Sexual recidivism among child molesters released from a maximum security psychiatric institution

Moderators of Sexual Recidivism as Indicator of Treatment Effectiveness in Persons With Sexual Offense Histories: An Updated Meta-analysis

The present meta-analysis is an update of the meta-analysis by Schmucker and Lösel [Campbell Syst. Rev. 2017; 13: 1-75], which synthesized evidence on sexual recidivism as an indicator of treatment effectiveness in persons with sexual offense histories. The updated meta-analysis includes 37 samples comprising a total of 30,394 individuals with sexual offense histories, which is nearly three times the sample size reported by Schmucker and Lösel (2017: 28 samples, N = 9781). In line with Schmucker and Lösel (2017), the mean treatment effect was small with an odds ratio of 1.54 [95% CI 1.22, 1.95] (p < .001). A moderator analysis suggested three predictors of importance, i.e., risk level, treatment specialization, and author confounding. Greater treatment effectiveness was suggested in high- and medium-compared to low-risk individuals and in specialized compared to non-specialized treatments. Authors affiliated with treatment programs reported larger effectiveness than independent authors. These findings were overall in line with Schmucker and Lösel (2017), though the effects of risk level and treatment specialization were stronger in the current meta-analysis. The findings of the updated meta-analysis reinforce the evidence for the first and second principle of the Risk-Need-Responsivity model. The results may support researchers and decision-makers in interpreting the current evidence on sexual recidivism as an indicator of treatment effectiveness, and, based on that, implement and carry out informative, methodologically sound evaluations of ongoing treatment programs in persons with sexual offense histories.

Acceptance of Sexual Interest in Minors in Self-Referred Individuals Under Treatment - An Exploratory Pilot Study

Some therapists/scientists argue that “acceptance” of sexual interest in minors (SIM), i.e., the integration of the sexual preference into the individual self-concept, is a prerequisite for dealing with SIM in a responsible way. However, if one assumes that – even in some persons – SIM might change over time, “acceptance” could also run counter to therapeutic targets because the motivation to change as well as the specific self-efficacy for modifying SIM might be reduced. This exploratory pilot study analyzes the relationship between acceptance of SIM and (1) dynamic risk for contact sexual reoffending, (2) SIM and frequency of the use of child/adolescent (sexual abuse) imagery, (3) frequency of sexual desire/behavior toward children/adolescents, and (4) the change of the level of acceptance of SIM during the course of treatment. The majority of the participants (N = 79) was not exclusively interested in children (85%) and used child pornography but did not commit child sexual abuse (54%). Acceptance of SIM, frequency of the use of child/adolescent (sexual abuse) imagery and frequency of sexual desire/behavior toward children/adolescents are assessed via self-report questionnaires, dynamic risk for contact sexual reoffending is measured by STABLE-2007. Pretreatment data are analyzed via Spearman’s correlation (N = 79). Intragroup analysis compares acceptance of SIM from pre- and posttreatment (n = 35). There was no correlation between acceptance of SIM and dynamic risk for contact sexual reoffending. However, there was a medium, positive correlation between acceptance of SIM and the frequency of the use of legal imagery of children, a positive correlation between the item “My inclination is an integral part of my personality” and the frequency of the use of legal imagery of children, and a positive correlation between acceptance of SIM and the frequency of sexual activities with minors. Acceptance of SIM did not change during the course of treatment. The results suggest that “acceptance” of SIM has to be discussed in a differentiated way, i.e., as possibly being associated with positive and negative outcomes as well.

Investigating Mental Health Implications for Drug Court Participants

Drug Court Treatment (DCT) Programs seek to integrate substance abuse treatment into the criminal justice system by providing a structured environment for offenders who engage in treatment in lieu of incarceration. DCT has shown successes in reducing drug/alcohol use, recidivism, and cost, but the impact of DCT on non-substance-related mental health outcomes is less clear. This study evaluated mental health correlates within a DCT sample through analyses of participants' pre-entry and pre-graduation Minnesota Multiphasic Personality Inventory-Second Edition (MMPI-2) profiles. When diagnostic information was available, mood disorders had the highest comorbidity with alcohol/substance use diagnoses. Comparisons across administrations of the MMPI-2 indicated significant differences among mean scores on 6 Clinical scales, and mean profile elevation scores significantly decreased. Results suggest a significant presence of mental health comorbidities in DCT programs, and significant mental health improvements were seen for graduates, suggesting the utility of DCT for treating mental health problems in addition to substance use.

Increasing Valid Profiles in Phallometric Assessment of Sex Offenders with Child Victims: Combining the Strengths of Audio Stimuli and Synthetic Characters

Penile plethysmography (PPG) is a measure of sexual interests that relies heavily on the stimuli it uses to generate valid results. Ethical considerations surrounding the use of real images in PPG have further limited the content admissible for these stimuli. To palliate this limitation, the current study aimed to combine audio and visual stimuli by incorporating computer-generated characters to create new stimuli capable of accurately classifying sex offenders with child victims, while also increasing the number of valid profiles. Three modalities (audio, visual, and audiovisual) were compared using two groups (15 sex offenders with child victims and 15 non-offenders). Both the new visual and audiovisual stimuli resulted in a 13% increase in the number of valid profiles at 2.5 mm, when compared to the standard audio stimuli. Furthermore, the new audiovisual stimuli generated a 34% increase in penile responses. All three modalities were able to discriminate between the two groups by their responses to the adult and child stimuli. Lastly, sexual interest indices for all three modalities could accurately classify participants in their appropriate groups, as demonstrated by ROC curve analysis (i.e., audio AUC = .81, 95% CI [.60, 1.00]; visual AUC = .84, 95% CI [.66, 1.00], and audiovisual AUC = .83, 95% CI [.63, 1.00]). Results suggest that computer-generated characters allow accurate discrimination of sex offenders with child victims and can be added to already validated stimuli to increase the number of valid profiles. The implications of audiovisual stimuli using computer-generated characters and their possible use in PPG evaluations are also discussed.

Validity in Phallometric Testing for Sexual Interests in Children: A Meta-Analytic Review

Valid assessment of pedohebephilic interests (i.e., sexual interest in children) is fundamental to forensic clinical practice. Phallometric testing-which measures changes in penile circumference or volume, while stimuli depicting different ages and sexual activities are presented-is widely used in clinical and research settings to detect such interests. This meta-analysis summarizes studies comparing sexual offenders against children and various types of controls on phallometric tests for pedohebephilic interests (37 samples; N = 6,785) and studies examining the relationship between phallometric test scores and sexual reoffending (16 samples; N = 2,709). The findings suggest that several phallometric testing procedures are valid indicators of pedohebephilic interest. Certain methodological features of phallometric tests were associated with greater validity, such as, slide or audio-plus-slide stimuli and z-score-based indices. In addition, phallometric tests for pedohebephilic, pedophilic, and hebephilic interests predicted sexual reoffending which provides further evidence that phallometric test scores are valid indicators of sexual interest in children. In general, the interpretation of phallometric test scores as indicators of pedohebephilic interests is supported.

Treatment Progress and Behavior Following 2 Years of Inpatient Sex Offender Treatment

Emerging research highlights the role of self-regulation in the treatment of sexual offenders. Safe Offender Strategies (SOS) is a manualized sex offender treatment program that emphasizes the role of self-regulation and self-regulatory skills development in sex offender treatment, particularly for offenders with serious mental illness and intellectual/developmental disabilities. The current study involves 156 adult male sexual offenders in an inpatient psychiatric setting who received SOS treatment for a period ranging from 6 months to 1 year. Participants' baseline and treatment data were obtained from archival medical records describing 1 year pre-treatment and up to 2 years of treatment participation. Dependent variables included monthly count rates of verbal and physical aggression and contact and noncontact sexual offending, as well as sexual deviancy attitudes, self-regulatory ability, and cooperation with treatment and supervision, as measured by the Sex Offender Treatment Intervention and Progress Scale (SOTIPS). Data were examined via paired-samples t tests, regression, and multilevel modeling, examining the impact of overall percentage of SOS groups attended over time, comparing participants' baseline measures to data from 2 years of treatment. The impact of predicted risk was also evaluated. Significant treatment dose effects were identified for improvements in aggression, sexual offending, and indicators of treatment compliance and change. These findings suggest that the skills-based, self-regulation approach utilized in SOS may be effective in improving clients' aggressive and sexual behaviors, attitudes toward their offenses and treatment, and self-regulatory ability over time. Implications for further research and treatment generalizability are discussed.

The Effect of Social Bonds on Successful Adjustment to Probation: An Event History Analysis

Recent studies of the effect of social bonds on offenders' adjustment to probation have produced mixed results, with some suggestion that successful adjustment is the result of the deterrent effects of probation supervision rather than the stabilizing effects of social bonds. This article reports the results of a study of child molesters entering probation and is thus focused on an offender population that maximizes the physical and social estrangement from society. The article uses measures of employment and of the quality of social relationships with family and friends to test the hypothesis that social bonds will significantly affect successful adjustment to probation supervision. An event history analysis of the data provides rather uniform support for the hypothesis that positive social bonds enhance offenders' positive adjustment to supervision. Employment was found to have a significant effect on the length of time to an unsuccessful probation termination, and support of family and support of friends were found to affect both the time to a revocation petition and the time to an unsuccessful termination. These findings have important implications for offenders' ability to successfully adjust to the problems of community reentry.

Recidivism Rates of Sexual Offenders up to 7 Years Later

This article critically reviews the evidence on sex offender treatment and subsequently provides new estimates on short-term recidivism among sexual offenders released from prison in New Jersey. The sample of male sex offenders is drawn from the Adult Diagnostic Treatment Center (ADTC), New Jersey’s only sex-offender-specific prison, and the general population of nine prisons within the state of New Jersey. The ADTC sample receives treatment while incarcerated ( n = 495), whereas no treatment is provided to the offenders in the general population sample ( n = 223). Overall, 33% of the total sample ( N = 718) commits a new offense. Of the total sample, 14% commits a new sexual offense and 24% commits a new nonsexual offense. Significant differences exist between the ADTC and the general population samples with respect to nonsexual reoffending only. In the final analysis, treatment appears to matter in terms of a reduction in recidivism but not in conventionally expected ways.

Are Sex Offenders Different? An Examination of Rearrest Patterns

Sex offender registration and community notification requirements are universally applied to all sex offenders irrespective of their type. In this way, these policies treat sex offenders as a homogenous group, assuming that they exhibit similar reoffending patterns regardless of the age of their victims or the nature of their crimes. In this article, the authors highlight the assumption of homogeneity underlying sex offender laws and reviewit in light of current empirical evidence. They also offer a case study of recidivism rates for sex offenders in Illinois. The authors find that sex offenders are not the homogenous group that our policies assume, and they discuss the implication of this finding for the application of sex offender laws.

The Effectiveness of Psychological Treatment for Reducing Recidivism in Child Molesters: A Systematic Review of Randomized and Nonrandomized Studies

In this systematic review, the effectiveness of psychological treatment interventions for child molesters was examined. Studies were restricted to randomized control trials (RCTs), controlled trials, and cohort designs where recidivism had been used as the outcome variable. ASSIA, NCJRS, Medline, PsychINFO, EMBASE, Pro-requests Dissertations and Theses A&I, and the Cochrane Library were searched. Ten experts were contacted and the reference lists of 12 systematic reviews and 40 primary studies were observed. The number of hits was 3,019, of which 564 duplicates, 2,388 irrelevant references, and 38 that did not meet the inclusion criteria were removed. Fourteen studies using mixed samples had to be omitted because it was not possible to determine the recidivism rates of child molesters in the samples described. One RCT and 9 cohort studies were included in the data synthesis, providing 2,119 participants. In all, 52.1% received the intervention under investigation and 47.9% did not. The reported recidivism rates were 13.9% for the treated child molesters compared to 18.6% for the untreated child molesters. Three studies reported statistically significant lower recidivism rates for treated child molesters. Eight studies were assessed as weak. Four studies were assessed as having bias which increased the chance of finding a treatment effect and four studies were assessed as having bias which reduced the chance of finding a treatment effect. It was not possible to determine the direction of bias for two studies.

Progress in violence risk assessment and communication: hypothesis versus evidence

We draw a distinction between hypothesis and evidence with respect to the assessment and communication of the risk of violent recidivism. We suggest that some authorities in the field have proposed quite valid and reasonable hypotheses with respect to several issues. Among these are the following: that accuracy will be improved by the adjustment or moderation of numerical scores based on clinical opinions about rare risk factors or other considerations pertaining to the applicability to the case at hand; that there is something fundamentally distinct about protective factors so that they are not merely the obverse of risk factors, such that optimal accuracy cannot be achieved without consideration of such protective factors; and that assessment of dynamic factors is required for optimal accuracy and furthermore interventions aimed at such dynamic factors can be expected to cause reductions in violence risk. We suggest here that, while these are generally reasonable hypotheses, they have been inappropriately presented to practitioners as empirically supported facts, and that practitioners' assessment and communication about violence risk run beyond that supported by the available evidence as a result. We further suggest that this represents harm, especially in impeding scientific progress. Nothing here justifies stasis or simply surrendering to authoritarian custody with somatic treatment. Theoretically motivated and clearly articulated assessment and intervention should be provided for offenders, but in a manner that moves the field more firmly from hypotheses to evidence.

Treatment and management of child pornography use

Advances in Internet and other digital technologies have created ready and affordable access to pornography involving real children or computer-generated images of children. To better understand and manage child pornography users, clinicians must acquaint themselves with the characteristics and behaviors of these offenders. This article distinguishes motivations to use child pornography and different types of child pornography offenders and provides a brief overview of the assessment, diagnosis, and management options available. The authors conclude with recommendations on future directions in the assessment, diagnosis, and management of child pornography offenders.

[Injunction to care. Results of a study carried out in the regions of Alsace and Lorraine]

INTRODUCTION

The act of June 17, 1998 created a new form of compulsory treatment: the injunction to care. This is a legal measure intended to fight against recidivism of offenders and sex offenders through medical measures. The only therapies that have demonstrated partial efficacy are cognitive behavioural therapy and treatment with anti-hormone. In France, psychodynamic therapies are paramount in the treatment of perpetrators of sexual violence, although such treatments have not demonstrated effectiveness in reducing sexual recidivism. Very few studies are available regarding the implementation of court-ordered treatment in France. The recent report by the General Inspectorate of Social Affairs (IGAS) in 2011 confirms the absence of medical statistics on the implementation of court-ordered care.

OBJECTIVE

We conducted a study on the procedure of the injunction to care in the regions of Alsace and Lorraine. The aim of the study is to develop an inventory coordinator for practitioners (number, type of exercise) and the profile of patients undergoing the injunction of care (type of offense convicted for, psychiatric comorbidity identified for example).

METHODS

We first identified the practicing coordinator doctors by contacting the High Courts in the geographic area studied. We then sent out a questionnaire by post to coordinator doctors to profile their patients on care injunctions.

RESULTS

We identified 16 practicing coordinator doctors in two study areas: 13 are state hospital doctors and three are private practice. Of the 16 doctors contacted, six returned the completed questionnaires (38% of the sample). This allows characterizing a sample of 50 patients on care injunctions. The majority of convicted crimes are of a sexual nature (92% of cases). This is mostly for crimes or sexual offenses involving minors aged under 15 (83% of cases). Psychiatric comorbidity is the most frequently identified paedophile primary (38%) followed by mental retardation (14%), dissocial personality disorder (6%) and a borderline personality, and emotional liability (6%). Other comorbidities are divided between paranoid schizophrenia, chronic alcoholism, or other personality disorder. The follow-up is monitored by a physician in 82% of cases, while it is provided by a psychologist in 18% of cases. The management consists of a simple psychotherapy in 66% of cases. Pharmacological treatment is most often prescribed with antipsychotics (26% of cases), followed by anti-depressants (4%) and the anti-hormone (4%).

CONCLUSION

Our study confirms that the majority of patients on care injunctions are sexual offenders involving minors under the age of 15. The most implemented treatment is a simple psychotherapy. The pharmacological option is infrequent and generally involves the use of inappropriate treatment (neuroleptics). Suppressive libido treatment (antidepressants and anti hormone) remains an exception in France.

Bayes and base rates: what is an informative prior for actuarial violence risk assessment?

Bayes' theorem describes an axiomatic relationship among marginal and conditional proportions within a single "experiment." In many ways, it has been fruitful to greatly extend this idea to the task of drawing inferences from data much more generally. Commonly, what matters is how all prior knowledge is revised (or not) by new findings resulting in posterior (sometimes "subjective") probabilities. And, to address many important problems, it is sensible to conceive of probability in such subjective terms. However, some commentators in the domain of violence risk assessment have assumed an analogous axiomatic relationship among marginals (i.e., priors in the form of base rates) observed in one study and conditionals (i.e., posteriors in the form of revised rates) expected in a separate study or assessment context. We present examples from our own research to suggest this assumption is generally unwarranted and ultimately an unaddressed empirical matter.

Psychological interventions for adults who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a legal construct that overlaps, but is not entirely congruent with, clinical constructs of disorders of sexual preference. Sexual offending is both a social and a public health issue. Victim surveys illustrate high incidence and prevalence levels, and it is commonly accepted that there is considerable hidden sexual victimisation. There are significant levels of psychiatric morbidity in survivors of sexual offences.Psychological interventions are generally based on behavioural or psychodynamic theories.Behavioural interventions fall into two main groups: those based on traditional classical conditioning and/or operant learning theory and those based on cognitive behavioural approaches. Approaches may overlap. Interventions associated with traditional classical and operant learning theory are referred to as behaviour modification or behaviour therapy, and focus explicitly on changing behaviour by administering a stimulus and measuring its effect on overt behaviour. Within sex offender treatment, examples include aversion therapy, covert sensitisation or olfactory conditioning. Cognitive behavioural therapies are intended to change internal processes - thoughts, beliefs, emotions, physiological arousal - alongside changing overt behaviour, such as social skills or coping behaviours. They may involve establishing links between offenders' thoughts, feelings and actions about offending behaviour; correction of offenders' misperceptions, irrational beliefs and reasoning biases associated with their offending; teaching offenders to monitor their own thoughts, feelings and behaviours associated with offending; and promoting alternative ways of coping with deviant sexual thoughts and desires.Psychodynamic interventions share a common root in psychoanalytic theory. This posits that sexual offending arises through an imbalance of the three components of mind: the id, the ego and the superego, with sexual offenders having temperamental imbalance of a powerful id (increased sexual impulses and libido) and a weak superego (a low level of moral probation), which are also impacted by early environment.This updates a previous Cochrane review but is based on a new protocol.

OBJECTIVES

To assess the effects of psychological interventions on those who have sexually offended or are at risk of offending.

SEARCH METHODS

In September 2010 we searched: CENTRAL, MEDLINE, Allied and Complementary Medicine (AMED), Applied Social Sciences Index and Abstracts (ASSIA), Biosis Previews, CINAHL, COPAC, Dissertation Abstracts, EMBASE, International Bibliography of the Social Sciences (IBSS), ISI Proceedings, Science Citation Index Expanded (SCI), Social Sciences Citation Index (SSCI), National Criminal Justice Reference Service Abstracts Database, PsycINFO, OpenSIGLE, Social Care Online, Sociological Abstracts, UK Clinical Research Network Portfolio Database and ZETOC. We contacted numerous experts in the field.

SELECTION CRITERIA

Randomised trials comparing psychological intervention with standard care or another psychological therapy given to adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or who are seeking treatment voluntarily for behaviours classified as illegal.

DATA COLLECTION AND ANALYSIS

At least two authors, working independently, selected studies, extracted data and assessed the studies' risk of bias. We contacted study authors for additional information including details of methods and outcome data.

MAIN RESULTS

We included ten studies involving data from 944 adults, all male.Five trials involved primarily cognitive behavioural interventions (CBT) (n = 664). Of these, four compared CBT with no treatment or wait list control, and one compared CBT with standard care. Only one study collected data on the primary outcome. The largest study (n = 484) involved the most complex intervention versus no treatment. Long-term outcome data are reported for groups in which the mean years 'at risk' in the community are similar (8.3 years for treatment (n = 259) compared to 8.4 in the control group (n = 225)). There was no difference between these groups in terms of the risk of reoffending as measured by reconviction for sexual offences (risk ratio (RR) 1.10; 95% CI 0.78 to 1.56).Four trials (n = 70) compared one behavioural programme with an alternative behavioural programme or with wait list control. No meta-analysis was possible for this comparison. For two studies (both cross-over, n = 29) no disaggregated data were available. The remaining two behavioural studies compared imaginal desensitisation with either covert sensitisation or as part of adjunctive drug therapy (n = 20 and 21, respectively). In these two studies, results for the primary outcome (being 'charged with anomalous behaviour') were encouraging, with only one new charge for the treated groups over one year in the former study, and in the latter study, only one new charge (in the drug-only group) over two years.One study compared psychodynamic intervention with probation. Results for this study (n = 231) indicate a slight trend in favour of the control group (probation) over the intervention (group therapy) in terms of sexual offending as measured by rearrest (RR 1.87; 95% CI 0.78 to 4.47) at 10-year follow-up.Data for adverse events, 'sexually anomalous urges' and for secondary outcomes thought to be 'dynamic' risk factors for reoffending, including anger and cognitive distortions, were limited.

AUTHORS' CONCLUSIONS

The inescapable conclusion of this review is the need for further randomised controlled trials. While we recognise that randomisation is considered by some to be unethical or politically unacceptable (both of which are based on the faulty premise that the experimental treatment is superior to the control - this being the point of the trial to begin with), without such evidence, the area will fail to progress. Not only could this result in the continued use of ineffective (and potentially harmful) interventions, but it also means that society is lured into a false sense of security in the belief that once the individual has been treated, their risk of reoffending is reduced. Current available evidence does not support this belief. Future trials should concentrate on minimising risk of bias, maximising quality of reporting and including follow-up for a minimum of five years 'at risk' in the community.

WITHDRAWN: Managements for people with disorders of sexual preference and for convicted sexual offenders

This review has been withdrawn (Issue 9, 2012) as it is no longer current and is to be superseded by two new reviews.

The editorial group responsible for this previously published document have withdrawn it from publication.

Adolescents who have sexually offended: is phallometry valid?

It is unclear whether deviant sexual preferences distinguish adolescents who commit sex offenses in the same way that such deviance characterizes adult sex offenders. We compared male adolescents (mean age = 15 at the time of a referral sex offense), matched adult sex offenders, and normal men (adult nonoffenders or nonsex offenders). We hypothesized the following: phallometric responses of the adolescents would be similar to those of adult sex offenders and would differ from normals; adolescents with male child victims would exhibit greater evidence of sexual deviance than those whose only victims were female children; among adolescents who had molested children, those with a history of sexual abuse would exhibit more evidence of sexual deviance than those with no such history; and phallometric measures would predict recidivism. With some notable exceptions or qualifications, results confirmed the hypotheses. Phallometry has valid clinical and research uses with adolescent males who commit serious sex offenses.

Is pedophilia a sexual orientation?

In this article, I address the question of whether pedophilia in men can be construed as a male sexual orientation, and the implications for thinking of it in this way for scientific research, clinical practice, and public policy. I begin by defining pedophilia and sexual orientation, and then compare pedophilia (as a potential sexual orientation with regard to age) to sexual orientations with regard to gender (heterosexuality, bisexuality, and homosexuality), on the bases of age of onset, correlations with sexual and romantic behavior, and stability over time. I conclude with comments about the potential social and legal implications of conceptualizing pedophilia as a type of sexual orientation in males.

Correlates of recidivism among adolescents who have sexually offended

The present study investigates the recidivism rates of a sample of 351 male adolescents who sexually offended, and were assessed at an outpatient psychiatric clinic in Montreal, Canada, between 1992 and 2002. The mean age of the participants was 15.8 years (SD=1.8). Data on adolescent and adult recidivism were collected in Summer 2005 from official criminality sources in Canada. Over an 8-year follow-up period, 45% (n=158) of the participants were charged with a new criminal offense, 30% (n=104) were charged with a violent offense, and 10% (n=36) were charged with a sexual offense. Cox regression results suggest that overall, violent, and sexual recidivism can be predicted by a variety of developmental, social, and criminological factors. Paternal abandonment, childhood sexual victimization, association with significantly younger children, and having victimized a stranger were associated with a higher risk of sexual recidivism. Previous delinquency, attention deficit disorder, and childhood sexual victimization were found to increase the risk for both violent and overall recidivism. Also, the use of violence during a sex crime and victimizing a stranger were associated with violent recidivism, and school delay and association with delinquent peers were predictive of overall recidivism. The results confirm that a significant proportion of adolescents who have sexually offended pursue a criminal activity beyond adolescence, although few specialize in sexual offending.

Sampling Extreme Groups Invalidates Research on the Paraphilias: Implications for DSM-5 and Sex Offender Risk Assessments

Psychiatrist and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) text editor Michael First has criticized the addition of victim counts to criteria proposed by the Paraphilia Sub-Workgroup for inclusion in DSM-5 because they will increase false-positive diagnoses. Psychologist and Chair of the DSM-5 Paraphilia Sub-Workgroup, Ray Blanchard, responded by publishing a study of pedohebephiles and teleiophiles which seemed to show that victim counts could accurately identify pedohebephiles who were selected per self-report and phallometric testing. His analysis was flawed because it did not conform to conventional clinical practice and because he sampled groups at opposite ends of the clinical spectrum. In an analysis of his full sample, we found the false-positive rate for pedohebephilia at the recommended victim count selection points was indeed very large. Why? Because data analyses that eliminate intermediate data points will generate inflated estimates of correlation coefficients, base rates, and the discriminative capacity of predictor variables. This principle is also relevant for understanding the flaws in previous research that led Hanson and Bussiere to conclude that sexual recidivism was correlated with "sexual interest in children as measured by phallometric assessment." The credibility of mental health professionals rests on the reliability of their research. Conducting, publishing, and citing research that reflects

Risk communication in sexually violent predator hearings

Sexually violent predator (SVP) laws use the civil commitment process to confine mentally disordered and dangerous offenders who are at high risk to reoffend. Few studies have examined how jurors decide SVP cases. As a result, a pilot study and three experimental studies were conducted, in which victim type, risk communication, and juror education were manipulated to assess juror response. Results continually illustrated that victim type was the most salient manipulation across studies and that the manner of risk communication and juror education had little impact on jurors.

Long-term predictive validity of the risk matrix 2000: a comparison with the static-99 and the sex offender risk appraisal guide

The purpose of this study is to examine the predictive accuracy of the Risk Matrix 2000 on an independent sample of 351 sexual offenders, followed in the community for an average duration of 11.4 years (range 0-20 years, SD = 4.4 years). For comparison purposes, this study also examines the predictive accuracy of two other risk assessment instruments, specifically modified versions of the Static-99 and the Sex Offender Risk Appraisal Guide (SORAG). Results indicate that the Risk Matrix 2000 demonstrates convergent validity by correlating with the other risk assessment instruments. Moreover, the Risk Matrix 2000 is predictive of recidivism above chance levels, exhibiting medium to large effect sizes, although in general, the other two instruments, particularly the SORAG, are superior. Results also indicate differences in predictive validity when comparing 2-year, 5-year, and variable follow-up periods. Finally, a cumulative meta-analysis compares and integrates current findings with those obtained from the accumulation of previous studies, and new cumulative estimates are provided.

WITHDRAWN: Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

AUTHORS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Pornography use and sexual aggression: the impact of frequency and type of pornography use on recidivism among sexual offenders

In this study, we examined the unique contribution of pornography consumption to the longitudinal prediction of criminal recidivism in a sample of 341 child molesters. We specifically tested the hypothesis, based on predictions informed by the confluence model of sexual aggression that pornography will be a risk factor for recidivism only for those individuals classified as relatively high risk for re-offending. Pornography use (frequency and type) was assessed through self-report and recidivism was measured using data from a national database from the Royal Canadian Mounted Police. Indices of recidivism, which were assessed up to 15 years after release, included an overall criminal recidivism index, as well as subcategories focusing on violent (including sexual) recidivism and sexual recidivism alone. Results for both frequency and type of pornography use were generally consistent with our predictions. Most importantly, after controlling for general and specific risk factors for sexual aggression, pornography added significantly to the prediction of recidivism. Statistical interactions indicated that frequency of pornography use was primarily a risk factor for higher-risk offenders, when compared with lower-risk offenders, and that content of pornography (i.e., pornography containing deviant content) was a risk factor for all groups. The importance of conceptualizing particular risk factors (e.g., pornography), within the context of other individual characteristics is discussed.

Seeking enlightenment on the dark side of psychology

A life devoted to the study of antisocial behavior and anomalous sexual preferences is examined. Although successive ontogenetic intellectual metamorphoses have yielded theoretical and applied progress, future reincarnations will be necessary for the achievement of full enlightenment.

Reducing Housing Options for Convicted Sex Offenders: Investigating the Impact of Residency Restriction Laws Using GIS

Sex offender registries have been established throughout the United States. To date, 16 states have adopted additional residency restriction policies, precluding registered sex offenders from living within a certain distance of places where children gather. This study quantifies the impact of residency restrictions on housing options for registered sex offenders using Orange County, Florida, as a case study. A Geographic Information System (GIS) is employed to identify all occupied residential properties using parcel-level zoning data as well as those that fall within the 1,000-foot restricted buffer zones around attractions, bus stops, daycares, parks, and schools. Results indicate that housing options for registered sex offenders within urban residential areas are limited to only 5% of potentially available parcels and that bus stop restrictions impact the amount of livable area the most, followed by daycares, schools, parks, and attractions. The limited options to establish residency exist mostly in low-density rural areas. This supports the argument that residency restrictions for sexual offenders are a strong contributing factor to their social and economic isolation. The impacts of increasing the buffer to a proposed 2,500-foot zone are discussed, and a comparison of the individual restriction categories is presented.

Review of medical reports on pedophilia

The present report is a review of all 554 papers published on Medline on pedophilia. The first discussion is the history of the disorder from ancient Greece to the present time, especially the influence of the liberal country of the Netherlands, the North American Man-Boy Love Association, and the sexual crisis in the Catholic Church. One important question is the relationship between homosexual pedophilia and adult homosexuality. Evidence for and against this relationship is presented. Next discussed are the characteristics of the victim and the long lasting serious effects of sexual abuse. Laboratory correlations are included, especially phallometric tests in order to objectively measure the physical responses to sexual stimuli. Electrophysiological and radiographic tests are also mentioned, including electroencephalography, computed tomography, magnetic resonance imaging, and positron emission tomography scans. An important section is the characterization of pedophiles with emphasis on their frequent previous sexual abuse, their past, their present, and their anticipated future. The final topic is treatment of this disorder with surgery, medication, behavioral therapy and the combination of medication and behavioral therapy.

The utility of the random controlled trial for evaluating sexual offender treatment: the gold standard or an inappropriate strategy?

This paper examines the scientific, practical, and ethical issues surrounding the employment of the Random Controlled Trial (RCT) in the evaluation of sexual offender treatment. Consideration of these issues leads us to conclude that the RCT design is not suitable for determining the effectiveness of sexual offender treatment. We also examine the RCT study by Marques et al. (Sexual Abuse: A Journal of Research and Treatment and Evaluation 17:79-107, 2005) that is often held up as the model for the evaluation of sexual offender treatment. We found several problems with this study that, in our opinion, reduce its relevance for deciding whether treatment is effective with these clients. Finally, we examine two alternative strategies for evaluating treatment that may allow treatment providers to more readily examine, and report, the results of their programs.

The validity of phallometric assessment with rapists: comments on Looman & Marshall (2005)

In a recent article Looman and Marshall (2005) questioned the validity of phallometric assessment of rapists based on the results of a study of incarcerated rapists and child molesters. In this commentary we offer (1) a critique of the methods used and conclusions reached by Looman and Marshall and (2) a discussion of important methodological issues relevant to phallometry. We conclude that the correct inference from Looman and Marshall's study is that rapists, as a group, show a pattern of sexual arousal to audiotaped scenarios of coercive and non-coercive sex that significantly differs from the pattern of groups of non-sex offenders, in agreement with the general literature on this question.

Improving forensic tribunal decisions: the role of the clinician

Three empirical investigations of forensic decision-making were conducted: a study of 104 hearings by a forensic tribunal; an evaluation of which aspects of forensic patients' clinical presentation were empirical predictors of violence; and a survey of forensic clinicians to determine which factors they said they used to assess risk of violent recidivism and which they actually used. Results showed a significant correlation between actuarial risk and clinical advice to the tribunal, and a nonsignificant trend for patients higher in actuarial risk to receive more restrictive dispositions. Psychotic diagnoses and symptoms were not indicators of increased risk of violent recidivism. Clinicians endorsed some empirically valid indicators of risk, but also relied on some invalid indicators. There was also inconsistency between factors clinicians said they used and factors actually related to their hypothetical decision-making. An automated system is presented as an illustration of how the consistency and validity of forensic decisions could be enhanced.

[Evaluation of risk assessment instruments for sex offenders]

In order to evaluate risk assessment instruments for sex offenders in Germany, we compared the predictive validity of the Static-99, HCR-20, SVR-20, and PCL-R scales for 134 sex offenders. The mean follow-up time was 9 years (range 1-340 months), using the first entry into the National Register of Criminal Convictions as endpoint variable. For the estimate of predictive power, the area under the curve (AUC) of receiver operating characteristic (ROC) analysis was calculated. The AUC plots accurately identified violent or sexual recidivists and "false positives" at all scale levels. Comparing the predictive validity of these four instruments, the results favored Static-99. As for the limited sample size, differences between the assessment instruments were, however, not statistically significant. The ROC analysis for Static-99 showed that including treatment dropouts does not improve predictive accuracy (including dropouts: AUC 0.710; excluding dropouts: AUC 0.721). Kaplan-Meier survival analyses yielded highly a significant correlation to recidivism time point for two Static-99 and SVR-20 risk categories. Higher-risk categories were related to earlier recidivism. However, relying on the Static-99 and SVR-20 alone showed false positive results: for up to two out of three sex offenders, they predicted recidivism which did not occur.

The Characteristics of Persistent Sexual Offenders: A Meta-Analysis of Recidivism Studies

A meta-analysis of 82 recidivism studies (1,620 findings from 29,450 sexual offenders) identified deviant sexual preferences and antisocial orientation as the major predictors of sexual recidivism for both adult and adolescent sexual offenders. Antisocial orientation was the major predictor of violent recidivism and general (any) recidivism. The review also identified some dynamic risk factors that have the potential of being useful treatment targets (e.g., sexual preoccupations, general self-regulation problems). Many of the variables commonly addressed in sex offender treatment programs (e.g., psychological distress, denial of sex crime, victim empathy, stated motivation for treatment) had little or no relationship with sexual or violent recidivism.

The criminal activity of sexual offenders in adulthood: revisiting the specialization debate

Two major hypotheses have been put forward to describe the criminal activity of sexual offenders in adulthood. The first hypothesis states that sexual offenders are specialists who tend to repeat sexual crimes. The second hypothesis describes sexual offenders as generalists who do not restrict themselves to one particular type of crime. The current state of knowledge provides empirical support for both the specialization and the generality hypothesis. The presence of both generality and specialization in the offending behavior of sexual offenders is not as contradictory as it may first appear. However, methodological problems limit the possibility of drawing firm conclusions. Indeed, the specialization hypothesis is based on just one parameter of criminal activity, that is, recidivism, which only takes into account two consecutive crimes. The generality hypothesis is focused mainly on two criminal activity parameters, participation and variety, which do not take into account the dynamic nature of criminal activity over time. Developmental criminology provides a new paradigm to explore the issue of generality and specialization in the offending behavior of sexual offenders.

Mental disorders and DSM-IV paedophilia in 185 subjects convicted of sexual child abuse

The objective of this study was to explore how sexual child abusers who meet the DSM-IV criteria for paedophilia differ from those who do not. We studied DSM-IV disorders and paedophilic interests in all cases of sexual child abuse referred to forensic psychiatric investigation in Sweden between 1993 and 1997 (n=185). Frequency and severity of other mental disorders did not differ between subjects with and without DSM-IV paedophilia. However, men with paedophilia had more previous paedophilia convictions, same-sex and younger victims and less often intoxicated status when committing the act. The concept of paedophilia as a mental disorder is not supported by the DSM-IV diagnosis, which primarily describes the acting out of attraction.

What sex abusers say about their treatment: results from a qualitative study on pedophiles in treatment at a Canadian penitentiary clinic

This exploratory study used qualitative methodology to examine what pedophiles think about treatment, as well as their daily experience of a treatment program. To this end, twenty-three offenders receiving treatment from the La Macaza federal penitentiary clinic were interviewed using non-directive semi-structured interviews. Comparative analysis was used to analyze the resulting material. The following themes are discussed based on the results of this analysis: (a) the participants' past experience of therapy; (b) motivations for choosing the La Macaza clinic for treatment; (c) the structure of the program; (d) the group dynamics; (e) the therapists; and (f) the hardships and difficulties of treatment. Results suggest that the therapists and the program may have a function of containment or holding. Although part of the therapeutic process involves a focus on identifying and reducing cognitive distortions, results also warn therapists against misusing this concept by applying it to legitimately different opinions. Findings are discussed in terms of possible program improvements. The authors conclude that greater attention must be given to process research.

Comparing sex offender risk assessment measures on a UK sample

The purpose of this study on 139 sex offenders was to consider the application of six measures of risk: Static-99, SACJ-Min (Structured Anchored Clinical Judgment Scale-Minimum), RRASOR (Rapid Risk Assessment for Sexual Offence Recidivism), Risk Matrix 2000-Sexual/Violent, and SVR-20 (Sexual Violence Risk-20) and to compare risk assessments conducted by a Regional Secure Unit (RSU) and the Probation Service. Levels of risk for the RSU sample ranged from 1% to 42% low risk to 1% to 66% high risk compared with the Probation sample of 8% to 43% low risk to 4% to 70% high risk. Offenders with adult victims obtained significantly higher scores using the RM2000/S and SACJ-Min than did those with child victims who obtained significantly higher scores on the RRASOR. Sex offenders referred to a RSU scored significantly higher on RRASOR and RM2000/S than did sex offenders supervised by the Probation Service. Forensic practitioners may be better served if risk measures assess specific subcategories of sexual offenders.

Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

REVIEWERS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Effect sizes in the treatment of sexual offenders

This article considers the benefits of sexual offender treatment in terms of the magnitude of the effect size produced by these interventions. Comparisons are made of the effect sizes with those generated by treatment of other offenders, by treatment for mental health problems, and by treatment for physical health problems. In all cases, effect sizes with sexual offenders are comparable to (and in some cases better than) effect sizes for the treatment of the other groups. As a final note, it is suggested that using a harm reduction index to estimate effect sizes for treatment with sexual offenders would produce more meaningful results.

A multivariate analysis of sex offender recidivism

Sex offender recidivism risk is a multifaceted phenomenon requiring consideration across multiple risk factor domains. The impact of treatment involvement and subsequent recidivism is given limited attention in comparison to other forensic mental health issues. The present analysis is a retrospective study of sex offenders treated at a secure facility utilizing a cognitive-behavioral program matched with an untreated correctional sample. Variables studied included demographic, criminal history, offense related, and treatment progress. Recidivism was assessed through arrest data. Multivariate analysis suggests that recidivism is significantly related to quality of treatment involvement, offender demographics, offense characteristics, and criminal history. Successfully treated offenders were significantly less likely to subsequently reoffend. Recidivists were also significantly younger, less likely married, had engaged in more victim grooming or less violent offending behavior, and had significantly more prior property charges. The authors discuss the clinical and policy implications of the interrelationship between treatment involvement and recidivism.