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BACKGROUND: The treatment of sexual dysfunction in patients with prior sexual offenses poses an ethical and legal dilemma to urologists. Sex offenders are not obligated by law to disclose their status as offenders to medical professionals, and as a result, urologists may treat these individuals unknowingly. Sexual dysfunction among sex offenders is a known entity with a prevalence of up to 20%; however, the prevalence of sex offenders seeking medical evaluation for sexual dysfunction is unknown. In addition to the ethical and legal concerns, social impact must also be considered. Upon scrutiny of tax dollar usage, Federal Medicaid reimbursement for treatment of impotence in sex offenders was banned in 2005. This is a topic that has not previously been discussed in urologic literature.
METHODS: A clinical psychologist as well as a physician asks all new patients independently about a history of sexual offenses. Follow up questioning regarding the nature of the offence was pursued. In some cases, further criminal documentation was requested from the patient. The Sex Offender Registry Board, a Massachusetts public database of Level 3 sex offenders was queried. Details were examined including the sexual offense, sentence, and time elapsed since serving the sentence. An institutional ethics committee and legal counsel were assembled for guidance regarding this issue.
RESULTS: Using protocol for screening all new patients, or patients who had not been seen in a number of years, in a dedicated sexual dysfunction clinic, six cases of registered sex offenders were identified over a 9 month period. In 5 of 6 cases, the patients disclosed the status as a sexual offender voluntarily upon. Two patients were Level 1 offenders, one Level 2, and three Level 3. Prior to disclosure, four patients had previously been treated for sexual dysfunction. Legal counsel noted no precedence for cases of this nature at our institution and recommended against placing legal information in the medical chart. The ethics committee concluded that treatment of these patients was not unethical and could be left to the discretion of the provider.
CONCLUSIONS: Development of a protocol to screen for sexual offenders seeking treatment for sexual dysfunction can lead to the identification of individuals who may have otherwise been treated unknowingly. As such, additional information regarding the nature of the crime and risk for re-offense can be elicited and taken into account, and the decision to treat can be rendered on a case-by-case basis. Multi-disciplinary teams can aid in the establishment of a protocol on an institutional level. We bring this issue to the attention of urologists who will undoubtedly see similar patients in their clinic.