I read in the paper last week about the case of a man who has had psychological disorders of one kind or another from an early age, and who was convicted of sexually assaulting a young girl. It reminded me of all the cases of sex abuse I've encountered while practising here.If a sex offender-specific evaluation had been completed on the convicted man when he was convicted for two counts of sexual exploitation of a young person, previous to this particular incident, I believe he would have been deemed a high risk to re-offend. If that was done, then either it was ignored or there was no realistic resource available to follow up on it. Sex offenders at a high risk to re-offend should be enrolled in secure, sex-offender treatment programmes, and their release into the general public should be contingent on their progress in treatment.In the current situation the man convicted of child sexual abuse was being treated at the Mid Atlantic Wellness Institute (MAWI) for at least one of his psychological disorders, but MAWI is not set up to address the treatment needs of sex offenders who often manifest impulse problems, developmental cognitive delays, and other aspects associated with paraphilias. It is also often the case that professional clinical staff in community mental health must follow the laws of the land governing involuntary commitment. If a person manifests no conscious intent to hurt himself or others, and that person is taking medication and cooperating with treatment, there is no reason to keep him or her in the hospital. It would actually be against the law to do so.The Diagnostic and Statistical Manual of Mental Disorders (DSM) describes paraphilias as “recurrent, intense sexual urges, fantasies, or behaviours that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning”. They include things such as voyeurism (peeping at others in their bedrooms), non-consensually rubbing private parts against people in public places, paedophilia (using children for sex), sadism (cruel and brutal sexualising of others), and fetishes (the dependence on objects as a way to create or maintain sexual gratification). Paraphilias are considered psychological disorders, but their treatment requires accurate and careful diagnosis and focused therapy, with accountability and (in the case where this disorder results in a crime) security and monitoring.And here is where it becomes necessary to point out an ugly truth. A very small percentage of child sex offences occur with a stranger attacking a child. Most often child sex abuse involves family members. It's not the people of the world, like the man in the paper last week, that most children need to be protected against; it's Uncle So and So or even their own brothers and/or fathers. When family members offend their children, people are loathe to deal with it, and I've learned from years of practice here that Bermuda has a long history of concealing the sexual offences of family members. There is even a euphemism to make it sound less alarming. People call it being “interfered with”.Personally, I think child sexual abuse rises above the level of nuisance that is conveyed by the normal use of that word, “interfere”. Grown men who exploit children sexually often destroy a child's sense of innocence, trust, and safety. They sexualise the child long before the child has the emotional and even cognitive capacity, to understand what sex is and how it fits into the normal adult life of a human being. There is no going back.So, what would be considered best practice in dealing with people who sexually offend against children? There are steps in the process, especially as outlined by the international organisation called the Association for the Treatment of Sexual Abusers . ATSA indicates that the majority of sex offences committed go unreported and undetected; consequently, all methods of assessing the risk of future sex offences rely on re-arrests and re-convictions and produce substantial underestimates of relative risk. They further maintain:“Research has identified risk factors that can be used to identify those sex offenders at a higher risk to re-offend. Several researchers have studied particular combinations of risk factors which, in designated combinations, are associated with different levels of risk for future sex offending. These are typically known as “actuarial tools” and are similar to actuarial tables utilised by insurance companies to determine relative risk.”Because the actuarial type risk assessments customarily used to evaluate sex offenders depend in part on an offender already having been adjudicated, the process in some countries is as follows: (1) The police investigate, gather and document evidence, and bring a strong case against an accused. (2) The courts decide whether or not the accused is guilty or innocent. If innocent, the process stops right there. If guilty, the court orders a sex offender-specific evaluation prior to sentencing in order to ascertain the level of risk to re-offend. (3) The psychologist conducts that evaluation using actuarial risk schedules, based on psychological testing, review of records, and clinical interview. (This would normally include physical measures of deviant arousal and polygraph as well, but these are currently not available in Bermuda). (4) Then, the court reconvenes and, taking the risk assessment contained in the sex offender-specific evaluation into consideration, imposes sentence. The sentence would include assignment to an organised sex offender treatment programme. (In the case of high-risk offenders this would take place in secure settings, ie prison; in the case of low- to some medium-risk offenders, this would take place in outpatient, community sex offender treatment programmes).I believe both the needs of offenders and victims need to be considered in this issue. Offenders are not happy, successful people, and they have a lot to lose if they re-offend. We are all aware of the tragedies associated with being offended against, and the social outrage when a case such as the one recently reported occurs. It helps when people think through the complexities of the situation and take comprehensive steps that can make for lasting change. Momentary thoughtless reaction does little by way of prevention.