Rape Beyond Crime

Public health experts agree that sexual violence constitutes a significant public health issue. Yet criminal law dominates rape law almost completely, with public health law playing at best a small supporting role. Recent civil law developments, such as university disciplinary proceedings, similarly fixate on how best to find and penalize perpetrators. As a result, rape law continues to spin its wheels in the same arguments and obstacles. This Article argues that, without broader cultural changes, criminal law faces a double bind: rape laws will either be ineffective or neglect the importance of individual culpability. Public health law provides more promising terrain for rape prevention because it is a strong legal framework that can engage the complex causes of rape, including the social norms that promote sexual aggression. While criminal law can only punish bad behavior, public health interventions can use the more effective prevention strategy of promoting positive behaviors and relationships. They can also address the myriad sexual behaviors and social determinants that increase the risk of rape but are outside the scope of criminal law. Perhaps most importantly, public health law relies on evidence-based interventions and the expertise of public health authorities to ensure that laws and policies are effective. Transforming rape law in this way provides a framework for legal feminism to undertake the unmet challenge of “theorizing yes,” that is, moving beyond how to protect women’s right to refuse sex and toward promoting and exploring positive models of sex. Criminal law is simply incapable of meeting this challenge because it concerns only what sex should not be. A public health framework can give the law a richer role in addressing the full spectrum of sexual attitudes and behaviors

Taking Pedophilia Seriously

This Article pushes lawmakers, courts, and scholars to reexamine the concept of pedophilia in favor of a more thoughtful and coherent approach. Legal scholarship lacks a thorough and reasoned analysis of pedophilia. Its failure to carefully consider how the law should conceptualize sexual attraction to children undermines efforts to address the myriad of criminal, public health, and other legal concerns pedophilia raises. The result is an inconsistent mix of laws and policies based on dubious presumptions. These laws also increase risk of sexual abuse by isolating people living with pedophilia from treatment. The Article makes two central arguments: (1) although pedophilia does not fit neatly into any existing legal rubric, the concept of mental disorder best addresses the issues pedophilia raises; and (2) if the law conceptualizes pedophilia as a mental disorder, we must carefully reconsider how several areas of law address it. Specifically, it argues that sexually violent predator statutes expand state power to civilly commit individuals by distorting the concept of pedophilia as a mental disorder. At the same time, anti-discrimination law is dismissive of pedophilia as a mental disorder, excluding it from civil rights protections ordinarily associated with mental illness. Closer examination of these distinctions reveals them to be based on questionable premises. The law should take pedophilia seriously as a mental disorder. Many individuals living with pedophilia pose a danger to others. Yet we should not categorically deny pedophilia the civil rights protections afforded to other mental disorders without a convincing normative justification supported by cogent scientific evidence. Strengthening civil rights protections for those with pedophilia also increases access to treatment and support that helps prevent child abuse

Rethinking HIV-Exposure Crimes

This Article challenges the current legislative and scholarly approaches to HIV-exposure crimes and proposes an alternative framework to address their flaws. Twenty-four states criminalize consensual sexual activities of people with HIV. Current statutes and the scholarship that supports them focus on HIV-positive status, sexual activity, and knowledge of HIV-positive status as proxies for risk, mental state, and consent to risk. As a result, they are dramatically over- and underinclusive and stigmatize individuals living with HIV. Criminalization should be limited to circumstances in which a defendant exposed her partner to a substantial degree of unassumed risk and did so with a culpable mental state as to transmission. This approach requires a fact finder to consider all evidence relevant to the risk of transmission and the victim’s understanding of that risk, a modest requirement that would nonetheless invert outcomes in numerous prosecutions. The Article contextualizes these arguments within the larger debate on the use of rules and standards in the criminal law and explores the implications of its approach for HIV-exposure criminalization as well as any offense drafted in response to an emerging threat

Rethinking HIV-Exposure Crimes

This Article challenges the current legislative and scholarly approaches to HIV-exposure crimes and proposes an alternative framework to address their flaws. Twenty-four states criminalize consensual sexual activities of people with HIV. Current statutes and the scholarship that supports them focus on HIV-positive status, sexual activity, and knowledge of HIV-positive status as proxies for risk, mental state, and consent to risk. As a result, they are dramatically over- and underinclusive and stigmatize individuals living with HIV. Criminalization should be limited to circumstances in which a defendant exposed her partner to a substantial degree of unassumed risk and did so with a culpable mental state as to transmission. This approach requires a fact finder to consider all evidence relevant to the risk of transmission and the victim’s understanding of that risk, a modest requirement that would nonetheless invert outcomes in numerous prosecutions. The Article contextualizes these arguments within the larger debate on the use of rules and standards in the criminal law and explores the implications of its approach for HIV-exposure criminalization as well as any offense drafted in response to an emerging threat

The Draw-A-Clock Contest: A Strategy for Improving Cognitive Status Assessment by Trainees

Background: Historically, psychiatrists have been less inclined than neurologists to utilize pencil and paper tasks during bedside cognitive assessments. Objective: The Draw-AClock Contest was established in 1986 at the University of Massachusetts to promote use of cognitive assessment tasks by psychiatry residents. Methods: Used in neuropsychological assessments since the 1930’s, clock tasks have been popular screening tools for executive function, praxis, visuospatial and constructive ability, often as part of dementia screening. Given its broad utility as a screening tool and the ease and speed of its administration, the Draw-A-Clock task (with hands set to 11:10 and no circle provided) was selected for use by UMass psychiatry residents, with further bedside assessment encouraged to explore any detected deficits. To encourage participation and foster clinical inquiry, residents are asked to submit clinically interesting de-identified patient clocks. For 21 years, clock contest entries have been collected each spring, with basic demographic, diagnostic, and process notes. Resident names are encoded, and entries are judged by a neuropsychiatrist (SB) and a neuropsychologist (EK). A “clock trophy” and detailed analysis of the submission is presented to the winner at the annual graduation banquet. Results: As a result of this contest, mental status examinations by trainees have become more comprehensive and an atmosphere of neuropsychiatric inquiry has been maintained. Faculty members have also incorporated this task into their mental status assessments, thus establishing a culture of cognitive inquiry and an academic tradition. Examples of winning clocks and common findings will be presented. Published abstract: Sullivan J, Benjamin S, Case Report: CADASIL with Cysteine-Sparing Notch-3 Mutation, American Neuropsychiatric Association, abstract, Journal of Neuropsychiatry and Clinical Neuroscience 21(2):221, 2009. DOI 10.1176/appi.neuropsych.21.2.221

Suicide Associated with Military Service

Suicide rates among soldiers and veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) have been steadily growing since 2004, with sharp increases observed more recently. Suicides in the Army are a growing concern on Capitol Hill and in the media. Last month, the Senate Armed Services Committee held hearings on the growing incidence of suicides across the armed forces (Federal city digest, 2009, March 18). The Associated Press (AP) underlined the increasing suicide rates among Army personnel (Army reports sharp rise in suicides in January, 2009, Feb. 5). According to the AP, there were 64 suicides in 2004, and this number has doubled in 2008, with 128 confirmed deaths and 15 pending investigation. This is the largest number of suicides among active-duty soldiers in the Army observed in the past 28 years (Kuehn, 2009)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries