Many of the conditions that are now in place would seem to be entirely appropriate. The most important interventions would include treatment and monitoring through the Community Forensic Team, the Forensic Psychologist Services and his general practitioner. He will need to take medication as directed and to continue with cognitive behavioural therapy. It is positive that he has not had any alcohol for eight years but I would still regard him as being at some risk of relapse given his past history of heavy drinking. It would be important for his general practitioner to monitor his lever functions including his mean cell volume and gamma glutamyl transferase as a way of ensuring that he is not drinking excessively or harmfully. He seems somewhat reluctant to have follow up with drug and alcohol services or to attend AA and states that he would contact these organisations if he needed them. In my view it would be appropriate if follow up through his local drug and alcohol service was made a mandatory requirement and this would be an initial safeguard. The frequency of contact with such a service could be determined by the treating practitioner and Mr Mitchell.
Mr Mitchell is extremely socially isolated and it seems that his only real contacts are in Henty but it would obviously be difficult to put in place an appropriate treatment and monitoring program in that locale. He should in the early stages remain in the COSP facility and then be moved to a living situation in which ideally he would have some supports and there would be capacity for monitoring. He should be restricted by a curfew and there should restrictions in regard to whom he associates with and he certainly should not be allowed unsupervised contact with young males. I understand there are already provisions that he should notify Probation and Parole and the team that will monitor him in the community of any new contacts or acquaintances that he makes, including their full contact details and this would be entirely appropriate. He should be limited in his access to establishments that serve alcohol. He obviously should not be allowed to frequent areas where there are children and he obviously should not work in either a paid or voluntary capacity in any situation in which he might have access to potential victims.
The issue of age does have relevance to the length of the extended supervision order. Mr Mitchell does have some health problems, particularly in relation to mobility and possibly some lung-related problems secondary to his smoking history. I would suggest that a shorter period of extended supervision be considered in the first instance - perhaps three years - as it is very likely that over the course of the next five years his health status will change considerably and this could significantly impact on his risk of reoffending .
3. The extent to which and the means by which any alcohol-related disorder of Mr Mitchell should be medically treated in the community
As noted above, Mr Mitchell tells me he has had no desire to drink for the last eight years and plans to remain abstinent. I do have some concerns however that given social isolation and other factors he could relapse. I think it would be appropriate that he is followed up by a drug and alcohol service and that the frequency of contacts be determined by his treating practitioner. If the drug and alcohol service feel there is a need for regular blood testing, urine drug screening or any other interventions Mr Mitchell will need to comply with these. They may also feel that he should attend a drug and alcohol support group and this would be appropriate as well if that was there (sic) recommendation.
4. The suitability of Mr Mitchell for anti-libidinal medication, including any issues related to the prescription or administration of anti-libidinal medication
Currently Mr Mitchell is on an SSRI-type antidepressant. He states that this has reduced his sexual thinking and capacity for erections. He is happy to take the medication but says he is getting some side effects in the form of headaches and gastrointestinal disturbance. These are quite common problems associated with SSRI-type antidepressants and tend to get better over time.
If there is any evidence that Mr Mitchell is continuing to have deviant sexual thinking it may become necessary to contemplate a more powerful anti-libidinal medication such as cyproterone acetate. He is quite frail and elderly and has some underlying medical conditions and there may be some contraindications to the use of that type of medication (emphasis added)
9 Dr O'Dea expressed his conclusions in the following terms:
As before, I did not diagnose Mr Mitchell as suffering from a major psychiatric illness.
I note his history of alcohol use disorder that was reportedly in remission with reported abstinence from alcohol for approximately 11 years. I note that he related some but not all of his sex offences to alcohol abuse.
I note, as in my report dated 25 July 2006, his apparent problems with short term memory and now apparent problems with attention and concentration on routine testing, and his IQ testing in the low average intelligence range. As before, I would recommend that he undergo some formal and complete psychometric testing of his cognitive functioning as part of his ongoing assessment in order to further clarify his level of cognitive functioning and any impact it may have on his overall management. His level of intelligence and potential cognitive impairment may further limit the impact and effectiveness of psychological interventions alone in helping manage and minimise his risk of engaging in further sex offending behaviours in the community in the long term.
As before, Mr Mitchell reported awareness of a specific, strong, long term sexual attraction to male children around puberty, and a criminal history of repeated sex offences against male children around puberty as well as older vulnerable males. Although this sexual attraction to pubertal males was not exclusive, Mr Mitchell described it as a predominant focus of his sexual interest. As such, he would satisfy the psychiatric diagnostic category of Paedophilia, Sexually attracted to males, Non exclusive, Not limited to incest (homosexual paedophilia).
As before, and on the basis of his history of specific sexual deviance (homosexual paedophilia), repeated sex offending against male children and vulnerable young adults, his history of alcohol use disorder (albeit in apparent remission), his level of cognitive functioning and his apparent social isolation, on full clinical psychiatric risk assessment and taking into consideration actuarial risk management tools (such as the STATIC-99), Mr Mitchell would be considered to fall into the group of sex offenders with a significantly high risk of engaging in further sex offending behaviours in the community in the long term and of committing a further "serious sex offence" as defined by the New South Wales Crime (Serious Sex Offenders) Act 2006. It would seem reasonable to assume that this risk would be of a nature and severity to warrant specific risk management on his return to the community .
I note that Mr Mitchell's age and increasing musculosketetal problems that may attenuate this risk, and increasingly so with age. However, at least at this stage, neither are likely to reduce the risk to a clinically significant level that specific risk management strategies were not appropriate.
As has been continually discussed in relation to the New South Wales Crime (Serious Sex Offenders) Act 2006 , and similar legislation elsewhere, although Mr Mitchell's risk of engaging in further sex offending behaviours would be considered significantly high, I do not consider that the current evidence regarding the assessment of risk is suitably advanced to predict his risk of committing a further "serious sex offence" with the required degree of accuracy.
Although Mr Mitchell's score on the STATIC-99 (of 7/12) would place him in the group of individuals with a high risk of engaging in further sex offending in the long term, as judged by this instrument, limitations in the use of this tool are widely discussed, including by the authors of the instrument. As implied in the name, the instrument measures static and therefore for the most part unchangeable parameters. The margins of error for risk estimates using this test, particularly in endeavouring to make risk predications for an individual with an individual score, are considered so high as to significantly reduce the appropriateness of relying on this score alone to make decisions about release of individuals into the community. Of additional relevance is the fact that the STATIC-99 measures the risk of an individual engaging in a further sexual offence as defined by this measure, rather than a further "serious sex offence" as defined in the New South Wales Crimes (Serious Sex Offenders) Act 2006, that is set at a higher threshold.
The single most important risk factor identified in Mr Mitchell's case pointing to a significant clinical risk of him engaging in further sex offending behaviours in the community in the long term would be his history of homosexual paedophilia .
To date psychological interventions alone have not proved successful in preventing him committing further sex offences. His accounts of the benefits of the CUBIT and other recent psychological interventions appear at best superficial. I was not able to convince myself, or even have significant confidence, that he had a good working understanding of the concepts he told me he had learnt from CUBIT, and that he would be able to translate this knowledge into a significant reduction in his risk of engaging in further sex offending behaviours in the community in the long term.
I note that he continued to deny at least significant components of his sex offending behaviours. As before, I am not aware of good evidence that denial in and of itself predicts the commission of further serious sex offences. However, in conjunction with his identified homosexual paedophilia, and his level of intellectual and psychological functioning, this may point to the judicious use of specific testosterone lowering medication being likely to be more effecting in assisting him to control his homosexual paedophilia and sex offending behaviours in the community in the long term.
I understand that Mr Mitchell has commenced antidepressant medication (Zoloft) in an assumed attempt to reduce his libido and sexual performance and therefore assist him to better manage his sexually deviant urges. Whilst this medication can assist in this process, with Mr Mitchell's sex offending history and his identified homosexual paedophilia, I would consider that the judicious use of testosterone lowering medication (such as cyproterone Acetate, aka Androcur, or Medroxy Progesterone Acetate, aka Provera) is likely to prove more effective in reducing his sex drive and therefore his homosexual paedophilic urges, fantasies and behaviours.
In addition, it would seem crucial that Mr Mitchell remain abstinent from alcohol or illicit substance use in the community in the long term in order to minimise his risk. It would seem appropriate from a risk management perspective that monitoring and supervision, as is in place with COSP and Forensic Psychology, continue. It would seem sensible and appropriate that he (sic) part of a risk management program be that Mr Mitchell not be supervising children or in the company of children without direct adult supervision.
In the absence of marked and significant deterioration in Mr Mitchell's physical status, his risk of engaging in further sex offending behaviours in the community is likely to be relatively long term and of at least 5 years duration . Whilst the prescription of psychiatric medication should be reviewed regularly and on at least a 1 to 3 monthly basis when stabilised, it would seem reasonable to review the other conditions of any long term risk management program on a yearly basis . (emphasis added)
10 Dr Ellis was asked to address the following questions:
1. What medication is Mr Mitchell taking, and in what dosage have you prescribed that medication?
2. In broad terms, what does the medication do for Mr Mitchell and what are the potential side effects?
3. Are the side effects Mr Mitchell is currently experiencing like to improve? If so, what is the likely timeframe of that improvement?
4. Is there any time limit with respect to the duration for which a patient can safely continue to take SSRI-type medication that Mr Mitchell is taking? If there is any such time limit, for how long are patients able to safely take the medication?
5. Are there any other medications you recommend for Mr Mitchell and if so, what are they and why do you recommend them for Mr Mitchell?
11 He expressed his conclusions in the following terms:
1. Mr Mitchell is current (sic) prescribed Sertraline, a Selective Serotonin Reuptake Inhibitor ("SSRI") antidepressant (brand name - Zoloft) at a dose of 100mg daily. He is also prescribed a Calcium and Vitamin D supplementation and treatments for arthritis and gastroesophageal reflux.
2. Broadly speaking SSRI medication increases the availability of a particular neurotransmitter (serotonin) in the junctions between nerve cells in the brain. This chemical effect has been associated with decreases in depressive ruminations, obsessional thinking and specifically in the case of Mr Mitchell associated with reduction in the frequency, intensity and duration of recurrent deviant sexual fantasies. It has also been associated with reduction in physical sexual arousal to deviant stimuli. SSRI medications are also anxiolytic in that they reduce the experience of anxiety. SSRI medications are generally well tolerated and most persons taking them do not experience side-effects. The typical side-effects of these medications can include headaches, tremors and gastro and intestinal disturbance. These side affects are usually transitory. More longer term side-effects are difficulty with erectile function, ejaculation and reduced libido.
3. As with my last review of Mr Mitchell on the 2 June 2009, all side effects with regard to sertraline medication had resolved, which as discussed in the question above is a typical pattern. He reports a benefit from the medication in that he is sleeping better, he feels more relaxed and calm in his mood and finds that he concentrates better. He reports that he does not experience any erections in the morning. He reports that he has no sexual fantasises while taking the medication. He reports that he has not engaged in any masturbation for the past six months. It is likely that the early headaches and gastro and intestinal side-affects that he has experience will not reoccur. It is likely that diminished sexual function will continue if he is compliant with the medication.
4. SSRI medications have been used extensively over the past 30 years. They have been used for lengthy periods of time and there does not appear to be significant problems with taking them for decades. As long as Mr Mitchell's general cardiovascular health remains good, it is likely that he will be able to continue taking SSRI medication.
5. Another medication class that could be considered in Mr Mitchell's case is cyproterone acetate or medroxyprogesterone acetate respectively androcur and depo-provera in trade name. These medications are colloquially termed anti-libidinal medications. Both of these medications exert their therapeutic effect by reducing the availability of the male sex hormone testosterone. Both these medications have been more extensively studied in the treatment of deviant sexual fantasy and arousal. Both have laboratory evidence of decreasing physical arousal and decreasing sexual fantasy and preoccupation. Observational studies of these medications indicate low rates of sexual recidivism when taken at an adequate dose. The use of these medications requires the full informed consent of the patient. The use of these medications also require that the person be in an adequate state of physical health. Mr Mitchell has one relative contra indication to the use of this medication, in that his bone mineral density is somewhat diminished. A recent bone mineral density scan indicates that he has osteopenia which indicates that his bone mineral density is below that of other men his age. It does not necessarily confer an increased risk of fractures, however the use of anti-libidinal medication can lead to increased de-mineralisation of bones. It is certainly medically possible for him to take this medication, particularly if he is supplemented with vitamin D and calcium to protect existing bone mineral density. Advantages of anti-libidinal medication are that compliance can be effectively monitored by serum blood testing. Compliance can also be monitored with depo-provera as it is given in injection form. There are theoretical reasons why it maybe more effective than SSRI medication given that it directly affects the male sex hormone. The evidence surrounding their use in the treatment of paraphilias is more extensive than that of SSRIs. Disadvantages to its use are that they tend to have more side-effects than SSRI medication and are less well tolerated. Possible side-effects of this medication include development of increased breast tissue which can be painful and embarrassing, decreased bone mineral density and fractures, weight gain, lethargy, an increased risk of development of clotting disorders and liver function impairment. With appropriate medical monitoring these side-effects can be minimised. Mr Mitchell has had the rationale for these medications explained to him and in the opinion of this author has complementally refused their use at this point. He has entertained their use in the future should he find a recurrence of sexual fantasies or urges towards children. These kinds of medications are indicated in Mr Mitchell's case given the clinical diagnoses of a paraphilia (pedophilia) with corresponding contact offences related to this paraphilia.
12 Mr Nambiar sets out in some detail in his affidavit the functions performed by the CCG which has responsibility for monitoring the compliance of offenders who are subject to community based orders, such as the one to which the defendant is subject. He also provided a considerable amount of information about the fashion in which the various COSP centres function. Mr Nambiar observes that his dealings with the defendant to date have been positive and that the defendant's response to supervision has been "one of compliance and cooperation". He states that his current expectation is that the defendant will reside at the COSP facility for a period of up to six months. He says however that there is no "absolute time limit" upon how long he may stay there and that he can remain there "until suitable alternative accommodation is found for him". That is an important consideration since the defendant's expressed desire to move to the Albury area is not deemed to be suitable because the Department would not be able to effectively supervise him in that location.
13 Ms Youssef is involved in the Community Maintenance Program the aim of which she says "is to promote the successful reintegration of offenders by providing follow-up sexual offender services to offenders who have completed…CUBIT." Ms Youssef has particular responsibility for the maintenance group in which the defendant participates. In her report she explains how the group, which has 8-12 participants in it, operates. The defendant's progress within the group, which he attends weekly, appears to have been entirely satisfactory.