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Sex Offenders 1
Running head: SEX OFFENDERS: CURRENT DEBATES
Sex Offenders: Current Debates in
Treatment Efficacy and Classification of Offenders
Student Name
Minnesota State University Moorhead
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Sex Offenders: Current Debates in
Treatment Efficacy and Classification of Offenders
One recent estimate stated that there are 234,000 convicted sex offenders under
the supervision of various corrections agencies in the United States (Bureau of Justice
Statistics [BJS], n. d.). Of these 234,000 offenders, approximately 60%, or 140,400
offenders, are not imprisoned, but are being supervised either on probation or parole in
communities throughout the country (BJS, n. d.). Twenty-four registered sex offenders
presently reside in Cass County, North Dakota alone (North Dakota Attorney General’s
Office, n. d.). Additional statistics indicate that sex offenders constitute roughly 4.7% of
the nearly 5 million people presently in prison (federal and state) or jail or on probation
or parole (BJS, n. d.). Sex offenders are, in fact, the second largest prison population in
the country, following only offenders convicted of drug-related crimes (T. W. Barrett,
personal communication, April 5, 2004).
It should come as no surprise, then, that sex offenders are a concern not only to
those working in the human services or correctional system, but also to private citizens
everywhere. As many as 27% of women and 16% of men report being sexually abused
as children (Anderson, 1998). If this many people were being diagnosed with cancer, it
would be labeled a public health epidemic. What the available data suggest is that sexual
offending may indeed be reaching epidemic proportions.
If the rate of sex offending in the United States could be characterized as an
epidemic or some other equally important public health concern, then it stands to reason
that the treatment of sex offenders should receive specific attention. And it has;
unfortunately, this specific attention has yielded nothing conclusive. Certainly, there will
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always be debate over the technicalities of the various drug therapies or clinical
treatments used for bipolar disorder or schizophrenia, but on the whole, these treatments
are accepted as being effective. Treatments for sex offenders, and their underlying
pathologies if they do indeed posses them, are not so well accepted. Therein lies the
debate—does sex offender treatment work, or as some critics argue, is there no viable
treatment or “cure” for sex offenders. The purpose of the present review is to examine
previous literature about specific treatments for sex offenders and to review the impact of
these treatments on sex offender recidivism. Broadly, the present review will describe
the opposing viewpoints: (1) sex offender treatments can and do work when the
appropriate treatment is applied to the appropriate type of offender and (2) sex offenders
cannot be treated because of the nature of their offending.
Definitions
Before going further, it is important to define the population that is being
addressed and delineate the characteristics of each population group. In fact, herein lies a
debate of its own because there are differences in the terminology used in both the legal
and psychological realms, and there are even differences within the psychological
research. In legal terms, “sex offender” can indicate any number of sexual offenses and
is not particularly descriptive of the type of offense committed (Doren, 1998). “Sex
offender” in this context can also refer to those who perpetrate non-contact sex offenses
such as exhibitionism. “Sex offender,” then, in legal terms is a catchall for any type of
criminal behavior involving sexuality. For the present review and for a large body of
clinical research, “sex offender” refers to one of three different types of offenders: (1)
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incest offenders, (2) extrafamilial child molesters, and (3) rapists (Doren, 1998;
Firestone, Bradford, Greenberg, & Serran, 2000).
Incest offenders perpetrate their crimes against members of their own family and
may engage in molestation, rape, or both (Doren, 1998). Although incest offenders may
carry out their offenses against adult family members, the clinical literature about incest
offenders generally addresses those who offend against relatives age 18 and under
(Becker, 1994). Extrafamilial child molesters are those offenders who have had a victim
or victims outside of their immediate and/or step-family and whose victim(s) are under
age 13; however some literature defines the upper age of victims of extrafamilial child
molesters as 18 (Doren, 1998). In truth, extrafamilial child molesters select their victims
on the basis of pre-pubescence, and 13 years old is a generally accepted middle ground
for the onset of puberty among males and females. Finally, rapists are sexual offenders
who force sex acts upon adult (post-pubertal) women (Doren, 1998). Moreover, the
category of rapist may be further divided to differentiate between “acquaintance” rapists
and sadistic rapists (Doren, 1998; Firestone, Bradford, Greenberg, & Serran, 2000).
Sadistic rapists are predatory and psychopathic in nature and differ markedly from
“acquaintance” rapists who suffer deficits in social and interpersonal skills but are
probably not diagnosable for mental illness (Firestone, Bradford, Greenberg, & Serran,
2000). Unless otherwise noted, the three above listed categories refer to adult men.
A final important distinction must be drawn between the terms “pedophile” and
“child molester.” Many would assume that these two terms are synonymous because
they are often used interchangeably in the media, but these two terms are not one in the
same. Pedophilia is a psychiatric diagnosis characterized by persistent sexual fantasies
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about prepubescent children (American Psychiatric Association [APA], 2000).
Pedophilia, by the Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSMIV-TR) criteria, does not necessarily involve sexual contact with children. Others
describe pedophilia as a sexual orientation not unlike heterosexuality or homosexuality;
those with a pedophilic orientation have a sexual orientation toward children, are likely
aware of their orientation toward children, and may or may not act upon it (T. W. Barrett,
personal communication, April 26, 2004). Child molesters, on the other hand, may be
pedophiles (either by DSM-IV-TR criteria or the orientation criteria) who act upon their
fantasies, or they may be sexual predators who prey upon children because of the
vulnerability of that population (T. W. Barrett, personal communication, April 26, 2004).
Given the above information, then, it can be stated that not all pedophiles are child
molesters and not all child molesters are pedophiles, but that some offenders are both
pedophiles and child molesters. As a final not on the differences between pedophiles and
child molesters, some critics have argued that the diagnosis of “child molester” should be
added to future editions of the DSM because there is no clinical utility in having a
diagnosis for those who have fantasies about children, but not those who act upon these
fantasies (Anderson, 1998).
It seems that one of the best ways to advance the research in the area of sex
offender treatment is to have standardized terminology that reflects essential
characteristics of offender types. The research that would then be produced would be
more easily applicable to offenders in treatment settings, and counselors and clinicians
would not be forced to guess at the intentions and ideas of the authors of clinical research
that they utilize. The DSM-IV-TR, as compared to the greater body of clinical research,
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does not have enough designations for sexual disorders involving contact, and the
designations that the DSM-IV-TR uses are not descriptive enough for the needs of clinical
research. If future editions of the DSM would adopt more specific diagnosis for sexual
disorders, it would allow for greater accuracy in the diagnositic and treatment processes.
Treatment Efficacy
Perhaps the biggest debate involving sex offenders is over treating them. Some
critics argue that treatment for sex offenders can be effective if the correct type of
treatment is matched to the correct type of offender. Others contend that the treatment
effects demonstrated in the literature are too small to be considered significant and that
there is no true treatment for these offenders. The debate of sex offender treatment
efficacy is not so black and white, and “…the broad question, ‘Does sex offender
treatment work?’ needs to be broken down into a number of more specific and useful
questions” (Marques, 1999, p. 437). There is also debate over whether those who treat
sex offenders should be specially licensed, as is the case in Washington (Becker, 1994).
Special licensing for sex offender therapists would allow for training in specific process
variables that have received some support in increasing treatment efficacy (Marshall,
Fernandez, Serran, Mulloy, Thornton, Mann, & Anderson, 2003; Serran, Fernandez,
Marshall, & Mann, 2003). Special licensing issues, however, are not the focus of the
current discussion. This section of the present review is set aside for discussion of
specific approaches to treatment of sex offenders and the effectiveness of each approach.
Drug therapy. As outlined by Katz (1998), drug therapies are used in the
treatment of offenders under four different circumstances:
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“1) offenders who have been unresponsive to other treatment modalities, 2)
offenders who pose an immediate risk to society and must be prevented from reoffending, 3) offenders with comorbid psychiatric disorders that may have an
impact on offending (e. g., OCD, ADHD, intermittent explosive disorder), and, by
far the most common usage, 4) offenders with paraphilias, or persistent, deviant,
sexual urges, in which the goal of treatment is to reduce sexually deviant behavior
by suppressing the sexual drive” (p. 306).
Katz’ final reason for drug therapy treatment with sex offenders is discussed here.
Various substances have been used to suppress the sex drives of sex offenders; the most
common class of which are the antiandrogens (Becker, 1994; Katz, 1998). Cyproterone
acetate (CPA) and medroxyprogesterone acetate (MPA) are the two most commonly used
antiandrogens (although CPA cannot be used in the United States) (Katz, 1998).
Antiandrogens are used in the treatment of incest offenders, extrafamilial child molesters,
and rapists who are adults, but because of negative side effects, it is not used with
adolescent sex offenders (Katz, 1998). Antiandrogens work to decrease the level of
testosterone in the body, which results in a lower level of arousability and a reduction in
the frequency and intensity of sexual urges. Antiandrogens do not change the nature of
sexual offenders’ fantasies, just the ability to act them out (Katz, 1998). Katz (1998)
concluded that psychopharmacological treatments may be used as the primary treatment
for high-risk sex offenders, but Prentky et al. (1997) caution against this.
Drug therapies may certainly be effective in decreasing the observable behaviors
of sex offenders, but one could easily argue that drug therapies simply treat a symptom
and not the illness. Another argument against using drug therapy as the primary means of
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treatment is that offenders who are not properly supervised may suspend selfadministration of the medication, thereby leaving a high-risk individual in a community
setting with nothing to keep his deviant behavior in check. It is probably most advisable
to use drug therapy in conjunction with other treatment approaches.
Group and family therapy. Group therapy is often used in conjunction with
individual treatment (Abracen & Loomah, in press; Anderson, 1998; Becker, 1994).
Some indicate that group therapy coupled with individual therapy is no more effective
than is individual therapy alone (Abracen & Loomah, in press). Others do not argue the
issue of effectiveness, but rather outline the added values of participating in group
therapy. For example, group therapy can have the added benefit of making members feel
accountable to other members within their group, and group members may sometimes
reach important points in their treatments during group discussion of treatment-related
issues (Anderson, 1998). Family therapy is most often used in the treatment of
adolescent offenders and incest offenders. In the case of incest offenders, it is essential
that they receive individual therapy and family therapy where the family is still intact and
willing to participate (Becker, 1994).
Thus, it would seem that group and family therapy may be worthwhile if only to
act as an additional buffer and source of social support during the treatment process.
While the results of Abracen and Loomah (in press) indicate that group therapy along
with individual therapy has no different effect than group therapy alone, their results do
not indicate that group therapy is in any way detrimental. Therefore, there is no reason to
resist the use of group therapy if its use is economically feasible.
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Cognitive-behavioral therapy. Cognitive-behavioral therapy is by far the most
widely used treatment for all sex offenders today (Becker, 1994; Craig, Browne, &
Stringer, 2003; Shaw, Schlank, & Funderburk, 1998). Craig et al. (2003) refer to
cognitive-behavioral treatment as “the principal type of sex offender treatment” (p. 86).
Cognitive-behavioral therapy seeks to alter inaccurate beliefs (cognitions) and to develop
ways of controlling inappropriate behaviors (Becker, 1994). This type of therapy can
also be considered highly effective because it targets criminogenic factors (T. W. Barrett,
personal communication, April 26, 2004). Cognitive-behavioral therapy can be used with
incest offenders, extrafamilial child molesters, and rapists. There are many different
approaches to treatment within cognitive-behavioral therapy (Shaw et al., 1998). The
most controversial of these approaches is the self-administered satiation approach. In this
approach, offenders are taped while verbalizing a deviant fantasy and masturbating.
These tapes are then played back to the offenders during therapy sessions, and the
thought is that offenders will become bored with their own deviant fantasies. Selfadministration satiation also seeks to replace deviant fantasies with acceptable fantasies
during the period of taping and replaying (Shaw et al., 1998). Another approach is
olfactory aversion. With this approach, offenders are presented with a very unpleasant
odor (often an ammonia inhalant) while verbalizing deviant fantasies. The logic here is
that aversive conditioning will take place, and the deviant fantasy will come to produce a
disgust reaction (Shaw et al., 1998). A final approach that has been gaining in popularity
is vicarious sensitization. Vicarious sensitization uses videotaped aversive stimuli that
are spliced with images of deviant fantasies that are revealed by offenders during
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treatment. This approach, then, aims to create aversive conditioning without forcing the
offenders to experience the unpleasantness of inhaling noxious odors (Shaw et al., 1998).
Cognitive-behavioral therapy seems to be the most effective way of treating sex
offenders; however, there is, of course, still debate over whether or not it is significantly
effective. Some studies have indicated significant results, while others have
demonstrated a positive treatment effect but no significance (see Craig et al., 2003 for a
review). Another debate within this subtopic is whether or not the approaches in
cognitive-behavioral therapy are ethical. Taping an offender who is masturbating and
verbalizing his fantasies seems bizarre, but it also seems to work (Shaw et al., 1998).
Perhaps, the best way to conceptualize this debate is to compare the offenders’ loss of
privacy or mild physical discomfort with the psychological ramifications for the victims
of the offenders. When viewed in this light, the benefits to society as a whole far
outweigh the costs to the population of offenders receiving the treatments.
Relapse prevention. Relapse prevention (RP) began in the early 1980’s as a
treatment for addictive behaviors (Launay, 2001; Polaschek, 2003; Shaw et al., 1998). It
was first applied by Pithers in the treatment of sex offenders (Polaschek, 2003). Some
would describe RP as a subtype of cognitive-behavioral therapy (Shaw et al., 1998), but
because of its growing popularity, which is coming to rival all of the cognitive-behavioral
therapies combined, many researchers and clinicians view RP as separate (Polaschek,
2003). RP may be used in the treatment of all previously defined sex offenders.
RP helps offenders to identify precursors to offending behavior such as a mood
state (depressed) or a specific place (the playground of a local elementary school).
Offenders are taught techniques to manage their behavior when these precursors arise
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(Becker, 1994). Launay (2001) stated that RP is designed to help offenders abstain from
a behavior or behaviors, but not to completely stop an undesired behavior. RP also
involves some level of community-based supervision (Becker, 1994; Polaschek, 2003).
The research about the efficacy of RP has been mixed. Some studies have
indicated that RP does not demonstrate the desired effects (Launay, 2001). Polaschek
(2003) indicated that there is not sufficient research to justify the wide usage of RP in
treating sex offenders. Further, more and more research is being produced that
demonstrates that “several common offense patterns… fit less and less well with the
assumptions of RP treatment” (Polaschek, 2003, p. 366). Polaschek (2003) concludes
that RP should not be stopped on the basis of lack of supporting evidence, but that
supporting evidence should be produced if RP continues at its present level of popularity.
Amenability to treatment. It is generally accepted that for treatment to work
offenders must be amenable to it. Becker (1994) provided a succinct definition of
“amenability to treatment”:
“a sex offender can be considered amenable to treatment only if he acknowledges
that he has committed a sexual offense, he considers his sexual offending a
problem behavior that he wants to stop, and he is willing to participate fully in
treatment” (p. 187).
Becker (1994) goes on to state that given the above requirements, most offenders would
not benefit from treatment. It is important to keep in mind that amenability to treatment
is a highly fluid variable and can change dramatically over time (McGrath, 1991, as cited
in Becker, 1994). Contrary to the generally accepted beliefs about the necessity for
amenability to treatment, one study (Terry & Mitchell, 2001) produced the finding that
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rapists did not need to be motivated to participate in treatment to experience positive
effects. The same study did, however, confirm the previous finding that motivation is
necessary for effective treatment with incest offenders and extrafamilial child molesters.
Recidivism
Recidivism may be the most important issue involving sex offender treatment
efficacy, and it is a common way of measuring the success of treatment (Craig et al.,
2003). A number of meta-analyses have been performed with the existing literature on
recidivism. These meta-analyses have produced widely varying results. What can be
stated is that recidivism for sex offenders (which includes, in this context, non-contact
sex offenses such as exhibitionism) is generally no greater than recidivism for other
serious criminals, but recidivism for specific subsets of sex offenders is high (Craig et al.,
2003; Hall, 1995; Hanson & Bussière, 1998; Marshall & Pithers, 1994).
The current debate about recidivism began in 1989 with the publication of a
review by Furby, Weinrott, and Blackshaw. This review stated that recidivism rates were
rather high and treatments were rather ineffective across all offender types. These
findings sparked the production of several meta-analyses refuting the findings of Furby et
al. Marshall and Pithers (1994) and Hall (1995) both wrote articles that indicated that
treatment for sex offenders demonstrated a positive effect, though Hall (1995)
acknowledged that his findings showed only a “robust treatment effect” (p. 802) not
actual significance. In their review, Polizzi, McKenzie, and Hickman (1999) stated that
roughly half of the treatment programs they reviewed were effective and the other half
were not. Polizzi et al. (1999) also set out to examine the difference between prisonbased treatment programs and non-prison based treatment programs. Non-prison based
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treatment programs were judged to be more effective than their prison-based
counterparts, but the authors indicated that prison-based treatment programs did have a
positive effect on reducing recidivism, just not a significantly positive effect. Hanson and
Bussière (1998) produced a meta-analysis that identified the characteristics of those
offenders who were most likely to recidivate. Those with identified deviant sexual
preferences, a larger number of previous sex offenses, and failure to complete treatment
had a higher rate of recidivism (Hanson & Bussière, 1998).
Perhaps the best meta-analysis to date is by Prentky, Lee, Knight, and Cerce
(1997). Two specific reasons place Prentky et al.’s (1997) meta-analysis above the metaanalyses of others: 1) the meta-analysis uses one of the longest published follow-up
periods and 2) the authors do not define recidivism by reconviction but simply sexual reoffending. Prentky et al.’s (1997) meta-analysis produced some staggering findings.
Over the 25 year follow-up period, 52% of child molesters re-offended. During that same
follow-up period, 39% of rapists recidivated. What is even more concerning is that these
estimates are drawn from data that is likely underreported, so the recidivism rates may be
much higher. Many studies have used a five year follow-up period, but research with
longer follow-up periods indicates that re-offense may not begin taking place until
roughly eight years after release from prison (Prentky, 1997). Interestingly, incest
offender were demonstrated to have a very low rate of recidivism (Prentky, 1997). This
may provide support for the assertion that incest offenders have underlying pathologies
different those of extrafamilial child molesters (Doren, 1998).
The data regarding recidivism is certainly split among those who characterize it as
a common occurrence and those who believe it to be relatively infrequent. The meta-
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analysis of Prentky et al. (1997) provides strong favor to the former argument.
Additionally, the meta-analysis of Hanson and Bussière (1998) may help those in the
corrections field by identifying common characteristics of those who recidivate. Of
course, the characteristics identified by Hanson and Bussière (1998) are those
characteristics that would be most commonly help by the populations Prentky et al.
identified as recidivating most often. The best of the present research, then, indicates that
for specific populations recidivism is a common occurrence, and the data disputing this
finding may have some empirical support, but it is not significant
Special Populations
In general, the large majority of the literature discusses adult male sex offenders
because adults males are the largest offender population. Throughout the 1990’s though,
there has been growing interest in two smaller, but still significant, offender populations:
adolescent sex offenders and female sex offenders. What follows is a discussion of the
characteristics and treatments of each.
Adolescent sex offenders. Until the 1990’s, most of the research regarding sex
offenders was focused on adult offenders (Becker, 1994; Boyd, Hagan, Cho, 2000).
However, this focus has changed as several research reports have published estimates
ranging from 58% to 80% of adult sex offenders engaging in deviant sexual acts during
adolescence (Becker, 1994). Adolescent sex offenders can be incest offenders,
extrafamilial child molesters, and rapists. Adolescent sex offenders perpetrate a
significant number of the sexual offenses in any given year; in 1990, they committed one
fifth of the rapes and one fourth of all other sex crimes (Boyd et al., 2000). Furthermore,
the incidence of sex offenses committed by adolescents is on the rise. Between 1981 and
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1990, the rate of adolescents committing rape rose 28% and the rate of adolescents
committing other sexual crimes rose 32% (Boyd et al., 2000).
While sex offenders as a whole are widely variable, there are some common
characteristics shared by adolescent offenders. Over 90% of adolescent sex offenders are
male (Becker, 1994). The most common age of adolescent sex offenders ranges from 14
or 15 (Becker, 1994) to 16 years old (Boyd et al., 2000) with victims averaging 7 or 8
years old (Becker, 1994; Boyd et al., 2000). Adolescent rapists tend to be slightly older
than other adolescent sex offenders (Boyd et al., 2000). Approximately three fourths of
the victims of adolescent sex offenders are girls and, obviously, the other one fourth boys
(Boyd et al., 2000). In roughly half of documented cases, the victim of the adolescent sex
offender is known to the perpetrator (Boyd et al., 2000). Sixty percent of offenses
perpetrated by adolescent sex offenders involve penetration (Becker, 1994).
Many adolescent sex offenders have an unstable family history that likely
involves some form of abuse (Becker, 1994; Boyd et al., 2000). Many families of
adolescent sex offenders are characterized by violence (Boyd et al., 2000), and for this
reason, many adolescent sex offenders live outside of their biological families (Becker,
1994; Boyd et al., 2000). Adolescent sex offenders have a rate of depression higher than
that of non-offenders, which is the case for most classes of adolescent offenders (Becker,
1994).
Treatments for adolescent sex offenders are generally the same as those used with
adult sex offenders. There are, of course, some variations. Parental therapy is often
provided concurrently with therapy for the adolescent and may emphasis training parents
in coping with inappropriate behaviors and reinforcing appropriate behaviors in their
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children (Shaw et al., 1998). In the case of self-administered satiation, ethical concerns
have been raised about therapists having access to adolescents’ private sexual behaviors
on tape, so self-administered satiation with adolescents may involve only the repetition of
deviant fantasies (Shaw et al., 1998). Adolescent sex offenders are quite commonly
involved in group and family therapy settings along with their individual treatment
(Becker, 1994). The treatment outcomes for adolescent rapists and adolescents who
commit other sexually offenses are generally quite similar (Hagan & Cho, 1996).
In the case of adolescent sex offenders, the ethical concerns involved in treatment
and reporting are issues of debate. Some treatments are probably not acceptable to
administer to adolescents, but if they are effective, the benefits to society may outweigh
the costs to the perpetrator. Also, adolescent sex offenders are not compelled to register
when they move, and that is not likely to change. Many adolescent offenders do begin
registering as sex offenders when they reach adulthood (Boyd et al., 2000). Some argue
that forcing adolescents to register when they reach adulthood provides no reinforcement
for participating in treatment and may decrease motivation (Boyd et al., 2000).
Female sex offenders. Less than 5% of sex offenses committed against children
are perpetrated by a female (Grayston & DeLuca, 1999). This is a small, but clinically
interesting statistic. Also, it has been suggested that sex offenses perpetrated by females
are even less likely to be reported than sex offenses perpetrated by males because of the
different contexts in which female-perpetrated sex offenses take place (Grayston &
DeLuca, 1999). Thus, the 5% estimate may be rather low.
Most female sex offenders know their victims (Grayston & DeLuca, 1999). Also,
the victims of female sex offenders are often younger than are the victims of male sex
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offenders (Grayston & DeLuca, 1999). There is conflicting data on whether female sex
offenders victimize boys or girls more commonly (Grayston & DeLuca, 1999; Green,
1998). Female sex offenders tend to be unemployed and of lower socioeconomic status
(Green, 1998). One final, interesting finding is that female sex offenders often victimize
children with a partner, usually a male (Grayston & DeLuca, 1999).
In the case of female sex offenders, the debate is really over the incidence of
female sex offending being taken seriously in the clinical literature. In general, society
does not conceive of women as being capable of committing sex crimes (Grayston &
DeLuca, 1999) and this bias may be keeping relevant research from taking place.
Conclusion
A number of debates are involved in the treatment of sexual offenders. Broadly,
these debates involve the terminology used for and the classification of offenders, the
efficacy of treatment, the rate of recidivism, and the prevalence and treatment of special
offender populations. Each debate has mental health and corrections professionals on
either side arguing vehemently for their point of view. In perhaps the largest debate,
which encompasses all of the others, some critics argue that there is no effective
treatment for sex offenders while others counter that treatment efficacy is a matter of
matching the right treatment with the right offender. There is, of course, convincing
evidence that provides support to both sides.
After reviewing the applicable data, the present review would argue that the rate
of sex offending in the United States has reached epidemic proportions. Unlike other
epidemics, the vehicles of infection cannot simply be killed off and the population of
possible victims cannot be inoculated. In the face of dire research findings that indicate
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there may truly be no effective therapy for sex offenders and of continually rising rates of
sex offense, it seems that all that can be done at the present time is more research. The
best way for this research to be produced is through the unified effort of the scientific
community. In this way, we may finally obtain conclusive results about sex offending,
which will not simply serve to confirm or to disconfirm scientific inquiries, but serve the
greater good of society as a whole.
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