Malignant Sex and Aggression: An Overview of Serial Sexual

Wade C. Myers, M.D., Lawrence Reccoppa, M.D., Karen Burton, M.D., and Ross McElroy, M.D.

Serial murderers have attracted considerable attention in the popular press and criminal justice field, but scientific literature about these individuals is limited. This article provides an overview, from a psychiatric perspective, of serial sexual homi- cide, one type of serial killing. Characteristics of this type of and of these offenders are discussed. Defining qualities and diagnoses applicable to serial sexual killers are reviewed. Various etiologic theories are discussed, with emphasis on the role of fantasy and psychodynamic explanations. Governmental agencies involved in combating this type of crime, along with the role of mental health professionals in criminal profiling, are presented. Finally, the authors explore the reaction of society to this phenomenon.

Serial murder has been receiving an in- of one type of serial homicide-serial creased amount of attention by popular sexual homicide. Occasionally, reference and law enforcement media, but psychi- will be made to literature on serial hom- atric literature on this topic, with a few icide alone, when appropriate, in order notable exceptions, remains relatively to supplement the limited data on serial scarce. The literature on serial sexual sexual homicide. As stated in the follow- homicide is even more limited; further- ing section, most serial killers are serial more, the majority of studies do not sexual killers, thus at times we have ex- differentiate between sexual and nonsex- trapolated from the serial murder liter- ual homicide.' According to Dietz,* a ature in an attempt to fill information possible explanation for this dearth of gaps. literature is that these "occur Prevalence and History with a frequency too low to permit the ordinary research habits of psychiatrists As many as 4,000 to 5,000 Americans to elucidate their characteristics." each year may be victims of serial kill- This article will present an overview er~.~,~The FBI calculates that there are approximately 35 of these killers pres- Address correspondence to: Wade C. Myers, M.D., ently operating in the U.S.3 However, Division of Child and Adolescent Psychiatry, Depart- ment of Psychiatry, University of Florida, Box 100256, many criminologists consider this a Health Science Center, Gainesville, FL 326 10-0256. gross underestimation, suggesting that a

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Myers et a/. figure of 100 is more a~curate.~These Southwest between 1976 and 1982, is figures pertain to serial murder, and not believed to be the most prolific serial specifically to serial sexual homicide. murderer in U.S. history, although some However, it is generally believed among law enforcement agents believe Theo- law enforcement officials and clinicians dore Bundy may have killed more than alike that most serial killers are serial 300 young women.3 sexual killer^.',^^^ Unfortunately, no ex- Recent works have shown that serial act figures on the incidence and preva- homicide is by no means a new phenom- lence of serial sexual homicide are avail- enon. In his review, Jenkins8 found 24 able. instances of "extreme" cases in the U.S. Much debate persists in the literature from 1900- 1940 and some cases tracing regarding the scope of this problem in back to the 18th and 19th centuries. In our society. In 1966, only six percent of Europe, there are reports of criminals homicides had no apparent motive. By who lived in much earlier times but 1985, this figure had risen to 20 per~ent.~ committed atrocities similar to those of During the period from 1977 to 1984, contemporary serial murderers. For ex- with unknown motives in- ample, Gilles de Rais, a 15th century creased by 270 percent while all murders French nobleman, tortured, raped, and rose by only 12 per~ent.~From 197 1 to killed hundred of children. Peter Stubb, 1988, there have been at least 49 "ex- a 16th century "werewolf," raped, sex- treme" (10 or more victims) cases of ually tortured, and cannibalized a num- serial murder.' There has been a nearly ber of girls and women.4 Fritz Haarman, 10-fold increase in the number of serial "the ogre of Hanover," sodomized, mur- murder cases in the last two decades in dered, and cannibalized scores of young comparison with the previous two cen- boys in 19th century germ an^.^ Prob- t~ries.~Some pundits believe that serial ably the most infamous serial murderer murder is stable in rate and any "in- in history, Jack the Ripper, terrorized crease" is a result of enhanced reporting England in 1888 by butchering five or procedures by the media.' six prostitutes. Similar cases have oc- Only three states-Hawaii, Iowa, and curred in 20th century England. Maine-have remained free of docu- mented ^.^ These offenders Definition are not just a problem for western soci- There is no single, generally accepted eties. A man was recently executed in definition for serial homicide. Egger7 Harbin, China, for dismembering and gives the following definition: murdering seven women; many if not Serial murder occurs when one or more indi- all of these victims were prostitute^.^ viduals commits a second murder and/or sub- Three of the victims were unable to be sequent murder; is relationshipless (victim and identified due to missing body parts. attackers are strangers); occurs at a different time and has no connection to the initial (and To date, Henry Lee Lucas, who bru- subsequent) murder; and is frequently com- tally murdered over 140 victims in the mitted in a different geographic location.

436 Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Malignant Sex and Aggression Although this definition implies that a lia.15 The distinction between serial sex- series of two murders is sufficient, most ual murder and other types of serial sources use higher minimums, ranging murder is important in regard to demo- from four" to five,2 or even greater. graphics, diagnosis, and etiologic theo- Central to the definition of serial hom- ries of this type of murder. ~ietz~has icide is its differentiation from "mass" divided serial killers into five categories: homicide, another form of multiple kill- (I) psychopathic sexual sadists; (2) crime ing. Dietz2 defines as "of- spree killers (kill repeatedly in series mo- fenses in which multiple victims are in- tivated by excitement, money, and val- tentionally killed by a single offender in uables; the "Bonnie and Clyde" crimi- a single incident." Similarly, another nals) ;(3) organized crime members (i.e., definition of mass murder describes ". . . the Mafia, street gangs); (4) custodial a single incident within a short span of poisoners and asphyxiators (e.g., serial time . . .," while defining the time ele- killings in nursing homes); and (5) "sup- ment for serial murder as having ". . . posed psychotics" (for murderers like time breaks between murders, as mini- David Berkowitz, the "Son of Sam," mal as two days to weeks or months" who claimed a neighbor's dog had di- (1 1). rected his killings). The first category, The National Center for the Analysis "psychopathic sexual sadists," correlates of Violent Crime at the FBI Academy in with serial sexual murderers. Jenkins''' Quantico, Virginia, divides serial mur- study of serial murder in England ex- der into two types: "spree" and "clas- cluded politically motivated and profes- sic."'* Spree serial killings involve two sional "contract" killers. or more murders at separate locations After separating sexual from other se- with no cooling off period between acts. rial homicides, further distinctions The time interval between murders can about this type of offender can be made. be minutes or days, and the offender Important dichotomies include the geo- tends to have a high excitation level and graphically stable versus transient3 and may be a fugitive. Classic serial killings the organized versus disorganized16 ty- require at least two separate murderous pologies. The geographically stable killer episodes, usually by one offender, sepa- is one who permanently resides in and rated by a period of hours to years. Typ- kills his victims within a particular area. ically, a predatory/stalking method is Examples of this type are John Wayne employed and crime scene evidence re- Gacy in Chicago and Wayne Williams flects sadistic, sexual overtones. in Atlanta. The other type of killer is the A variety of synonyms have been geographically transient. 's coined for the sexual type of serial killer, roving murders occurring in such states including lust murderer (from the Ger- as Washington, Utah, Colorado, and fi- man "l~stmorder"~),sadistic mur- nally Florida fall in this category; he derer,13compulsive murderer,I4 sexually admitted to murders in six state^.^ The sadistic m~rderer,~and erotophonophi- transient killer is by no means a product

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 437 Myers et a/. of the modern interstate highway sys- dy's career he drank heavily, capri- tem, as shown in the murder "career" of ciously used stolen credit cards, and the 1920s' serial killer Earle Nelson. seemed to be experiencing increasing From February 1926 through June paranoia and desperation, unlike his for- 1927, Nelson committed 2 1 murders in mer, more-controlled self.4 nine states, ranging from California to Other characteristics important for New York, and Canada. describing serial sexual homicides are Another important dichotomy in typ- types of victims, modus operandi ing serial sexual killers is the organized/ (method of killing), and crime scene disorganized descriptor16 used to classify variables. In general, victims of serial the crime scene and life history variables killers tend to have two characteristics, of offenders. In one study of 36 con- vulnerability and ease of control." Sa- victed sexual murderers, organized mur- distic killers often prey on one type of ders were twice as common as disorgan- victim: young women, children, prosti- ized murders.16 Organized crime scenes tutes, and vagrants are frequently tar- show evidence of repetitive, well- geted."ed Bundy targeted young planned, and executed "productions" women with long dark hair, while that are distinguishable from sponta- Wayne Williams chose young black neous, chaotic murders committed by males. disorganized killers. Organized serial In contrast to other homicides, where killers are believed to take great pride in firearms are the most common weapon, the "expertise" with which they plan and serial sexual offenders often kill by stage their murders, and these killers "hands-on" methods, i.e., asphyxiation seem to be strongly driven by fantasy as (a relatively uncommon murder compared with disorganized killers who methodla), beating, or multiple stab kill more impulsively. In brief, organized wounds. "Seldom will the last murderer offenders are more likely to: (I) plan, (2) use a firearm to kill, for he experiences use restraints, (3) commit sexual acts too little psychosexual gratification with with live victims, (4) show or display such an impersonal weapon."19 In a se- control of the victim, and (5) use a ve- ries of 159 serial murderers collected hicle. Disorganized offenders are more from 1795 to 1988, the following were likely to: (1) leave a weapon(s) at the several of the more common methods scene, (2) position the dead body, (3) used during the process of inflicting perform sexual acts with the dead body, death: (1) mutilation (55%), (2) stran- (4) keep the dead body, (5) try to deper- gulation/suffocation (33%), and blud- sonalize the body, and (6) not use a geoning (25%).4 vehicle. l6 Serial sexual homicide victims are Interestingly, the murder career of often mutilated, which is an uncommon many organized killers tends to become feature in regular homicides. Most com- more disorganized over time. For ex- monly, the breasts, genitals, rectum, ample, toward the end of Theodore Bun- and/or abdomen will be mutilated.13

438 Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Malignant Sex and Aggression Bite marks are frequently found, and scene arrangements in subsequent kill- evidence of vampirism and cannibalism ings. are at times rep~rted.~'The killer may Characteristics or may not have sexual intercourse with ~rittainl~cautioned other clinicians the victim; he also may masturbate be- about generalizing from his "clinical de- side or upon his victim. scription of the sadistic sexual murderer." Eckert et aL2' reviewed a number of However, different st~dies~,'~,~~,~~ cases of sex-related violence, injury, and have revealed that serial sexual killers death from the perspective of forensic do share a number of characteristics. pathology, and a significant portion of In contrast with virtually all other vi- their article addresses the mutilatory and olent crimes, the great majority of of- murderous behaviors of serial sexual fenders and victims are whitc4x9 Al- killers. They provide a classification of though there have been isolated cases of sexually related injuries and deaths com- female serial killers,* there is no record prised of: (I) conventional sexual activ- of female serial lust murderers. Carol ity (i.e., vascular collapse secondary to a Wuornos, a 35-year-old prostitute, was cerebrovascular accident during sexual charged with killing by gunfire five men activity); (2) criminal sexual activity in Florida after having sex for hire with (this category encompasses serial sexual each of them. Although her motivation murderers under a homicide subcate- will probably never be known for cer- gory); and (3) other sexual activity (ix., tain, one might speculate that her crim- anorectal fisting, bestiality, ). inal behavior represents a form of serial Commonly, the serial sexual killer will sexual homicide by a female. arrange the body in the position in which These offenders are usually less than the murder took place. Many offenders 35 years old and often begin their "ca- seem to take special pride in the theatrics reers" in their ~OS.~These careers last of their offenses, ". . . as if there were a roughly four years in England, but are deliberate attempt to offend modesty."13 often longer in the United States.'' In a Evidence of and other paraphi- series of 222 classic serial murderers col- lias is frequently found; DietzI8 studied lected by The National Center for the the crimes of 30 multiple sexually sadis- Analysis of Violent Crime,12 the mean tic offenders and found that 23 had used age of their first murder was 27.5 years. bondage in their offenses. He also re- The NCAVC has identified a total 357 ported that many of these offenders had serial killers since 1960 through a com- prepared a stage, props, costumes, and puter search of various informational sometimes even a script for their crime. sources.12 These offenders have filled or A final characteristic is that the crime are suspected of killing a total of 3,169 scenes of many killers tend to be similar; victims, an average of nine victims per that is, the killer will use the same offender. method of killing and similar crime Killing by the serial sexual murderer

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 439 Myers et a/. as a juvenile may not be unusual. Bur- had committed at least one sexual hom- gess et reported that 10 of 36 (28%) icide (29, or 8 1 %, had killed more than men convicted of sexual homicide com- one victim), 42 percent had been physi- mitted murder as juveniles. Author W. cally abused, 74 percent emotionally C. M. evaluated two male youths, ages abused, and 43 percent had been sex- 13 and 16 years, who may have been ually ab~sed.~ manifesting the onset of precocious se- Retvitch14 described an extremely am- rial sexual homicidal behavior. The first bivalent relationship to the mother char- boy attacked a neighborhood female acterized by either maternal overprotec- baby sitter unknown previously to him, tion, infantilization and seduction, or and told her he was going to rape her as outright rejection of the son. Also, ma- he repeatedly stabbed her with a knife. ternal promiscuity, real or fancied, is She survived, in spite of suffering a common.'4 The father may be cold, dis- pneumothorax, a puncture wound to the tant, authoritarian, and punitive.I3 Phys- eye resulting in unilateral blindness, and ically, these criminals appear "normal" multiple other stab wounds. The second and are not disfigured "hulking boy killed a middle-aged female next- brutes."13 This attribute of having a nor- door neighbor by strangulation, and mal appearance may add to the hysteria then had intercourse with her corpse. of the public when the actions of a serial Both boys were tried in adult court and sexual murderer have been identified, received lengthy sentences; the natural similar to the fear and suspicion of one's course of their future behavior will never neighbors prevalent during the Salem be known. Neither one would or was witch trials of the late 17th century. able to disclose his fantasies leading to Some st~dies~~,~~have shown that, un- the murderous behavior, but it is pre- like other killers, roughly 80 percent of sumed that powerful sadistic fantasies serial sexual killers possess average to were at play. Reluctance on the part of superior intelligence. Nevertheless, those who commit sexual homicide to Hickey4 states that the offender's ability discuss their associated fantasies is com- to kill without being caught is "more a mon.'' function of cunning and deceit than in- Offenders generally commit their of- tellectual abilities." In general, organized fenses while alone; only one-quarter to serial sexual murderers have average to one-third have one or more partner^.^ above-average intelligence, while disor- Many are born out of wedlock and suffer ganized sexual murderers are often be- physical, emotional, or sexual abuse as low average in intelligen~e.~ ~hildren.~,"In a series of 30 sexually Only 20 percent of serial murderers sadistic offenders, with 22 (73%) having have a history of psychiatric treatment.4 committed at least one murder, one-fifth However, Burgess et a/.23found that 70 had been physically abused and nearly percent of men who had committed sex- one-half had been sexually abused." In ual homicide (8 1 % having committed another series comprising 36 men who more than one murder) had undergone

440 Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Malignant Sex and Aggression "some type of psychiatric assessment or that serial sexual murderers in compar- confinement as a child"; yet the presence ison with single sexual murderers had of overt mental illness in such offenders significantly higher , particu- does not appear to be common. Fur- larly fetishism (71% versus 33%) and thermore, Ressler et al.' found that a cross-dressing (25% vs. 0%). Dietz" family history of psychiatric disturbance found an average of 2.7 paraphilias in was present in one-half (53%) of these 30 sexually sadistic offenders (22 had cases. Family problems with alcohol committed murder), concluding that (69%), drug abuse (33%), and criminal- "contrary to what is often taught, para- ity (50%) were also common.' philias are rarely isolated in sexually sa- A significant number of these men distic offenders." have no prior criminal records or only The serial sexual murderer has a psy- convictions for nonviolent crimes at the chological need to have absolute control, time of their apprehension. However, 60 dominance, and power over his victims, percent of serial murderers have some and the infliction of , pain, and form of criminal his to^-y.4 Moreover, ultimately death is used in an attempt about half (44%) of 42 serial murderers to fulfill this need." In the words of Roy in one series had previously committed Norris, who along with Lawrence Bit- sex-related offense^.^ In Ressler et al.'s taker kidnapped, raped, tortured, and study' on those having committed sex- murdered five teenage girls, "the rape ual homicide, conduct disorder symp- wasn't really the important part, it was toms such as stealing (8 1 %), lying (75%), the dominance." These men cultivate and assaultiveness toward adults (84%) rich fantasy lives and will masturbate to to name a few, were extremely common recurrent sexually sadistic themes.29 in adolescence. As adults, such antisocial Those who have been married (as high behaviors continued to be reported, i.e., as 50%) may enact these fantasies with stealing (56%), chronic lying (68%), and their spouse or children.22 assaultiveness toward other adults Some have stable employment rec- (86%). ords and hold white-collar jobs. They In terms of sexual orientation, most often pursue occupations that bring are heterosexual, but some have a his- them into contact with injured/suffering tory of homosexual activity. The preva- animals or people over whom they exert lence of sexual dysfunction and nonsa- control.13 Hospitals, correctional facili- distic paraphilias (e.g., transvestism, ties, mortuaries, and butcher shops are , fetishism, ) ap- attractive locations for these men. In the pears high. In one report on sexual mur- U.S., security guard appears to be the derers,' almost half of the offenders re- most prevalent line of work.2 A history ported "an aversion to sex." Interest- of extreme cruelty to animals is com- ingly, 8 1 percent of these offenders rated mon. The incidence of drug and alcohol pornography as their highest ranking abuse in sexual killers is controversial. sexual interest. Prentky et a1.22 found Some studies report an incidence as high

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 441 Myers et a/. as 50 percent.l39l8 They are known to schizophrenics, particularly the para- collect material containing violent por- noid subtypes, present "real risks," but nography, police paraphernalia, and even these individuals most frequently even written accounts of their own attack acquaintances (e.g., family mem- crimes and those of their predecessors. bers, hospital staff, fellow patients), not Often they show an avid interest in Naz- strangers. In the case of serial sexual ism, black magic, torture, monsters, and murderers, it is unlikely such offenders, particularly weapons. l3 if psychotic, would have "the where- Their personalities have been de- withal repeatedly to escape apprehen- scribed as well-mannered, gentle, re- si~n."~In his 1965 study, Retvitch14 served, timid, religious, prudish, inade- made the diagnosis of "clinical schizo- quate, studious, obsessional, and hypo- phrenia" in nine of 43 male gynocidal ~hondriacal.'~Of note, often they will offenders, several of whom had commit- not display their temper to others al- ted murder more than once. It is un- though some may admit a hatred of known whether these nine men would women. LiebertZ0postulated that "no have met current DSM-111-R criteria for lust murderer has been in intensive psy- schizophrenia, particularly in view of the chotherapy," partly because they are past tendency to overdiagnose schizo- incapable of genuine intimacy. phrenia. Moreover, not enough infor- After apprehension, these men are mation is provided to determine how often "model" prisoners/patimts ac- many of these subjects were serial sexual cording to staff. However, they may be murderers. Nevertheless, there have unaccepted, detested, and even attacked been some celebrated cases of serial by peers, as in the case of Albert De- homicide in which the perpetrator likely Salvo, "the Boston Strangler," who was suffered from a schizophrenic disorder, stabbed to death by another inmate.17 Jenkindo reported that the insanity History indicates that they are extremely defense was employed in eight cases of recidivistic.13 One serial sexual killer serial murder in England between 1940 warned authorities never to release him and 1985, but only one successful. Even from prison, as he was certain he would in other cases with convincing psychi- reoffend. atric evidence of paranoid schizophrenia (e.g., John George Haigh in 1949, Peter Diagnostic Considerations SutclifTe in 1980), the defendants were According to Orne et al.,24 "It is a deemed "sane" and found guilty. Of widely held view that anyone who com- note, in the Haigh case, prosecutors ar- mits a series of heinous, apparently gued that any statement by the accused senseless murders must ipso facto be was invalid because he had "so strong considered insane. " Generally, an interest in saving his life" (thereby, studie~~~~~~do not support the stereotype4 effectively excluding the majority of psy- of schizophrenic persons as violent and chiatric testimony).1° In the trial of Peter dangerous. Bloomz7 noted that some Sutcliffe, the "Yorkshire Ripper" who

Bull Am Acad Psychiatry Law, Vol. 21, No. 4,1993 Malignant Sex and Aggression mutilated 13 prostitutes after incorpo- return for his disclosure of where he had rating them into his paranoid delusional hidden seven of the bodies. Following system, and judge simply overruled sev- his imprisonment, he continued to tor- eral expert witnesses' testimonies and ment the families of his victims by mail- found him fit to stand trial, which re- ing from comments about their chil- sulted in a life sentence. dren's murder. There has been a similar lack of suc- It has been proposed that the "sup- cess with the "not guilty by reason of posed psychosis" seen in some of these insanity" (NGRI) defense in U.S. courts, individuals is merely the product of mal- and some experts attributes this to he ingering by a cunning sociopath.' How- hostile public opinion associated with ever, Brittain13concluded that it is "use- these cases. For example, despite the fact less" and incomplete to "simply label that several psychiatrists diagnosed se- such a person a psychopath." Money,'' vere "paranoid psychosis" in Albert a forensic sexologist, added that such a Fish, who savagely murdered many chil- diagnosis is "judicially irrelevant," as dren in the Northeast in the 1920s and there is no precedent in which it has 1930s, he "fell short of the legal defini- absolved a criminal sex offender from tion of insanity" and was exe~uted.~ being legally responsible for his conduct. Mental health professionals have typ- Moreover, by the absence of lengthy ically categorized these men as psycho- criminal records, substance abuse, and paths. As Levin and Foxi7 suggested in unstable employment, many of these their review of mass killers: men are not necessarily "typical" socio- Though their crimes may be sickening they paths. are not sick in either a medical or a legal sense. Most experts in this field agree that Instead, the serial killer is typically a socio- these criminals are sexual sadists, defin- pathic personality who lacks internal control- guilt or conscience-to guide his own behav- ing sadism as the repeated practice of ior, but has an excessive need to control and behavior and fantasy which is character- dominate others. ized by a wish to control another person Clifford Olson, Canada's "most noto- through domination, humiliation, or in- rious and reviled criminal," was sen- flicting pain for the purpose of produc- tenced to life imprisonment in 1982 for ing .29MacCulloch et aLZ9 the torture and killing of 11 or more suggested that even if a psychotic illness male and female ~hildren.'~Hare et ~1.'~is present, it may be parallel and unre- described his personality structure as lated to their sadism. MoneyI5 claimed that of a typical psychopath. He had an that although a criminal sex-offense is inflated sense of self-worth, a violent antisocial, it is not necessarily a symp- temper, an ability to manipulate and tom of the "diffuse disease of antisocial- deceive others, a lack of guilt, glibness ism." and charm, and was a pathological liar. The possibility of an organic dysfunc- He outraged the public by arranging for tion in these murderers has been ques- the Crown to pay his family $100,000 in tioned. Some authors discuss isolated

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 443 Myers et a/. cases in which the perpetrators had a Although several lust murderers history of serious head trauma and ab- equate their acts to overwhelming com- normalities on CT, EEG, and neuropsy- pulsions with repetitive, ritualistic fea- chological te~ting.~.'~Money15 has pos- tures, and describe severe anxiety on tulated a parallel between the "paraphi- attempts to resist these needs, these ac- liac attacks" in serial lust murderers and tivities are not true compulsions (as in psychomotor seizures in temporal lobe obsessive-compulsive disorder) because epileptic. No comprehensive studies ex- "the person derives pleasure from the ist that have included thorough organic particular activity and may wish to resist work-ups (i.e., CT or MRI scans, electro- it only because of its secondary delete- encephalograms (EEGs), androgen and rious consequences." Professionals with neurotransmitter levels) on a sample of a more analytical approach have been serial sexual murderers. prone to consider severe borderline or In some cases, most notably in that of narcissistic personality disorders in these , the "Hillside Stran- cases due to specific abnormalities in the gler," the diagnosis of multiple person- ego functioning of these individuals. ality disorder (MPD) has been raised. In summary, when applying DSM-III- Some clinicians have found an associa- R nomenclature to serial sexual murder- tion between criminality and MPD; and ers, most clinicians diagnose sexual sad- they note that reports of amnesia (a car- ism on Axis I and antisocial or mixed dinal feature of MPD) after homicide ("cluster B") personality disorder on are frequent, ranging from 40 to 70 per- Axis 11. cent.30However, Orne et stated that caution must be used in diagnosing Etiology MPD in situations involving secondary What causes some individuals to be- gain because some individuals can effec- come serial sexual killers? Just as foren- tively simulate hypnotic states and sic experts disagree about the diagnostic MPD. In such instances, independent labels for these individuals, there is wide- cohoboration of the preexistence of spread difference of opinion about etiol- "distinct, autonomous personalities with ogy. It has been said that the etiology of specific behavior patterns and social re- serial murder is in its "infan~y."~Theo- lationships" is essential.24 Bianchi, who ries posited about causality include so- brutally strangled at least 10 women in ciocultural explanations, psychological the Los Angeles area from 1977 to 1978, factors, psychodynamic models, and or- displayed marked inconsistencies in his ganic or biological etiologie~.'?~ clinical presentation and could not pro- Studies of psychologic factors active vide essential corroborating evidence, in serial sexual homicides date back at thereby failing to convince the court that least as far as 1886, when Kraft-Ebing he had MPD.~~TO date, there are no in his text Psychopathic Sexualis de- well-documented cases of MPD in serial scribed case studies of German serial sexual killer^.^ killers to illustrate sadism, lust murder,

444 Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Malignant Sex and Aggression and sexual vi~lence.~More recent writ- serial sexual murders, suggesting that ings on psychologic motivation for sex- ". . . the selective reinforcement of de- ual killings have focused on the critical viant fantasies through paired associa- role of fantasy in this ~ffense'~,'~,~~,~~tion with masturbation over a protracted and the compulsive nature of these period" contributes to repetitive sexual acts. '4*20 homicides. Although not expressly stud- Brittain's classic description of sadistic ied, their findings lend support to the murderers emphasized the importance conclusion that killers who are moti- of fantasy, "He is typically a daydreamer vated by a rich, violent fantasy life are with a very rich, active fantasy life . . . more likely to translate these ideas into his fantasy life is in many ways more organized, repeated offenses (i.e., important to him than his ordinary "staged" murder productions) than are life."' Revitch l4 described the presence disorganized, spontaneous killers. of a "violent fantasy life" in his paper A British study by MacCulloch et a/.29 on sexually motivated murderers. also focused on the role of fantasy in Burgess et have proposed a mo- sadistic offenses. Sixteen forensic hospi- tivational model for sexual homicide tal patients, each who had been diag- that is based on the role of fantasy. The nosed as having psychopathic personal- model suggests that five factors (im- ity disorder and had committed violent paired early attachments, early psycho- sexual crimes, were interviewed about logic trauma, patterned responses that their crimes and their fantasy life. A generate fantasy, a violent fantasy life, striking finding from this study was that and a "feedback filter" that nourishes in 13 of the 16 offenders, the crimes repetitive thinking patterns) are causa- were specifically linked to prior fanta- tive in sexual homicide. A study by sies; these offenders had engaged in pro- Prentky et suggested the importance gressively active behavioral try outs of of fantasy as an internal drive mecha- their fantasies that finally culminated in nism for repetitive sexual violence. Se- the offense for which they were appre- rial sexual killers were compared with hended. In the index crime of these 13 subjects who had killed a single victim. offenders who had rehearsed their offen- A significantly higher prevalence of vi- ses, there was no identifiable external olent fantasies (86% versus 23%) was precipitant to the violent behavior. In found in the serial murderers. Prentky contrast, in the remaining three of- et also examined the issue of crime fenders (those without related fantasies), scene organization and found that serial the crime followed an unsuccessful sex- sexual killers were significantly more ual advance. likely to have organized their crimes MacCulloch et al.'~~~finding of an than single murderers (68% versus "escalating sequence of sadistic behav- 24%). They further proposed that a clas- ior," from progressively sadistic fantasies sical conditioning model may partially to increasingly active "in vivo trials" and explain the driving power of fantasy in then the ultimate acting out of the entire

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 445 Myers et a/. fantasy, is related to the concept of model: "It is the fusion of destructive "compulsive" murders proposed by Re- impulses from disorganized sexual im- vitch.14 Revitch14 described a spectrum pulses evolving out of the preoedipal of motivational stimuli in the murder of matrix of these individuals, together women by men: (1) environmentally with the incapacity for empathic bond- stimulated crimes; (2) situational crimes; ing typical of the sociopath . . ." (3) impulsive crimes; (4) catathymic Weinshel and Calet32 hypothesized crimes (refeking to a release of accu- about the psychodynamic underpin- mulated psychic tension through an ag- nings of the bizarre mutilations often gressive catharsis); and (5) compulsive found in serial killings, ". . . in some of crimes, with most sexually motivated these cases the wish to re-enter and to murders falling into this latter "compul- explore the interior of the mother's body sive" category. "In these cases the need may be an important ingredient. . . ." to commit the act is compelling and with Pornography and the issue of cultural a strong potential for repetition . . . some acceptance of violence have been men- of these offenders attempt to resist the tioned as contributing to the phenome- need, and this usually brings on severe non of sexual killings. There are no stud- anxiety with somatic manifestations."14 ies that specifically address the effects of The psychological formulation pro- pornography on crimes such as serial posed by Liebert20 is the most in-depth sexual homicide, nor that relate these exportation of the compulsive nature of effects to personality types.' However, serial killings. Liebert offered a psycho- many a~thorities~,~.~,'~,'~,~~who have dynamic explanation of the "restorative studied case histories of serial killers sug- function of violent sexual impulses" de- gest that violent pornography may con- scribed by Revitch14 and others. He pos- tribute to the final act of murder in the tulates that most serial sexual killers predisposed individual. On a larger have a borderline or narcissistic person- scale, it also has been suggested that ality structure along with an antisocial, widespread acceptance and broadcasting sadistic impulse disorder. In these indi- of violence through the mass media (tel- viduals, the aggressive/destructive ele- evision, movies, videos, popular music) ments of the early motherlchild rela- may contribute to this extreme form of tionship are introjected as "unmetabol- sexual violence. In his paper on serial ized" (dissociated) elements. These killers who target children, Wilson5 pro- individuals split the introjected "bad- posed that ". . . contemporary video ma- ness" from self and project it onto the terial, popular music, or at least sections female victim. This is the concept devel- of it, add to a milieu where violence and oped by Otto Kernberg in his discussion the premature extermination of life are of "characterological sadism," in which increasingly taken for granted." ". . . primitive aggression is directly in- Others have approached the linkage filtrated into the pathological, grandiose of sex and aggression in serial sexual self. . . ."20 Liebert20 summarized his killers from a biologic perspective.

446 Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Malignant Sex and Aggression Money1' takes the extreme position that the FBI Academy in Quantico, Virginia, sexual killing (and other forms of sexual was established in 1984 through funding sadism) is not a type of antisocial behav- from the National Institute of Justice, ior, but rather a "specific sexological and is now completely supported disease." According to Money,I5 in this through the FBI budget. The NCAVC disease ". . . the brain becomes patholog- serves as "a law enforcement oriented ically activated to transmit messages of behavioral science and data processing attack simultaneously with messages of center designed to consolidate research, sexual arousal and mating behavior." training, and investigative/operational As does Revitch,14 Money'' cites support functions for the purpose of pro- ma clean'^^^ elucidation of the proximity viding expertise to any law enforcement and interconnection of limbic structures agency confronted with unusual, bi- linked to feedinglaggression (the amyg- zarre, and/or repetitive crime^."^' dala) with structures controlling sexual A subunit of the NCAVC, the Violent functions (the hippocampus and sep- Criminal Apprehension Program (VI- tum). Money'' further draws "a parallel CAP), became operational in 1985. This between the episodic seizures of sexual program receives criminal reports from sadism" and temporal lobe epilepsy. He the United States, Canada, and other also proposes a five-part "clinical sexol- ogy workup" in explaining the contrib- countries "in an effort to link homicides utory changes of sexual sadism in serial committed by serial violent offenders.")' killers: (1) hereditary predisposition, (2) In addition to providing investigative hormone functioning (prenatal and cur- support, VICAP aims to alert and in- rent), (3) pathological relationships, (4) form various law enforcement agencies history of sexual abuse, and (5) symp- that might be attempting to capture the toms of other syndromes. same offender who has committed The role of individual hormones and crimes in their separate jurisdictions. VI- neurotransmitters in serial sexual killers CAP has a growing staff that includes has not been specifically investigated. crime analysts and case specialists in its Studies of the role of testosterone in effort to assist homicide investigators sexual violence show conflicting re- from around the country. At the end of sult~.~~,~'The possible role of serotonin 1992, over 7,000 cases (involving nearly in violent killings is another area of in- 8000 victims) had been entered into the terest, with one finding that sub- VICAP system. jects who had killed a sexual partner had Another subunit of NCAVC is the significantly lower levels of CSF 5- Criminal Investigative Analysis Program HIAA, a metabolite of serotonin. (CIAP). One of the functions of Special The National Center for the Agents assigned to this program is crim- Analysis of Violent Crime/Criminal inal profiling, which was previously re- Profiling ferred to using the terms "psychological The National Center for the Analysis profile" or "criminal personality pro- of Violent Crime (NCAVC), located at file."38 The profiling process is a tech-

Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 447 Myers et a/. nique used to identify major personality acts of such a murderer reflect the devia- and behavioral characteristics of the of- tions of his mind and these he conceals fender based upon an analysis of the as best he can from others. . . ." Liebert2' crime(s) committed; it is not able to suggested that the psychiatric consultant provide the identity of a particular of- can be of most use in helping investiga- fender.38There are typically seven steps tors study the biographies of suspects to in the profiling process: (I) evaluation look for ". . . overt but, perhaps, subtle of the criminal act itself, (2) comprehen- antisocial, polymorphous perverse and sion evaluation of the specifics of the sadistic trends not registered often on crime scene, (3) comprehensive analysis police records." He noted the resistance of the victim, (4) evaluation of prelimi- among many investigators to uncover- nary police reports, (5) evaluation of the ing the sexual motivation for this type medical examiner's autopsy profile, (6) of crime, and believes that psychiatrists development of profile with critical of- can play an important role in education fender characteristics, and (7) investiga- to overcome this resistance. The sexual tive suggestions predicated on construc- nature of these murders is not always tion of the profile.38 apparent, as conventional evidence may The psychological profile may provide be lacking at the scene of the crime,' useful in narrowing down the range of thus raising the risk of the offense not aspects, but is not designed to pinpoint being categorized as a sexual homicide. one particular subject. Swanson et states that the goal of the profile is to Impact on Society "provide enough information to inves- Despite the figures presented in this tigators to enable them to limit or better paper, many feel the significance of se- direct their investigations. In one survey, rial murder remains uncertain. For ex- FBI profiles were only successful in 17 ample, even the FBI's highest estimate percent of cases in directly identifying a of annual victims represents less than suspect; but in three-fourths of solved 10% of automobile fatalities per year.7 cases the profile helped to focus investi- Yet, the government has allocated con- gative efforts.17 Professional opinion on siderable research, manpower, and the utility of psychological profiling is funds to the investigations of these hom- mixed; and at its current stage of devel- icides. For instance, the "Green River opment, it remains an art rather than a Killer," who has claimed possibly 30 ~ervice.~.l7 victims in Washington State since 1982, Addressing the issue of profiling, has been the focus of an ongoing, intense Liebert2' cautions that a generalized pro- investigation costing well over $20 mil- file may blind investigators to the unique lion. The financial burden placed on identity of a given serial murderer. society once a serial murderer has been BrittainI3 also cautioned that ". . . no apprehended is also staggering, and trial one should be ruled out as a suspect costs easily run into the millions of dol- because of preconceptions . . . for the lars. Initial defense costs of $ l million

448 Bull Am Acad Psychiatry Law, Vol. 21, No. 4, 1993 Malignant Sex and Aggression are projected for the trial of Danny Roll- ened in the weeks following the murders. ings, who is charged in the 1990 serial Large numbers of residents also reported sexual murders of five University of experiencing a number of "post-trau- Florida students. Ted Bundy's trial and matic stress disorder" symptoms includ- appeals totaled roughly $9 milli~n.~ ing increased startle response (36%),dis- Liebert20asserted that "the excitement tressing thoughts (35%), sleep difficulties generated within a community upon ( 19%), and concentration difficulties identification of serial murder far ex- (10%). Those residents most affected ceeds its morbidity and mortality risks." were female students living close to the One possible explanation for this reac- murder sites. The psychological distress tion is the vast publicity or even sensa- tended to decrease over time with most tionalism given to this phenomenon by residents reporting little distress at 18 the media and entertainment industry. month follow-up. However, anxiety and Some fear the influence or disinhibiting fear symptoms were the most persistent effect that such coverage has on poten- with 10 percent of residents reporting tial serial killers in our society. Of note, increased startle response and seven per- investigations have shown that some cent reporting distressing thoughts 18 killers tend to study and imitate other months after the murders. Residents at- celebrated cases." Egger7 suggested that tempted to deal with these stresses a community's anxiety level rises after an apparently "motiveless" murder be- through a number of coping responses cause, unlike other "routine" homicides, including increasing home security "everyone is at risk." (84%), avoiding traveling alone (29%), The psychological impact of serial sex- and purchasing/carrying a firearm ual homicide on a community can be (I 1 %). Media coverage of events was profound. In the fall of 1990, Gaines- generally criticized as being sensational. ville, Florida, police discovered the mur- In fact, one-third (36%) of residents re- dered, mutilated bodies of five college ported that hearing about the body mu- students. Herkov40 surveyed area resi- tilations caused them to become more dents to determine the community's re- frightened. sponse to this violence. One hundred Sociologists4' theorize that these sixty-four Gainesville residents were sur- crimes carry such a substantial impact veyed at three time periods (initially, because they violate traditional taboos nine months, and 18 months following in western society, namely murder and the murders) regarding their psycholog- illicit sexual relations. From a psychoan- ical distress, coping responses, and per- alytic level, perhaps the most unsettling ceptions of police and media perform- aspect of these crimes is that they divulge ance. Nearly half (46%) of residents re- an extremely potent, destructive id resid- ported moderate to severe disruption of ing in "normal" humans. Is our tend- their daily lives and one-third (35%) in- ency to view these serial sexual homi- dicated that they felt panicked or fright- cides as the product of "madness" an

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