Insights From the 2022 AAPL Annual Meeting

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SPECIAL REPORT: FORENSIC PSYCHIATRY

CONFERENCE REPORTER

The American Academy of Psychiatry and the Law (AAPL) hosted its first in-person meeting in October 2022. Susan Hatters Friedman, MD, 2021-2022 AAPL president, presided over the meeting, with the theme “The Whole Truth: Recognizing Gender and Culture in Forensic Psychiatry.” In her presidential address, Hatters Friedman urged attendees to consider the gender and culture of forensic evaluators as well as forensic evaluees and patients during the evaluation process.

At the AAPL business meeting, Hatters Friedman passed the baton to incoming AAPL President James L. Knoll IV, MD, who chose “Balance” as the theme for the next annual meeting, which will take place in Chicago, Illinois, October 19 to 22, 2023. Knoll is editor emeritus of Psychiatric Times™.

Fatality Review Teams

Susan Hatters Friedman, MD; Joshua Friedman, MD, PhD; Jason Beaman, DO, MS, MPH; and Kathleen Kruse, MD

This presentation introduced the public health role of forensic psychiatry through participation in local, state, and regional fatality review teams. The panel of speakers presented on models for fatality review teams, their role in public health prevention measures, and the opportunity for forensic psychiatric involvement in these organizations.

Multidisciplinary fatality review teams have existed for decades in the United States and globally. The primary goals of these teams involve collaboration across disciplines to examine individual deaths in a community to determine manner of death and preventability of death, and to make recommendations regarding prevention of future death through public health, mental health, and legislative measures. Participants include representatives from various community stakeholders, including local law enforcement, forensic pathologists, social service agencies, and health care agencies. At meetings, each case is explored individually with a review of available data from each agency, resulting in the publication of reports and recommendations for future prevention. Review meetings are closed with confidentiality agreements, given the classified nature of the information discussed. Determinations from these teams improve accuracy of death certificate data and interagency coordination.

Fatality review teams began in the 1970s with an initial focus on child deaths, but have since expanded to include other deaths from preventable causes. Examples of specialized multidisciplinary review teams implemented across the United States include child fatality, opioid overdose fatality, domestic violence fatality, elder abuse fatality, and homicide review teams. Many widely known public health measures that exist today resulted from the recommendations of fatality review teams, including newborn safe haven laws, firearm laws, and expansion of domestic violence screening measures.

The panel presented the case for the involvement of forensic psychiatrists in fatality review teams, given the forensic psychiatrist’s specialized training and knowledge about the intersection of mental illness and violence. In these settings, the forensic psychiatrist provides education about mental health diagnoses and addiction, decreasing stigma and misunderstandings regarding their roles in death outcomes and prevention recommendations. Furthermore, the forensic psychiatrist helps the multidisciplinary team members understand risk factors and preventability when providing recommendations for public health interventions.

Dr Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; a professor of psychiatry, reproductive biology, and pediatrics; and an adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. Dr Friedman is an assistant professor at Case Western Reserve University in Cleveland, Ohio. Dr Beaman is chair and clinical assistant professor of psychiatry and behavioral sciences at Oklahoma State University Center for Health Sciences in Tulsa. Dr Kruse is a clinical assistant professor at the University of Michigan in Ann Arbor.

Forensic Psychiatric Consequences of McGirt v Oklahoma

Jeffrey Sanders, MD; Tessa Manning, MD; and Britta K. Ostermeyer, MD, MBA

In 2020, the US Supreme Court heard a criminal appeal case titled McGirt v Oklahoma to determine whether a large portion of land in the state of Oklahoma was in fact “Indian country,” a form of federal reservation. In a 5 to 4 decision, they ruled affirmatively on this question, and, as such, crimes committed by Native Americans in this territory would be subject to tribal or federal jurisdiction (depending on the crime’s seriousness) rather than state jurisdiction. For a time, it seemed as though this determination might have to be retroactively applied with all previously prosecuted Native Americans whose criminal acts took place in Indian country retried, but the Oklahoma Supreme Court subsequently determined that this would not happen. Further, the US Supreme Court eventually heard a follow-up case known as Oklahoma v Castro-Huerta and clarified that McGirt only applied specifically to Native American defendants.

After McGirt, the tribal and federal courts found themselves with an obligation to handle their expanded caseload, which required securing ways to procure assessments and recommendations from psychiatric professionals for cases involving capacity and restoration and to establish forensic inpatient placement arrangements for those not guilty by reason of mental illness. They would further need to expand their general judicial capacity and law enforcement and containment capabilities. Such infrastructure is expensive, and, as of now, it is unclear whether tribes will seek acknowledgement of certain taxation rights to cover costs.

All these matters unfortunately add further processing complications to a state with an already overburdened system of care. Even before McGirt, defendants were routinely waiting a long time for forensic inpatient psychiatric placement and went without robust jail-based restoration options. Native American tribes are currently working with the state and other actors to address these various problems.

Dr Sanders is a resident at the University of Oklahoma School of Community Medicine in Tulsa. Dr Manning is an assistant professor, associate program director, and medical director for consultation-liaison psychiatry at the University of Oklahoma School of Community Medicine in Tulsa. Dr Ostermeyer is professor and chairman, the Paul and Ruth Jonas Chair in Mental Health, and chief of psychiatry for OU Health at the University of Oklahoma College of Medicine in Oklahoma City.

LGBTQIA Issues in the Criminal Justice and Corrections Systems

Elie G. Aoun, MD; Barry Wall, MD; Bethany Hughes, MD; Ren Belcher, MD; and Charles Dike, FRCPsych, MBChB, MPH

Not unlike cisgender heterosexual persons, LGBTQIA (lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender) individuals interact with every level of the justice system. For LGBTQIA individuals, however, their sexual or gender minority status is commonly directly related to their justice involvement, regardless of whether they are the victims or the perpetrators of the alleged crime. A few examples of such situations include a transgender female being assaulted in a hate crime, a lesbian woman subjected to sexual harassment in the workplace, a bisexual man murdering his parents after they forced him to undergo conversion therapy, or a gay man raping another in what started as a voluntary bondage and discipline, dominance and submission, sadism and masochism (BDSM) sexual encounter.

Forensic psychiatric experts are often called upon to weigh in on various aspects of such legal cases. Deciding whether to retain an expert who identifies as LGBTQIA is complex, and this was a focus of our panel presentation. Other LGBTQIA topics included a review of the so-called “gay panic” criminal defense, the mitigation of suicide risk within the transgender population, and common barriers LGBTQIA persons face in criminal adjudication as well as in accessing mental health treatment within jails, prisons, and forensic settings.

The panel relied on a composite case discussion involving a transgender woman who had run away from home because of early abuse and began drinking alcohol, using illicit drugs, and trading sex for money. During one such encounter, she had agreed to offer a man oral sex for money. During the encounter, he brutally assaulted her when he touched her genitalia and realized she had a penis. Both were arrested. She attempted suicide while incarcerated. In court, the man pleaded not guilty and claimed a “gay panic” defense.

The panel discussed the assessment and mitigation of suicide risk among transgender patients in forensic settings. They illustrated how risk factors relevant to both incarcerated individuals and transgender individuals coalesce to result in a particularly elevated risk of victimization, violence, and suicide among this clinical population. The minority stress model and gender-based victimization model, commonly referenced in studies on suicide risk in transgender patients, can help explain the potential for self-harm among transgender inmates, and may give rise to points of clinical intervention.

Data on suicide among incarcerated transgender people are scarce, but results from 1 retrospective study suggested that about half of transgender people who had been incarcerated had also made a suicide attempt at some point in their lifetime. Incidents of gender-based violence increased the risk of suicide, whereas state laws permitting comprehensive medical care of transgender inmates were associated with decreased risk. Importantly, only a small minority of transgender inmates in the United States are housed with their lived gender, and the implications of this for mental health and suicide were discussed.

Dr Aoun is an assistant clinical professor of psychiatry at Columbia University Vagelos College of Physicians and Surgeons in New York, New York. Dr Wall is a clinical professor of psychiatry and human behavior and program director of the Forensic Psychiatry Fellowship at Brown University in Providence, Rhode Island. Dr Hughes is a forensic psychiatrist and the medical director at North Texas State Hospital in Wichita Falls, Texas. Dr Belcher is house officer at Massachusetts General Hospital and McLean Hospital and a clinical fellow in psychiatry at Harvard Medical School in Boston, Massachusetts. Dr Dike is an associate professor of psychiatry and codirector of the Law and Psychiatry Division of Yale University Department of Psychiatry in New Haven, Connecticut, as well as medical director of the Connecticut Department of Mental Health and Addiction Services.