“It’s almost a life and death sentence”: Stakeholder perspectives on determinants of substance use risks and treatment access for individuals convicted of sexual offenses

Abstract

Sex offender registration and notification (SORN) policies have significantly destabilizing material and psychosocial collateral consequences for people required to register. There are strong theoretical and anecdotal reasons to believe that SORN policies likely increase substance-use-related harms for registrants. However, no research has directly examined relationships between SORN policies and substance-use-related harms. 20 qualitative semi-structured interviews were conducted with criminal legal, substance use, and forensic stakeholders who work with people required to register in Philadelphia. Interviews investigated how multilevel SORN consequences structure substance use risk environments for registrants. Through inductive and deductive coding, six broad themes emerged: “Sex offender” is an extremely stigmatized and villainized identity; SORN related restrictions transform the social and material context of reentry; SORN restrictions and the “sex offender” label have “devastating” impacts on mental health and self-concept; these material and psychosocial consequences of SORN increase substance use risk; SORN related policies severely restrict access to court-referred drug treatment; and this overall landscape of deprivation and restriction has dangerous and destructive implications, especially for overdose risk. Results suggest that sex offender registration and notification laws operate as social determinants of poor health for registrants, and are previously unstudied collateral consequences of sex offender criminalization. These findings provide evidence for providers, funders, policy advocates, and officials on the need to reform harmful and ineffective policies and improve access to treatment services for people required to register.

1. Introduction

People convicted of sexual offenses are perceived and portrayed as the “worst of the worst” in the American criminal legal system and in broader popular culture (Furst & Evans, 2015; Werth, 2022). Sex offender registration and notification (SORN) policies, which are designed to track, monitor, and apprehend people convicted of a wide array of criminal sexual offenses (Zgoba & Levenson, 2012), both reflect and perpetuate long-standing assumptions about sex offender danger and deviance. These federal laws require that states collect and publicize identifying information about people convicted of sexual offenses (Spraitz et al., 2015), and have additionally been accompanied by state-level policies that restrict where people required to register (PRR) may live, and limit access to publicly funded resources and services (Terry & Ackerman, 2015).

PRR face extreme levels of marginalization due to formal and informal collateral consequences of SORN policies. These policies have had well documented negative impacts on housing stability, opportunities for employment, access to programs and social services, stigma and social support, and mental health. This study seeks to build upon existing social science literature documenting SORN collateral consequences for PRR by using public health frameworks to explore how SORN law and policies can be understood as social determinants of health. Specifically, it engages viewpoints from professional stakeholders and providers who work with PRR in Philadelphia to investigate substance use-related collateral consequences of SORN policies. This previously unexplored area of inquiry is particularly salient for public health in Philadelphia and nationally, given that approximately 1400 individuals in Philadelphia (Philadelphia Department of Public Health, 2023) and almost 108,000 nationally (Spencer et al., 2024) died of fatal overdoses in 2022.

1.1. Background

The Sex Offender Registration and Notification Act (SORNA) stipulates federal standards for the registration and notification of people convicted of sexual offenses, mandating that states publicize information on PRR, including physical description, criminal offense history, registration offense, photograph, fingerprint sample, DNA sample, and a copy of an ID on an internet based registry (Spraitz et al., 2015). In addition to federally mandated registration and notification policies, over 30 states have enacted residency restrictions, which prohibit PRR from traveling, working, or living within designated distances of spaces where children congregate (Terry & Ackerman, 2015).

As of 2017, over 861,000 people in the U.S, 98 % of whom are men, were classified as PRR for offenses ranging from public urination to consensual sex between teens when one is over age 18, viewing child pornography, indecent exposure, assault, or rape and other forms of sexual violence (Byrne et al., 2022). Compared to white men, Black men are twice as likely to be registered (Hoppe, 2016) and more than twice as likely to be overclassified, i.e., placed in a higher risk and more restrictive offense tier (Ticknor & Warner, 2020), despite not engaging in sexual offending at higher rates. This is largely a function of long-standing racist conceptualizations of Black sexual predation, and disparities in policing, prosecution, and punishment decisions (Barrett & George, 2005).

A multidisciplinary evidence base of sexual offending recidivism literature has yielded limited evidence that registration and notification laws have had significant impacts on rates of sexual or general recidivism (Bonnar-Kidd, 2010; Jennings et al., 2012; Letourneau et al., 2010; Levenson, 2018b; Sandler et al., 2008; Veysey et al., 2008; Welchans, 2005; Zgoba & Mitchell, 2021). Several studies have analyzed individual or multistate state policy effectiveness, using quasi-experimental methods to evaluate policy variations over time. While limitations in the available data and analyses preclude definitive declarations, studies have consistently failed to find evidence that registries enhance public safety (Agan, 2011), and have found that registries have no significant impact on the number or type of sexual crimes committed (Sandler et al., 2008) or on the number of victims involved in sexual offenses (Veysey et al., 2008). Additionally, studies suggest that rates of recidivism for people convicted of sexual offenses are generally low, compared to non sexual offenders (Zgoba & Mitchell, 2021).

SORN policies–and their associated restrictions, prohibitions, and exclusions–have wide ranging, significant, and often debilitating impacts on the lives and wellness of PRR. PRRs face numerous policy and legal proscriptions, as well as intense stigma and alienation, both of which have destabilizing effects on physical, social, and emotional health. Collectively, these impacts of SORN on PRR and their communities can be understood as collateral consequences. Broadly defined, collateral consequences are consequences or sanctions that exist in addition to, and distinct from, direct criminal punishments (Hamilton et al., 2022). Collateral consequences have generally been conceptualized as arising from two separate mechanisms: formal policy and informal social control.

Formal consequences for PRR include ineligibility for programs or services, legal prohibitions against employment opportunities or participation in community activities, and limitations on travel. Residency restrictions also impose additional significant formal consequences. In states that have enacted them, PRR experience significantly elevated rates of transience, residential instability, and houselessness (California Sex Offender Management Board, 2011; Levenson, 2008; Levenson et al., 2015; Savage & Windsor, 2018; Zandbergen & Hart, 2009, p. 69). Residency restrictions also prohibit PRR from being able to enter restricted zones at all, limiting employment and educational opportunities, isolating individuals from their families, and prohibiting access to supportive institutions like churches and treatment centers (Levenson, 2018a).

Informally, PRR are at heightened risk of losing homes or being unable to find housing even in states without residency restrictions, due to discrimination and rejection from landlords, neighbors, and community members, as well as strained social ties to family members. PRR also frequently report experiences of vigilantism, public labeling, shaming, and harassment, and social exclusion from neighbors, family members, romantic partners, and employers (Cubellis et al., 2019; Hamilton, 2017; Levenson & Hern, 2007; Levenson & Cotter, 2005; McAlinden, 2005; Robbers, 2009; Tewksbury, 2005). As a result of these experiences, studies have shown that PRR are at increased risk of poor mental health post-release (Hamilton, 2017; Robbers, 2009).

The many consequences described above can be understood as examples of how SORN laws and policies operate as social and structural determinants of health for PRR. Social determinants of health, at the most basic level, are defined as any non-medical factors that influence health, and are typically used to explain how social factors and environments, such as neighborhood conditions; working conditions; education; income; race; and stress are powerful drivers of population health (Braveman et al., 2011). The Law as Social Determinant of Health Framework extends this explanation to consider how law produces a macro-social environment that influences health behaviors and outcomes at multiple levels (Burris, 2011). This study argues that SORN laws are one such case, in that they produce a legal and social landscape of restricted access to social, economic, and health resources, and perpetuate and exacerbate health disparities.

This study conceptualizes multidimensional stigma as the mechanism through which SORN laws impose collateral consequences and operate as social determinants of health. Stigma is defined as the “co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised” (Hatzenbuehler et al., 2013, p. 813). Stigma is here theorized to impact PRR at the internal, interpersonal, institutional, and socio-political levels. Most broadly, socio-politically, stigma has a bidirectional relationship with SORN policies; stigma against people who commit sex offenses led to the introduction of SORN policies, and stigma continues to be enacted and perpetuated through policy implementation and enforcement. Institutionally, stigma manifests through restrictions on where PRR can live and work, and by preventing PRRs from accessing medical and substance use treatment services, as well as vocational and educational training. Interpersonally and internally, public notification of PRR status leads to discrimination and alienation from family, neighbors, employers, and community members, creating and exacerbating feelings of isolation and alienation, and limiting opportunities for employment and community engagement.

1.2. Substance use: a need for research

While existing evidence has comprehensively linked SORN policies to significant material, social, and emotional hardship, substance use related harms are missing from the SORN literature. This absence is notable for several reasons. Substance use and substance use related harms have been frequently identified as significant collateral consequences of criminal legal system exposure, and are often linked to the destabilizing biopsychosocial and structural effects of arrest and incarceration (Streisel & Bachman, 2020). Additionally, drug overdose is a leading cause of premature mortality and has contributed to recently stagnating life expectancy in the U.S (Rehm & Probst, 2018). As such, substance use is a major topic of public health concern and attention broadly, and PRR struggle with substance use at higher rates than the general population; 50 % of PRRs have a lifetime diagnosis of substance use disorder (Kraanen & Emmelkamp, 2011), compared with lifetime drug and alcohol use disorder rates of 10 % and 33 %, respectively, in the general population (NIH, 2015). Beyond the public health importance of addressing potential risk factors for substance use and overdose in a vulnerable population, the lack of substance use related research is also critical from a community safety perspective; substance use is a significant risk factor for sexual offending (Kraanen & Emmelkamp, 2011), and drug and alcohol use have been associated with elevated risks of recidivism (Looman & Abracen, 2011).

Despite the lack of research, there are compelling reasons to hypothesize that substance use related harms may be important and unexamined collateral consequences of SORN laws and requirements, and that being subject to SORN policies may create or exacerbate a substance use risk environment and increase the likelihood of substance-use-related harms for PRRs. Indeed, existing empirical literature has documented indirect and theoretical links between SORN and substance use consequences, through demonstrated associations between substance use and many of the previously described SORN collateral consequences in the general population. For example, inability to access employment—and the resultant financial stress—has been associated with substance use and substance use relapse (Binswanger et al., 2012; Compton et al., 2014; Henkel, 2011; Lee et al., 2015; Streisel & Bachman, 2020). Additionally, for those leaving incarceration with a history of alcohol or substance use dependence, inability to find or access stable housing arrangements and/or living alone or away from supportive family increases risks of relapse (Streisel & Bachman, 2020; Walter et al., 2006). Finally, PRR may also face challenges accessing substance use treatment and support resources due to residency restrictions that limit access to treatment facilities near restricted public areas (Levenson, 2018a), funding and eligibility exclusions that restrict participation in programming (Tevah et al., n. d.), and low treatment availability in neighborhoods where PRR are likely to live as a result of structural disadvantage and residential segregation (Griffin & Evans, 2021; Hipp et al., 2010).

1.3. Current study

This study seeks to address the important gap in knowledge related to PRR substance use and access to care. Through qualitative semi-structured interviews with Philadelphia-based legal practitioners, probation officers, forensic social workers, treatment and service providers, and program management officials, this study qualitatively explores the processes through which SORN policies, and the subsequent categorization of PRRs as a hyper criminalized and stigmatized group, act as social determinants of substance use and produce a risk environment (Rhodes, 2002) that increases vulnerability to substance use related harm and restricts access to substance use treatment services.

2. Methods

2.1. Sampling

One-time semi-structured interviews were conducted (N = 20) with Philadelphia-based legal and social service providers and stakeholders with experience working with PRR. Participants for this cross-sectional qualitative interview study were recruited through convenience and snowball sampling. Eligible participants included Philadelphia-based professional stakeholders who worked with PRR in some capacity, either as a criminal legal professional, a treatment provider, or as a program manager or official. The author began with outreach to stakeholders with whom she had a prior professional relationship and requested that initial interview participants share study information with additional colleagues and contacts. The author also solicited interviews directly with relevant stakeholders through cold emails.

The study sample included a public defender (N = 1), a criminal court judge (N = 1), assistant district attorneys (N = 2), specialized sex offender probation and parole officers (N = 3), forensic social workers working for the local public defender’s office (N = 4), mandatory sex offender therapists (N = 3), city officials/program managers (N = 2), substance use and reentry program directors (N = 2), and halfway house personnel (N = 2). Approximately 27 people were in the sampling pool.

The seven individuals who were invited but did not participate included recovery and halfway house personnel, additional attorneys and probation officers, and representatives from local community-based organizations. These individuals either never responded to solicitation, or were lost to follow-up between the initial positive engagement and the interview. No subjects turned down an interview request. Data were collected between June 2023 and December 2023. Participants were not compensated for their time.

2.2. Data collection

The author developed a semi-structured interview guide (Appendix A) to explore participants’ experiences working with PRR in Philadelphia. Questions asked participants to detail their professional engagement with PRR, to broadly describe the challenges and barriers that they observed PRR facing during their reentry as a result of SORN policies, to reflect specifically upon their experiences working with PRR who used drugs, and to recount any direct or indirect experiences helping PRR access substance use treatment. The guide was designed to be broad and therefore applicable to participants across stakeholder groups. The guide was also designed to be participant driven; it used open ended questions and reserved space and time for discussion of unique or unexpected conversations that emerged over the course of the interview. The author conducted all interviews, which lasted 30–70 min and took place over Zoom, phone, or in-person in private offices. Interviews were audio recorded with consent and transcribed verbatim. The author carefully reviewed all transcripts for accuracy and removed all identifying information. Audio files were destroyed immediately following transcription.

2.3. Data analysis

The author analyzed the data using a thematic content analysis approach to coding and analyzing interview data (Braun & Clarke, 2006). The codebook was developed iteratively over time, and included a mix of inductively and deductively derived codes relating to SORN, observed material and psychosocial challenges/barriers for PRR, substance use, and treatment/resource access. An initial codebook was created based on the study questions, prior literature, the author’s prior work experience, and a preliminary review of a subsample of interview transcripts (Hsieh & Shannon, 2005). Additional inductive codes were then added based on emergent themes from the interviews. Coding focused at the domain level, which allowed for cross-stakeholder analysis and facilitated efficient comparison and theme building across groups. The author coded all transcripts, and then identified emergent themes within and between the codes. The author reflected on her positionality throughout the data collection and analysis process, and took care to consider how her status as a researcher, as well as a former social worker in Philadelphia’s criminal legal system, might influence her data collection and interpretation. Transcripts and codes were stored and analyzed using NVivo 14 (QSR International). This study was approved by the Columbia University IRB.

3. Results

Six key themes emerged from the data: 1) “Sex offenders” are highly stigmatized “lepers of the 20th and 21st century” 2) SORN related restrictions transform the social and material context of reentry into a landscape of deprivation and hostility 3) SORN restrictions and the “sex offender” label have “devastating” impacts on mental health and selfconcept 4) these material and psychosocial consequences of SORN increase substance use risk 5) SORN related policies severely restrict access to court-referred drug treatment 6) and this overall landscape of deprivation and restriction has dangerous and destructive implications for overdose and incarceration risks.

Themes 1–3 describe the broad, wide-ranging effects of SORN policies through the lens of the Law as Social Determinant of Health framework, demonstrating how multilevel stigma acts to influence the wellbeing of PRR through the many formal and informal consequences of SORN policies. Many of the specific collateral consequences in these themes have largely been documented elsewhere in existing literature. However, they are also included here as critical components of a previously unexplored pathway that stakeholders described connecting SORN policies to increased risks of substance use related harms (described in themes 4–6). Substance use, which was noted as highly prevalent among PRR, was most frequently described as a response to the challenging realities of living with SORN restrictions, and often either a direct or indirect consequence of the previously described barriers. Describing how stakeholders perceived these difficult social and material conditions, therefore, underscores the intensity of the challenges faced by PRR, offers essential context for how and why stakeholders understood substance use to manifest for PRR, and provides valuable avenues for considering potential intervention. Fig. 1 demonstrates these pathways between policy, diverse formal and informal consequences, and substance use related harms, as well as the ways in which stigma functions as the intermediary mechanism through which SORN law and policy operate as social determinants of health.

Fig. 1.

Conceptual demonstrating impact of SORN policies on substance use and incarceration.

1. “Lepers of the 20th and 21st Century”

Despite representing a wide range of professional identities (many of which have directly conflicting missions, orientations, and professional obligations), stakeholders across the prosecution, enforcement, defense, and treatment spectrums used very similar descriptors to characterize the way that society treats and regards people on sex offender registries. There was unanimous agreement that PRR face an extremely challenging landscape post-conviction, and that the PRR experience is distinct from that of any other group returning to the community from incarceration or criminal punishment. As a specialized probation officer noted: “How society views sex offenders is a little bit rougher, a little bit harsher than they would a murderer, someone who’s committed robbery or aggravated assault”. A public defender described PRR as “literally the lepers of the 20th and 21st century”, while both a social worker from the public defender’s office and a county probation officer analogized the registry to being “kind of like the scarlet letter of our society”.

Although some stakeholders expressed hostility towards PRR, all participants expressed some level of empathy for the challenges faced by those on the registry, as well as distaste for the way in which current laws uniquely stigmatize or ostracize those on the registry. One assistant district attorney, even after exclaiming “I hate them. I’m not going to lie. I have a personal place in hell for child abusers” and describing many traumatic experiences she had representing child victims of sexual violence, was still reflective about the way that SORN policies are treated in courts and in broader society. She described:

It’s essentially, let’s be honest, almost a death sentence, right? A judge’s big line was ‘you’re serving a life sentence in installments’. And he meant that for a lot of our drug guys, but thinking back, I’m like, this is a lot of our sex offenders. They just come in, and they’re serving this lifetime punishment.

She went on to note that, if she were in the position of many of the PRR on the registry, she too would “give up and stop trying” to earn an income, pursue stability, or maintain recovery from substance use.

2. A Landscape of Deprivation and Hostility

As illustrated in Fig. 1, stakeholders described SORN policies severely restricting access and enacting barriers to resources and services in the community through both formal and informal mechanisms. Participants outlined how federal and local funding restrictions, as well as informal social exclusion, barred PRR from participating in a variety of programs and from receiving much-needed services that other individuals returning to the community might have access to. One program director for a reentry support organization characterized the experience of clients on the registry as: “People who are on the registry are excluded from so much in every realm. Employment, housing, treatment, emotionally, socially, I think it’s really difficult for people”. Housing, employment, stigma, and harassment were some of the most frequently described barriers by providers across professional domains.

3.1. Housing

Challenges finding and maintaining housing was often primarily due to restrictions against living with or in proximity to minors, which were imposed by county or state community supervision. A state parole agent described how Pennsylvania’s parole restrictions against living in proximity to minors seriously limited housing options: “you couldn’t live in an apartment complex where there’s kids and there may be a gym or a daycare next door. So it’s kind of hard”. Additionally, a Philadelphia county probation officer noted that “if your offense involved a minor … you were not permitted to reside with any minors, including your biological children unless you had a court order”. These limitations are particularly notable because Pennsylvania’s SORN legislation does not include residency restrictions. This means that, according to Pennsylvania state law, PRR can live in proximity to minors, or even in a home with children. However, specialized sex offender units within probation and parole agencies have the discretion to impose additional restrictions and compliance requirements, which they did with regularity, as in these examples.

Beyond the restrictions imposed by probation and parole, stakeholders described housing related challenges due to public housing restrictions, informal exclusions by landlords and family, and interactions with other barriers and challenges. A state parole agent described: “I don’t want to so much say discrimination, but a lot of opposition … because nobody wants that in their backyard or next door to them”. Another county probation officer noted: “finding valid residence could be tough. There are independent homeowners or landlords that would say, ‘nah, sorry’ … being on the registry specifically definitely made it difficult to secure, obtain good housing”. A public defender similarly described: “public housing precludes you because of sex offenses, and it’s harder to get jobs. So if you don’t have jobs, and you can’t get public housing, you’re often homeless. And so you’re just in the shelter system”. In this case, public housing restrictions interacted with employment challenges to create negative consequences for PRR.

3.2. Employment

As mentioned by the public defender above, finding and maintaining employment was another of the biggest material barriers for PRR observed by stakeholders. In many ways, employment barriers followed similar patterning as housing; challenges were attributable to a combination of employer discrimination/hesitation, formal policy exclusions, and restrictions imposed by probation and parole. The former was described by a county probation officer’s statement “a lot of employers don’t want individuals on the registry” and reiterated by a city program manager who described “I mean, I think people who are the registry are restricted in so many aspects of their life, like employment. A lot of times employers will not hire folks who have sexual offenses on their records”.

Policy exclusions often came into play when it came to reentry and vocational programming, which would have provided avenues for longterm employment opportunities. Many job training or placement programs that supported individuals returning from incarceration excluded people with sex offense convictions. A social worker for the public defender’s office described: “there is a work program, like immediate employment plus case management for finding more long-term employment that we use a lot. But sex cases are forbidden, and I believe you can’t be on the registry either”. This was often because funding mechanisms for many of the city’s biggest reentry and vocational programs categorically excluded PRR. A city program manager explained:

So it was all funded by the Department of Labor … these grants specifically were for folks who were justice involved. Many reentry organizations around the country use this funding … And the grant comes with a lot of restrictions and reporting and this and that. And one of the things is that they don’t accept folks who have sex offenses.

Similar restrictions also existed for individuals in custody. In Philadelphia’s county jails, opportunities to participate in pre-and post-release reentry and diversion programs were out of reach for PRR. In some cases, this was because of the setting or context that the programs operated in, such as churches or other community centers. Another limiting factor was that early parole [which was often a component of jail diversion and reentry programs] for PRR required victim agreement. As the same assistant district attorney explained, “so the other thing factoring in is that a lot of these guys can’t get into the reentry programs, because the victims don’t want them out early”. Not only did this mean that PRR tended to be incarcerated longer than their non PRR counterparts, but it also meant they returned to the community without job skills or connections to potential employers that might be willing to hire individuals with criminal records. Combined, these barriers significantly strained and destabilized PRR returning to the community.

3.3. Stigma and vigilantism

In addition to barriers related to employment, housing, and access to programming—challenges which can be categorized as material or service related–stakeholders across professional identity groups enumerated significant, wide ranging, and intense psychosocial consequences of SORN policies. These ranged from stigma, to alienation, to isolation, to threatened and actual harassment, and were described by participants as equally as devastating and impactful as the material restrictions.

The highly public and easily accessible nature of the online registry posed significant challenges for PRR, especially due to the public’s minimal or misunderstanding of sexual crimes. Stakeholders acknowledged that the registry could become a tool for public harassment, vilification, and shaming by neighbors and community members, despite warnings on the websites intended to deter the public from “misusing” the information. Many participants described how neighbors or community members would find out that someone was on the registry, or look someone up on the registry, and assume the worst possible scenario—typically a violent abuse of a child—regardless of the details of the specific offense. This would put PRR at risk. A mandatory sex offender therapist described: “anybody can find out where they work, find out where relatives are, and harass them. Lots of my clients have been harassed, maybe even by a coworker who has found them on the registry because they were nosey”. A state parole agent noted:

A lot of people will get scrutinized or they get called out in public a lot. People sometimes have been victims of vigilantism, I guess you might call it that. A lot of people abuse the sex offender registry and they take it and they disseminate it when they’re not supposed to disseminate it–only the state police are supposed to do that.

A mandatory sex offender treatment therapist similarly described:

I had a participant where three guys jumped him when the flyer came out and they beat him up, called him a ‘pedo’, all sorts of stuff. I had another participant who moved into a new apartment and two days after the flyers [flyers with a PRR’s identifying information are distributed to all neighborhood residents within a five-block radius when a PRR moves in] went out, people vandalized the apartment, they broke the door down.

This harassment and public shaming could have severe ramifications for PRR’s access to supportive institutions or even housing. One county probation officer described:

I’ve had people who have been asked not to return to their parish, their church because somebody found out they were on the registry … Once someone sees, a lot of times it’s, ‘so, oh, the people in my building found out now they don’t want me there and the landlord’s giving me a hard time’.

Overall, public registration and notification procedures contributed to hostile environments for PRR returning to the community. As one county probation officer noted: “I’ve had to explain to guys when they’re under supervision, it’s going to be hard to get the community to welcome you back”. As a result, PRR were more likely than other individuals returning to the community to face significant isolation and alienation. As a city policy official noted: “a lot of folks in these circumstances find, experience intense like isolation. They can be cut off from their family system as well”. This sentiment was reiterated by a reentry program director, who stated that “our clients on the registry tend to not have many social supports and don’t seem to have as many friendships as the other clients that we work with do”. This isolation had significant ramifications for individuals who struggled with substance use, and compounded other existing triggers and barriers to achieving or maintaining recovery.

3. “Just Really Shattered”: Mental Health Consequences

Stakeholders noted that material and psychosocial collateral consequences of SORN policies had significant and long-lasting impacts on PRR mental health and self-concept. A mandatory sex offender treatment (MSOT) therapist described, generally, that “I think obviously it is the stigma, right? It’s the discrimination, I think being discriminated against overall, it impacts your mental health”. The reputational, physical, and social risks posed by the public nature of the registry was also more specifically a significant source of anxiety and poor mental health. An MSOT therapist noted:

I think it [SORN] does contribute to depression and anxiety for sure. I think a lot of participants talk about this vigilance. Anyone can know at any time, anyone can find out. These records are in no way difficult to acquire and again, you don’t know what you’re looking at. So there’s a lot of fear around that.

Another MSOT therapist added, “I think there’s a lot of shame associated with just the fact that your name is plastered on Megan’s law sex offense registry with your name and your address and your workplace”.

Participants described how the macro experience of being labelled and stigmatized by the law and by supportive institutions could also be emotionally damaging. One social worker from the public defender’s office noted: “I also notice mental health effects a lot. The way people view themselves I think is very affected by being on the registry”. She went on to describe:

I have a client who was recently found a sexually violent predator … Those words were excruciating for him and me. And this is a grown man who I have not really seen show much emotion for months of knowing him and he broke down sobbing in jail about this. And just having to use those words and say that someone thinks that about someone, I very much worry about how they view themselves and how that makes them feel.

An MSOT therapist described the experience of a client who was banned from attending his church:

He told me ‘I can’t be here because kids come here, families come here’. And he’s like, ‘well, I thought that you guys [churches’] accept everyone’ … And I think that’s even a whole other issue is that then they’re questioning all the things they’ve ever learned about religion or faith or their god. So that brings in a whole other existential crisis.

Required participation in MSOT could also exacerbate the destructive consequences of SORN labeling and contribute to self-concept damage. One social worker from the public defender’s office described how MSOT impacted her clients’ mental health and wellbeing. She explained:

I have this one client who … has this phrase that he remembers that he was made to say over and over again from sex offender treatment, ‘I am deviously sexually attracted to children, rape, and violence’. And he said he’ll never forget those words. And how they made him feel about himself and how he felt almost like a monster. And those types of conversations are not uncommon among people who have had to say those things about themselves

She went on to elaborate that she saw these types of experiences as contributing to her clients’ “symptoms of depression, symptoms of anxiety, and just overall just really, really shattered identity”.

4. SORN Policies Contribute to a Substance Use Risk Environment

In general, most participants described substance use as a moderately frequent to frequent issue among PRR. A public defender estimated that 65 % of her PRR clients struggled with mental health issues, while 80 % struggled with drug issues. One MSOT therapist noted that only a handful of her clients currently reported substance use, but that the majority had substance use in their history. Similarly, another MSOT therapist estimated that “I would say more than three quarters, at some point, if not currently” used drugs, while a third MSOT therapist and a state parole agent also each put their estimates at 75–80 %. Finally, estimates from social workers at the public defender’s office ranged from 50 % to 100 % of their PRR caseload struggling with substance use.

Across stakeholder groups, there was widespread agreement that the multifarious collateral consequences of SORN polices, described in the previous three themes, contributed to the elevated risks of substance use and substance use relapse that they observed for their clients on the registry. Participants identified SORN policies as directly and indirectly impacting clients’ use through two primary mechanisms, as illustrated in Fig. 1. The first was through defining a structural landscape and risk environment that wasn’t conducive to sustained recovery for PRR. A city program manager described how the structural limitations on housing and employment detailed in theme two elevated PRRs’ environmental risk factors for substance use relapse:

We know that folks have a hierarchy of needs. And often when they’re not able to meet their needs, they find themselves resorting to things that might help them feel better or resorting to environments that might lead to use again. And so again, it’s all kind of related, right? Environments, employment, the registry that restricts those environments and employment. Think about the registry restricting housing. If you can’t live in an area that is good for your recovery, you might have to end up living in an area that’s not so good for your recovery.

By restricting housing options, she was explaining, PRR might end up living in areas with high levels of drug use, areas where they previously used drugs, or areas without access to treatment or other resources that might promote stability and maintained recovery. Another city policy official similarly described how SORN’s limitations on housing– and associations with housing instability—exacerbated risks associated with substance use for PRR. He explained:

And we’re scattering folks too. So again, if they’re isolated and insecurely housed, they’re bouncing around different neighborhoods … that’s making them have to interact with changing drug supply on a regular basis …. We know that that can be an extremely serious risk factor for a fatal overdose.

The second and most frequently noted mechanism through which SORN polices impacted PRR was that PRR used substances as a response to the challenging and demoralizing reality of life on the registry. As a public defender described, “I’ve had guys who are just like, they start using again because they just feel hopeless and there’s no end”. A social worker for the public defender’s office described substance use as a form of self-medication for her clients who were struggling:

I see a lot of connection between family separation and isolation, losing your supports, and symptoms of depression and anxiety and substance use. So kind of self-medicating those symptoms of mental illness that come from isolation and come from years of, or lots of time being isolated.

Another social worker for the public defender’s office explained that she also saw her clients turning to drugs to remove themselves from their difficult circumstances: “I think just all the stigma surrounding the charge and the inability to support themselves, unless they have good family support. I think the housing and the unemployment issues lead people to really increase their drug use just as a way to disassociate”. A state parole agent similarly added that he saw drug use become an issue “when people hit rock bottom when they’re trying to find a job and they just can’t keep getting turned down because of their background check”.

As these stakeholders illustrated, there were clear connections between both the material consequences—like housing, unemployment, restricted access to family—as well as the resulting psychosocial consequences like isolation, despair, and stigma, and substance use. They saw their clients either using substances as a coping or dissociation mechanism, or because, given the desperate and hopeless circumstances that they faced, there was no apparent value in engaging in the difficult work of maintaining recovery.

5. “Based on Our Funding We Cannot Accept Sex Offenders”: Restricted Access to Substance Use Treatment

Beyond structuring a risk environment that contributed to elevated risks of substance use and substance use related harms, almost all of the legal and social service stakeholders perceived that SORN policies significantly restricted access to substance use related treatment services in Philadelphia. This was particularly true for PRR that were connected to the criminal legal system; the most significant and most frequently noted barrier was related to the city’s main mechanism for court referred substance use treatment. In typical cases, a judge, attorney, or probation officer can refer an individual who is either incarcerated or in the community for a substance use evaluation, followed by a referral and placement into an appropriate level of substance use treatment. Placement into drug treatment though this pathway is often used as a mechanism for diverting individuals with substance use disorders from jail, or for avoiding incarceration for a substance use related offense or probation violation. It is also by far the most widely accessible way for people with Medicaid or without insurance to access inpatient drug treatment, especially from custody. However, as a public defender succinctly explained: “if you have a sex offense … they will not fund you”. A reentry program director expanded upon this to note that this preclusion also extended to recovery houses [sober living facilities where individuals can stay while attending outpatient drug facilities, and which are typically funded through this mechanism and the city]: “a lot of recovery housing won’t let people in if they’re on the registry. I mean, almost all of them. Anything, like I mentioned, government funded, none of them that I know of will take anyone on the registry”.

None of the study participants worked for this referral program, and the sample was mostly comprised of legal and social service providers who refer clients to drug treatment, rather than drug treatment providers themselves. Therefore, participants could not speak directly to the reasons for the blanket funding or admissions exclusions. However, beyond formal funding limitations, many hypothesized that treatment facilities made choices to exclude PRR for reasons related to fears of liability and aversions towards people on the registry. As a county probation officer noted:

I think that the funders choose to exclude individuals on the registry or individuals with sex offenses ….I think that that comes from the fear of liability … everyone thinks that these guys are just going to come in and be raping everybody, but that’s not really most likely what’s going to happen.

An assistant district attorney, who had previously worked as a probation officer, explained that “a textbook type of situation might be a program may treat adolescents, they might treat adolescents as well as adults at the program. So they might say, ‘based on our funding or whatever we cannot accept sex offenders’”.

In addition to concerns about direct liability, participants perceived and hypothesized that many treatment centers found working with PRR distasteful, or, as one social worker from the public defender’s office described it, “they just don’t want people there that are convicted of these types of charges”. They also speculated that facilities might have been influenced by concerns that allowing PRR would expose them to negative community attention. As a county probation officer noted, “The volunteering of their facilities’ addresses to the registry … I think inpatient treatment centers and recovery houses may just not want to be involved at all. A substance use treatment program director provided further clarity, explaining that “I’ve heard that certain recovery houses have agreements with the neighborhood that they won’t take people on the registry because the neighbors don’t want them there anyway, so they had to make some concessions”.

Regardless of the reasons, referral program and treatment centers’ exclusions created challenges for study participants trying to support PRR with substance use related needs, and, as a social worker from the public defender’s officer explained, “severely limits the resources you are able to give to somebody”. A county probation officer noted succinctly, “finding inpatient treatment for an individual who is also in the registry can be extremely difficult”. Additionally, participants often lamented that, while they did everything they could to support their clients on the registry, the realities of the severe limitations on services meant that PRR clients often received less or worse quality services than other clients with whom they worked. An assistant district attorney described her frustration with the extremely limited options she had for handling cases for PRR who were in jail with substance use issues:

The best they can get when they’re saying ‘I have an addiction issue’ is just being like, ‘well, we’ll see you in court next month and don’t forget to piss in the cup’. But it’s that or keep them in custody simply because no facility will take ‘em … sometimes the only drug treatment we can offer them is them coming into court on a regular basis, which is absurd.

In essence, she found herself trapped in a set of frustrating and unsatisfying choices. She could extend a client’s time in custody so that they could continue to receive the minimal drug treatment services available in the county jails and remain physically removed from the community-based risks and triggers. However, this would continue to expose them to the many destabilizing and destructive impacts of incarceration and was unfairly a form of extended and unwarranted punishment. Often, her only other option would be to release a client without linkages to necessary and desired treatment and rely upon surveillance through court status hearings and urinalyses as a likely insufficient source of protection and accountability.

A social worker from the public defender’s office similarly explained that helping her PRR clients with substance use issues get out of custody often involved unpleasant tradeoffs and referrals:

I’ve sent clients to horrible places, horrible places where they call me afterwards and they’re like, ‘this place is infested with bedbugs.’ I’m like, ‘I’m sure it is. I’m so sorry.’ … Just to get them out [of jail], you have to sign them up to be transported to this worst place you can think of.

In this case, to facilitate her client’s freedom, the social worker found herself forced to provide linkages to poor quality services in inhumane conditions. She did not expect her client to actually engage in continued services there. Instead, she explained that once her clients were free, had at least slightly better options for providing alternate referrals and support. However, this method involved significant downsides; there were substantial likelihoods that clients might relapse and disconnect before these new linkages could be made, violating the conditions of their release and jeopardizing their continued freedom, as well as putting them at further risk of substance use related harms.

6. “It’s Almost a Life-or-Death Sentence”

In the previous two sections, participants described how SORN policies structured a substance use risk environment characterized by elevated vulnerability to substance use and restricted access to treatment services. The damaging and even dangerous implications of this substance use landscape cannot be overstated. Echoing the dilemmas of prolonged incarceration and/or poor options for placement raised by in the previous theme, a city program official noted that PRR were likely to face increased and extended exposure to the harmful effects of incarceration, compared to others involved in the criminal legal system. He explained:

Folks that are on the registry with [drug treatment orders] tend to have longer lengths of stay compared to similarly situated people with criminal convictions not on the registry …. A lot of times that person’s languishing in custody, awaiting placement, and a lot of those situations take longer than for the average person.

A reentry program director reiterated and expanded upon these concerns, describing how SORN policies and the resulting limited treatment options also contributed to her client’s difficulties avoiding repeated and extended incarceration:

He has been re-incarcerated twice since we started working with him last year. And it’s always a [drug] possession charge … I really think if he weren’t on the registry, he would not be going to jail. He ends up sitting in jail longer. There’s only one drug and alcohol program that people know of that will take people who are on the registry and it’s not through the traditional avenues. And they have a wait list that’s three months long. So this person who I do not think is at all a danger to society, ends up being incarcerated, spending a lot of time in jail and then going to this program, he goes to the same program again and again.

In addition to incarceration, participants noted that the substance use risk landscape created by SORN policies increased PRR’s risk for fatal and nonfatal overdose. The city program official explained how limited access to substance use treatment and other health and social services elevated overdose risk:

There’s a connection of dots between limiting people’s options for legitimate healthcare and the likelihood of self-medicating … we’re pushing people into the black market to seek things like medication and things that’ll help them cope. And we’ve seen that be a driver to non-fatal and fatal overdoses …. I think the more we don’t allow folks to access the preferred standard of short-term detox to inpatient treatments, to recovery housing, then people are set up in pretty impossible circumstances.

Overdose risk was also a major concern for the assistant district attorney who, in the previous section, expressed her frustration with the lack of treatment options available for PRR clients with substance use issues. Here, she expanded upon the ethical and practical conflicts she noted previously:

It’s terrifying when it’s the heroin and fentanyl users … it’s almost a life and death sentence because I’m like, if I let him out of jail and he immediately relapses because we have nothing set in place and with how potent, this shit is … and he dies? I let him out with no plan for success. But also, do I want to keep this guy in jail purely because of drug treatment? I’m punishing him for a lack of resources in the community.

Struggling to reconcile PRRs’ rights to freedom from incarceration with the very real risks of overdose posed by the potent drug supply and lack of available supports was a continual source of anxiety and frustration, and was a major challenge that she identified with working with PRR.

4. Discussion

This qualitative study used the observations and perspectives of professional stakeholders who work with individuals convicted of sexual offenses in Philadelphia to explore public health related collateral consequences of SORN policies for PRR. This study builds upon the existing collateral consequences literature to provide the first evidence of a relationship between SORN policies and substance use related harms.

Despite some variation in specific experiences and perspectives, all of the themes in this study emerged across stakeholder groups, with general substantive agreement. This is notable and somewhat surprising, given the wide variety of ideological positioning, primary commitments, and professional roles represented in the sample. In most instances, it is relatively unusual to see such consensus across prosecution, defense, supervision, treatment, and policy. Here, alignment might potentially speak to the intensity and hypervisibility of the collateral consequences experienced by PRR, which proved unignorable even to stakeholders who may have been instinctively oriented against empathy or concern for PRR wellbeing.

It is also possible that the high and unusual level of stakeholder agreement is reflective of how SORN policies negatively impacted not only PRR, but also stakeholders. While participants described how SORN created material, social, and emotional hardship for their clients, they also emphasized feeling significantly professionally constrained and limited by SORN policies in their work. The overall PRR service landscape was defined by deprivation and limitation as a function of policy proscriptions, resource scarcity, and discrimination. This made stakeholders’ work with PRR clients substantially harder and less effective. Participants described being constrained in their ability to creatively problem solve and tailor individualized services to their PRR clients, as well as often needing to informally cobble together services based on personal favors, informal treatment planning, and compromised expectations. Regardless of positioning or power within their organizational or professional settings, no stakeholders—even a judge—had the ability to use discretion or influence to mitigate the difficulties or barriers faced by PRR. This, combined with concerns about the potential health and safety ramifications of their limited ability to support PRR, led to frustration and dissatisfaction, and may have contributed to the general perceived agreement that SORN policies are not working for anyone across political or professional divides.

Stakeholders described myriad material and psychosocial consequences of SORN policies for PRR, many of which have been previously discussed in existing literature. These included: housing instability; employment difficulties; exclusion from vocational programming; stigma, harassment; vigilantism; isolation; and poor mental health. Importantly, stakeholders also identified, for the first time, how many of these consequences contributed either directly or indirectly to increased risks of substance use or relapse for PRR. Additionally, stakeholders shared how SORN policies directly restricted access to substance use treatment services, especially through the criminal legal system, exposing PRR to increased risks of harms from fatal and nonfatal overdose, as well as from the harms of additional and extended incarceration. Substance use often manifested among PRR as a coping mechanism and tool for self-medication and dissociation from the challenging reality of living with SORN restrictions and resulting material and social consequences. In this way, PRR substance use was often an indirect consequence of SORN policies. Restricted access to substance use treatment services, in contrast, was more often directly tied to direct SORN policy exclusions and structural limitations.

Stigma has often been cited as a primary collateral consequence of criminal conviction and as a multi-level driver of substance use (Earnshaw, 2020) in other contexts. These relationships between stigma, criminalization, and substance use are also apparent in this study. Additionally, both PRR substance use and treatment access limitations can be understood from a Stigma as Fundamental Cause framework. Stigma operates as a fundamental cause of health inequality, in that it influences diverse outcomes through multiple risk factors, and acts as both cause and consequence of health inequities over time (Hatzenbuehler et al., 2013). Here, stigma operates multidimensionally at the interpersonal and institutional levels to impact PRR’s vulnerability to substance use and service access. Interpersonally, participants noted that SORN policies, and particularly public notification of PRR status, led to challenges related to employment, housing, vigilantism, as well discrimination and isolation from family, neighbors, employers, and community members. These stigmatizing experiences cultivated and exacerbated feelings of hopelessness, anxiety, and depression among PRR, and led to frequent use of substance as a coping and dissociative mechanism. While not observed by participants, vulnerabilities to substance use related harms may have been amplified by the fact that stigma is also intersectional; systems of interlocking and reinforcing oppression mean that people may embody multiple stigmatized statuses, which shape experiences of inequality. For example, stigmatization for having been incarcerated, for being a minoritized man, or having a physical/mental illness might intersect with and amplify the stigmatization of being a PRR (Earnshaw, 2020; Walters et al., 2023) and further heightened risks for substance use and relapse.

Structurally and institutionally, stigma is enacted and perpetuated through policy implementation and enforcement mechanisms that decrease PRR access to substance use treatment and harm reduction resources. As discussed by stakeholders, most governmental and nonprofit funding mechanisms for connecting individuals in the criminal legal system in Philadelphia to substance use and mental health treatment, reentry programming, and social services explicitly exclude PRRs from eligibility. Based on residency restrictions imposed by community supervision, PRRs are also often unable to access inpatient detoxification and substance use treatment in facilities located near schools or public areas. Less directly, stakeholders noted instances in which treatment centers excluded PRR based on hyperbolized fears of liability and concerns about community response. While not noted by stakeholders in this study, it is additionally possible that substance use stigma, which has been found to deter substance use treatment seeking in the general population, may intersect with PRR stigma to act as an additional barrier to PRR substance use treatment engagement (Stringer & Baker, 2018).

4.1. Limitations

This qualitative study is subject to several limitations, primarily related to the construction of the sample and the scope and depth of knowledge able to be gleaned from them. First, while the author attempted to recruit subjects with a variety of professional experiences and identities, recruitment began with individuals who were known to her, and snowballed from those individuals. It is also possible that individuals with strong opinions about SORN collateral consequences may have been more likely to respond to cold recruitment emails or to choose to participate in the study. Both of these factors may have influenced the range of perspectives included in the study and may have introduced potential selection and social desirability bias. Second, this study explores the experiences of providers in just one jurisdiction. Given the hyperlocal nature of resource availability, as well as jurisdictional variation in SORN policies, the geographic specificity of this study limits the generalizability of study findings and suggests a need for further research.

Third, while there was general agreement about the nature of SORN policies for PRR, some inconsistencies and lack of clarity emerged about the specific nature and causes of actual funding and eligibility limitations. Future studies should seek to interview individuals responsible for developing and enforcing specific policy decisions, particularly related to funding restrictions, in order to obtain more definitive information than what was available from included participants. Relatedly, respondents may also not have been able to share a complete picture of the substance use treatment landscape in Philadelphia. Most interviews were conducted with providers who had experience referring PRR to substance use treatment, rather than with those providing direct substance use related care. As a result, discussions of substance use treatment access focused primarily on the challenges that providers had with connecting PRR clients to treatment, and particularly residential/inpatient treatment programs and recovery housing. It is possible that this focus elided the more abundant services for which referrals were less necessary. In particular, the city’s outpatient treatment services–including medications for opioid use disorder—and low threshold harm reduction resources may have been much more easily accessible to PRR, given their reduced vulnerability to residency restrictions or community hostility. These types of programming may have mitigated the barriers described by stakeholders in the study, including those posed by FIR ineligibility.

Future work should engage more specifically with these service options, and should include more substance use treatment providers who could provide substantive insights into PRR’s ability to engage these community-based services. Additionally, these substance use treatment providers may be better able to speak to the feasibility and effectiveness of scaling up or adapting treatment resources to meet the demands and needs of PRR. Finally, this study explored PRR substance use and treatment access indirectly, from the perspectives of stakeholders and providers who work with them. Future research is needed to investigate the perspectives, experiences, and behaviors of PRR themselves, in order to better inform policy and intervention development.

Despite these limitations, this study provides compelling new evidence of the ways that SORN laws and policies operate as social determinants of health (Burris, 2011; Burris et al., 2016, p. 7) for PRR and confer substance-use-related harms through numerous dimensions of stigmatization. These findings are important from a public health perspective, in that they identify a vulnerable, high-risk population with high rates of untreated substance use and mental health issues—two public health priority areas. Perhaps more compellingly to a broad audience, the findings of this study also have implications for improving public safety and wellbeing. Almost 50 % of sexual offenses are committed by someone who is using drugs or alcohol (Kraanen & Emmelkamp, 2011), and substance use has been associated with elevated risks of recidivism among sexual offenders (Abracen et al., 2017; Looman & Abracen, 2011). Providing additional substance use related services and supports to PRR may, therefore, have both public health as well as community safety benefits by functioning as a sexual violence prevention strategy.

4.2. Policy implications

While removing or changing SORN policy restrictions may be the most direct and efficacious route for addressing the multilevel harms identified in this study, such a sweeping policy recommendation would have to balance significant potential benefits for PRR against the possibility of unanticipated public safety risks, as well as public perceptions of risk or injustice for victims of sexual violence. Practically, there are no indications that macro SORN policy changes are likely or even politically possible in the near term.

However, the high prevalence estimates of PRR substance use issues, as well as the serious and potentially deadly ramifications of treatment limitations identified by stakeholders in this study reveals a clear and previously undocumented unmet need for substance use treatment services and supports for people convicted of sexual offenses. Given the challenges associated with macro policy change, improving local level access to and funding for services and resources to support PRR is likely more feasible than changing state or federal policy. As a city official described, there are two main avenues through which local governments could better support PRR access to services: requiring more inclusive eligibility criteria for existing programs that receive city funding or creating/expanding specialized services for PRR. The former option would be preferable, in that it would extend opportunities to PRR while reducing stigma and exclusion. However, in the context of barriers described by stakeholders in this study, including federal funding exclusions and facilities’ proximity to minors, the latter option may be more viable in the short term. Designating specialized, city funded PRR inpatient drug treatment centers and recovery houses, as well as housing units and vocational programming (with linkages to permanent employment opportunities) could potentially provide valuable and lifesaving benefits for PRR while reducing incarceration and reducing risks of sexual reoffending and recidivism. Further research is needed to develop, implement, and test the effectiveness and acceptability of these policy options.

5. Conclusions

In sum, SORN policies impose wide-ranging restrictions that have broad impacts on the health and wellness of PRR. As one public defender described:

It’s one of those things where individually, there’s a lot of restraints where it’s like, ‘oh, that one thing isn’t bad. I get why we do that’. The problem is when you realize that there’s 82,000 of them, and when all of these things need to be met at the same exact time, you are giving people a herculean task.

Using the perspectives of stakeholders across professional identities, this study provides preliminary evidence of how these “82,000” restrictions structure an elevated substance use risk environment for PRR, and suggests a need for future research and policy innovation to improve public health and public safety. Further, this study lays out a public health framework for holistically analyzing the harms associated with SORN law and policy, beyond the realms of just substance use and mental health. Future research should consider this framework to further assess how SORN policies act as broad drivers of PRR and community health and wellness.