The long-term evaluation of a behavioral treatment program for child molesters

Outcome of an institutional sexual offender treatment program: a comparison between treated and matched untreated offenders

Data from a sexual offender treatment program operated by the Correctional Service of Canada at the Regional Psychiatric Center (Saskatoon) supported the conclusion that cognitive behavioral treatment can reduce sexual offense recidivism. The study compared 296 treated and 283 untreated offenders followed for a mean of 6 years after their release. An untreated comparison subject was located for each treated offender on three dimensions: (a) age at index offense, (b) date of index offense, and (c) prior criminal history. Data were analyzed using tests of proportion, survival analysis, and analysis of offender Criminal Career Profiles. Over a mean follow-up period of almost 6 years, convictions for new sexual offenses among treated offenders were 14.5% versus 33.2% for untreated offenders. During the follow-up period, 48% of treated offenders remained out of prison compared to 28.3% of untreated offenders. Time series comparisons of treated and comparison samples also showed that treated men reoffended at significantly lower rates after 10 years. A Criminal Career Profile (CCP) was constructed by taking the Age at First Conviction and plotting the offender's successive lengths of time free against time incarcerated. Pre- and posttreatment slopes of the CCP were lower for both groups posttreatment; however, the degree of change was significantly greater for the treated group, indicating a greater reduction in criminal activity among these offenders. Taken together, the results of all three analytic techniques supported the efficacy of appropriate correctional treatment for effective reduction of recidivism.

Pharmacotherapy of paraphilias in the next millennium

Paraphilias are psychiatric disorders of abnormal sexual behavior whose prevalence has markedly increased during the last decade. Treatment modalities currently used fall into three categories: surgical castration, psychotherapy, and pharmacotherapy. The pharmacological interventions consist of antiandrogens that either completely reduce testosterone secretion and/or antagonize the action of testosterone at the level of the receptor, and psychotropic drugs, namely antidepressants. Cyproterone and medroxyprogesterone acetates are the two antiandrogens more commonly used. They are only effective in relatively high doses, but have a substantial number of severe side effects which has considerably limited their use. Psychotropic drugs may be effective solely in men with a definite obsessive-compulsive disorder component. Because of the erratic results and lack of permanent eradication of the paraphilic manifestations their use in paraphilias is highly controversial. Long-acting gonadotropin-releasing hormone (GnRH) agonist analogues are the most potent antiandrogens, and selectively abolish testosterone secretion in a totally reversible fashion. They are administered parenterally once every 1 to 3 months, and have the fewest side effects. Long-acting GnRH analogues, together with psychotherapy, are highly effective in controlling selected paraphilias (pedophilia, exhibitionism, and voyeurism), and are the most promising mode of therapy in the next millennium. There is an urgent need for good methodological research; carefully designed double-blind controlled studies with a large number of subjects in order to validate or not the use of the various pharmacotherapies.

Psychological assessment, treatment, and outcome with sex offenders

The frequency and impact of sexual offenses have led to the recent enactment of sexual "predator" laws. Such laws are intended to reduce sexual violence through treatment and involuntary confinement. Sixty years ago, similar laws identifying "sexual psychopaths" were enacted and, in many states, eventually repealed for multiple reasons; among those reasons was an inability to demonstrate that treatment had any significant impact on recidivism. That inability forced us to reexamine, among other issues, the population(s) which undergo treatment, the outcomes that are used to measure treatment effectiveness, and the processes that constitute treatment itself. Those issues are considered in this paper through a review of treatment programs based on psychodynamic, behavioral, and cognitive-behavioral theories. Although the evidence is sparse, it is fair to conclude that the latter have been found to be effective. We call for dynamic measures, effective treatments, and the resources necessary for both developments.

Sexual offender treatment efficacy revisited

Several authors have recently addressed current views of sexual offender treatment efficacy. Some maintain that offenders can gain from treatment while others argue that the vast majority cannot. Some researchers say that the field of sexual offender treatment is too new to be able to determine whether or not treatment works. This latter group notes that most studies in this field have not yet reached the point at which meta-analytic techniques can be applied; for this reason no definitive statements can be made about the utility of treatment. The present analysis examines the issues from a slightly different perspective. Data from a large group of studies are combined to identify patterns which can be examined later in more detail. More specifically, 79 sexual offender treatment outcome studies are reviewed, encompassing 10,988 subjects. Recidivism rates for treated versus untreated offenders are investigated according to age of offender, age of victim, offense type, type of treatment, location of treatment, decade of treatment, and length of follow-up. Each study is used as the unit of analysis, and studies are combined according to the number of treated versus untreated subjects who reoffended in each category. Clinical implications are drawn from these results.

Factors associated with sexual behavior problems in young sexually abused children

OBJECTIVE

To identify variables associated with the presence of sexual behavior problems in young sexually abused children.

METHOD

Data were gathered from the clinical records of 100 sexually abused boys and girls ages 3-7 years enrolled in two treatment programs. Information was coded systematically on approximately 350 areas related to the child and family's history and functioning, the sexual abuse experience, and treatment outcome. The children were grouped and compared according to their presenting sexual behavior into three categories: (1) developmentally "expected"; (2) "sexualized/self-focused"; and (3) problematic "interpersonal" sexual behavior.

RESULTS

Bivariate and multivariate analyses highlighted five variables which were predictive of sexual behavior problems among sexually abused children. Sexual arousal of the child during his/her sexual abuse, the perpetrator's use of sadism, and a history of physical and emotional abuse differentiated between those children with and without "interpersonal" sexual behavior problems. Who the child blamed for his/her sexual abuse further contributed to the distinction between children whose sexual behavior was exclusively "self-focused" (sexualized) versus "interpersonal."

CONCLUSIONS

The five major predictor variables, as well as other variables identified in this study, have potential utility in assessing child risk for negative outcomes and determining referral priorities for sexual abuse treatment. Given that sexual arousal and who the child blames for the abuse are prominent variables associated with sexual problems and self-blame, clinicians will need to ensure that sexually abused children and their caregivers are given specific opportunities to deal with these areas in the supportive context of treatment. Children with sexual behavior problems differ not only in the type and level of sexual behavior they exhibit but in most other areas as well, suggesting a need for differential assessment and individualized treatment approaches.

Sexual recidivism in sex offenders

OBJECTIVE

To examine the recidivism rates of the various types of adult sex offenders including incest offenders, extrafamilial child molesters, exhibitionists, and rapists.

METHOD

An examination of the literature over the past 4 decades and the data from our own study group.

RESULTS

Methodological shortfalls and differences across the studies make statistical appraisal of the results difficult. Nevertheless, there is a consensus that incest offenders are less likely to reoffend compared with extrafamilial child molesters. Rapists and exhibitionists are thought to be at a higher risk for recidivism.

CONCLUSION

A combined actuarial predictive approach in conjunction with empirically guided clinical assessment is probably the best method to predict recidivism of sex offenders.

Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone

BACKGROUND

Men with deviant sexual behavior, or paraphilia, are usually treated with psychotherapy, antidepressant drugs, progestins, and antiandrogens, but these treatments are often ineffective. Selective inhibition of pituitary-gonadal function with a long-acting agonist analogue of gonadotropin-releasing hormone may abolish the deviant sexual behavior by reducing testosterone secretion.

METHODS

In an uncontrolled observational study, we treated 30 men (mean age, 32 years) with severe long-standing paraphilia (25 with pedophilia and 5 with other types of abnormal behavior) with monthly injections of 3.75 mg of triptorelin and supportive psychotherapy for 8 to 42 months. The efficacy of therapy was evaluated monthly by the Intensity of Sexual Desire and Symptoms Scale and yearly by the Three Main Complaints questionnaire.

RESULTS

All the men had a decrease in the number of deviant sexual fantasies and desires, from a mean (+/-SD) of 48+/-10 per week before therapy to zero during therapy (P<0.001), and a decrease in the number of incidents of abnormal sexual behavior (from 5+/-2 per month to zero, P<0.001) while receiving triptorelin. These effects were evident after 3 to 10 months of therapy (P<0.001) and persisted in all 24 men who continued therapy for at least 1 year. The men's mean serum testosterone concentration fell from 545+/-196 ng per deciliter (18.9+/-6.8 nmol per liter) before therapy to 23+/-14 ng per deciliter (0.8+/-0.5 nmol per liter, P<0.001) after 42 months of triptorelin. The main side effects were erectile failure, hot flashes, and decrease in bone mineral density in some men.

CONCLUSIONS

Continuous administration of triptorelin, a long-acting agonist analogue of gonadotropin-releasing hormone, together with supportive psychotherapy, may be an effective treatment for men with severe paraphilia.

Rape and rapists: theory and treatment

The sexual assault of adult women is noteworthy by its huge social and personal cost to the victims, their families, and ultimately society as a whole. The past decade has seen burgeoning research and clinical interest regarding child molesters but a lack of equivalent effort concerning rapists. Rapists are significantly different from child molesters. While considerable heterogeneity exists within this group, there is a lack of distinctiveness when compared to the wider population of serious criminal offenders. These two features of rapists have implications both for research and treatment. We also argue that despite the advances of the last decade this has been in terms of theory proliferation rather than integration, and that major explanatory gaps remain. In particular, there is a need for more middle-level theory that articulates mechanisms and can underpin treatment. Current treatment approaches have typically been developed for child molesters, and while there has been a significant increase in comprehensiveness and sophistication, the evidence for treatment efficacy with rapists remains tentative. Treatment programs need to be tailored to the specific needs of rapists and to the issues of treatment engagement and completion. We conclude with a variety of suggestions for the research agenda over the next decade.

The treatment of child sex abusers in England

A Council of Europe Fellowship was used to visit several centres in England managing and treating child sex abusers in a community setting. Aspects of the services reviewed included organisation, training of staff, assessment of abusers, methods of treatment and resources and facilities available. The application of the English experience to the establishment of treatment programmes in Ireland is discussed.

Child sexual abuse. 3: Treatment and recidivism in paedophiles

Although various courses of treatment for paedophilia have been tried, there is little evidence of their effectiveness. Important factors that mitigate against success are the inability of paedophiles to see their sexual activity as warranting treatment and their reluctance to change their behaviour.

Therapy with victimized children and their families

The treatment of children who have been sexually abused requires intervention at the individual, parental, and family level. A treatment model is proposed to address the negative affect, distorted beliefs, sexualized behavior, and disturbed personality development often associated with sexual abuse.

The treatment of exhibitionists: a focus on sexual deviance versus cognitive and relationship features

Two studies compared treatment of exhibitionists aimed at either: (1) modifying deviant sexual preferences; or (2) changing cognitions, enhancing relationship and interpersonal skills, and improving awareness of relapse prevention issues. Recidivism rates of these two programs were compared with each other and with the rates observed in untreated offenders. Results supported the focus on broader cognitive and social issues. Clearly exhibitionists can be treated effectively.

Assessment and treatment of sex offenders: the Prince of Wales Programme

The treatment programme for sex offenders at the Prince of Wales Hospital, Sydney, is described. Penile circumference assessment is not used as there is no evidence it provides a valid measure of individuals' paedophile or rapist tendencies. Sex offenders' self-reports remain the major source of information in their assessment. The development of the two major techniques used--imaginal desensitization and short-term medroxyprogesterone--is outlined. About 80% of subjects can be expected to show a good response to one or other of these therapies. Of those who do not, most respond to the alternative or aversive therapy. Adolescent offenders appear to require more intensive treatment. Results appear comparable with those of more intensive programmes in use overseas.