptance and find that instead they have been used.
Others have also developed theories, for example the Sexual Coping hypothesis was put forward by Wulfert et al. (1996). They posit the existence of ‘situational paedophiles,’ a term which suggests that paedophilic behaviour can occur because of reasons other than attraction, and their studies show that this type of paedophile, because of lack of access to typical expression, receives reinforcement through stress reduction when they engage in paedophilic behaviour. Again, they found that the behaviour appears to indicate deviant interest but other factors are at play.
Another possible hypothesis is based on the hypothesis of Power and Control. This is especially notable with persons with intellectual disabilities, who may lack autonomy in a system where virtually every decision is made for them by others. For this population, any chance to exercise control is valuable and incredibly reinforcing. Marshall & Marshall (2000) suggest that deviant sexual behaviour may be ‘driven by or associated with a need to exercise power and control over another person’ (p. 256). This power and control would serve as a replacement to something that they have lacked for most of their lives.
The Medical Hypothesis was expanded by Griffiths (2002) and Griffiths et al. (2007) who noted that syndromic behaviours and psychiatric behaviours can serve as the aetiology for an apparent sexually inappropriate behaviour. Some individuals with specific genetic syndromes might be at risk to display an inappropriate behaviour that is viewed as sexual. One syndrome-related example provided was polyembolokoilamania (the insertion of objects into orifices, including the vagina or anus) associated with Smith–Magenis syndrome, which is often diagnosed as a paraphilia, although there is no evidence that the behaviour serves a sexual function.
Additionally, psychiatric conditions such as mania can present as oversexualized behaviour. APA suggests that differential diagnosis should be conducted to examine whether the identified behaviour is a preferred and recurrent sexual pattern, if it is associated with another active mental disorder, and the age of onset. These cautions were elaborated more fully in the Diagnostic Manual – Intellectual Disability (DM-ID) (Fletcher et al. 2007); the DM-ID is the companion diagnostic manual designed specifically to provide guidelines for the diagnoses of persons with intellectual disabilities.
Finally, as Lindsay (2009) suggests, the moral vacuum hypothesis would benefit from expansion. He suggests that there needs to be further exploration regarding moral understanding as it relates to social and cultural conventions and knowledge of the law.
It becomes clear, then, that there will probably never be a finite list of hypotheses because people with disabilities live very different lives in very different circumstances. The only constant is that ‘disability’ itself places each person at risk to make mistakes because of the environment or because of the decisions or manipulations of others. It is probably best to view ‘counterfeit deviance’ as an idea and the list of hypotheses as a guide, but not a static list. The more clinicians pay attention to ‘counterfeit deviance’ as a possibility, the more the concept of ‘person-centred approaches’ enters into the mind set of service providers, there will be more and different examples of the phenomenon.
Future directions
With this article, we hope that the term ‘counterfeit deviance,’ including what it is and what it is not, is now current in the literature in a way that will clarify previous misunderstandings. The hypotheses were not meant to be a diagnostic tool, rather areas of investigation to persuade assessors to ask questions. The original article stated 11 hypotheses that encompass ‘counterfeit deviance,’ and since then, others have been added by both the original authors and other researchers. As such, it has become a dynamic concept that grows and develops as new research into the lives of people with disabilities is undertaken.
The theory of ‘counterfeit deviance’ was designed to encourage clinicians, many of whom may not be cognisant of the experiences of those with intellectual disabilities, to think ‘outside the box’ and inside the life of a person with a disability and to show caution in making diagnoses based on the offence behaviour alone. To delve into the history and context of the situation may provide the explanation and hence, make treatment decisions for inappropriate behaviour. It is important for those who work with sex offenders with an intellectual disability to look beyond topography. However, by thinking critically about seemingly deviant behaviour, it is possible to come up with a variety of other explanations. The theory of ‘counterfeit deviance’ provides some of these other possible explanations.
‘Counterfeit deviance’ determines the underlying motives behind offending behaviour. It provides direction for individualized treatment programmes rather than the ‘one size fits all’ approach to treatment. An important first step is to determine whether the offender has a paraphilia. Differentiating between true deviance and ‘counterfeit deviance’ is a very crucial initial step to take to guide appropriate treatment programmes. Determining whether an individual has a paraphilia versus behaviour that appears as paraphiliac marks the beginning of developing individualized treatment approaches that target the outcomes of the initial assessment.
No one variable can adequately explain inappropriate or offending sex behaviour; understanding the range of aetiologies and primary motivations behind inappropriate sex behaviours committed by people with intellectual disabilities can lead to effective prevention and treatment. This alone highlights the need for a bio-psycho-social model for people with intellectual disabilities who sexually offend (Griffiths 2002). We need a comprehensive model that encompasses all these factors, to provide a solid framework to help clinicians target primary motivations and develop individualized treatment programmes.
With the concept of ‘counterfeit deviance’ being revisited, future research should aim to expand the concept by focusing on differential diagnosis and designing evaluative treatment strategies that differentially treat paraphilia and those with ‘counterfeit deviance.’ The efficacy of various treatment programmes should also be evaluated and critiqued, so that people in this field can work further towards protecting the community and effectively serving the needs of people with disabilities. In addition, the theory streamlines treatment pathways such that appropriate treatment is differentially targetted for the appropriate aetiology, thereby ensuring that individuals are not unduly labelled and that resources are targeting the correct areas of risk for the offence. Logic, efficiency and human interest dictate that careful diagnostic evaluation informs treatment. The theory of ‘counterfeit deviance’ suggests only that clinicians provide such a comprehensive assessment.
Conclusion
The primary concept involved in ‘counterfeit deviance’ is that people with intellectual disabilities, because of their unique histories and unique living situations, may engage in inappropriate sexual behaviour for reasons other than deviance. Hingsburger (2012) has posited that the theory can, and should, be expanded to the concept of ‘Counterfeit Criminality’. He suggests that people with disabilities may be involved in crimes for reasons other than criminal enterprise. Social acceptance, manipulation and victimization represent some of the hypotheses. He points to literature as early as Dickens (2003) originally published in 1840 and as recent as Picoult (2010) wherein popular culture has come to recognize that sometimes people with disabilities behave differently and that different can be mistaken for criminal. Perhaps, then the biggest contribution by ‘counterfeit deviance’ will be that people with disabilities will be better understood, in the context of both their disability and the society in which they live, by those who serve them.
The original counterfeit deviance article was a motivator for service providers and clinicians to reflect carefully on the type of service provided to the individuals they served. The ideas presented in the original article in regard to thinking critically about behaviour were a driving force behind agencies advocating for larger changes that positively affected service. In the region in which we started, there are now no agencies that have negative policies; rather they provide the opportunity to participate in anti-abuse training and sex education. The hypotheses presented in ‘counterfeit deviance’ make way for change in the lives of all people with disabilities, change that can have a profound impact on the enrichment of their lives.
