Life on “the List” is a Life Lived in Fear: Post-Conviction Traumatic Stress in Men Convicted of Sexual Offenses

Abstract

In recent years, there has been a rapid expansion of increasingly restrictive laws managing the post release behavior and movement of individuals convicted of sexual offenses. In the US, this legislation has led to many barriers for people returning to their community as “registered sex offenders.” We consider the often ignored but undeniable traumagenic impact of life on “the list” and conceptualize this experience as Post-Conviction Traumatic Stress. We present a qualitative content analysis of secondary data collected from interviews with over 70 men. Emergent themes were first organized according to the human needs identified in Maslow’s hierarchy, and then by the established symptoms of PTSD, and finally in terms of resilient coping versus traumatic coping when basic human needs were unmet. We discuss the unexplored impact of traumatic instability on risk for recidivism and present recommendations for trauma-informed policies and practices with individuals required to register as “sex offenders.”

Keywords

sex offending registration re-entry post-conviction traumatic stress quaternary prevention

Since the early 1990s, US jurisdictions have witnessed a proliferation of registration and community notification laws aimed specifically at individuals convicted of sexual offenses (especially against children) (Levenson et al., 2016). As the net gets wider, and the mesh gets finer, the number of Americans registered as sex offenders (RSO) approaches one million (National Center for Missing and Exploited Children, 2018). Collateral sanctions include public disclosure and restrictions on where they can live and work, extending fa r beyond the registrant and impacting their families, children, friends, colleagues, employers, and communities. In this study, we direct attention to the often ignored but undeniable emotional impact of life on “the list” by describing what we call Post-Conviction Traumatic Stress (PCTS). The lived experience of community re-entry following a custodial sentence is generally fraught with challenges (Western, 2018), but the plethora of additional obstacles and restrictions faced by RSOs undermines and complicates their post-release experience, often obstructing successful reintegration.

Introduction

A growing body of qualitative research illustrates the psychosocial impact of these policies with a focus on the lived experience of RSOs. Previous studies have focused largely on issues of housing, employment, support systems, and access to services. This line of research is vital because the evidence is clear: transience, homelessness, lifestyle instability, civic disengagement, social disorganization, and unemployment are criminogenic (Andrews & Bonta, 2017; Pettus-Davis et al., 2019; Uggen et al., 2004; Western et al., 2015). One dimension of re-entry that has been neglected in the literature is the traumagenic toll associated with reintegration barriers, and the resulting stigma, shame, and fear experienced by RSOs and their families (Bailey, 2018; Harris et al., 2017; Sample et al., 2018; Willis, 2017).

Longitudinal research now demonstrates that desistance is the modal outcome upon release and that recidivism rates for sexual offenders are generally low (Hanson et al., 2018; Harris, 2017). We know that successful community re-entry and desistance are most likely achieved in the presence of protective factors such as positive interpersonal connections, the pursuit of intimacy and self-efficacy, the development of social supports, and living a purposeful and productive life (Craig & Rettenberger, 2018; de Vries et al., 2015; Livingston, 2018; Willis & Ward, 2013). We also know that the cumulative consequences of adverse life experiences can contribute to maladaptive coping and self-regulation deficits that manifest in dynamic risk factors for both sexual and nonsexual recidivism (Levenson et al., 2017; Pettus-Davis et al., 2019). The experience of fear and stigmatizing labels can be traumagenic and can therefore challenge an RSO’s already compromised coping skills.

We contribute to knowledge about successful community reintegration by considering the psychosocial burden of navigating one’s re-entry while labeled as a “sex offender.” Using a trauma-informed framework, we draw on the research about strain (Agnew, 1992), labeling (Paternoster & Iovanni, 1989), and human needs (Maslow, 1943) to describe how fear and functioning intersect. We illustrate how each component obstructs the pursuit of desistance using rich insights from RSOs who are living in the community.

We introduce the phrase PCTS to describe the specific suite of cognitive-emotional symptoms experienced by RSOs which are related to post-conviction circumstances and are similar to the DSM-5 criteria for Post-traumatic Stress Disorder (PTSD): intrusive thoughts, avoidance, negative thinking and affect, and hypervigilance (American Psychiatric Association, 2013). Indeed, the experience of every stage of one’s passage through the criminal justice system can be simultaneously traumagenic and criminogenic (DeVeaux, 2013; Western, 2018). We focus specifically on the ways that fear and stigma jeopardize the re-entry process for this already severely disenfranchised population.

The Construct of Traumatic Stress

Trauma is described as an experienced or observed event that threatens one’s sense of physical or psychological safety and produces feelings of anxiety and helplessness (American Psychiatric Association, 2013; Bloom, 2013). The experience of trauma can involve a single event and its aftermath, but many people live in traumagenic environments that create chronic and cumulative toxic stress. Such overwhelming conditions can hinder the integration of emotions and experiences, leading to dysregulated feelings and behavior (Bloom, 2013). In an effort to adapt to the demands of an environment that feels unsafe, some people develop unhealthy ways of thinking about themselves, others, and the world, and they engage in maladaptive coping strategies, which can include addiction and criminal behavior (Bloom, 2013; Kubiak et al., 2017; Najavits et al., 2009). The clinical presentation of trauma and stress-related disorders varies among individuals, but symptoms usually involve re-experiencing the trauma, avoiding triggers, and suffering negative emotional reactivity (American Psychiatric Association, 2013).

The DSM-5 clinical workgroup explored the controversies about how to define whether a specific event is considered traumatic, and elected to narrow the definition in Criterion A to life-threatening events, serious injury, or sexual violence (Friedman, 2013). However, after other experiences that do not explicitly meet criteria for PTSD Criterion A, people can display clusters of very similar symptoms that are perceived as persistent and distressing. Post-trauma responses can mimic and intersect with symptoms of other disorders, such as dysphoria, negative-mood states, insomnia, irritability, and cognitive impairment (Friedman, 2013). Significant traumatic experiences can create a sense of discontinuity, with the trauma representing a before and after moment (Friedman, 2013). Though they may not specifically meet DSM-5 inclusion criterion A, a sex crime accusation, arrest, incarceration, and registration can constitute a constellation of experiences that are life-altering and create fear and powerlessness, rendering them traumatic (Liem & Kunst, 2013; Pettus-Davis et al., 2019).

Early Trauma and Adult Offending

In the mid-1990s, research by the Centers for Disease Control (CDC) revealed the staggering prevalence of a certain set of developmental traumas called Adverse Childhood Experiences (ACEs) (Centers for Disease Control and Prevention, 2013a; Felitti et al., 1998). Nearly two-thirds of American adults in the sample (n > 17,000) experienced at least one form of child maltreatment or family dysfunction, and about 13% had experienced four or more (Centers for Disease Control and Prevention, 2013b; Felitti, 2002). The accumulation of ACEs is associated with poorer physical and mental health as well as negative psychosocial outcomes in many different domains across the lifespan (Anda et al., 2010).

Many people who commit crimes have higher rates of ACEs than the general population, and higher ACE scores increase risk for crime and incarceration (Baglivio et al., 2014; Harlow, 1999; Jäggi et al., 2016; Maschi et al., 2011; Roos et al., 2016). Men convicted of sex crimes in particular tend to have extensive histories of childhood trauma, with about 46% falling into a high-ACE category (four or more) (Levenson et al., 2016). Early adversity paves the way for disrupted attachment, dysregulation, distorted cognitive schema, and poor interpersonal skills (Bloom, 2013; Grady et al., 2016; Harris & Fallot, 2001).

When children are exposed to ongoing trauma, survival mechanisms are strengthened while other areas of the brain—particularly executive functioning (cognitive processing, decision-making, and self-regulation)—are compromised. These neuro-cognitive deficits in adaptive functioning seem to underlie what are known as dynamic risk factors and the central eight criminogenic needs (Cheng et al., 2019; Wojciechowski, 2020).

To be clear, not all abused children grow up to engage in crime, but the biological, social, and psychological consequences of early trauma raise the risk for criminal behavior later in life (Baglivio & Epps, 2016; Jäggi et al., 2016; Topitzes et al., 2011; Wallace et al., 2011). Mistreated youngsters may display impulsive or risk-taking behavior; they are more likely to associate with delinquent peers, to self-medicate with drugs or alcohol, and to provoke interpersonal conflict with others. For people who sexually offend, early adversity may have contributed to emotional congruence with children, or hostile feelings or behaviors directed toward women (Levenson et al., 2017). Early relational traumas can lead to a tendency to seek out or exploit others who are more vulnerable and less threatening (Ardino, 2012; Grady et al., 2016; Grady et al., 2018).

Theoretical Model: The CJS is Traumagenic

Other researchers have described the negative consequences of CJS involvement and the traumatic stress of re-entry (Liem & Kunst, 2013; Listwan et al., 2013; Western et al., 2015). Even single, brief contacts with police, courts, and jails can create traumatic stress and negatively affect physical and mental health over time (Fernandes, 2020). The most salient challenges identified after incarceration included severe financial hardship resulting from unemployment, necessitating a reliance on public assistance and/or relatives (if available) for support and housing. For those with histories of addiction and mental illness, these challenges are exacerbated by estrangement from family, unstable housing, and under-employment; the resulting anxiety, social isolation, and material insecurity creates significant stress during the transition to life outside prison (Pettus-Davis et al., 2019; Western, 2018; Western et al., 2015).

Upon release from custody, RSOs in most states face enhanced restrictions and surveillance while they pursue life goals and daily activities (Ten Bensel & Sample, 2018). Many registrants confront limited housing availability and displacement due to residential restrictions (Levenson & Cotter, 2005; Tewksbury & Mustaine, 2008; Zandbergen & Hart, 2006). They endure reduced employability, complicated by restrictions on computer use and internet access (Rydberg, 2018; Tewksbury & Zgoba, 2010). The social stigma of registration extends to the RSO’s children, household members, and romantic partners, who suffer disruptions in family life, housing and financial insecurity, shame, and fear (Kilmer & Leon, 2017; Lytleet al., 2017). The severity and duration of collateral sanctions are perceived as insurmountable to RSOs and their families; indeed, in many states they persist for life with no opportunities for redemption (Bailey, 2018; Sample et al., 2018).

There is a body of knowledge that details the distress caused by the adversarial nature of our court systems, the devastating physical and psychological effects of incarceration, and the need for trauma-informed correctional services (Fernandes, 2020; Kubiak et al., 2017; Levenson et al., 2017; Liem & Kunst, 2013; Sadeh & McNiel, 2015). An emerging literature describes post-incarceration syndrome, pointing to the unique cluster of complex PTSD symptoms in former prisoners (Liem & Kunst, 2013; Pettus-Davis et al., 2019). Men returning home after long periods of incarceration described the endurance of all four clusters of PTSD symptoms: intrusive thoughts and nightmares, hyper-arousal and startle responses, avoidance of crowded places or overwhelming external stimuli, and emotional detachment associated with protection against vulnerability (Liem & Kunst, 2013). Institutionalization and paranoia can persist even after release (Liem & Kunst, 2013). There has been a call for consideration of a post-incarceration subtype of PTSD in future DSM revisions, with additional criteria including institutionalized personality traits, spatial-sensory disorientation, and social-temporal alienation (Liem & Kunst, 2013). For men convicted of sexual offenses in the USA, post-release supervision and re-entry are fraught with challenges that are exceptionally daunting. We use theories related to strain, labeling, and human needs to conceptualize the unique factors that contribute to PCTS for RSOs.

Strain theory

General Strain Theory (GST) postulates that sources of social and psychological stress can compel people toward committing crimes (Agnew, 1992). These strains can include relationships in which an individual is not being treated well by others, situations or perceived obstacles that prevent someone from achieving their goals, or the inability to escape from painful life circumstances or social injustice. Stark disparities between one’s aspirations and achievements can cause anger, disempowerment, and learned helplessness. Inequities can cause someone to engage in crime in desperate attempts to meet human needs, to seek vengeance against perceived unfairness, or to re-establish a lost sense of self (Agnew, 1992). Recent investigations of GST lend credence to the idea that traumagenic prison conditions, and the secondary hardships of re-entry, can increase risk for recidivism when stressors aggravate negative mood states, reduce self-control, and push individuals to seek connection with criminal peers (Listwan et al., 2013).

Labeling Theory

Labeling shapes the construction of social identity (Goffman, 1963; Maruna et al., 2004). As a result of negative societal narratives, people sometimes adopt behaviors that create a self-fulfilling prophecy (Paternoster & Iovanni, 1989; Willis, 2017). The stigma of a felony label hinders employment, housing stability, and access to social supports; these obstacles can foster disempowerment, social isolation, hopelessness, and shame (Braithwaite, 1989; Laub & Sampson, 2001; Listwan et al., 2013; Maruna et al., 2004; Uggen et al., 2004). Stigmatizing labels undermine self-efficacy and prevent the process of cognitive transformation associated with desistance and reduced risk of recidivism (Maruna et al., 2004; Willis, 2017).

In the U.S., sex offender registration policy obstructs successful reintegration, labeling individuals for life (sometimes because of a single incident) in ways that negate any positive aspect of their character and behavior. The RSO label is ostensibly used to alert and protect community members, but can preclude stakes in conformity, paradoxically reinforcing deviant identity and criminal behavior (Bernburg et al., 2006; Paternoster & Iovanni, 1989). Registration and its associated life-long stigma can create stress, anxiety, fear, shame, depression, loneliness, social isolation, and hopelessness (Jeglic et al., 2011; ten Bensel & Sample, 2019; Tewksbury & Mustaine, 2009). Facing significant impediments to safe and successful re-entry, many registrants describe deep desperation and despair (Harris, 2017), along with the constant and crippling fear and anxiety we refer to here as PCTS.

Maslow’s hierarchy of basic human needs

Maslow’s hierarchy (Maslow, 1943) proposed that all humans have basic needs for survival, safety, social acceptance, self-efficacy, and self-actualization. Post-incarceration syndrome also reflects difficulties securing and maintaining the range of basic human needs described in Maslow’s hierarchy: some men described profound social alienation and a fear that the life they are rebuilding could be taken away at any time (Liem & Kunst, 2013). Self-actualization might be impeded when a moral injury results from conviction and imprisonment, and is reinforced by systemic de-individuation and stigmatization (van Willigenburg, 2020).

Simply put, when basic human needs are absent or lacking, the amygdala is activated due to a sense of physical or emotional danger. Traumatic stress reactions occur when someone is exposed to a perceived threat, feels helpless or vulnerable, and capacity for coping is overwhelmed (van der Kolk, 2006). Neurocognitive stress responses can include intrusive or ruminating thoughts or images, avoidance of reminders of traumatic events, negative thoughts or feelings, and hyperarousal with increased reactivity to environmental cues (American Psychiatric Association, 2013). RSOs may experience PCTS when triggered by situational challenges post-release, and current stressors can intersect with and re-activate trauma responses from earlier in life (Levenson & Willis, 2019; Listwan et al., 2013; Pettus-Davis et al., 2019). Coping strategies can be maladaptive or resilient.

Purpose of the Study

The present study explores the lived experience of community re-entry for RSOs. Using qualitative data from an existing database of interviews, we examine the under-researched traumagenic burden on men with convictions for sexual offences and focus on how they negotiate their life after custody under intensive public scrutiny, in the face of invasive monitoring, and while complying with strict supervision requirements. We first draw on the interview narratives to provide examples of Maslow’s (1943) basic human needs. Next, we articulate the ways that an inability to meet those basic needs can result in PCTS and use the men’s own words to illuminate those themes. Finally, our analysis reveals the emergence of two sets of coping strategies and we provide evidence of each one using the narratives verbatim.

Method

Participants and Data Source

The present study involved the secondary analysis of a qualitative database of interview transcripts. Participants in the original study included 74 men incarcerated for sexual offenses and released to the community in the Northeastern U.S. The average age of the sample was 53.7 years (Range = 24–79 years) and almost all of them (88%) identified as White. The men were recruited and interviewed between 2011 and 2013 as part of a separate study (Harris, 2017). Interviews were initially guided by the Life History Interview Protocol (McAdams, 1993) and additional semi-structured questions were added to elicit further details about the interviewee’s: (1) family and relationships; (2) employment, education, and military service, and; (3) lived experience of the criminal justice system (including arrest, prosecution, incarceration, and community re-entry). Interested readers are referred to Harris (2017) for more specific details about the interview process and original data collection procedures.

Analytical Approach

The interview database was analyzed using a qualitative narrative approach (Atkinson, 1998; Franzosi, 2010) that was ultimately informed by the nature of the themes that emerged in the original study (Harris, 2017). In particular, we began with the often-described experience of paralyzing fear and hypervigilance. These characteristics have elsewhere been identified as typical of a rehearsed or restricted style of desistance (Harris, 2017). In reflecting upon these themes and the strength with which they emerged, we found it useful to conceptualize these experiences within the diagnostic descriptors of PTSD.

We returned to the original transcripts to each of the four domains of lingering symptoms of PTSD. The transcripts were revisited by the first author and coded by two trained graduate students. It is important to note that the formal interview protocol did not include any specific prompts about an individual’s experience of hypervigilance or PTSD. Instead, the phenomenon of fear, the description of its many layers, and the often irreparable impact it had on participants were all themes that emerged naturally. As we analyzed the emergent themes, we found Maslow’s hierarchy of needs (survival, safety, belonging, self-esteem, and self-actualization) to be a useful framework in which to organize the fears the participants expressed. These themes of fear and the emergent coping styles that the men articulated are discussed in more detail below.

This study adheres to “emergent design” (Creswell, 2013, p. 47) and was intended to be exploratory rather than confirmatory. Therefore, our goal was to amplify our participants’ voices and share their stories. Although we comment on the abundance of some themes, we acknowledge that the size of our sample and the nature of the questions asked precluded us from performing compelling statistical analysis. Although the overall impact of our findings is limited by these shortcomings, these flaws do not preclude our original intent of presenting the emergent themes of Post Conviction Traumatic Stress in our sample.

Results

We conceptualized PCTS as the result of the deprivation of human needs and the obstacles to pursuing them. Results are presented in three parts. We provide evidence of each theme below using direct quotations from the participants. First, we observed a remarkable chasm between having and meeting the needs described by Maslow. Next, we illustrate how the characteristics of PCTS were described by participants, organized by the DSM-5 symptom categories listed for PTSD. Finally, we present two distinct coping strategies that emerged in the men’s stories: traumatic and resilient coping, which we illustrate with the men’s own words.

Themes Organized by Maslow’s Hierarchy

Survival

One’s need to survive and the simultaneous fear of not being able to survive was prominent in the minds of most men. Saturation was reached very quickly on the basic human need of housing. Almost without exception, participants expressed considerable difficulty finding a place to live:

I would like to get a new apartment. I would like to get off these streets. Just stop being scared, man.

So sex offenders can’t get jobs, they can’t get a place to live, they have to live with family or whatever, but they don’t get no public assistance, no jobs, they can’t work, so if you can’t work, you can’t get a place to live, what are you going to do? Many of them are going to reoffend only to go back, it’s a revolving door.

[I’m] having a hard time finding a place to live. That’s the worst part about being a sex offender, is that nobody wants, “not in my neighborhood,” “we want to help you, we’ll spend the money for the treatment” but “. . . go somewhere else.”

Safety

Safety fears related to perceived threats from vigilantism, police, false accusations, and the dangers inherent in living on the streets. The fear of public exposure was a common theme that elicited great anxiety. This was frequently described in terms of fear for one’s physical and personal safety and security.

I don’t ever want to be put in a situation where somebody can say [something] and I cannot refute it, because what can I say?

My concern is that somehow someone could say something about me, make up a story about me. You could go right now to the police and say that I did something to you and even though I didn’t, they’re going to believe you before they believe me, so I worry about that.

When I leave the shelter I’m at risk. When I’m in that shelter, I’m safe.

Some described a specific fear of vigilantism. This fear was not unfounded, as many of the men recalled an incident where RSOs were shot after having been identified in the public registry.

There was a footnote in the Wall Street Journal I think back in 2006 about two men in Maine being killed because they were sex offenders. Some guy from Canada had come over, had their address from the registry and knocked on their doors and killed them. The headlines were “two sex offenders shot in Maine”, not “two men murdered”. The value of a sex offender is minimal. Once you’re on the sex offender list, it’s all over. You’re subject to lifelong punishment.

I’m a target for any vigilante group or vigilante person. Anybody that wants to know where you are or who you are can find you.

Belonging

Substantial literature indicates that social connection, the pursuit of intimacy, and the support of a loving family and friends can ease one’s transition back into the community (Western, 2018). Of the men in our sample who had romantic partners at the time of their conviction, only two had remained in the same relationship. Almost no one was actively dating. They expressed fears of meeting new people due to the stigma of their easily discovered registration status, and the dilemma of who to tell, when, and under what circumstances.

I mean, when I first got out, I thought the world knew my background. I was afraid to sit next to a woman on a train, you know?

There’s paranoia in me because, um, my probation conditions are to, if I meet a woman, I have to tell her my whole background, y’know?

Of the men who had children, almost all had lost custody of and contact with them years ago. They were not at all confident about forming friendships or relationships in the future. For some men, this was a terrible loss:

The biggest thing I miss is being with a woman my own age. Being with a woman, on my own, just the company and somebody to be around.

[My fear is] to not have a relationship. You know, I’m a sex offender now, but I’m young. I’m 26, and it would be nice to have a family before I die.

Many men felt abandoned by their friends and families and few had been able to successfully reconnect with anyone from their past.

I ruined my family. I mean, I can’t see them. To my knowledge my kids think I’m dead.

I lost the trust of my family and. . . I don’t know if they’ll ever talk to me again.

Some felt that pursuit of hobbies could lead to situations that might be misinterpreted. The impact of the registry had serious bearing on their ability to connect or engage with others.

[when asked about hobbies or what he likes to do in his spare time] I don’t dare at this point. Again, that’s part of getting out there. Do I want to join a bowling league or something? Yeah I might like to, but what if they [the other players] find out [I’m on the registry]?

Self-esteem

Many men described great difficulty finding a job upon release. This situation is well documented for anyone with a criminal record, but employment barriers were exacerbated by laws requiring participants to identify their place of employment on public registries. For example, one man had a long work history of landscaping but felt deterred from looking for a job. He said:

I want to get work but I just back down. I don’t want to be put out there more, you know? Plus, as I gotta work in a yard, they might have kids running around, summer time out, I don’t want anything to happen, like, for them to think I look[ed] at them the wrong way, they follow up on who I am, and that’s what scares me so, you know, and they have their right.

The men frequently described feeling depressed because they were unable to participate in meaningful activities, like employment. The feeling of being disengaged and the fear of being rejected intersected with a loss of an important part of their identity:

I was very good at my job; my career. I was respected. I was well liked in the companies that I worked for. I was liked within my community. . . I have applied to 150 companies. I’ve had five interviews, and I consider myself very fortunate to get interviews. Three out of the five interviews that I had, the company wanted to hire me, and then the background check comes in. . .

Self-actualization

It was rare for the men to articulate a desire for the opportunity to reach their potential. To be sure, they were too often concerned with more basic human needs like where they would be sleeping that night or where their next meal would come from. For the small group of men who had managed to meet those more basic needs, some did mention a desire to better themselves, through study or volunteer work. One man described the obstacles that stood in the way of him going to college. Shortly before his interview, he was very close to graduating with a degree in communications. Suddenly, although he had been living an offense-free life in the community for almost 7 years, the laws changed:

I got right into college. I hit it like a duck to water. I loved education, being educated. I loved being, um, an older person in class. All these kids—18, 19, 20 years old would be able to look to me for the answers and I would be able to draw on them for their enthusiasm and it was a great synergistic relationship we were having and I knew they weren’t my victim pool, y’know? It was great. It was fantastic. And I was getting straight A’s.

I was at the school for almost eight months and then they called me up to the dean’s student’s office and they said, “We’re going to put your picture up, your poster up, because you’re a level 3.” . . . The cops—campus police—were chasing me around all the time, harassing me and finally I just said. . . I had 12 more credits to go and I just couldn’t take it. I couldn’t deal with it, so I left.

One man was preparing to run a marathon and proudly described his involvement in an exercise club that advocates for the homeless through running. He explained the constant feeling of being marginalized, never able to fully embrace the organization:

It’s hard for me because I can’t embrace Back on My Feet. . . it helps homeless people and a lot of them struggle with addiction. We get people that are showcased [on the website and newsletter] like a guy that ran his first marathon…. So, I have to take a step back from any of the type of situations where I’m connected with any type of organization or anything where I could be in the public eye.

More commonly, they talked with sadness of lost opportunities:

I’ve always known what it is to be independent and self-sufficient and capable and now I feel handicapped because I still am smart and educated and capable but I’m handicapped because now if I apply for a job I get scrutinized and my criminal history gets looked at

For those whose offenses were a long time in the past, they acknowledged the loss of dreams and hopes, and lamented that their other positive qualities would always be over-shadowed by the RSO label:

I’d like to be remembered for being a good man, and not just being a sex offender, y’know? That’s all he was—the sex offender who painted or the sex offender who. . . anytime you read a newspaper article and you know, if the guy jay walked he was “the sex offender who jay walked.”

Themes of PCTS Symptoms

Inability to meet basic human needs can generate a traumatic stress response. As the participants described their thoughts and feelings about the challenges of re-entry, the four categories of PTSD symptoms emerged very strongly. We present our observations of each symptom below.

Intrusive thoughts or images

The DSM-5 describes intrusion as persistent memories of a traumatic event. Intrusive thoughts or flashbacks may come in the form of recurrent themes and content related to the traumagenic situation and may arise when exposed to internal or environmental cues that symbolize the traumatic context.

I will still have flashbacks at night or bad dreams about prison or some of the crap that I did and I just get up the next morning and I don’t feel well. That’s when I get busy, go to my brother’s, ride my bike, or try to find and read the Bible or try to find something good on television (which is hard to do).

Some obsessively feared that they would unintentionally breach a rule without knowing it.

I was petrified the day I got out, because I was told that if I was even seen near a school or day care I was going back to jail. Well, the thing is, you don’t know where all of the schools and day-cares are. There could be a home-run day care that you don’t know anything about.

Avoidance

PTSD can generate a persistent avoidance of people, places, activities, or situations that evoke distress. Although some men considered “being seen” as an alibi, most expressed a fear of being seen or worse—being wrongly accused—as reason enough to rarely leave the house. As a result, they avoided relationships.

I’m just human, y’know? I would love to [have a relationship], but I’m scared, y’know? I’m scared that if I tell her who I am, maybe they’ll say “no.” Then my business [will be] out there again. You know what I mean?

Some avoided places or circumstances in which they might encounter children. While in some cases this might have been an appropriate part of a relapse prevention plan, in other cases it seemed to interfere with the everyday tasks of daily living. One man described being afraid to move autonomously in his community:

It’s like, how can we go anywhere? I mean, you get out, you’re afraid. We got some guys [in group] that get out and they’re afraid to go grocery shopping.

Another man described shopping with his elderly mother, and seeing a woman’s shopping cart spill over. He wanted to help her, but she had a small child in a stroller, and he was scared that his offer to help could be misinterpreted. He was the only other person around and described how difficult it was to walk away without offering to assist her.

You don’t know how difficult it is, just to go day by day by day and say, well, y’know, I don’t want to be a real jerk. I want to be a gentleman and help that lady or something, but, like I say that thought is there, and it’s a scary thing.

The biggest problem I have is uh, is uh, I tend to isolate and my life has kept, gotten to a point where isolating is even easier because I don’t have to tell people I don’t want to do stuff, I just don’t have people to do stuff with.

I come to group, I don’t drink, I stay home, I try to avoid kids. But I mean life is life, you cannot go around the rest of your life try[ing] to avoid kids. I don’t go anywhere without somebody with me.

Negative thoughts or feelings

According to the DSM-5, alterations in cognition and mood can include negative beliefs about self or others, a sense of persistent danger, diminished interest in activities, feelings of detachment or estrangement, and the inability to experience joy. Many men expressed these feelings:

I spend every minute of every day that I am not sitting in my house, when I’m out in the world, I look everywhere and ask myself: “Okay, how can this situation turn negative for me very fast?

And honestly the thing that frightens me more than being shot, because I am not suicidal in any manner, but I am, I favor death and uh if someone came and shot me, the only thing I would say is “please make sure you do the job.”

Hyperarousal

The DSM-5 describes alterations in arousal as irritability, anger, reckless or self-destructive behavior, hypervigilance, startle response, problems with concentration, or sleep disturbances. The most common description of hyperarousal was a vigilant reliance on surveillance, scanning the environment for danger, as a form of insurance or protection, like an alibi.

I look over my own shoulders to see who’s behind me. I’m protecting me, while society’s protecting me.

My cell phone, I have the GPS on it and I leave it on so people know, not so much so people know where I am as they know where I’m not. So, you know, if something happens across town maybe they can look at my GPS and see that I wasn’t there.

[GPS] can prove where you were. If someone were to throw some accusations that you did such and such, you can go to the monitor and say “no, because it says I was here at this time.”

In another example, what might otherwise appear to be an attempt at belonging was actually an example of maintaining one’s safety:

I always have my aunt with me. You know, for a witness, everybody always tell me too, why you always got your aunt out here, because a witness or anything, protection, a support person, and that’s good you know, she keeps talking with me, me and her talk all the time, on the train.

Themes of Coping Strategies

Having examined the extent to which the participants were unable (or afraid) to get their needs met upon release, and their PCTS symptoms, we then explored the coping strategies that they described using in the face of these challenges. Two main themes emerged—traumatic coping (or “hypervigilance”) and resilient coping. We describe each one below.

Traumatic coping

Most participants displayed a style of coping which was accented by crippling and ultimately futile hypervigilance. Unlike the resilient coping strategies described next, these men did not describe a motivation to atone or turn over a new leaf, but instead seemed obsessive about complying with the law to avoid exposure or re-incarceration. In many examples, these coping skills were typical of the “resistant” and “regulated” desistance strategies identified by Harris (2017). Maladaptive avoidance of certain people, places, and situations appeared to have been emphasized so heavily during their treatment that it was now all-consuming and thwarted their pursuit of healthy relationships or activities. For some, this appeared to be too much:

[Walking] is the only thing I can do for exercise at this point in my life but you know what? I take a walk and I’m walking down the street and there’s kids going to school, Oh no! What do I do now? Right, I gotta cross the street, get outta the way.

The men who subscribed to a more maladaptive style of traumatic coping focused on the here and now, and long-term future plans seemed impossible. They moved 1 day at a time, with one foot carefully in front of the other. They were cautious and they lived as if every action they took was carefully monitored and controlled. When asked how they maintained an offense-free life, what they looked forward to, or how they spent time, a common response was simply to never leave the house. As one man describes:

What really scares me is having no alibi. That’s the scariest part because if I get blamed for anything, I’m already in the wrong. I’m on probation. I’m a sex offender. I already got the three strikes against me right off the bat. You know what I mean? I’m a convict. I got three strikes before I even walk out my door.

This is consistent with the “reclusive” style of regulation described by Harris (2017). These men obsessively monitored their behaviors and regimented their every move, not because they felt they needed to avoid certain areas or circumstances to prevent an offense or because they felt at risk of relapse, but because they were paranoid that someone would accuse them of doing something that they didn’t do, or they would end up “being in the wrong place at the wrong time.”

I don’t feel at risk but I feel really nervous because I was accused already of that with a girl and I feel. . . I usually have anxiety anyway, so you know I feel a little nervous just out of the anxiety part and plus I’m on probation.

The men also experienced hypervigilance in their interactions with law enforcement. The man below describes feeling a pressure to reach out to his probation officer for “every little thing” due to what were regular occurrences in the rough neighborhood where he lived:

Having to call my probation officer to say, “hey. I’m gonna have police contact today cos we have a dead body in the rooming house [where he is staying]. This guy passed away in the house.” I mean, there is nothing I can do about it, I mean the PD is going to question everybody.

Two men described a restricted life where all time was accounted for, and every interaction was detailed, dissected, and reported:

My grandson, 9 years old, before he came out of my daughter’s belly, we had a long, long talk. I will never be left alone with him. Not because I’m going to do anything, y’know? I’ve never done anything to her, it wasn’t about that, but you cannot give the image; you can’t give the image, the perception. . .

[Some guys in group] are worried that they’re gonna bump into a kid in the shopping aisle and probation will be right there and they’ll be violated and some people have that legit fear.

For some people, maladaptive coping might include using substances to self-medicate, becoming quick to anger, or over-reacting to environmental stressors. From his prison cell, a man who recidivated reflected on the impact that PCTS had on him during his short release. He articulated how his traumatic coping style was ultimately an ineffective approach to living an offense free life and attributed his return to custody to the obstacles of belonging and social acceptance described above.

It is very understandable, that sex offenders are to be worried about. But I worry that if in making it more difficult, the community doesn’t make more problems for itself. If you tend to segregate them, make it more difficult for them to transition, then you are creating something pretty negative in people who very reasonably and logically need that support.

Resilient coping

In stark contrast to the traumatic coping illustrated above, some men described their approach to re-entry as a proactive method of keeping themselves safe. These men tended to be more accepting of their life circumstances, and reflected Harris’ (2017) resilient or rehabilitated desistance strategies. Their narratives were characterized by an apparent motivation for true reform, and a perceived internal locus of control. Resilient coping was more typical for the better educated and higher functioning men in the sample. Those who were employed in skilled positions before their conviction or who had participated gainfully in many years of cognitive behavioral therapy were able to articulate how they had changed their thoughts and behaviors upon release. They seemed to reframe fear as an adaptive type of caution that could be construed as a positive attribute:

I say this in group all the time ‘cause you have to have a heightened state of awareness constantly, constantly, and people don’t like that, they say: “How can you live like that?” and I say, “you know what, I don’t look at it that way, I look at it as [if] this is my special gift. I have a very special gift that people out in the world don’t have. I have this sense of awareness about who I am.”

Basically, paranoia is underrated. If everyone were a little bit more paranoid, the world would be a better place. I believe that we all, offenders, have to live the rest of our lives with a low heat setting of paranoia. You’ve got to be paranoid because you have to be thinking, “well, how will they think? I know why I’m standing here, but if somebody sees me, what will they think?

I’ve got a car with cruise control on it and if the speed limit is 25 I put cruise control on to make sure I don’t speed. I am beyond compliant with my parole and probation. I don’t break any laws. If I’m on the highway down to [next town] and the speed limit’s 70 and people are going around me, let ‘em go, I’ll get there when I get there.

The power of surveillance (whether real or imagined) emerged as a strong motivator for law-abiding behavior. For example, one man described how he stopped himself from stealing when he noticed himself examining the security vulnerabilities at his local shopping mall.

I’m just too careful. One of the things that, another thing I remember from treatment that I took from treatment, actually I took it from anger management, is when you start to have certain feelings that you should have a red flag word. . .I decided on the word “camera” because never a day goes by that somebody’s not caught doing something on a camera, cell phone, or whatever. So, whenever I have thoughts of any kind, not necessarily sexual but anything that is, you know, speeding, whatever, I pop the word “camera” in to my mind. The first time I went to the mall I found myself looking at security systems instead of the goods, checking things out so to speak and just thought “camera”. You know, wherever you’re at, somebody’s looking at you.

Many men still worried about incidental contact, despite reassurance from probation officers:

They hype you up so much while you’re in [prison]. Y’know, if you are near a kid you get violated, if you talk to a kid you get violated. . . My first couple days out, I mean, I’m walking down the street and a kid almost ran into me and that’s when I talked to the probation officer. He says, “look, if you aren’t there staring at the kid, don’t worry”

In general, the participants seemed to understand the rationale behind the restrictive legislation. But they also articulated how these approaches were likely ineffective because they interfered with the ability to meet basic human needs, precluding protective factors known to be associated with successful re-entry. When asked what he wanted to share with the public, or what he wished others could understand, one participant reflected on his own childhood trauma and its intersection with his current circumstances:

We are complicated people. One thing sums it up: Trauma. Whether you think about it as a war victim, or someone who has been brutalized in a particular way, I think there’s a philosophy and a feeling about life that is directly related to trauma. I think for most people, since we are composed of all the experiential dots in our life, that how those dots are connected will determine how you live your life.

Discussion

We conceptualized PCTS in three parts: (1) Challenges meeting basic human needs; (2) Facing unmet needs, participants displayed post-traumatic stress symptoms; and (3) Coping strategies were sometimes maladaptive or disruptive, and sometimes reflected astounding resilience. We noted that although human needs are universal, not everyone is equally equipped to have their needs met. Their descriptions captured the primary DSM-5 symptoms of PTSD: intrusive thoughts, avoidance, negative emotions, and hyperarousal. The techniques they used to navigate their re-entry were commonly marked by fear-management, paranoia, hyper-vigilance, and self-enforced isolation. A smaller number of men described turning their fear into empowerment and adopting a resilient coping approach that allowed them to feel an internal locus of control.

It is possible that traumatic coping was more likely for people with past adversities in life, while resilient coping was reflected more consistently by those who exhibited better functioning prior to their conviction. Other authors have highlighted that many people returning to communities from prison have a lifelong history of trauma and violence, and their current anxiety is reinforced by a turbulent lifestyle, intersecting with the enduring effects of a stressful incarceration experience (Western, 2018). Western described how human frailty can be deeply embedded in the psyche of those lacking a sense of agency, empowerment, hope, and dignity. Future research integrating our understanding of ACEs, incarceration trauma, resilience, coping, and desistance would help to elucidate the way these factors are connected.

Taken together, the strongest emergent coping styles in this study were hypervigilance, with an understandable but misplaced reliance on the insurance of surveillance. We know, however, that desistance is facilitated (and that risk of recidivism is reduced) by pursuing meaningful employment and pro-social relationships, being part of a community, and maintaining mental and physical wellbeing. In stark contrast to this vision, many of the men described fear and avoidance goals, such as people, places, behaviors, and situations to stay away from. We suggest that by reframing reintegration goals as approach-oriented, RSOs would be enabled to identify realistic and meaningful objectives that they can acquire, attain, or achieve rather than simply circumstances to be avoided (Yates & Prescott, 2011).

Western (2018) noted that recidivism is viewed as “failed re-entry. . .the offender has failed by returning to crime” (p. 147). He pointed out that the entire correctional system does little to deter crime through rehabilitation, and that recidivism as the only marker of success ignores the need to foster a productive life and personal wellbeing. Indeed, a focus on strengths and prosocial goals rather than on shaming and stigma is more consistent with empirically-supported strategies for minimizing dynamic risk and enhancing successful re-entry (de Vries Robbé et al., 2015). Supportive probation officers and treatment providers can promote resilient coping through corrective relationships that humanize offenders and model adaptive interpersonal skills (Levenson & Willis, 2019).

Limitations

This paper is not without limitations. In this section we consider the ways in which our sample is biased and reflect on some analytical shortcomings. First, it is necessary to point out that the present sample is made up of men exclusively, and therefore, the themes that emerged and the trends we observed are not expected to be relevant for female participants. Second, the sample was drawn exclusively from the North Eastern United States and thus will not be necessarily generalizable to other jurisdictions. Further, the limited number of participants of color precludes us from making specific claims about the relevance of our results to other ethnicities. Each of these areas certainly warrant further attention.

Another way in which the sample is biased is that all our participants have been convicted for sexual offending. Although we certainly imply that their status as RSOs confounds and exacerbates their re-entry experience, without any variation in their offense type, we can’t completely attribute their PCTS to their type of offence. It may well be (as Liem & Kurst, 2013) have suggested, that individuals convicted of nonsexual crimes face similar obstacles upon release. We acknowledge the limits of the generalizability of our findings, but it does not diminish the profound challenges our interviewees reported while living on the list.

Although thoroughly consistent with the qualitative tradition, our results might leave a quantitatively-oriented reader underwhelmed. Our small sample, unfortunately, prevents any sophisticated statistical analysis. However, given that our intention in this piece is simply to tell the stories and share the experiences of a population who are rarely provided a voice, we don’t consider these limitations to be fatal flaws. We are in the development stage of a future survey to allow for a more focused examination of PCTS symptoms with a built-for-purpose questionnaire to solicit a larger and more diverse sample. Consistent with a narrative approach, this paper simply represents a first step in this broader research agenda. By focusing on storytelling and introducing PCTS, we now have a foundation from which to ask specific questions and test directional hypotheses.

Implications for Trauma-informed Treatment

According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), trauma-informed care (TIC) incorporates research about the neurobiological, social, and psychological effects of trauma into delivery of services. The trauma-informed correctional rehabilitation conceptualizes client problems (including criminality) as a set of maladaptive strategies that helped an individual survive and cope with traumagenic conditions (Levenson & Willis, 2019; Listwan et al., 2013; Pettus-Davis et al., 2019). Victimizing behaviors are never acceptable, of course, but are better understood and addressed when informed by knowledge of the neurocognitive and psychosocial impacts of trauma on emotions and behavior. Finally, correctional mandates and court-ordered services can be disempowering and oppressive, reproducing dynamics like those in abusive families. Thus, positive relationships with clinicians that feel emotionally safe and respectful can heal trauma’s effects and reinforce a positive self-narrative, increasing community safety (Levenson & Willis, 2019).

RSO clients often come from childhood homes with family dysfunction and adversity, and therefore trauma-informed treatments are important in building skills for adaptive, resilient, and law-abiding reintegration (Levenson et al., 2017). In most American jurisdictions, registrants are required to attend counseling programs as part of their probation or parole conditions. Treatment should address dynamic risk factors and criminogenic needs for each individual, including self-regulation problems, intimacy deficits, deviant sexual interests, criminality, lack of empathy, and co-morbid conditions such as substance abuse, anxiety, depression, or PTSD (Andrews & Bonta, 2010, 2017; Levenson et al., 2017; Yates et al., 2010). A good community adjustment, grounded in stability and positive support systems, enables the cognitive transformation and prosocial identity associated with desistance from crime (Lussier & Gress, 2014; Maruna et al., 2004; Western, 2018; Willis, 2017). Such approaches focus on meeting basic human needs, while reducing traumatic stress and the emotional and behavioral dysregulation associated with it. Better self-regulation is a crucial aspect to achieving goals of reduced recidivism and safer communities.

Men with criminal histories of sexual offending understandably incite community fear and contempt. Connecting clients with opportunities for acceptance and belonging might be best facilitated by faith-based programs, 12-step recovery models, provision of trauma-informed treatments, and halfway house environments with supportive services. For many people, self-efficacy and a self-actualized identity is closely tied to employment. Success in meaningful employment reinforces the cognitive transformation associated with desistance from crime, as well as the pragmatic and necessary material costs of living (Maruna et al., 2004; Uggen, 2002; Western, 2018). Quite simply, providing assistance with job seeking, job readiness programs, and employment training achieves the dual goal of successful re-entry and enhanced community safety. Making an honest living, spending time productively and experiencing mastery in a meaningful job can be viewed as protective factors that reduce dynamic risk (de Vries Robbé et al., 2015).

Treatment failure and recidivism are often viewed as individual shortcomings related to resistance, lack of motivation, or defiance (Western, 2018). However, perceived lack of choice, control, or support can activate traumatic stress, causing clients to revert to maladaptive coping strategies (Levenson et al., 2017) and increasing the likelihood of treatment failure (Sturgess et al., 2016). A trauma-informed practice model recognizes that helping clients meet their basic needs reduces anxiety and allows for better cognitive processing and decision-making. Under such circumstances, positive behavioral change is reinforced and the pursuit of an offense-free life becomes more likely. Attention to the link between (past or present) trauma and problematic behavior introduces a novel approach to reducing risk and promoting successful re-entry.

Such a paradigm shift begins by thinking about Maslow’s (1943) hierarchy of basic human needs (survival, safety, social acceptance, self-esteem, and self-actualization) as closely tied to the factors that predict desistance and success for former prisoners: lifestyle stability, housing, jobs, self-efficacy, and social support (Kruttschnitt et al., 2000; Laub & Sampson, 2001). If correctional services were to adopt a trauma-informed approach, they could ensure that RSOs transition to the community with the basic requirements of survival: food, clothing, and accommodation. Physically safe spaces and psychologically safe social environments are key components for allaying the stress of community re-entry and adjustment.

Levenson et al. (2017) proposed the acronym SHARE (safety, hope, autonomy, respect, empathy) to help clinicians translate trauma-informed concepts into services that conform to the principles outlined by SAMHSA (2014). First, rehabilitation programs should provide consumers with a feeling of Safety. Correctional counseling should foster physical and emotional wellbeing, facilitated by helpers who are trustworthy. Hope is created when clients believe that change is possible, reducing despondence and learned helplessness. Autonomy empowers a client’s right to self-determine and prioritizes life goals that are most meaningful to them, contributing to an internal locus of control. Treating clients with Respect restores a sense of value and worth, counteracting the impact of societal shaming and stigma. Through shared humanity and treatment with dignity, we model the healthy interactions we want our clients to learn and generalize in other areas of their lives. The final component, Empathy, demonstrates and teaches the skill of listening to the perspectives of others. When we listen to our clients with curiosity and compassion, we facilitate and model connection—a deterrent to harming others.

Implications for Policy and Prevention

We have witnessed a growing need for criminal justice scholars to look further afield and draw upon advances in prevention science and public health for inspiration on how to reduce recidivism and prevent sexual abuse. In a public health model, primary prevention of a social problem utilizes universal precautions, secondary prevention targets high-risk groups, and tertiary prevention intervenes after a problem emerges, designed to prevent recurrence (German et al., 2001; Kaufman, 2006; McMahon, 2000). Most responses to sexual offending constitute tertiary prevention and occur in the aftermath of an offense—for example: trying the facts, convicting the guilty, dispensing punishment, providing treatment, and eventual community re-entry with restrictions and monitoring. Secondary prevention caters to a larger population and seeks to intervene with those identified to be at risk before abuse occurs. Primary prevention, in turn, applies even more broadly to the general population and is designed to eliminate initial exposure to risk factors.

We consider the new notion of “quaternary prevention” to be especially salient to this discussion. Quaternary prevention “completes the cycle of prevention” (Gofrit et al., 2000, p. 500), urging those operating in the tertiary prevention space to reflect critically upon their actions with “emphasis on the need to do no harm”(Jamoulle, 2015, p. 1). We encourage the adoption of this adage to emphasize the importance of mitigating or avoiding the unintended consequences of strategies designed to promote community safety, but which ultimately hinder that same goal. When the stress and stigma of probation, parole, or registration obstruct the ability to meet basic human needs, they facilitate anxious symptoms of dysregulation and maladaptive coping. In turn, dynamic risk may increase, undermining prevention goals. Clinicians, researchers, and policymakers should consider quaternary prevention concepts in future research and practice, avoiding re-traumatization in the re-entry process.

Conclusion

A life lived in fear is a life inconsistent with research on risk and protective factors. Our current practices likely and paradoxically increase risk for reoffending by producing traumatic stress that leads to emotional dysregulation. Western (2018) describes a community supervision philosophy that has moved away from rehabilitation to a “prevailing culture that emphasizes surveillance over services” (p. 126). The result, he says, is an overly punitive response to the common challenges of re-entry, with supervision violations making up a staggering proportion of returns to incarceration. Instead, trauma-informed practices partner with clients to reduce barriers, promote adaptive coping, and facilitate successful re-entry outcomes, creating conditions that make registered citizens less prone to recidivism (Western, 2018).

We know that current stressors and living in a constant state of anxiety can re-activate maladaptive coping styles (Harris & Fallot, 2001; Miller & Najavits, 2012). We know that people who have committed crimes were often exposed earlier in life to many forms of childhood adversity. They are also more likely to be from minority, impoverished, oppressed, and marginalized communities that have been endured historical and cultural trauma. A life lived in fear reactivates early maladaptive schemas about the world as a dangerous place and fosters an understandable mistrust of authority figures. A life lived in fear weakens an individual’s capacity for emotional management, because when people are constantly in survival mode, their cognitive processing skills are compromised. Under such circumstances, their capability for healthy self-regulation is undermined.

Our clients are likely to come from (and therefore, return to) socially marginalized and economically impoverished communities (Tewksbury & Mustaine, 2006). These communities are marked by a dearth of prosocial opportunities and role models, and therefore increase the risk for both perpetration and victimization. Contextual risk factors (Firmin, 2018) contribute to the conditions that enable crime, substance-abuse, antisocial peer associations, and exploitation of more vulnerable individuals. Such conditions undermine stable housing, prosocial relationships, meaningful employment, and appropriate leisure activities—all of which increase one’s sense of self-esteem, social belonging, and self-actualization and protect against reoffending (de Vries Robbé et al., 2015; Kruttschnitt et al., 2000).

Correctional supervision should be designed to facilitate success, rather than simply reinforcing the power of authority figures to monitor and apprehend. If we want people who have committed crimes in the past to live productive law-abiding and offense free lives, we need to support them by teaching skills and creating conditions that facilitate a good (or a good enough) life. Trauma-informed practices create the opportunity for front line practitioners (law enforcement officers and therapists) to establish human connections to be harnessed as a tool for healing and a model for prosocial behavior. Rather than focus exclusively on monitoring, interrupting, and intervening with punitive consequences, treatment providers and supervision officers can model healthy communication and relationship skills, coach clients to improve self-regulation strategies, and provide opportunities for self-correction and post-traumatic growth. Decades of trauma research indicates unequivocally that a life lived in fear undermines the interpersonal coping mechanisms that enable resilience and decrease risk. As one participant reminded us:

There is a better system than one where I am off on my own with people being afraid of me because of the one thing they know about me. I am more than my label. I am more than just a sex offender. I’m not the sum total of my worst behaviors.

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) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Danielle Arlanda Harris

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