Psychosis and Sexual Offending: A Review of Current Literature

Abstract

Sexual offending is a public health concern and societal risk requiring a multi-disciplinary approach. While current data give an indication of the frequency of sexual victimization, these figures likely underestimate the severity of the concern as many of these incidents go unreported. And while sex offender research has increased over the past several decades, particular attention to those offenders with severe mental illness remains limited. In this descriptive review, literature describing sex offenders with psychotic disorders is explored with a focus on recent research. Important considerations are described, including theories surrounding psychosis and sexual offending, hospitalization rates, recidivism, not guilty by reason of insanity (NGRI), female offenders, and treatment considerations. By exploring these important aspects of sex offenders with psychosis, conclusions are drawn and future directions are proposed, with a particular emphasis on clinical application for the mental health treatment provider.

Keywords

sex offending psychosis

Introduction

Sexual offending is a significant public health and societal concern. Data from the National Intimate Partner and Sexual Violence Victimization Survey (NISVS) indicate that nearly one in five women in the United States have been raped and nearly one in two women have experienced some form of sexual violence victimization (M. C. Black et al., 2011). In 2012 in the United States, there were 346,830 rapes and sexual assaults including verbal threats of each according to the U.S. Department of Justice (DOJ; Federal Bureau of Investigation, 2012). While data collected through DOJ provide insight, these statistics likely represent considerable under-reporting of actual rates of sexual assaults (Kilpatrick & McCauley, 2009). Victims of sexual assault are at an increased risk of mental health sequelae; they are 3 times more likely to suffer from depression, 6 times more likely to suffer from posttraumatic stress disorder, 13 times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times more likely to contemplate suicide (Rape, Abuse, and Incest National Network, 2009). Through a better understanding of sexual offenders, there is potential to increase community safety, lower sexual recidivism, and develop strategies for prevention of sexual violence (Association for the Treatment of Sexual Abusers, 2015).

Building evidence in the scientific literature suggests a high prevalence of psychiatric comorbidities within the sex offender population. Substance use disorders, personality disorders, paraphilic disorders, and mood disorders are frequently cited as important psychiatric comorbidities requiring further investigation among sex offenders (Booth & Gulati, 2014; Dunsieth et al., 2004). For instance, with regard to substance usage, it has been shown that a history of substance abuse increases recidivism rates among sex offenders (Peugh & Belenko, 2001). Furthermore, in Abracen, Looman, DiFazio, Kelly, and Stirpe (2006), sex offenders with a history of alcohol abuse who completed both substance use treatment and sex offender treatment exhibited lower recidivism rates than those who only completed sexual offender treatment (Abracen et al., 2006). Better understanding of the specific relationship between an individual’s sex offending behavior and particular psychiatric comorbidities has the potential to influence evaluation, treatment, risk assessment, and prevention (Fazel, Sjostedt, Langstrom, & Grann, 2007). And despite expanding attention to psychiatric comorbidities in the sex offender literature, there remains a paucity of data surrounding those offenders with severe mental illness (Stinson & Becker, 2011).

Sexual offenders with comorbid psychosis are a distinct group of individuals requiring further study and attention in the sexual offending and general medical literature (Booth & Gulati, 2014; Craig, 2011; Craissati & Hodes, 1992; Drake & Pathe, 2004; Murrey, Briggs, & Davis, 1992; Sahota & Chesterman, 1998; Smith & Taylor, 1999; Stinson & Becker, 2011; Wallace, Mullen, & Burgess, 2004; Wallace et al., 1998). Among samples of sex offenders, rates of psychotic spectrum disorder diagnoses range from 5% to 10%, while in more specialized forensic sex offender treatment units, as many as 16% of patients have been reported to have a psychotic disorder (Booth & Gulati, 2014; Stinson & Becker, 2011). In comparison, lifetime prevalence of psychotic disorders among the general population is approximately 3%, with the Centers for Disease Control and Prevention (CDC; 2011) reporting prevalence of schizophrenia at 1% (Perala et al., 2007).

When comparing sex offenders with nonsex offender groups, male sex offenders are 5 times more likely than nonsex offenders to be diagnosed with a psychotic disorder. Considering the higher occurrence of psychosis among sex offenders, better understanding of the mechanisms surrounding this correlation and potential treatment implications is imperative for evidence-based assessment and treatment (Drake & Pathe, 2004). In this descriptive review, the relationship between psychosis and sexual offending is highlighted with particular attention given to theories of etiology, recidivism, and treatment considerations. In addition, further information is reviewed regarding female offenders and those individuals found not guilty by reason of insanity (NGRI; Novak, McDermott, Scott, & Guillory, 2007).

The topical areas were selected based on a review of literature on sex offenders with psychosis, with a particular aim to provide practical review of relevant topics in this area for evaluators working with sex offenders with psychosis. Theories of the relationships between sexual offending and psychosis will facilitate creating models of thinking and provide a framework for subsequent findings included in the review. A brief discussion of hospitalization among sex offenders with psychosis is provided, as there are several studies with large samples that provide helpful insight into this important aspect of an offender’s history. Next, reviews of other important topics including NGRI, recidivism, and female offenders will help to further establish the complex relationship between psychosis and sexual offending. Finally, treatment considerations, conclusions, and future directions will aim to provide practical information for those in the position of evaluating or providing treatment for this particular subset of individuals within the sex offender population.

Method

A PubMed query was conducted by searching for manuscripts containing the key words “sexual offending” and “psychosis” within the title. This yielded 28 articles of which six were included in this article. Articles from this search were excluded primarily if they did not contain specific information regarding sexual offending or sexually aggressive behavior. In addition, a medical subject heading (MESH) search was conducted using the terms “sex offenses” and “psychotic disorders” which yielded 144 results, of which three articles were included for review. Similarly, exclusion criteria included articles that did not address the specific relationship between sexual offending and psychosis.

Next, a broader review of the literature included studies that addressed psychiatric comorbidities of sex offenders. A PubMed search of “mental illness” and “sex offending” yielded 361 results, of which 10 were included. Specific inclusion criteria for this review were English language, published in 1980 or later, adult populations, and content that specifically addressed psychosis among sex offenders. Both data driven and review articles were included. Of note, articles retrieved from these searches were also utilized to find additional literature on this topic area, yielding additional titles for review.

Relationships and Theories

In an effort to better understand the relationship between psychosis and sexual offending, many researchers have distinguished between a direct versus an indirect relationship. Smith and Taylor (1999) reviewed case files of individuals who were reportedly psychotic at the time of sexually offending. A metric was created to rate the level of congruence between the observers’ perspective of the delusion and/or hallucination and the sexual offense itself. They concluded that for some men, there might be a certain degree of premorbid sexual deviancy that may later be incorporated into psychotic symptoms. Of note, however, is that while almost all of the men were psychotic at the time of the index offense, specific delusional or hallucinatory drive to sexually offend was reportedly low (Smith & Taylor, 1999). Similarly, Sahota and Chesterman (1998) described psychosis that contributes directly or indirectly to sexual offending. In a direct relationship, command or sexually thematic hallucinations or delusional beliefs result in a sexual offense. Indirectly, factors such as heightened arousal, chaotic thinking, and poor social functioning may contribute to the sexual offense (Sahota & Chesterman, 1998).

More directly, Jones, Huckele, and Tanaghow (1992) described a case series of four individuals with schizophrenia who attempted sexual assault in response to command type auditory hallucinations, concluding that command hallucinations should be taken seriously as patients may be likely to act on them (Jones, Huckele, & Tanaghow, 1992). An important consideration in this study is that offenders were receiving psychiatric treatment in an inpatient treatment facility when they exhibited the sexually aggressive and inappropriate behaviors. This suggests that for certain individuals with psychosis, sexual offending may occur in the context of a decompensated psychiatric illness.

Drake and Pathe (2004) described subtypes of sex offenders with schizophrenia. These include individuals with positive symptoms, disinhibition, and alterations of personality (e.g., social withdrawal) that may directly contribute to the sexual offense during an active state of mental illness (Drake & Pathe, 2004). Alternatively, an individual with schizophrenia and a preexisting paraphilic disorder may sexually offend as a result of the paraphilic disorder or the comorbidity is further exacerbated in the context of schizophrenia. Another important consideration includes sexual offending as a manifestation of generalized antisocial behavior (Drake & Pathe, 2004). For these individuals, sexual offending may represent physical aggression expressed sexually, as opposed to sexual offending with a paraphilic origin.

Other critical factors to consider include neurocognitive conditions such as dementia or traumatic brain injury, which may contribute to the sexually deviant behavior and require further evaluation. In addition, sex offenders with schizophrenia may have comorbid substance usage that contributes to sexually inappropriate behaviors through disinhibition, interpersonal impairment, and attenuating appropriate social and sexual functioning (Drake & Pathe, 2004).

Sexual offending as a result of dementia is understood through various neurobiological changes occurring in the frontal system, temporo-limbic system, striatum, and hypothalamus (B. Black, Muralee, & Tampi, 2005). When trying to assess inappropriate sexual behavior in these individuals, considerable thought should be given to whether the behavior is a result of and consistent with a history of sexual misbehavior or whether it is resulting from dementia, or related causes. Examples include psychiatric disorders, use of dopamine agonists, or a urinary tract infection resulting in delirium. If identifiable secondary causes are addressed, then sexual misbehavior may improve, when the secondary cause is treated or otherwise medically managed (Kettl, 2008). In the context of psychosis and sexual aggression, dementia should be considered as a contributing factor and evaluated accordingly, with attention to the individual’s history for sexually inappropriate behavior.

Fazel and colleagues (2007) described risk factors for sexual offending among those with psychosis including hostility, cognitive distortions, deviant sexual fantasies, and poor social skills. They also describe psychosis as a nonspecific disinhibiting factor that may interact with other risk factors at the time of the crime (Fazel et al., 2007). These conclusions imply that psychosis may interact and contribute to sexual offending but that there is not always a direct role between psychosis and sexual offending.

In a retrospective comparison study, Alish and colleagues (2007) compared adult male sex offenders meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for schizophrenia, nonsex offending criminals with schizophrenia, and a control group of sex offenders without schizophrenia. Findings suggest that sex offenders with schizophrenia were unique in terms of certain demographics including they were more likely to be married, employed, and nonheterosexual. In addition, they had less hospitalization, antisocial personality disorders, substance abuse, negative symptoms, and overall illness severity. Of note, when comparing sex offenders with and without schizophrenia, the nature of their crimes was similar. Authors concluded that schizophrenia and sexual offending should be treated as two clinical phenomena as opposed to a unique and distinct clinical entity (Alish et al., 2007).

In reviewing literature that aims to describe relationships and associations between sex offending and psychosis, several themes emerged. First, individuals with a psychotic disorder are not necessarily at a higher risk of sexually offending than other sex offenders. Next, the state of psychosis at the time of the sexually inappropriate behavior is an important consideration. Active psychotic symptoms could contribute to sexual offending; however, other factors such as antisocial personality disorders, paraphilic disorders, and substance usage should be considered as these factors may also significantly influence the sexually aggressive behavior.

Hospitalization

Another important consideration among sex offenders with psychosis is evaluation of hospitalization patterns to determine if unique differences exist within this population. In a study of 8,495 males convicted of a sexual offense, Fazel and colleagues (2007) determined there was a sixfold increase in history of psychiatric hospitalization compared with a general population control group. In addition, sex offenders were significantly more likely to have a diagnosis of severe mental illness when compared with the general population (Fazel et al., 2007). In a large Danish cohort study, Alden, Brennan, Hodgins, and Mednick (2007) examined the relationship between psychosis, sexual offending, and hospitalization. Results indicated that individuals with psychotic disorders did not have an increased rate of arrest for physically aggressive sexual offenses (i.e., rape, pedophilic disorder, frotteuristic disorder) when compared with the general population; however, they had a threefold increase in likelihood of being arrested for nonphysically aggressive sexual offenses (i.e., voyeuristic disorder, exhibitionistic disorder).

In addition, there was a significant difference between sexual offending in men with psychosis and no other mental health diagnosis verses men with psychosis and a substance use disorder and/or a personality disorder. Men with psychosis and comorbid personality or substance use disorders have a sixfold increase in risk of perpetrating a physically aggressive sexual offense and a three- to fivefold increase in risk of a nonphysically aggressive sexual offense (Alden et al., 2007). Based on these findings, it becomes apparent that it is important to consider that personality disorders and substance use disorders may interact in a synergistic manner with a psychotic disorder and increase the likelihood to sexually offend.

NGRI

Novak et al. (2007) examined a group of sex offenders at a state hospital in California who were found to be NGRI of their sexual offending. Within this sample, two out of three (n = 42) individuals had a diagnosis of schizophrenia or schizoaffective disorder; these rates are much higher than typically reported in the sex offender literature with regard to psychotic disorders. In addition, there was a high comorbidity of substance usage among those sex offenders found NGRI. These authors concluded that this sample of individuals could represent a previously unstudied group of sex offenders who have a psychotic spectrum disorder. Alternative explanations include improper evaluation of the substance use, intoxication, or malingering, as well as improperly applying the legal standard for insanity (Novak et al., 2007).

Miller, Stava, and Miller (1988) reviewed the insanity defense for sex offenders in Wisconsin to determine the impact of repealing Wisconsin’s Sex Crimes Act, which allowed the hospitalization of individuals convicted of sexual offenses. They found that post-1980 (following repeal of the state’s sex crimes act), there was a statistically significant increase in the proportion of sex offenders found NGRI, with an increase from 6.5% to 21.3%. Of the 47 sex offenders found NGRI after the repeal of the Act, 24 were diagnosed as psychotic and 23 were diagnosed as nonpsychotic (i.e., personality disorders, paraphilic disorders, or developmental disabilities). The authors focused on the significant portion of sex offenders in this sample found NGRI who were nonpsychotic. They explain this discrepancy by arguing that jurors and courts are making decisions about individual defendants to protect the public and provide treatment, as opposed to using strict guidelines of NGRI (Miller et al., 1988). However, similar to Novak and colleagues, this work also demonstrates a high number of sex offenders with psychosis found NGRI, without further inquiry into the nature of these individuals and the offense details.

Based on these data, further research is needed to better understand those sex offenders who have been found NGRI as they may have high rates of psychosis as demonstrated by Novak and colleagues as well as Miller et al. By better understanding this group of sex offenders, a clearer picture of whether they are a unique subset of sex offenders or instead if other factors surrounding the NGRI defense better explain this population. When searching the literature for sex offenders found NGRI, there was a paucity of research regarding those defendants specifically noted to be psychotic as well as addressing how these individuals were found NGRI (i.e., how their mental illness caused them to not be responsible for their actions at the time of the sexual offense).

Recidivism

Literature examining recidivism among sex offenders reveals conflicting opinions making it difficult to draw cohesive conclusions (Booth & Gulati, 2014; Greenberg, 1998). In a review of sexual recidivism in sex offenders, Greenberg highlights several limitations. Study samples are from vastly different populations, making larger generalizations about these individuals more difficult. In addition, descriptive variables about sex offenders vary with regard to choice and definitions, making it difficult to compare. Next, study design varies among prospective and retrospective studies. Finally, various definitions of recidivism are utilized (Greenberg, 1998). Despite these limitations, there are several studies worth further examination as they specifically address psychosis among sex offenders.

Langstrom and colleagues reviewed records of over 1,000 Swedish men imprisoned for sexual offenses. They identified a subgroup within this sample that met criteria for psychosis based on the International Classification of Diseases, ninth and 10th Revisions (ICD) diagnoses. Within this group, individuals were 5.1 times more likely to have a sexual reconviction compared with those without psychosis, with an average follow-up time of 5.7 years (Langstrom, Sjostedt, & Grann, 2004). This supports a meta-analysis completed by Hanson and Bussiere (1998) that also showed an association between sexual recidivism rates and sex offenders with severe mental illness.

Fazel and colleagues utilized data from Swedish national registries to further understand the risk of sex offending in those individuals with severe mental illness. They found sex offenders were 6 times more likely to have a history of psychiatric hospitalization when compared with the general population. They determined that sex offenders were more likely to have severe mental illness, including psychotic disorders and bipolar disorders (Fazel et al., 2007). The authors comment that these findings are in contrast to other literature in the field, requiring further study.

Broadening the search to recidivism among general offender populations, there is an increase in incarceration history for those with major psychiatric disorders, including psychotic disorders (Baillargeon, Binswanger, Penn, Williams, & Murray, 2009). Baillargeon and colleagues reviewed a retrospective cohort of 79,211 inmates and specifically looked at psychiatric histories. They found a significant increase in the number of incarcerations in the 6 years leading up to the index offense for those individuals with major psychiatric disorders (major depressive disorder, bipolar affective disorder, and psychotic disorders). In contrast, a meta-analysis by Bonta, Law, and Hanson (1998) determined that major predictors of recidivism were the same for those with and without psychiatric comorbidities for general offenders.

There is conflicting information as to whether or not psychiatric comorbidities, particularly psychosis, increase a sex offender’s likelihood of sexually reoffending. Also, the role of psychotic disorders is unclear with respect to general offenders and recidivism. Limitations found within the literature on this topic potentially explain the discrepancies noted; however, sex offenders with psychiatric comorbidities may differ from the general offender population and require further consideration for evaluation, risk assessment, and treatment (Stinson & Becker, 2011).

Female Offenders

Sexual offending perpetrated by women accounts for less than 10% of all reported sex crimes and considerably less is known about these offenders when compared with male sex offenders (U.S. DOJ, 2007). In a case-control study, Fazel, Sjostedt, Grann, and Langstrom (2010) reviewed convicted female sex offenders and compared them with a group of convicted female nonsexual violent offenders as well as a sample of women from the general population. They found that over a period of 13 years, 36.6% of female sex offenders had been admitted to a psychiatric hospital and that 7.5% received a diagnosis of a psychotic disorder. These findings were similar among the nonsexually violent offenders. In comparison with the general population, female offenders (both sexual and nonsexual) were at an increased risk of being hospitalized for a psychiatric illness and being diagnosed with a psychotic disorder. From these data, authors concluded that there is a lack of specificity with respect to psychiatric diagnosis in female sexual offenders.

West and colleagues reviewed information from alleged female and male sex offenders referred by the legal system to the court’s psychiatric clinic. They found that in the sample, there was only a small portion of women with severe mental illness (major depressive disorder and schizoaffective disorder) compared with male sex offenders with no reported severe mental illness. The low proportion of severe mental illness in this population was expected, based on the level of organization needed to commit a sexual offense (West, Friedman, & Kim, 2011). A significant limitation of these data was that it only represented those referred by the court for psychiatric treatment in the Cleveland, Ohio area. In addition, the sample size was small (n = 12) limiting generalizability of findings and increasing the probability for error.

There does not appear to be a significant difference between psychotic spectrum disorders among female sex offenders and those females engaged in other nonsexually violent offending. This, however, should be interpreted with caution as the literature on female sex offenders is limited, with the majority of empirically based studies being conducted only within the past 5 to 10 years (Cortoni, 2015).

Treatment Considerations

Sex offenders with severe mental illness, including psychotic disorders, frequently have unique treatment needs; however, this has received little attention in the recent literature addressing sex offender treatment (Booth & Gulati, 2014; Craig, 2011; Stinson & Becker, 2011). Booth and Gulati argue that an individual approach using bio-psycho-social treatment suited to the individual should be utilized. They recommend initially working toward establishing a diagnosis and subsequently identifying treatment goals with priorities for each specific psychiatric comorbidity. As an example, they conduct afternoon rather than morning groups for individuals with psychosis who may be sedated immediately following receiving morning medications. In theory, this would help to improve the patients’ ability to participate and learn during group sessions (Booth & Gulati, 2014).

Stinson and Becker report on prevention, risks, and clinical concerns surrounding sexual offenders with serious mental illness. In particular, an individual’s ability to self-regulate, medication compliance, comorbid substance usage, and establishing a support system around the sexual offender are crucial considerations. There may also be specialized needs such as living skills training or anger management (Stinson & Becker, 2011). Authors argue that a better understanding of this population is needed because of risk management, prevention, and policy implications.

Craig and colleagues highlight that although sex offenders with psychosis represent a minority of the sex offender population, they require a number of resources and higher levels of care for treatment. They recommend premorbid sexual pathology and “complicating illness-related factors” (i.e., sexual and social dysfunction) be considered during treatment planning. They support using a cognitive behavioral therapy (CBT) model for treatment, also noting that libido-suppressing medications should be considered for those individuals unable to participate in cognitive therapy (Craig, 2011). In addition, Craissati and Hodes (1992) reported on a small sample of sex offenders with psychosis who had reportedly committed sexual offenses during a relapse of psychotic illness, highlighting the need for close supervision and monitoring of these individuals.

Despite the growth in sex offender research over the past several decades, scientific understanding of sex offenders with psychotic disorders and treatment considerations for these individuals remain limited (Booth & Gulati, 2014; Cortoni, 2015; Craig, 2011; Craissati & Hodes, 1992). Based on what is available, a personalized approach to treatment for sex offenders with psychotic disorders is suggested with particular emphasis on aspects of the psychotic disorder that could limit the individual’s ability to participate effectively in treatment. In addition, monitoring for these sex offenders on an outpatient basis requires consideration of medication compliance, social support, and living skills (Stinson & Becker, 2011).

Conclusion

In this descriptive review, important aspects of sex offenders with psychotic illness have been described based on available literature. While sex offenders with severe mental illness may only constitute a small portion of the sex offender population, male sex offenders are 5 times more likely than nonsex offenders to be diagnosed with a psychotic disorder (Drake & Pathe, 2004). These infrequent but complex cases, with limited data available specifically addressing the relationship between the mental illness and sexual offending, can provide a dynamic challenge for providers in terms of evaluation and treatment (Booth & Gulati, 2014).

Multiple theories have been applied to describe the relationship between psychosis and sexual offending. Most theories identify the psychotic disorder as a distinct feature, which may or may not be related to the sexual offense itself (Drake & Pathe, 2004; Sahota & Chesterman, 1998; Smith & Taylor, 1999). One commonality from these theories is that the time course should be created for the development of psychotic symptoms, as well as any other psychiatric comorbidities. Doing so can help the evaluator/treatment provider better understand the context of the psychotic symptoms with regard to sexual offending. Additional factors such as antisocial personality disorder, paraphilic disorders, neurocognitive disorders, traumatic brain injuries, and substance usage disorders should be considered as important variables that may exacerbate sexually aggressive behavior, independently of psychotic symptoms (Drake & Pathe, 2004).

In reviewing literature exploring hospitalizations among sex offenders, Alden and colleagues (2007) concluded that men with psychosis and comorbid personality or substance use disorders have a sixfold increase in risk of perpetrating a physically aggressive sexual offense. And while psychiatric hospitalization rates appear to be higher for sex offenders with psychosis, less is known about recidivism rates for this population. Several studies suggest an increased rate of sexual recidivism for sex offenders with psychosis; however, this does not apply to recidivism rates among general offenders, a discrepancy that needs further attention by additional studies to address this concern (Booth & Gulati, 2014).

Much less is known about female sex offenders than males with psychotic illnesses. The presence of psychosis within this population does not appear to be different than men; however, this statement is made with caution as the literature on female sex offenders is in its infancy, with further research needed to validate findings. Because the majority of sex offender research has been conducted on males, it is critical to understand potential distinguishing features among female sex offenders and to apply understanding and principles of male sex offenders to females with caution (Cortoni, 2015).

Within the literature of sex offenders with severe mental illness, there remain significant opportunities for better understanding this population. First, further research is needed to test the various theories described above surrounding psychosis and sex offending. Next, further exploring NGRI patterns among sex offenders may help to elucidate whether this represents a unique population previously unstudied, as suggested by Novak and colleagues (2007).

In addition, recidivism research is needed to better understand rates among sex offenders with psychotic disorders. Limitations previously mentioned should influence newly designed prospective studies to produce results that are more generalizable for providers evaluating and treating these individuals, with a comprehensive evaluation of recidivism (i.e., sexual vs. nonsexual; Greenberg, 1998).

Finally, treatment considerations is a major area in need of empirical study in terms of specific treatment planning needs as well as after-care planning (Stinson & Becker, 2011). As noted by Booth and Gulati (2014), current practice is based on anecdotal experience with limited evidence-base for clinical practice.

In summary, sex offenders with comorbid psychosis present a particular challenge for mental health care providers and evaluators. A skillful approach to interviewing with a particular focus on history, index offense details, and psychiatric history will help to develop an understanding of the relationship between the sex offending and psychiatric comorbidity while treatment considerations require a more personalized and interdisciplinary approach. While sex offender research has increased in recent years, further attention is needed to address those sex offenders with severe mental illness.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The primary author received support for the research, authorship, and/or publication of this article through NIDA Grant Number R25 DA020537.

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