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Sexual crimes, medical cures: the development of a therapeutic approach toward sexual offenders in English prisons, c. 1900-1950.

I. Introduction

In 1949, an anonymous prison doctor defended the fact that he had only referred six individuals from his prison for specialist psychiatric attention in London, condemning "in the strongest possible terms" the view "widely held today that psychotherapy affords a panacea for all abnormality of conduct, particularly that in the sexual field." (1) This was a remarkable statement. Just a few decades earlier, psychotherapy--and indeed any form of psychologically-oriented treatment--had been virtually unheard of as an option for criminal offenders. By 1949, not only had the idea of medical cures for criminal tendencies evidently achieved widespread acceptance in some quarters, but treatment was also being offered within prisons. After twelve years of experimentation, a dedicated psychological unit opened in Wormwood Scrubs prison in London in 1946, and two specialist physicians there began studiously researching and recording the results of their efforts. By 1949, two more English prisons had introduced similar initiatives, and a recruitment drive was underway to hire significantly more psychologists and psychiatrists into the prison service. The hope that future crimes, and especially sexual crimes, could be prevented by addressing the medical conditions that might cause them gave forensic medicine a new avenue to explore. However, as this prison doctor's defensive comments suggest, only small numbers received treatment and the outcome was not as dramatic as some had expected. Although the value of psychotherapy for sexual offenders was questioned, many doctors continued to believe that "the need for psychiatry in prisons is indisputable" and that some sexual crimes could have medical cures. (2)

This article traces the evolution of forensic psychiatry in England, charts the increasing focus on sexual offenders within that specialty and examines the concepts that affected how such offenders were studied and treated. (3) The involvement of the medical profession in the regulation of sexuality has long been a subject of interest for activists and historians alike, from the scrutiny of nineteenth century doctors' publications on masturbation and prostitution, to recent debates over the presence and definitions of paraphilias and sexual dysfunctions in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, (4) Excellent studies of changing medico-legal attitudes toward homosexuality have been produced, along with examinations of early sexology and, for North America in particular, medico-legal approaches to sexual crime in the twentieth century. (5) However, British medicine since 1900 and its engagement with sexual deviance beyond homosexuality remain somewhat overlooked. Here, in the early twentieth century, a small number of doctors approached the study of sexual behaviour as part of the burgeoning field of forensic psychiatry, which had its roots in prisons. (6) As the criminal generally and the sexual offender specifically emerged as new objects for the psychiatric and psychological professions to study, doctors proposed new ways of understanding sexual impulses in relation to crime and mental disorder.

Using the research conducted by prison doctors and the reports compiled by the Commissioners of Prisons for England and Wales, this article charts the introduction of psychotherapeutic treatment for prisoners and especially sexual offenders. These official reports provide a year-by-year account of the activities and opinions of prison doctors, albeit one that can conceal struggles and disagreements taking place behind the scenes. They are thus usefully enhanced by Home Office records as well as the lectures, books, articles and opinion pieces through which doctors working in prisons and elsewhere debated the issues at stake. Of particular importance are the results of the first four years of experimental psychotherapy at Wormwood Scrubs prison, which were published by H.M. Stationery Office in 1939 as The Psychological Treatment of Crime', the case studies and analysis this volume contains--along with statistics and narratives in additional reports and articles from prison medical staff--provide valuable insight into how the medical profession interpreted sexual crimes and introduced treatments to prisoners.

The documents considered in this article were compiled exclusively for an audience of civil servants and interested parties from the worlds of government, medicine, and law. Although some of them did make reference to public opinion, and even enjoyed coverage in the press on occasion, their public was usually a narrow one. (7) The purpose of these reports and articles was, for the most part, to explain existing approaches to mental disorder within the prison population, to suggest practical alternatives, and at all times to justify medical activities and proposals with reference to penology as well as the latest medical thought. The ways in which such theories and activities were used in the course of criminal investigations and court proceedings, whether by doctors or lawyers, judges or juries, lies beyond the scope of this article. What can be gleaned from the work of prison doctors and the prison service is, rather, how psychiatric provision for those serving prison sentences evolved in the first half of the twentieth century, and how doctors interpreted sexual crimes during this period.

As interest in the mental state of the criminal expanded during the first half of the twentieth century, prison medicine became more closely associated with psychiatry. Its practitioners strove to investigate whether proactive treatment in the form of psychotherapy could prevent prisoners from reoffending after release. (8) Their focus upon the sexual offender was the first sustained medical interest in sexual deviance in Britain, and was based upon a widespread consensus among doctors regarding the nature of normal and abnormal sexual offenders and offences, healthy and deviant sexualities, and male and female criminality in the sexual field. Physicians working with offenders focused upon the "perversions" in men and the purportedly uncontrollable impulses that caused them, but displayed a notable lack of interest in heterosexual violence and a wholly different approach to the sexually delinquent woman.

However, despite this consensus, there was a lack of clarity within the medical profession regarding diagnosis and limited information about the efficacy of treatment. Forensic psychiatry during this period was characterized by caution, and even as the prison population grew following the end of World War II and public anxiety around crime, especially sexual crime, was heightened, the status of psychiatry as a solution to crime remained unclear. (9) Constraints upon treatment --financial, practical, and theoretical--prevented clear-cut conclusions or policies for action and helped to ensure that prison psychiatry remained marginal. However, the designation of the abnormal sexual offender as mentally disordered had already taken root.

II. From Criminals to Patients

At the start of the twentieth century, psychiatry had been relegated to the bottom of the medical hierarchy. As a specialty it had, in the words of historian Roy Porter, "been bumping along the bottom ... bemired by the unsavoury associations of huge, squalid public warehouses for the mad poor." (10) Although there had been a society and journal for its practitioners since the mid-nineteenth century, even by the 1920s there was very limited specialist training available in Britain. The President of the Medico-Psychological Association complained in 1924 that psychiatry "still occupies a position of isolation," and although five universities had recently introduced diplomas in psychological or psychiatric medicine, there remained much to be done "before psychiatry as a branch of medicine can be considered to be in a satisfactory position." (11) However, with the foundation of the Central Association for Mental Welfare in 1913, the National Council for Mental Hygiene in 1922, and the opening a year later of the Maudsley Hospital, a large new facility for both in- and out-patient treatment as well as research and training, interest in psychiatry was on the increase. Clinics such as the Tavistock provided focal points in large cities through which psychoanalytically-influenced practitioners could more widely offer their services in the years following World War I, and although British psychoanalysis remained somewhat distanced from both general medicine and the wider psychoanalytic community, many of the ideas associated with it were quietly adopted in the decades that followed. (12)

As has often been noted, the large number of shell-shock sufferers issuing from the battlefields of World War I played a significant role in the growth of psychiatry. (13) The problems of crime and anti-social conduct in relation to mental disorder, especially among young people, were also of interest to psychiatrists, especially as families were disrupted by war and its aftermath and the number of imprisoned juveniles rose significantly. By 1927 the Child Guidance Council had been established to treat difficult and delinquent children, and the Institute for the Scientific Treatment of Delinquency followed in 1932 to "initiate and promote scientific research into the causes and prevention of crime" and to "establish observation centres and clinics for the diagnosis and treatment of delinquents" of all ages. (14)

Those working for the prison service had been drawing attention to the importance of the "psychological point of view" in "the most recent methods of dealing with the criminal" for years, and the prison medical service contributed to, and benefited from, this interest in the relationship between criminality and illness. (15) Prisons, after all, had long been useful locations for medical research. Not only did they offer an audience of subjects for study that was, quite literally, captive, but they also contained a group that could be investigated for markers of difference from the population at large: in the late-nineteenth and early-twentieth centuries, prison doctors in England had been engaged in assorted endeavours to establish whether this difference took physical form, or could be identified in levels of intelligence, tendencies toward insanity, or in some other intriguing distinction. (16) The question of insanity and other mental disorders had quickly become the most pressing consideration for the prison medical service from the late nineteenth century. Herbert Gladstone's 1895 report on prisons recommended that all new recruits to the prison medical service should have "given special attention to the subject of lunacy" in their training, and that a "medical man" should sit on the Prisons Board to advise on the increasingly difficult medical questions associated with the criminal.

A doctor was ultimately appointed to the Board of the Prison Commissioners in 1914 in recognition of the "growing importance of the medical side of prison administration," and the promotion was consolidated in 1924 when the doctor in this role became a full Commissioner "on a footing of full equality with the other Commissioners." (17) As the Board made space for medical expertise at the highest level of prison management, prison doctors emphasized the specialist knowledge that their experience bestowed. In 1910, Dr. Herbert Smalley, then Medical Inspector of Prisons, announced that "the prison medical officer has justly acquired a reputation as an expert in mental disease," (18) and by the 1920s the publications and lectures given by prison doctors demonstrated an overwhelming focus on mental abnormality in its many guises. (19) By the mid-1930s, the examining boards of the Royal College of Physicians of London and the Royal College of Surgeons of England had acknowledged "the abundant material for study in H.M. Prisons" and were accepting a twelve-month appointment in "either of four large remand prisons as the equivalent of twelve months' mental hospital practice required for their diploma in psychological medicine." (20) That the experiences gained by working in prisons were believed to be equal to those acquired in mental hospitals demonstrated widespread agreement that mental disorder was rife among the prison population.

Changes to the prison population itself also affected the focus of medical interest. Coinciding with the rise in profile and status of psychiatry and prison medicine as recognized and increasingly reputable specialities, and heightened perceptions of mental disorder among offenders, was a significant decline in prisoner numbers over the first half of the twentieth century. New provisions for younger offenders and those unable to pay fines dramatically reduced prison admissions in the 1910s, as did the demand for labour during the war years and, some officials argued, increased restrictions around the sale and consumption of alcohol. (21) To a lesser extent, the Mental Deficiency Act of 1913 was also significant, partly because it introduced provisions for anyone deemed to suffer from "mental defect" to be removed to a suitable colony. This included convicted prisoners or prisoners awaiting trial, and it was hoped that the Act would "relieve the Prison Authority of a great burden and responsibility in dealing with these cases." (22) The anticipated impact largely failed to materialize, and even after the delays provoked by the outbreak of war had been overcome, prison doctors complained that the definition of "mental defect" in the Act was far too restrictive. (23) Although the Act had provided a degree of flexibility in its inclusion of the category of "moral defect," which did not require any defect of intelligence, the requirement that any mental defect had been demonstrably present from childhood proved impossible for many prison doctors to satisfy.

Medical disappointment in the operation of the Act was not limited to professional dissatisfaction with the clumsy legal rendering of medical concepts. It was driven, in part at least, by a genuine belief among doctors that many individuals were neither deterred by prison, nor reformed by the experience, due to disorders of the mind. They disrupted prison routine and their situation was felt to fly in the face of the latest medical and criminological theories. Perhaps the greatest significance of the Mental Deficiency Act lay in its formalization of a wider range of mental disorder, generating debate about those on its boundaries who appeared unchanged by prison, and how the prison service should manage them.

This was a "residue of persons who though not certifiable" were still "in medical opinion in an unsuitable environment in Prisons." These were described as "[b]order-line cases," consisting of "unstable, weak-minded offenders." (24) Attempts to describe or diagnose such cases ranged from accounts of "low intelligence and high suggestibility" to "imperfectly developed states of insanity; senility; weakmindedness due to alcoholic excess; and weakmindedness of undefined origin." (25) The medical profession persistently struggled to find a suitable vocabulary to describe and categorize this group of offenders, experimenting with "constitutional inferiority," the "non sane non insane" group, or the "mentally inefficient." (26) By the 1940s, distinguished psychiatrist Dr. Desmond Curran noted that "such terms as moral insanity, moral imbecility, temperamental instability, psychopathic inferiority, constitutional psychopathic inferiority, constitutional psychopathic state, and even neurotic character have been proposed," (27) without any great clarity or consensus as to the differences between them or how they might be defined.

This lack of coherence could not have helped psychiatry's claims to expertise, nor added weight to any arguments about managing the indefinable borderline group of prisoners differently. Between the 1910s and Dr. Curran's pronouncement in 1944, mentions of low intelligence faded away, to be replaced by increasingly common references to psychopathic states in which the personality was seen to be at fault. However, any distinction between individuals on the "borderline" of mental defect and those characterized as psychopathic was frequently unclear. Psychiatrist Dr. R.D. Gillespie, for example, defined the "so-called borderline defective" as being "deficient in foresight and emotional control," whereas the "psychopathic personalities" were "essentially unstable, very easily elated and as readily depressed, vain and selfish." (28) Quite how the physician might distinguish between these two states, Gillespie did not explain. Both were identifiable by emotional instability and a lack of self-control and forward-planning, and although both were seen as common characteristics among the criminal population, they were far from universally-present among offenders. Perhaps the only way in which such states could be understood was in opposition to a perception of "mental health" in which individuals were self-controlled and forward-thinking, even when these traits led to criminality.

This fluidity around terminology accompanied a persistent lack of certainty regarding the relationship between crime and mental illness, and the role of medicine. By 1936, Dr. (later Sir) William Norwood East, the most senior figure in prison medicine at the time and an efficient civil servant of moderate views, felt that "although psychological investigations may illuminate the factors which influence criminal conduct and assist in the classification of offenders," in the end, "their place in the prevention and treatment of crime is undetermined. The present position is fluid." (29) Those of his colleagues who were vocal proponents of psychoanalytical theories, such as fellow prison doctor Maurice Hamblin Smith and physician Grace Pailthorpe, a leading figure within the psychoanalytical community in Britain, were more confident in their assessments. Dr. Smith "insisted that the treatment of the offender was entirely a psychological problem, and that every case required individual investigation and consideration," while Dr. Pailthorpe argued "that criminals and asocial persons are not a class as such, but individuals suffering from psychological illness or defects." (30) All agreed that a psychological approach was illuminating, but the role that it could or should play in prisons was less clear.

The study of the psychology of the criminal found little appreciation within the Home Office, where the notion of crime as symptomatic of illness was routinely met with confusion. One unnamed civil servant noted in 1940, with reference to the title of The Psychological Treatment of Crime, that "I have never been able to appreciate what this phrase is intended to mean unless it were suggested, which I am sure it is not, that crime is a disease." (31) Nevertheless, the Home Office had long recognized the growing interest in medical approaches to crime and tried to keep up-to-date with expert opinion in the area, collecting articles and letters about psychoanalysis in relation to crime throughout the 1920s and monitoring the views of those magistrates and doctors who vigorously endorsed greater medical intervention in the assessment and management of offenders. (32) Proposals for an initial experiment in psychotherapy within prisons were originally rejected, and although its supporters only had to wait another year before receiving the green light and the funds to proceed, the absence of greater civil service enthusiasm for psychiatric treatments in prisons helped to keep medical interventions small in scope for decades. (33)

Despite official doubts and medical disagreements, preliminary efforts to offer treatment to offenders were introduced, albeit in piecemeal fashion and with emphasis upon keeping some of the curable cases out of prison. Dr. Smith was appointed to Birmingham prison in 1919 specifically because of his expertise in the field of mental abnormality, but it was largely "in connection with prisoners awaiting trial" that his services were required, rather than the treatment of those already convicted. (34) The following year, Dr. East had mentioned the possibility of treating "selected cases of crime, the result of psychasthenia and certain other conditions ... by psycho-therapeutic measures," but his only detailed case study was an offender who simply received a lighter sentence in recognition of an apparent mental abnormality. Others mentioned in passing had their cases discharged when magistrates were advised that their crimes were connected to "war psycho-neuroses," "neurasthenia," "hysteria," "psychasthenic inebriety," and "mental depression," suggesting that pre-trial diagnosis was, at first, far more significant than post-conviction treatment. (35) However, there were hints elsewhere, including within the report of the Committee on Persistent Offenders that some "few convicted offenders" had served as early test cases for psychotherapy within prisons. (36) Greater interest in the mental state of offenders was leading to more frequent examinations of defendants before trial and occasional judgements that responded to this medical evidence, but opportunities for the delivery of treatment post-conviction had relied so far upon the interests and time of the individual prison doctor. Without systematic investigation, its value to prisoners was unknown.

Medical treatment along psychiatric lines inside the prison was formally instituted in 1934 to address this lack of data. It was designed for a select few to receive psychotherapy on an experimental basis at Wormwood Scrubs prison, as part of a four-year investigation "to ascertain the value of psychological treatment in the prevention and cure of crime." (37) In 1946 Dr. Clifford Allen, a psychoanalyst and staunch supporter of psychotherapy for all offenders, wrote with frustration in the British Medical Journal that "I have seen many patients who have been imprisoned but have never seen one who has had any form of psychotherapy by the prison doctor." (38) While those he encountered in his private London practice may not have been an entirely representative selection of former prisoners, evidence elsewhere suggests that it would indeed have been extremely rare to receive treatment while in prison in the 1930s and 1940s, even after the appointment of the prison service's first dedicated psychotherapist, Dr. William Hubert. He joined with great enthusiasm in 1934, but his was only a part-time position attached to just one prison. In the first five years of his work only 406 cases, referred by prison medical officers from around the country, were investigated and of these a mere 214 were approved as suitable for treatment. (39) It is perhaps not surprising that not one individual in this highly select group had crossed paths with the private therapists of Harley Street, nor that prison doctors in the late 1940s, in the face of such criticism from their colleagues, felt it necessary to defend the persistently low number of cases being referred to psychiatric specialists. (40)

The small scale of medical treatment was the result of limited finance and facilities within the prison service. Prison buildings were dated, the staff was poorly paid and frequently dissatisfied, and Home Office spending was restricted during the depressed 1930s and subsequent war years. Although it was an era of some reform for prisons, such reform focused upon buildings, sanitation, and useful work and education to rehabilitate the prisoner. (41) More broadly, however, issues of crime and punishment were not particularly high on the social or political agenda. (42) Debates about sanity and self-control may have been aired more regularly, but the provision of treatment within prisons remained a low priority, with psychiatry remaining on the sidelines.

A lack of clarity from doctors regarding diagnoses and prognoses along with practical difficulties, governmental ambivalence, and little interest from the public, ensured that psychological treatment was not introduced more extensively. The experiment that began in 1934 continued quietly, with only a brief interruption during the war, expanding gradually in size and location in the decades that followed. (43) Nevertheless, confidence in psychiatry took hold: specialists were recruited to the prison service and in 1962 a hospital-prison for psychiatric treatment opened. This step forward was a belated but direct result of the interventions of the 1930s and 1940s. As a growing number of offenders were assessed for signs of mental disorder, studied, and treated, those convicted of sexual offences were consistently prioritized and over-represented in the patient-prisoner population. (44)

III. The Sexual Offender and Mental Disorder

While a psychiatric approach to crime was tentatively explored, the medical study of sexual deviance simultaneously became more prominent. Prior to the 1920s, doctors in Britain had said very little in public on the subject. Reviews of the works of the godfather of British sexology, Havelock Ellis, took brief and often hostile form, and after his first sexological text was the subject of an obscenity trial in 1898, he published little in Britain. Although a handful of doctors were actively involved in organizations such as the British Society for the Scientific Study of Sex Psychology, the absence of discussion within medical journals about sexual deviance prior to the 1920s suggests that professional standards combined with stringent obscenity legislation demanded either self-censorship or editorial censorship. (45) As late as 1924, Dr. East was correct when he observed with some irritation that sexual offences "seldom form the subject of an article in this country," although his explanation for this was that it was "on account of its distastefulness." (46) Whether due to personal revulsion or professional caution, it remained an unappealing subject for the medical man to address.

By the 1920s, though, previously unspeakable subjects were becoming the objects of serious medical enquiry. The expanding disciplines of criminology and psychiatry identified the sexual offender as uniquely disordered and therefore ideal for therapeutic intervention in the name of crime prevention, and publications by prison doctors began to consider the mental state of the sexual offender separately. (47) As Chris Waters has argued, the dissemination of Freudian thought in the interwar years proved useful to those with an interest in the causes of socially deviant behaviour, and he credits Dr. East with having "focused attention on the homosexual inmate population for the first time" in his 1936 textbook Medical Aspects of Crime. (48) Beyond this, however, Dr. East broached the subject of sexual offenders more generally, first publishing a study of 107 men convicted of exhibitionism and later, in 1925, a guide for the general practitioner to interpreting a range of sexual offences. These were followed by textbooks with sections on sexual crime, and a study of sexual sadism in 1938. (49)

The prison administration also acknowledged with increasing regularity that the sexual offender might be a special case for medical expertise. In the Prison Commissioners' annual report for the year ending in March 1925, it was noted without further explanation that prison medical officers placed many individuals under observation, "either from some mental characteristic observed at the time of examination or the nature of the offence., e.g., some sexual offences, arson and such like." In the same year, the medical officer of Brixton prison drew attention not only to those in his prison who were mentally abnormal as a result of senility or the after-effects of encephalitis, but also to "the cases of sexual perverts." (50) Although such reports became extremely brief during the years of World War II and immediately afterwards, by 1949 those working in the psychological unit at Wormwood Scrubs provided a detailed account of their diagnoses and treatments, distinguishing between sexual and non-sexual cases and providing numerous case studies of the former. (51) Consistently, the crimes of the "sexual perverts" were associated with mental disorder and addressed at length.

The idea that sexual offenders deserved particular attention from psychiatrists achieved growing acceptance in medical circles during the 1930s. In 1933, an editorial in the British Medical Journal expressed grave doubts regarding the prospect of medical cures for the supposed mental ills of offenders in general, but conceded that when it came to "pathological thieves and sexual offenders" in particular, it was true that some could be "reformed by treatment." (52) Dr. Letitia Fairfield, chief medical officer for London County Council and a significant but conservative figure in public health, had been sufficiently convinced to argue in 1938 that with "certain offences such a large proportion of the offenders turned out to be mentally abnormal that on the ground of common sense and economy the courts would be justified in employing a psychiatrist before verdict and sentence. The chief of these offences were the sex category." (53) In the same year, the medical officer of Leeds prison confirmed that the pattern of the 1920s had become policy: it "is our practice to examine as to his mental condition every offender charged with an offence of a sexual nature." (54) A joint committee, appointed by the British Medical Association and the Magistrates' Association to examine the situation regarding sexual offenders, concurred in 1949 that "those charged with sexual offences" should be dealt with differently, and the "principal reason is medical." (55) As was made plain by Nesta Wells, a police surgeon working in Manchester from the 1920s and writing in the 1950s, it was increasingly commonly agreed that "prison will not cure a sexual perversion." (56) "Perversion" was well on its way to becoming a matter for cure, not punishment.

However, this was not a universally-held view. Initial forays into research on the sexual offender in prison were met with stony silence in the medical press, and breakthrough articles and books by prison doctors prompted no letters to the editor that found their way into print, and little related research from other quarters. Medical views were slowly shifting, as suggested by Havelock Ellis's admission to the Royal College of Physicians in 1938, some forty years after his "disgusting and nauseous" sexological work had begun, but change took place slowly. It seemed that the "distasteful" nature of the subject prevented it from spreading far beyond the niches of forensic psychiatry and, to a lesser extent, public health. Historians have argued that general practitioners were frequently ignorant of sexual matters and little able to advise worried patients, even into the 1940s. Moreover, there were no general textbooks about criminal or "deviant" sexual behaviours until the 1950s and 1960s when publications addressing male homosexuality and ultimately a wider range of sexual acts became available. (57) Private clinics had begun to conduct research into the treatment of sexually deviant patients in the 1930s, but the fruits of their endeavours did not appear in British medical journals until the 1940s. Indeed, one such clinic sent a summary of its work to the Prison Commission for comment in 1937, requesting "whether some member of your staff might be able to give us some shrewd and destructive criticism about these results," suggesting faith in the advanced expertise of prison doctors at the time. (58) The wider medical world remained either unaware of psychiatric explorations of sexual behaviour or unwilling to discuss them, leaving prison doctors all but alone in forging a path of psychotherapy.

Research and treatment of the sexual offender was also hindered by the haphazard way in which medical services were deployed in cases of sexual crime. In contrast with North America, until the 1950s there was no heightened awareness of sexual offenders among members of the press or public, no public outcry, and no legislation equivalent to the "sexual psychopath laws" to distinguish the sexual criminal as a psychiatric concern. (59) Although English courts did request assessments of mental state prior to trial with increasing frequency, these were only compulsory in cases of murder and were usually restricted to a statement addressing the only issues of immediate interest to the court: whether defendants were insane or mentally defective as defined in law, and thus whether they were fit to plead to the charge. Mental disorder was rarely raised during criminal trials and sentencing, except when the defendant's behaviour provoked immediate concern among police or magistrates. It also came up in exceptional circumstances when the skilful counsel of a wealthy defendant used mental illness as a defence. (60)

Although some judicial officials such as magistrate Claud Mullins maintained that "there are many crimes which in themselves indicate the necessity for psychiatric treatment" including "all cases of sexual crime," this was a minority view, as Mullins himself recognized. (61) His preferred option was to use probation orders to enable offenders to seek medical help privately. However, most of those convicted of sexual offences would be sentenced without reference to medical opinion or recourse to medical treatment. One problem, in the words of the 1932 report of the Committee on Persistent Offenders, was that "[n]o witness was able to give us any precise information concerning the curative value of psychological treatment in any large number of law-breakers," which made any sweeping changes to the administration of justice difficult to justify. The committee maintained, however, that the "nature or the manner" of some offences indicated "an abnormal mental condition," particularly "some cases of indecency and certain other sex offences," and that this demanded attention. (62)

It was no coincidence that Dr. East, Prison Commissioner, was the chairman of the committee, and that his request for funding for a prison psychotherapist and four years of experimental treatment at Wormwood Scrubs came immediately after the committee's report. More precise information was needed, and an experiment in treatment would provide it. Throughout the years of the experiment, the focus upon sexual offences remained, with over half of those investigated classed as such. (63) When the results were ready for circulation, however, the lengthy section on sexual offenders came under threat of excision for reasons of propriety. Dr. East defended it firmly by citing an assumption held by the "general public" that sexual offences were often a medical matter, an assumption that this research needed to address in full. (64) Given that the report was only circulated among government departments, relevant professional journals, and prison staff, East's "general public" was unlikely to have consisted of the average readers of daily newspapers. Dr. East was concerned to make sure that his fellow doctors, as well as the psychoanalysts and magistrates who were making bold claims for or against psychotherapy for sexual offenders, would be able to read the modest conclusions of his research.

This response to Home Office intimations of censorship, along with notes of caution in many medical surveys of mental disorder in sexual offenders suggest that obtaining evidence of the results of treatment was a pressing concern. The objective was not simply to place claims for psychiatric treatment in prisons on a more secure footing, but also to counter the occasionally excessive claims made for the power of medicine by a vocal minority of magistrates and therapists. (65) The first four years of treatment at Wormwood Scrubs may have provided a template for future research by dividing cases into two roughly equally-sized groups, those dealing with "sexual" and "non-sexual" offences respectively; however, this research did not find sexual offenders particularly receptive to psychotherapy. Efforts here and elsewhere to specify exactly which sexual crimes indicated mental disorder were designed in large part to improve the means by which offenders were selected for treatment, whether by judges or prison doctors. They also served to clarify a new perspective toward sexual behaviour and deviance, in which new understandings of the sexual offence itself were put forward to distinguish between illegal but normal sexual behaviour on the one hand, and disordered sexual impulses on the other.

IV. Normal or Abnormal?

Medical theories relating to sexual offences were bound up with perceptions of what constituted the "sexual" and the "normal." During the nineteenth and twentieth centuries, the legal, medical, and social meanings of homosexual acts between men, prostitution, and the sexual behaviour of children have changed; at different times these have been characterized as sexual or otherwise, normal or abnormal. As prison doctors began to publish their research on the subject of the sexual offender, it became clear that they were striving to promote a specific idea of what constituted a sexual crime. The 1922 publication Psychology of the Criminal by Dr. Maurice Hamblin Smith argued that, although some offences such as indecent exposure should be seen as self-evidently sexually motivated, in fact "many other and widely different forms of delinquency may result from such a sex complex." (66) Understanding sexual deviance was therefore of primary importance, in his view, to a full understanding of criminality. In this approach, he was not alone. Dr. East illustrated the same point with the example of a thirty-year-old glass blower who had approached a girl in the street and cut off a lock of hair. He was found to have a collection of hair at his home, apparently from several different people, as well as seventy-two hair ribbons. Dr. East had examined the offender, and although the crime would not have been recognized as a sexual one for the purposes of prosecution or official statistics, he was for medical purposes a sexual offender: the diagnosis was one of fetishism. (67)

Violent attacks or murders were also classed as sexual offences for medical purposes if they were attributed to sadism, (68) as were some cases of theft. Dr. Mackwood of Wormwood Scrubs prison gave an account of "a transvestist" whose crime was the theft of women's clothing "that he wanted for his personal use," emphasizing in his tabulated reports of treatment that "it is the really important psychological factor that is classified in the tables, and not the recorded offence." (69) Sexual offences were, therefore, not simply those classified as such in the official criminal statistics (such as rape and indecency), but any crimes thought to have an underlying sexual motive.

Although the "sexual offence" was thus becoming a broader category than previously acknowledged by medical or legal thought in Britain, the crimes that fell within that category were not all equal in the eyes of doctors. Those commonly understood to be indicators of mental disorder were the so-called perversions. Dr. East summarized the most common examples as "fetishism, sado-masochism, transvestism, exhibitionism and homosexuality," (70) and demonstrated bias toward crimes involving these "perversions" in the circular sent to his colleagues to request subjects for the programme of research into treatment at Wormwood Scrubs. This circular specified that prison doctors should consider referring for treatment individuals who were convicted of "indecent exposure (other than cases of sexual invitation)" and "homosexual or abnonnal sex crimes." (71) Sexual crimes in general were not of interest. Although no further explanation was given to clarify the meaning of either "sexual invitation" or "abnormal" sex crimes, the results of the first four years of treatment confirmed that "[hjomosexual, exhibitionist and other offences in which the recognized sexual perversions are concerned are mostly abnormal" and can be "considered under the heading of abnormal mental states," while those "guilty of assaults on women and girls, belong to the normal group of offender." (72) Ideas of normal and abnormal crimes were here inextricably confused with understandings of normal individuals and normal or abnormal mental states. The perversions were both abnormal sexual acts, and commonly associated with an abnormal mental state, whereas heterosexual assaults were generally committed by the normal individual.

Reiterating this distinction, Dr. East specified elsewhere that the "crime of incest in this country does not usually present any complex psychological problem for investigation," being simply "the result of propinquity and opportunity." (73) Although he acknowledged that offenders who committed particularly violent rapes or sexually motivated murders might be mentally disordered, he argued that their crimes were better categorized as sadism and thus distinguished them from most sexual assaults. In one of the first British criminology textbooks he further explained that "the manner and circumstance of a sexual offence against women and girls requires no detailed presentation here." It was, he felt, "the transference of normal thought into criminal activity;" there was neither perversion, nor obscure motive, and therefore no mental disorder for the doctor to uncover and address. (74) Normal thought, it seems, sat in opposition to the abnormal thoughts, acts, and mental states of those engaging in the perversions. Offences such as rape, indecent assaults, or incest between male and female-or indeed any other crime that could be traced back to a desire for heterosexual sex--were held as intrinsically different in medical terms from the abnormal offences, and thus were less likely to be associated with any form of mental disorder.

This pattern was repeated in a classification system of criminals that appeared in the Report of the Prison Commissioners and Directors of Convict Prisons for the Year 1935 and was later reproduced and referenced on numerous occasions. (75) This system featured six top-level categories of mental classification: normal, subnormal, mentally defective, mentally inefficient, psychoneurotic, and psychotic. The number of separate conditions within this table was indicative of the range of behaviours that prison doctors were trying to interpret and their desire to attribute a distinctive medical status to a wide variety of symptoms and individuals. Of particular note is the sub-group of "Perverts," which fell within the category of "Psychopath" and included the various sexual offences that were considered to be signs of abnormality [figure 1]. These seven types did not include all sexual offenders, but reflected newly-stated definitions of sexual perversion. For the prison doctors of early- to mid-twentieth century England, those engaging in rape, incest, or sexual assaults that appeared neither homosexual nor sadistic were not engaged in sexual perversion, and their crimes did not indicate any unusual mental state.

As Elise Chenier has argued in relation to the sexual psychopath diagnosis in Canada, "the medical and psychiatric study of sex was built not on violent sex crimes but on sexual acts that merely deviated from accepted norms." (76) Prison doctors did not share the permissive outlook toward homosexuality that Chenier finds in 1950s Canadian psychiatry, and although the effect of normalizing sexual violence against women and girls was the same, their assessments of mental disorder among sexual offenders appeared to be strongly grounded in older medical models of sexual behaviour. These models conflated normal sexual instinct with the drive to reproduce and were, therefore, uninterested in heterosexual violence but troubled by almost all sexual behaviour that appeared not to have reproduction as its aim. (77)

Exceptions to this way of thinking were few but clearly defined; they suggested how medical diagnosis could help to reffame acceptable sexual behaviour. (78) Masturbation, for example, was occasionally mentioned in passing as a sign of precocious or excessive sexual impulses, but was not identified as a perversion or sign of disorder in and of itself. The Psychological Treatment of Crime noted that many exhibitionists had a "history of frequent masturbation from the age of puberty or even before," but it was otherwise unimportant. (79) Importantly, sexually deviant acts could also be viewed as the result of circumstances rather than as signs of a disorder. Dr. East suggested that in many of the cases of young men "arrested for immoral soliciting" of other men, the "dominant factor for them is an economic one," and perhaps more radically, that many men committing homosexual acts may only do so "when hetero-sexual opportunities are lacking." (80) Medical approaches to the abnormal therefore tried, in the first half of the twentieth century, to distinguish between actions that may be a matter for moral or legal condemnation in which mental disorder was unlikely, and those perversions that were the result of congenital or developmental defects that left the individual powerless to resist.

Researching the sexual offender allowed doctors to reflect changing sexual norms in this way, borrowing from long-established medical theories but offering modest clarifications and amendments. It was also a potent route through which doctors could address broader questions of individual responsibility in relation to sex. Many firmly believed in the futility of prison sentences without psychotherapy for those who seemed unable to resist the impulse to commit their crimes. An unnamed medical officer from Preston prison fretfully remarked upon the "large number of cases of mental instability with acts of uncontrolled, rather than uncontrollable, impulses whose treatment required anxious consideration and thought," and his colleague at Brixton added that short prison sentences achieved nothing. "This is so particularly in the cases of sexual perverts," he continued, for whom it was "certain that punishment is as a rule impotent to deter them. They apparently cannot resist their disordered impulses." (81) These views were in step with criminological and refonnist theories that called for greater emphasis upon individual psychology and personal circumstances, and also worked to redefine the level of self-control that could be anticipated from ordinary men. (82) The notion that men might be at the mercy of uncontrollable sexual impulses was also encouraged by the Freudian interpretations of sexual development and behaviour that proved popular among doctors studying deviance. Dr. East described "the evolution of sexual development" with references to the "stages" through which young people passed and the potential problems therein, from infantile sexual impulses and "arrested" sexual development to "parent fixation" and the power of early, unconscious memories to govern later sexual fantasies and crimes. Dr. Edward Glover, one of the most prominent English psychoanalysts of the time, provided a strikingly similar account in his lecture to the Medico-Legal Society in 1945. Prison doctor John Landers demonstrated in his case studies from 1938 that Freudian interpretations had taken root, and described one case of "psycho-sexual maladjustment" as a problem of "maternal fixation," noting that the prisoner's dreams "simply bristle with Freudian symbols." (83) Although doctors had some hopes for their own therapeutic interventions, much of their research on sexual offenders dwelt upon the ease with which sexual development could be distorted during childhood, resulting in sexual disorders that no man could control.

Although a line had been drawn between normal and abnormal sexual offences, with the perversions firmly situated on the abnormal side, particular perversions received more attention at different times. In the 1920s and 1930s, indecent exposure was commonly highlighted as a very strong indicator of mental disorder. The 1925 Report of the Committee on Sexual Offences Against Young Persons recorded that "cases of indecent exposure ... showed a comparatively large proportion of mental trouble" and recommended that in "all cases of indecent exposure ... the offender should be examined as to his mental condition." Indecent exposure had also received particular attention in the early medical publications on sexual offenders. (84)

However, although the Report on the Psychological Treatment of Crime included an entire chapter devoted to exhibitionism, it concluded that "the exhibitionist group is a disappointing one from the psychotherapeutic point of view." (85) This lack of therapeutic success, combined with growing concern about male homosexuality, led to a shift in the 1940s. (86) The potential for prison medicine to prevent future homosexual offences, and to manage prisoners who had been identified as homosexual (and were thus seen as a threat to the prison regime), came under increasing scrutiny. The issue was addressed in a pamphlet by the Prison Medical Refonn Council in 1944, and at a meeting of the Prison Commissioners in 1947 the question of "whether it was desirable to segregate homosexuals" within prisons was debated. (87) The same year saw the first paper on the subject of homosexuality at the Prison Medical Officers' Annual Conference, and the successes and failures of psychotherapy were carefully monitored. (88) Angus McLaren has argued that exhibitionism was treated disproportionately harshly in the twentieth century because of the threat it presented to ideals of masculine behaviour, and post-war anxiety about homosexuality was in part a reflection of the same fears. (89) Medical research and treatment of sexual offenders took heterosexual masculine desire as a clear signifier of normality and any deviations as signs of mental disorder. Perhaps unsurprisingly, the approach of prison doctors to women and sexual crime was quite different.

V. The Female Offender

Male sexual offenders were analyzed and divided into the normal and abnormal, the disordered and the simply criminal. Female sexual offenders, in contrast, barely qualified for a mention in the prison or medical literature. Annual statistics demonstrated that a steady stream of women were convicted of sexual offences including indecent exposure, crimes relating to prostitution, and to a lesser extent, indecent assaults, and yet they were almost entirely excluded from studies and discussions of sexual offenders. The relatively small number of women in prison meant that they were, as a group, simply not seen as a problem on the same scale as male prisoners. (90) Their numbers were also declining, both in real terms and as a percentage of the overall prison population, largely because it became increasingly rare for offences relating to prostitution and public drunkenness to result in a custodial sentence. (91) In the twelve months prior to March 1923, the first year in which the Prison Commissioners gave a breakdown of the nature of offences that had led to a prison sentence, 1,402 men had been jailed for offences described as sexual, compared to just 158 women. By 1939, there were only 110 cases of women imprisoned for offences relating to prostitution, and the numbers were too small to be recorded separately after 1949.92 In contrast, indictable sexual offences among men rose from 854 in 1923 to 1,458 in 1959; this was a steady rather than dramatic increase, but it meant that the male sexual offender remained a visible presence in the prison and a problem for the prison doctor. (93)

Dr. East noted in 1938 "the intriguing, well established, and, as far as I know, unexplained fact that women commit crime less frequently than men," and concluded that "the whole realm of female criminality needs much scientific study." (94) However, it was not a field that piqued his interest, nor that of any of his colleagues within the prison service. Of the limited medical research on women in prison, perhaps the best known was conducted by Dr. Grace Pailthorpe, who under the auspices of the Medical Research Council carried out a study on 100 women in Holloway Prison and 100 women in "rescue homes." Although she found that "mental imbalance is evident in a large proportion of the cases" and was adamant that psychotherapy would help many, she did not single out any particular type of offence as demanding particular attention and did not mention sexual offences at all. (95)

It was not that women were thought incapable of committing crimes in which the sexual motive might require some medical expertise to uncover. In 1925, two case studies of offences committed by women appeared in the Journal of Mental Science. Although in legal terms the crimes related to libel, they were presented to the psychiatric audience as sexual crimes. In the first instance, the offender had believed herself to be married to a clergyman and wrote to "bishops and other dignitaries of the Church, as well as to relations, announcing the marriage." The second case concerned letters alleging a seduction and pregnancy which were described as "grossly obscene." In both cases the medical explanation was that the offenders' "sexual desires were intolerable to their own moral training and peace of mind" so they "projected their wishes onto others." (96) These cases stood alone, however. Women were not considered for inclusion in the treatment programme at Wonnwood Scrubs from 1934, and although it was evidently agreed that psychotherapy could be of benefit to female as well as male prisoners when the programme was extended to Holloway women's prison in the mid-1940s, sexual crimes were not listed, discussed, or even mentioned as a feature of the work done at Holloway.

This absence stemmed in part from the fact that prostitution and its associated crimes of indecency were not considered to be sexual offences according to the majority of medical or legal definitions. In a notable departure from that view, however, Dr. Smith of Birmingham prison argued that women charged with prostitution and indecency were sexual offenders. He was an "unrepentant Freudian," and wrote that prostitution quite clearly had a "sex basis" and was therefore a matter for the psychologically-minded doctor. Similar commentary from this period, identifying prostitution as a disorder stemming from flawed sexual development, can only be found among other Freudian psychoanalysts, including Dr. Edward Glover. "Among the environmental factors in early prostitution, economic motives play a subsidiary role," Glover wrote, emphasizing that the activity was instead--for both prostitute and client--evidence of infantile sexuality or "sexual backwardness." Treatment, he maintained, could "alleviate those psychological conflicts that were responsible in the first instance for the choice of prostitution as a profession." (97) However, this perspective gained no traction across the prison service. Official statistics for the year to March 1923 listed the 2,015 sentences of imprisonment for offences relating to prostitution separately from "sexual offences," in a distinction that persisted until prostitution eventually disappeared from such figures. It was not registered for official purposes as a sexual offence, nor did it merit a mention from the majority of doctors considering the relationship between mental disorder and sexual crime.

Indeed, the only occasions when sexual offences committed by women were highlighted by doctors with any regularity--and indeed, almost the only occasions when female offenders were mentioned at all--were in connection with venereal disease. As Carolyn Dean and others have pointed out, criminality and sexual misconduct among women had been inextricably linked for decades, if not centuries, and it was clear in the assessments of women prisoners that their criminality alone was suggestive of sexual delinquency and its corollary, venereal disease. (98) In a 1933 circular from the Prison Commissioners to their staff, it was specified that the female prisoners to be examined for venereal disease were not only those convicted of prostitution, but "all cases of sexual offences, sleeping-out, wandering, begging and insulting behaviour." In the same vein, a project funded by the Rockefeller Institute, ostensibly to investigate the "social background of convicted women at Holloway Prison infected with venereal disease," made the connection between crime and sexual deviance explicit. This study confirmed that almost any crimes committed by women "may be considered offences essentially sexual in nature" and went on to discuss the problem of "sexual delinquency" in some detail. "Wandering or lodging out was associated with sexual promiscuity and soliciting," it noted, and the charge of "trespassing on Government premises" actually meant "that the women concerned were suspected of hanging round military or air force camps for immoral purposes." Even theft and military offences were "invariably connected with irregular modes of life" involving boyfriends and "undesirable cafes." This investigation concluded that it was "impossible to make a sharp distinction between sexual and other forms of delinquency in these women," since "one may lead to the other." (99)

Women in prison were, therefore, all viewed as sexually delinquent. The libellous letter-writers discussed in the Journal of Mental Science required explanation and psychiatric understanding, given that their educated, middleclass status and general mode of life did not suggest overt sexual misconduct, but for the vast majority of prisoners in Holloway their delinquency was not linked to mental disorder. This perspective reflected wider and persistent notions of female criminality and sexuality, but was also connected to the very nature of sexual misconduct among female offenders. In all of the examples given in the literature, delinquent women's misconduct was understood to share the same motive as the one driving "normal" sexual offences committed by men: heterosexual intercourse. There is no evidence of medical interest in prison toward non-heterosexual deviance, although it was certainly the case that, by the 1940s, lesbian women were being directed toward medical treatment, whether by police, probation officers, or friends. (100) Perhaps a small number of prisoners were dispatched to the psychotherapist at Holloway prison for similar reasons, but prison doctors seemingly paid little attention, preferring to focus upon curing venereal disease and preventing re-infection and re-offending through education and the promotion of a celibate lifestyle. By the 1940s the numbers and treatments of women with venereal disease became a mainstay of reported medical work in women's prisons, and a "venereal disease social worker" and "V.D. Clinic" were put in place. The absence of any discussion of the women seen by Holloway's psychotherapist or how they fared is in marked contrast with the space devoted to dealing with venereal disease and the sexually promiscuous young woman. (101)

It is revealing that discussions about abnormal sexual crimes or self-control in the face of sexual impulses, such as those expressed in relation to male "sexual perverts," did not extend to women. A longer history within medicine of characterizing women as lacking the willpower of their male counterparts meant that their criminality was, in one sense, viewed as a natural state. Although the case studies from 1925 hinted at the possibility of "abnormal" sexual crimes for certain classes of women, the boundaries of sexual conduct and self-control for women were not examined to the same extent, and the decreasing numbers of women in prison ensured that they remained a low priority for legal and medical systems alike. Penicillin rather than psychotherapy became the doctor's best line of attack to cure the sexual misconduct of the female offender.

VI. Conclusions

This article has argued that studies and attempts to cure the sexual offender in England began with prison doctors during the first half of the twentieth century. The Reports of the Prison Commissioners alongside publications by doctors and Home Office records reveal that legal and medical professionals developed a wider interest in the relationship between crime and mental disorder, which prompted closer examinations of the causes of crime and the management of prisoners. This enabled segments of the medical profession to address the subject of sexual deviance openly for the first time; they identified sexual crime as a frequent sign of mental disorder and introduced psychotherapy within prisons for small numbers of offenders. For reasons of finance, a lack of civil service enthusiasm, and the absence of coherent and convincing results from early experiments in therapy, medical intervention remained a small-scale endeavour, albeit one that expanded slowly and discreetly in the 1940s and 1950s.

Unlike studies focusing on medico-legal responses to homosexuality alone, this examination of theories of sexual deviance, broadly defined, reveals the extent to which medical models of sexual crime focused upon the abnormal "perversions," which included nearly all non-reproductive acts. This emphasis meant that prison doctors devoted little attention to heterosexual violence, which they deemed normal. However, as those doctors developed increasingly nuanced theories of sexual deviance, these underlying principles evolved to reflect changing sexual and social nonns. The idea that men were not necessarily able to exercise control over their sexual impulses, or even that economic need could be an underlying cause of sexual misconduct, offered new explanations for deviant acts. Such explanations began to move the boundaries between nonnal and abnormal behaviour. Sexual crimes among women, in contrast, were virtually never "abnormal" since the criminal woman was inevitably sexually delinquent. These distinctions between sexual offenders and other types of prisoners-between normal and abnormal sexual acts and mental states, and between male and female prisoners--were fundamental to medical diagnoses of sexual behaviour in relation to criminality and mental disorder.

Both the contribution of prison medicine to forensic psychiatry and the history of forensic psychiatry in the twentieth century have yet to be considered in depth. (102) This examination of prison doctors and their research into sexual offenders has suggested that these branches of medicine were not characterized exclusively by expansionist efforts to extend medical power, nor by enlightened calls for more humane approaches to crime. (103) Rather, medical interest in male sexual offenders committing abnormal crimes reflected shifting perceptions of acceptable male behaviour, and a desire among many of those working in the field of criminal justice to address individual difficulties as the roots of crime. These difficulties might stem from faulty childhood or adolescent development, or simply the temptations of a particular personal circumstance. Although the marginal status of prison medicine, prison psychiatry, and the sexual offender alike ensured that the treatment of sexual crimes remained limited, the seeds of the idea that certain sexual offences were signs of "sickness" rather than simply crimes had been sown, and this idea would prove as durable as the edifices of British prisons themselves.

(1) Report of the Commissioners of Prisons for the Year 1949 (London, 1950), p. 121.

(2) Report of Prisons for 1949, p. 99.

(3) This article focuses on English prisons and doctors working in England, although much of what is said might apply equally to Welsh prisons which were managed by the same Commissioners and shared staff with their English counterparts. The different medico-legal structures and histories of Scotland and Northern Ireland suggest that they would benefit from separate, dedicated studies.

(4) See, for example, Frank Mort, Dangerous Sexualities: Medico-Moral Politics in England since 1830 (London, 2000); Thomas Laqueur, Solitary Sex: A Cultural History of Masturbation (New York, 2003); Patrick Singy, "How to be a Pervert: A Modest Philosophical Critique of the Diagnostic and Statistical Manual of Mental Disorders," Revista de Estudios Sociales, 43 (2012), pp. 139-50; Katherine Angel, "Contested Psychiatric Ontology and Feminist Critique: 'Female Sexual Dysfunction' and the Diagnostic and Statistical Manual," History of the Human Sciences, 25 (2012), pp. 3-24.

(5) Just a few examples of these include Sean Brady, Masculinity and Male Homosexuality in Britain, 1861-1913 (Basingstoke, 2005); I.D. Crozier, "Taking Prisoners: Havelock Ellis, Sigmund Freud, and the Construction of Homosexuality, 1897-1951," Social History of Medicine, 13 (2000), pp. 447-66; Roger Davidson, "Law, Medicine and the Treatment of Homosexual Offenders in Scotland, 1950-1980," in Imogen Goold and Catherine Kelly (eds.), Lawyers' Medicine: The Legislature, the Courts and Medical Practice, 1760-2000 (Oxford, 2009), pp. 403-24; Lesley Hall, "Heros or Villains? Reconsidering British fin-de-siecle Sexology," in Lynne Segal (ed.), New Sexual Agendas (Basingstoke, 1997), pp. 3-16; Harry Oosterhuis, Stepchildren of Nature: Krafft-Ebing, Psychiatry, and the Making of Sexual Identity (Chicago, 2000). For North America, see Estelle B. Freedman, "'Uncontrolled Desires': The Response to the Sexual Psychopath, 1920-1960," Journal of American History, 74 (1987), pp. 83-106; Philip Jenkins, Mora! Panic: Changing Concepts of the Child Molester in Modern America (New Haven, 1998); Elise Chenier, Strangers in Our Midst: Sexual Deviancy in Postwar Ontario (Toronto, 2008).

(6) Chris Waters has drawn attention to the importance of prison doctors and criminologists in the interwar and post-war periods, although primarily in relation to their theories of male homosexuality. Chris Waters, "Havelock Ellis, Sigmund Freud and the State: Discourses of Homosexual Identity in Interwar Britain," in Lucy Bland and Laura L. Doan (eds.), Sexology in Culture: Labelling Bodies and Desires (Cambridge, UK, 1998), pp. 165-79.

(7) The Psychological Treatment of Crime, for example, was carefully circulated to relevant professional journals and was deliberately not sent to the Telegraph, Manchester Guardian, or The Times, but its publication did prompt some brief comment in the News Chronicle and Daily Sketch. See The National Archives (London) (hereafter TNA), PCOM 9/186.

(8) Suggestions of sterilizing or castrating prisoners were quickly rebuffed during this period, and although treatments such as insulin and ECT were tested from the mid-1940s, psychotherapy remained dominant within prisons.

(9) The average daily number of prisoners increased from a low of 9,377 in 1940, as many convicts were released in preparation for war, to 19,879 in 1949 and 26,349 in 1959. It was widely accepted that crime was on the rise, often seen as the result of disruptions of war as well as the temptations and moral flaws of modern life, and newspapers began to increase their coverage of sexual offences in particular. See Report of the Commissioners of Prisons and Directors of Convict Prisons for the Years 1939-1941 (London, 1946), p. 27; Report of the Commissioners of Prisons for the Year 1950 (London, 1951), p. 22; Report of the Commissioners of Prisons for the Year 1959 (London, 1960), p. 22; Robert Fabian, Fabian of the Yard (Kingswood, 1950), p. 11; Adrian Bingham, Family Newspapers?: Sex, Private Life, and the British Popular Press 1918-1978 (Oxford, 2009).

(10) Roy Porter, Madness: A Brief History (Oxford, 2002), p. 203.

(11) Edwin Goodall, C. Hubert Bond and John R. Lord, "Post-Graduate Study in Psychological Medicine," British Medical Journal, 1 (1924), p. 634. The Association of Medical Officers of Asylums and Hospitals for the Insane began life in 1841, and the Asylum Journal in 1853. These would eventually become the Royal College of Psychiatrists and the British Journal of Psychiatry.

(12) As one of the Tavistock's clinicians recalled, the clinic "had a curiously independent, indeed isolated, position somewhere between official psychiatry and medicine on the one hand and 'orthodox' psychoanalysis on the other." H.V. Dicks, Fifty Years of the Tavistock Clinic (London, 1970), p. 2.

(13) Of the Tavistock, the "need which had inspired its founding" has been said to have come "from the battlefields of Europe." Elizabeth F. Irvine, A Pioneer of the New Psychology: Hugh Crichton-Miller (Chatham, 1963), p. 26. On the impact of military psychiatric casualties, see also M. Stone, "Shellshock and the Psychologists," in W.F. Bynum, Roy Porter and Michael Shepherd (eds.), The Anatomy of Madness: Essays in the History of Psychiatry (London, 1985), pp. 242-71; and Peter Barham, Forgotten Lunatics of the Great War (New Haven, 2004). Shell shock as a watershed moment has been disputed in Mathew Thomson, Psychological Subjects: Identity, Culture, and Health in Twentieth-Century Britain (Oxford, 2006), especially pp. 182-84.

(14) Edward Glover, The Diagnosis and Treatment of Delinquency, being a Clinical Report on the Work of the Institute during the Five Years 1937 to 1941 (London, 1944), inside cover.

(15) J.P. Sturrock, "The Mentally Defective Criminal," Journal of Mental Science, 59 (1913), p. 315.

(16) See, for example, William Norwood East, "An Inquiry into the Susceptibility of Criminals to Atmospheric Changes," The Lancet, 162 (1903), p. 211; and by his fellow prison doctors, W.C. Sullivan, "Feeble-Mindedness and the Measurement of Intelligence by the Method of Binet and Simon," The Lancet, 179 (1912), pp. 777-80; and Charles Goring, The English Convict: A Statistical Study (London, 1913).

(17) Herbert John Gladstone, Report from the Departmental Committee on Prisons (London, 1895), p. 34; Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year Ended 31st March, 19 14 (London, 1914), p. 25; Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year Ended 31st March, 1924 (London, 1924), p. 33.

(18) Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year ended 31st March, 1910(London, 1910), p. 31.

(19) These covered topics including "moral imbecility," prison psychoses, psychopathic personality, adolescent mental conditions, and the mental conditions found in sexual offenders. Report of the Commissioners of Prisons and Directors of Convict Prisons for the Year 1925-26 (London, 1927), pp. 33-34.

(20) Report of the Commissioners of Prisons and the Directors of Convict Prisons for the Year 1935 (London, 1937), p. 56.

(21) The Children's Act of 1908 introduced Borstals to accommodate young offenders, in place of adult prisons, and the Criminal Justice Administration Act of 1914 allowed more time for the payment of fines instead of immediate imprisonment. Their impact was noted and appreciated in the official statistics, which showed a decline in annual prison admissions from over 200,000 in 1910 to 28,753 in 1919. See the commentary in, for example, Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year ended 31st March, 1917 (London, 1917), pp. 5-6.

(22) Report of Prisons for 1914, p. 22.

(23) Figures collected from the annual Reports of the Commissioners of Prisons and the Directors of Convict Prisons show a relative constant of between two and three hundred "defectives certified on remand" and a lower, decreasing number "certified during sentence" per year throughout the 1920s, 1930s, and 1940s. This seems to have been fewer than prison doctors initially anticipated, and represented only a tiny percentage of prisoners.

(24) Report of the Committee on Sexual Offences Against Young Persons (London, 1925), p. 57.

(25) Report of the Commissioners of Prisons and the Directors of Convict Prisons for the year 1926 (London, 1928), p. 18.

(26) See for example M Hamblin Smith, The Psychology of the Criminal (London, 1933), p. 170; William Norwood East, "The Non-Sane Non-Insane Offender," Eugenics Review, 39 (1947), pp. 616; William Norwood East, Medical Aspects of Crime (London, 1936), p. 256.

(27) Desmond Curran and Paul Mallinson, "Psychopathic Personality," Journal of Mental Science, 90 (1944), p. 266.

(28) R.D. Gillespie, The Service of Psychiatry in the Prevention and Treatment of Crime (London, 1930), p. 4.

(29) East, Medical Aspects of Crime, p. vii.

(30) William Norwood East and Alexander Walk, "Maurice Hamblin Smith," Journal of Mental Science, 82 (1936), p. 292; Grace Pailthorpe, Studies in the Psychology of Delinquency (London, 1932), p. 99. Maurice Hamblin Smith's career progression stalled in the 1920s, partly because of his psychoanalytical convictions, whereas Pailthorpe abandoned medicine in the 1930s and went on to achieve renown as a surrealist painter.

(31) Notes in response to enquiries from John Catterall Jolly KC JP in TNA HO 45/18736.

(32) See, for example, TNA files HO 45/18736 and HO 45/18736.

(33) On the initial introduction of psychotherapy, see TNA PCOM 9/186.

(34) East and Walk, "Maurice Hamblin Smith" p. 291.

(35) William Norwood East, "Some Cases of Mental Disorder and Defect seen in the Criminal Courts," Journal of Mental Science, 66 (1920), pp. 425, 437.

(36) Report of the Departmental Committee on Persistent Offenders (London, 1932), p. 45.

(37) William Norwood East and William Henry de Bargue Hubert, The Psychological Treatment of Crime (London, 1939), p. ii.

(38) Clifford Allen, E.A. Bennet, Frederick Dillon, Ellis Stungo, Eustace Chesser and Rodney H.N. Long, "Homosexuality," British Medical Journal, I (1946), p. 450.

(39) East and Hubert, The Psychological Treatment of Crime, p. 26.

(40) By 1949, only 322 individuals had been treated in the dedicated unit at Wormwood Scrubs over the previous six years. Report of Prisons for 1949, pp. 82-89 and pp. 100-102. The prison doctor whose comments open this article was keen to defend the fact that he had only referred six patients for treatment at Wormwood Scrubs, while the physicians there were equally keen to explain the difficulties that made large-scale interventions impossible. Report of Prisons for 1949, p. 121, pp. 82-89.

(41) See Alyson Brown, "The Amazing Mutiny at the Dartmoor Convict Prison," British Journal of Criminology, 47 (2007), p. 279 and Alexander Paterson, Paterson on Prisons (London, 1951).

(42) Clive Emsley has drawn attention to the absence of crime and punishment as electoral issues in the first half of the twentieth century in Britain, in Clive Emsley, Crime and Society in Twentieth-Century England (Harlow, 2011), p. 8.

(43) Psychiatric care in Britain underwent great changes in the late 1940s with the foundation of the National Health Service, but the prison medical service remained an entirely independent entity until the twenty-first century and was only indirectly affected.

(44) Of the thirty-three prisoners received at the psychiatric prison in its first year of operation, fifteen were sent purely because of the sexual nature of their crime, while the remaining eighteen were described by their diagnosis. Although equivalent figures become increasingly difficult to obtain from official publications, in 1992 for example the annual Home Office report confirmed that the "treatment needs of sex offenders" remained "the first priority," with a new "core treatment programme" underway. Report of the Commissioners of Prisons for the Year 1962 (London, 1962), p. 60; Report on the work of the Prison Service April 1991-March 1992 (London, 1992), p. 25.

(45) In the British Medical Journal, for example, volumes 1 and 2 of Havelock Ellis's Studies in the Psychology of Sex were characterized as "disgusting and nauseous" and "not interesting in themselves, nor are they important in connexion with any scientific principle, hypothesis or doctrine." See "Sexual Psychology and Pathology," British Medical Journal, 1 (1902), p. 340. On the subject of the obscenity trial, see Phyllis Grosskurth, Havelock Ellis (London, 1980), p. 195-99. Lesley Hall has suggested that the doctor-members of the Society were "somewhat outside the orthodox mainstream of the profession." and has also pointed to the legal risks run by doctors publishing about sex in the late nineteenth and early twentieth centuries. Lesley Hall, '"Disinterested Enthusiasm for Sexual Misconduct': The British Society for the Study of Sex Psychology, 1913-47," Journal of Contemporary History, 30 (1995), p. 669; Lesley Hall, Hidden Anxieties: Male Sexuality. 1900-1950 (Cambridge, 1991), p. 55.

(46) William Norwood East, "Observations on Exhibitionism," The Lancet, 204 (1924), p. 370.

(47) Such articles included East, "Observations on Exhibitionism"; M. Hamblin Smith, "The Mental Conditions Found in Certain Sexual Offenders," The Lancet, 203 (1924), pp. 643-46; H.T.P. Young, "Adaptability in Sexual Offenders at Convict Prisons and its Relation to Alcohol," British Journal of Inebriety, 27 (1929), pp. 15-23.

(48) Waters, "Havelock Ellis, Sigmund Freud and the State", p. 172.

(49) East, "Observations on Exhibitionism"; William Norwood East, "The Interpretation of some Sexual Offences," Journal of Mental Science, 71 (1925), pp. 410-24; William Norwood East, "Responsibility in Mental Disorder, with Special Reference to Algolagnia," Journal of Mental Science, 84 (1938), pp. 203-21. These were among the first articles in British medical literature to take sexual offences as their focus. 1924 is remarkably late, given that colleagues across the Channel had been studying and publishing on the subject of sexual deviance for many decades. There had been some previous forays in British medical journals into the subject, such as George Savage, "Case of Sexual Perversion in a Man," Journal of Mental Science, 30 (1884), pp. 390-91, but this was an extreme rarity. For more on Britain's late adoption of a medical model of sexuality, specifically male homosexuality, see I.D. Crozier, "Becoming a Sexologist: Norman Haire, the 1929 London World League for Sexual Reform Congress, and Organizing Medical Knowledge about Sex in Interwar England," History of Science, 39 (2001), pp. 299-329; Lesley Hall, '"The English Have Hot-Water Bottles': The Morganatic Marriage Between Sexology and Medicine in Britain since William Acton," in Roy Porter and Mikulas C. Teich (eds.), Sexual Knowledge. Sexual Science: The History of Attitudes to Sexuality (Cambridge, 1994) pp. 350-66 and Brady, Masculinity and Male Homosexuality.

(50) Report of the Commissioners of Prisons and the Directors of Convict Prisons for the Years 1924-1925 (London, 1926), p. 35; Report of Prisons for 1925, p. 42.

(51) Report of Prisons for 1949, pp. 66-97.

(52) "Treatment of Delinquency," British Medical Journal, 1 (1933), p. 625.

(53) "Reports of Societies," British Medical Journal, 2 (1938), p. 1169.

(54) Report of the Commissioners of Prisons and the Directors of Convict Prisons for the Year 1937 (London, 1938), p. 64.

(55) "Criminal Law and Sexual Offenders," British Medical Journal, I (1949), p. 135.

(56) Nesta H. Wells, "Sexual Offences as seen by a Woman Police Surgeon," British Medical Journal, 2 (1958), p. 1407.

(57) Lesley Hall, "'Somehow Very Distasteful': Doctors, Men and Sexual Problems between the Wars," Journal of Contemporary History, 20 (1985), pp. 553-74; Simon Szreter has persuasively argued that there was no end to "Victorian sexual attitudes and codes of behaviour until the 1960s," which is supported by this reticence even among doctors. Simon Szreter, "Victorian Britain, 18311963: Towards a Social History of Sexuality," Journal of Victorian Culture, 1 (1996), p. 139. General interest books from the 1950s included D.J. West, Homosexuality (London, 1955) and Anthony Storr, Sexual Deviation (London, 1965), both written by psychiatrists but for a wider audience.

(58) TNA HO 45/18736.

(59) Estelle Freedman and Philip Jenkins both identify a distinct increase in newspaper coverage and campaigning in relation to sexual crimes from the late 1930s in the United States, followed by new legislation. See Freedman, "Uncontrolled Desires" and Jenkins, Moral Panic.

(60) As Freedman argued in the context of sexual psychopath diagnoses, a finding of pathology was more common in the cases of better-educated, white defendants. In the case of TNA MEPO 3/ 397, for example, the defendant--a stockbroker--managed with his legal team and a private physician to persuade the judge that his sexual assaults and attempts at rape should be seen as the result of "exhaustion" and "insomnia," requiring private medical care.

(61) Claud Mullins, "The Twenty-Second Maudsley Lecture: Psychiatry in the Criminal Courts," Journal of Mental Science, 95 (1949), p. 268 and p. 263.

(62) Report of the Departmental Committee on Persistent Offenders, p. 45, p. 43.

(63) See the chapter divisions in East and Hubert, The Psychological Treatment of Crime, as well as their summary of the numbers treated and the nature of their offences.

(64) An unnamed Home Office official expressed concern that the "references to the various perversions" might lead to this plain Stationery Office publication being presented for other-than-educational purposes in the "shop fronts in Villiers Street along with the History of the Rod and the works of Kraffi-Ebing." TNA HO 45/18736.

(65) Numerous examples of such enthusiasm or interest in treatment have been retained in Home Office files. They include suggestions from the public that particular criminals should be psychoanalyzed, records of experiments in offering treatment that were undertaken by magistrates and doctors, and numerous requests for information about the treatment available to prisoners: TNA HO 45/18736; HO 45/18736. In the face of this interest and enthusiasm, Dr. East was anxious to ensure that medicine did not make excessive claims or interfere in the workings of the law. See East, "Some Cases of Mental Disorder," p. 425 and William Norwood East, "The Modern Psychiatric Approach to Crime," Journal of Mental Science, 85 (1939), p. 254.

(66) Hamblin Smith, The Psychology of the Criminal, p. 99.

(67) East, "The Interpretation of some Sexual Offences," p. 416. This particular example echoes German sexologist Richard von Krafft-Ebing's discussion of "hair-despoilers," first published in 1886. R. von Krafft-Ebing, Psychopathia Sexualis: With Especial Reference to the Antipathic Sexual Instinct (New York, 1998 [1965, 1902]).

(68) Two such examples included one young man convicted for attacking and killing a horse, and another for accosting and whipping children in the street. East and Hubert, The Psychological Treatment of Crime p. 121 and East, "Responsibility in Mental Disorder," pp. 213-14.

(69) Report of Prisons for 1949, pp. 76, 78.

(70) "The Court and the Sexual Offender," British Medical Journal, 2 (1951), p. 1459.

(71) TNA PCOM 9/186.

(72) East and Hubert, The Psychological Treatment of Crime, p. 149.

(73) East, Medical Aspects of Crime, p. 344.

(74) East, "The Interpretation of some Sexual Offences," p. 420. On sexual offences against women and girls, see William Norwood East, "Sexual Offenders," in L. Radzinowicz and J.W.C. Turner (eds.), Mental Abnormality and Crime: Introductory Essays (London, 1944), p. 190.

(75) The table also appeared in East and Hubert, The Psychological Treatment of Crime, and in East, "Responsibility in Mental Disorder." Its structure, with psychopathy and sexual perversion categorized as mental abnormalities, was replicated elsewhere. See, for example, John J. Landers, "Observations on Two Hundred Dartmoor Convicts," Journal of Mental Science, 84 (1938), pp. 961-68.

(76) Chenier, Strangers in our Midst, p. 27.

(77) Richard von Krafft-Ebing, for one, was clear that "every expression of [sexual instinct] that does not correspond with the purpose of nature--i.e., propagation--must be regarded as perverse." Krafft-Ebing, Psychopathia Sexualis, pp. 52-3. This point echoes elements of queer theory, which have drawn attention to a "sex hierarchy" that prioritizes reproductive sexual activity. See, in particular, Gayle S. Rubin, "Thinking Sex: Notes for a Radical Theory of the Politics of Sexuality," in Peter Aggleton and Richard Parker (eds.). Culture, Society and Sexuality: A Reader (Taylor & Francis e-Library, 2002), pp. 143-78.

(78) Estelle Freedman discussed this at length with reference to the sexual psychopath laws in the United States. Freedman, "Uncontrolled Desires."

(79) East and Hubert, The Psychological Treatment of Crime, p. 105.

(80) East, "The Interpretation of some Sexual Offences," p. 414.

(81) Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year Ended 31st March, 1924, p. 60; Report of Prisons for 1925, p. 42.

(82) On criminology and campaigning, see Paterson, Paterson on Prisons, and Vera Brittain, Prisoners' Circle: Essays by Ex-Prisoners (Chiselhurst, 1943). On masculinity and expectations of self-control in the late nineteenth and early twentieth centuries, see Brady, Masculinity and Male Homosexuality, Mort, Dangerous Sexualities; Lucy Bland, Banishing the Beast: Feminism, Sex, and Morality (London, 2002 [1995]), especially pp. 63-64.

(83) East, "Observations on Exhibitionism," especially pp. 411-13; Edward Glover, The Social and Legal Aspects of Sexual Abnormality (London, 1947) especially pp. 5-7; Landers, "Observations on Two Hundred Dartmoor Convicts," pp. 968-70.

(84) See Sexual Offences Against Young Persons, pp. 56, 58; East, "Observations on Exhibitionism"; and Hamblin Smith, "The Mental Conditions Found in Certain Sexual Offenders."

(85) East and Hubert, The Psychological Treatment of Crime, p. 108.

(86) Much has been written about the visibility of homosexuality during this period, and the reactions that were generated. See Matt Houlbrook and Chris Waters, "The Heart in Exile: Detachment and Desire in 1950s London," History Workshop Journal, 62 (2006), pp. 142-65; Bingham, Family newspapers? pp. 160-89; and Stephen Jeffery-Poulter, Peers, Queers, and Commons: The Struggle for Gay Law Reform from 1950 to the Present (London, 1991).

(87) TNA PCOM 14/8.

(88) Report of the Commissioners of Prisons and the Directors of Convict Prisons for the Year 1947 (London, 1947), p. 67; Report of Prisons for 1949, pp. 78-91. Report of the Commissioners of Prison for the Year 1954 (London, 1955), pp. 138, 142.

(89) Angus McLaren, "Exhibitionism and Deviance," in Robert A. Nye (ed.), Sexuality (Oxford, 1999), p. 182.

(90) Although changes in the method of recording prisoner numbers make comparisons difficult, some patterns can be extracted. To take two years as examples, in the twelve months prior to March 1920, 24,842 men entered the prisons of England and Wales on conviction compared to 9,437 women. By 1949, 43,892 men but only 4,601 women were received annually. Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year ended 31st March, 1920 (London, 1920), p. 48; Report of Prisons for 1950, pp. 13-14.

(91) The use of monetary fines, with an allowance of time for payment, meant that very few of those so convicted found themselves in prison. There may also have been changes in police activity and prosecutions.

(92) Report of the Commissioners of Prisons and the Directors of Convict Prisons, with Appendices, for the Year Ended 31st March, 1923 (London, 1923), p. 9. These figures for sexual offences exclude convictions for bigamy and include 548 convictions for indecent exposure among men, and 158 convictions for indecent exposure among women. Note that there were many more convictions for sexual offences that did not receive a custodial sentence. Undoubtedly men would have been convicted for behaviour connected to soliciting, but this would have been prosecuted under indecency or vagrancy laws, or in the case of procuration, as an indictable sexual offence. For later figures on prostitution see Report of Prisons for 1939-1941, p. 25.

(93) Report of Prisons for 1923, p. 9 and Report of Prisons for 1959, p. 18 (both excluding bigamy).

(94) East, "Responsibility in Mental Disorder," p. 204.

(95) Pailthorpe, Studies in the Psychology of Delinquency, pp. 87-90.

(96) East, "The Interpretation of some Sexual Offences," pp. 422-3.

(97) Hamblin Smith, The Psychology of the Criminal, pp. 99, vii; Edward Glover, The Psycho-Pathology of Prostitution (London, n.d.), pp. 10, 6, 15. This latter piece was first published as a pamphlet by the Institute for the Scientific Treatment of Delinquency and subsequently reprinted in 1945, 1957 and 1969.

(98) Carolyn J. Dean, Sexuality and Modern Western Culture (New York, 1996), especially pp. 3-10.

(99) TNA PCOM 9/412. The "Enquiry into the Social Background of Convicted Women at Holloway Prison Infected with Venereal Disease," by K. Edkins, may have ultimately been published in the Journal of Dermatology and Syphilis in or around 1945.

(100) See, for example, the first-person accounts in Alkarim Jivani, It's Not Unusual A History of Lesbian and Gay Britain in the Twentieth Century (London, 1997), pp. 95, 122, 126-27.

(101) Report of Prisons for 1950, p. 75 and Report of the Commissioners of Prisons for the Year 1952 (London, 1953), p. 103.

(102) Work on earlier periods and different countries include Theo van der Meer, "Voluntary and Therapeutic Castration of Sex Offenders in The Netherlands (1938-1968)," International Journal of Law and Psychiatry, 37 (2014), pp. 50-62; Asa Bergenheim, "Sexual Assault, Irresistible Impulses, and Forensic Psychiatry in Sweden," International Journal of Law and Psychiatry, 37 (2014), pp. 99-108; Tony Ward, "Psychiatry and Criminal Responsibility in England, 1843-1936," (PhD thesis, De Montfort University, 1996).

(103) These views have been put forward in Joe Sim, Medical Power in Prisons: The Prison Medical Service in England 1774-1989 (Milton Keynes, 1990); Pat Carlen, "Psychiatry in Prisons: Promises, Premises, Practices and Politics," in Peter Miller and Nikolas Rose (eds.), The Power of Psychiatry (Cambridge, 1986), pp. 241-66 and are discussed in Harry Oosterhuis and Arlie Loughnan, "Madness and Crime: Historical Perspectives on Forensic Psychiatry," International Journal of Law and Psychiatry, 37 (2014), pp. 1-16.

Janet Weston is a PhD candidate at Birkbeck, University of London, researching the medical approach to sexual offenders in twentieth-century Britain under the supervision of Professor Joanna Bourke. She is extremely grateful to the anonymous Birkbeck alumni who have funded her PhD studentship.
Figure 1: An excerpt from a classification table for criminals from
East's "Responsibility in Mental Disorder," p. 207. Note the
category "Perverts."

4. Mentally
inefficient: Unstable adolescents.
             Temperamentally unstable adults.
             Psychologically maladjusted persons.
             Psychopaths: Alcoholists.
                          Drug addicts.
                          Perverts: Homosexuals.
                                    Exhibitionists.
                                    Sadists and flagellants.
                                    Masochists.
                                    Fetichists.
                                    Eonists.
                                    Necrophilists.
                          Schizoids.
                          Cycloids.
                          Paranoid personalities.
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