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Psychiatr Serv 50:349-361, March 1999
© 1999 American Psychiatric Association
Are Sex Offenders Treatable? A Research Overview Linda S. Grossman, Ph.D., Brian Martis, M.D. and Christopher G. Fichtner, M.D.
 | Abstract |
OBJECTIVE: Recent legislation in several states providing forcivil commitment and preventive detention of sexually violentpersons has stirred legal, clinical, and public policy controversies.The mandate for psychiatric evaluation and treatment has animpact on public mental health systems, requiring cliniciansand public administrators to direct attention to treatment options.It is a common view that no treatments work for disorders involvingsexual aggression. The authors examine this assumption by reviewingresearch on the effectiveness of treatment for adult male sexoffenders. METHODS: MEDLINE was searched for key reviews andpapers published during the years 1970 through 1998 that presentedoutcome data for sex offenders in treatment programs, individualcase reports, and other clinically and theoretically importantinformation. RESULTS: Although rigorous research designs aredifficult to achieve, studies comparing treated and untreatedsex offenders have been done. Measurement of outcome is flawed,with recidivism rates underestimating actual recurrence of thepathological behavior. Outcome research suggests a reductionin recidivism of 30 percent over seven years, with comparableeffectiveness for hormonal and cognitive-behavioral treatments.Institutionally based treatment is associated with poorer outcomethan outpatient treatment, and the nature of the offender’scriminal record is an important prognostic factor. CONCLUSIONS:Although treatment does not eliminate sexual crime, researchsupports the view that treatment can decrease sex offense andprotect potential victims. However, given the limitations inscientific knowledge and accuracy of outcome data, as well asthe potential high human costs of prognostic uncertainty, anycommitment to a social project substituting treatment for imprisonmentof sexual aggressors must be accompanied by vigorous research.
| Introduction |
Few issues in the mental health field are capable of stirringmore controversy than the psychiatric treatment of sex offenders.Recent legislation in a growing number of states providing forcivil commitment and preventive detention of sexually violentpersons (1,2) has fueled long-standing debates on the diagnosisof paraphilias, the nature of mental illness, and the treatabilityof sex offenders (3).
Regarding treatment, a body of literature has evolved steadilyover the past two decades that addresses the effectiveness oftreatment programs for sex offenders, but it remains specializedand unfamiliar to many general psychiatrists (4,5,6,7). It iscommonly assumed, and even argued in support of public policy,that disorders involving aggressive sexual behaviors are unlikeother mental illnesses because they are untreatable. The purposeof this paper is to examine this assumption more closely byreviewing the research on the effectiveness of treatment forsex offenders, focusing primarily on adult males.
| Methods |
A MEDLINE search covering the years 1970 through 1998 was doneto identify key reviews and papers presenting data on outcomesfor sex offenders in treatment programs, individual case reports,and other clinically and theoretically important information.
| Background |
Recent research has suggested that more than half of all womenand one-fifth of all men in the United States will be sexuallyassaulted at some point. One study estimated that by the timerapists enter treatment, they had assaulted an average of sevenvictims and that nonincestuous pedophiles who molest boys hadcommitted an average of 282 offenses against 150 victims (8).The impact of these offenses on their victims can be devastating.The number of sex offenders in state prisons has increased bymore than two-thirds in the last decade, leading to increasingburdens on public budgets (9). The number of treatment programshas grown, although some programs have closed due to limitedfunds (9).
Identified on the basis of sexual behavior sufficiently aberrantand aggressive to bring the perpetrator to the attention oflaw enforcement officials, sex offenders as a group includea variety of types of individuals. Although it has been suggestedthat the vast majority of rapists have no mental disorder otherthan antisocial personality disorder (3), many offenders meetdiagnostic criteria for paraphilias, especially pedophilia,and may also suffer from comorbid anxiety, depressive, or psychoticdisorders.
Some treatment programs have attempted to assess the outcomesof their interventions. However, little is definitively knownabout the efficacy of many of the treatments currently in use,and research necessary to produce such knowledge must confrontparticularly difficult problems. Before discussing the natureof sex offender treatment and its outcome, we will review themajor difficulties this type of research must face.
| Problems in sex offender research |
Assessment
One of the most difficult issues in the treatment of sex offendersis how to measure improvement. Investigators have not identifieda standardized measurement technique that they agree can reliablyand validly measure the frequency of sex offenses.
Sex offenders’ self-reports or significant others’ reports arenot reliable indexes of recidivism (10,11). Arrest records underreportsexual offenses (5,12,13); the vast majority of sexual offenses,estimated at greater than 93 percent, are never reported tothe police, and fewer than 1 percent of sex offenders are arrested(14). Even fewer are convicted. Arrest and conviction recordsare also affected by administrative policies that determinewhich subjects are hospitalized rather than incarcerated. Furthermore,many sex offenders plea bargain—that is, they plead guiltyto lesser charges of crimes that are not sexual offenses.
Some researchers have attempted to answer the problem of assessmentby studying patterns of sexual response via penile plethysmography,which measures penile erectile responses to stimuli in the laboratory.Proponents have argued that plethysmography can identify rapistsand can differentiate those with the most victims and thosewho show sadistic behavior (15,16,17,18,19,20,21,22). Plethysmographyhas been successful in identifying child molesters, and in differentiatingoffenders who use excessive force in their assaults (23,24,25).
However, the reliability, validity, and appropriate uses ofplethysmography are the subject of debate. There is a lack ofreliability between the different types and models of plethysmographsin use (26). Methods for selecting and presenting stimuli andfor interpreting plethysmographic data also differ. Regardingvalidity, it is not known to what extent treatments that inhibitsexual response during plethysmography actually prevent sexualaggression in the community. Some studies have shown relationshipsbetween posttreatment deviant arousal on plethysmography andsubsequent recidivism (27,28,29,30), but other studies havereported no such relationships (10,31). Furthermore, some menwho are sexually aroused by images of children are not sex offenders(32,33). Many subjects can voluntarily suppress or produce erectionsin the laboratory (34). Subjects may suppress responses to theextent that the test is not helpful (26).
In general, plethysmography is useful in identifying individualswith high levels of inappropriate arousal and low levels ofappropriate arousal (22,35). Plethysmography can be a helpfuladjunct to treatment in that deviant arousal patterns can beused to confront offenders who deny deviant sexual interests.However, many professionals believe that plethysmography shouldnot be used to predict further acts of sexual offense and shouldnot be used to confirm or deny allegations of such behavior(36).
Study design
Besides difficulties in assessment, research involving sex offendersfaces problems in research design. One important factor is whetherthe study design compares treated and untreated samples of sexoffenders. The ideal design would involve matching patientson important variables and then randomly assigning them to groupsthat received treatment and groups that did not. However, becauseof ethical issues, this design is rarely achieved.
Sampling
Another problem is which patients are studied, because manyvariables other than treatment may affect outcome—for example,presence of deviant sexual arousal, occurrence of sexual intercourseduring the assault, number of victims, IQ, and socioeconomicstatus (27,37).
Program selection criteria also affect results. Some treatmentprograms select only patients fitting a given profile, suchas low-risk offenders. The use of differential selection criteriaby various treatment programs makes it difficult to draw conclusionsacross studies.
Which types of offenders are considered together in study groupsis also important. For example, research suggests that incestoffenders recidivate at approximately half the rate of extrafamilialchild molesters (10). Among extrafamilial child molesters, thosewho molest girls or boys or both should be differentiated (10,38).
In addition to affecting outcome results, sampling techniquesdefine and limit a study’s generalizability. Many studies reporton small samples and thus are vulnerable to the bias that positiveresults are more likely to be published than negative results.Other studies are limited to subjects who comply with treatment.Given the large dropout rates of many treatments, this practiceexerts a sampling bias in favor of positive results.
Follow-up and recidivism
Duration of the study follow-up period is another source ofvariability between studies. Longer follow-up periods generallyproduce higher recidivism rates (10,28,39). Several studieshave suggested that even a five-year period of risk for reoffenseis not long enough (28). One extremely long-term study indicatedthat approximately 19 percent of a large sample of child molesterswere reconvicted more than ten years after release, and somereconvictions occurred after more than 31 years (39).
The definition of recidivism is also important. Most studiesassess subjects as having recidivated if they are arrested orconvicted of a further sex offense after treatment, but otherstudies use arrest or conviction of a crime of any type or violationof probation or parole. This issue is important because sexoffenders may plea bargain to reduce their crimes to those ofa nonsexual nature. Adding to the complexity, some studies failto specify their definition of recidivism.
| Somatic therapies |
This section reviews research on somatic therapies for adultmale sex offenders. Several surgical and medical treatmentsnot frequently used today are described briefly. Next, we providea more extensive discussion of antiandrogen treatments for sexoffenders, including two tables summarizing the relevant studies.Antiandrogen treatment is the most successful direction forbiological treatment to date. Finally, we review other hormonaland serotonergic agents, relatively new medications that maybe promising in the treatment of sex offenders.
Surgical treatments
Surgical treatments for sex offenders are of two general types:neurosurgery and castration. The neurosurgical procedure, stereotaxichypothalamotomy, involves removal of parts of the hypothalamusto disrupt production of male hormones and decrease sexual arousaland impulsive behaviors. However, the neuroendocrine mechanismsinvolved are not well understood, and the procedure has showna significant failure rate and adverse sequelae.
For primarily ethical reasons, surgical castration has not beenwidely advocated as a treatment for sex offenders, and in somecountries such treatment is illegal. Castration has been shownto be highly effective in European literature. For example,Cornu (40) reported that among a group of sex offenders followedfor periods of five to 30 years, those who had accepted theoption of castration had recidivism rates of 5.8 percent comparedwith 52 percent for those who refused castration. Recidivismrates have been reported to decrease over time following theprocedure, which may be related to the rate of decline of testosteronelevels following the procedure (41). Such a finding, if substantiated,might contribute an empirical basis for determining clinicallyindicated lengths of hospitalization or institutional confinementfollowing surgery.
Favorable reports on castration have been countered by reviewsin which it has been disparaged on ethical grounds and scientificallydiscredited as not 100 percent effective. With the advent ofsexual predator laws, castration as a treatment option is nowsubject to discussion that includes media attention to individualcases as well as focused state legislation specifying the conditionsunder which orchiectomy may be performed. Recent legislationpermitting voluntary orchiectomy in Texas was coupled with arequirement for follow-up research on recidivism (42).
Medical treatments
Before the more widespread use of antiandrogens in the treatmentof sex offenders, clinicians attempted treatment with oral andimplantable estrogens (43) and with an estrogen analogue, diethylstilbesterol(44). In general, research findings agree that the potentialfor adverse effects limits the utility of estrogen treatmentfor sex offenders (45).
A number of early studies reported on the treatment of sex offenderswith neuroleptics (46,47,48). However, these agents were foundto be of limited benefit, which did not outweigh the risk oftardive dyskinesia. Antipsychotic agents may benefit sex offenderswith comorbid psychotic disorders, especially patients who arereceiving hormonal therapy, which may exacerbate psychosis (45).The advent of newer, atypical antipsychotic medications maywarrant a reassessment of therapeutic effects and side-effectrisks associated with these medications.
Antiandrogen medications
Among the most important biological advancements is the useof antiandrogen medications. The two most widely used formsare medroxyprogesterone acetate (MPA), available in the UnitedStates, and cyproterone acetate (CPA), available in Canada andEurope. Both are synthetic progesterones that reduce the serumlevel of circulating testosterone, with concomitant reductionsin sex offenders of self-reported deviant sexual fantasies andbehaviors (49,50). Reduction of testosterone has been shownto reduce libido, erections, ejaculations, and spermatogenesis(51). A library search covering the past 20 years found morethan 30 papers reporting the effectiveness of antiandrogensin reducing testosterone levels for sex offenders, along withdecreased self-reported deviant sexual drive, fantasy, and behavior.
Table 1 summarizes recidivism rates for eight outcome studiesof sex offenders treated with antiandrogens (50,52,53,54,55,56,57,58).The studies report a spectrum of differences between patientstreated with antiandrogens and those not treated, with recidivismrates as low as 1 percent for treated patients and as high as68 percent for untreated patients. Recidivism rates for patientsinitially treated with antiandrogens who discontinued treatmentfell between the rates for completers and nontreated patients.
| | Table 1. Results from outcome studies of sex offenders treated with antiandrogens |
Although the number of studies like these is still small, antiandrogenmedication appears promising in the treatment of sex offenders,especially because the effectiveness of antiandrogens in reducingsexual behavior generally is well documented. The outcome studiessuggest that antiandrogens, while not effective for all patients(59), appear to reduce sex offender recidivism in many cases.
Research findings have suggested that sex offenders treatedwith MPA may experience suppression of deviant fantasies andbehaviors earlier in treatment (one to two weeks) than suppressionof nondeviant fantasies and behaviors (two to ten) (53). Ifthese results are confirmed, they suggest that careful dosetitration may allow patients to maintain appropriate sexualbehavior while eliminating deviant behavior. Low-dose oral administrationof MPA has been attempted, but rigorous research is needed (60).
Although placebo-controlled studies may be difficult to achievewith antiandrogens, some have been attempted. Table 2 summarizesthe results of three placebo-controlled double-blind crossoverstudies (61,62,63), which show mixed results. All three studiesalternated antiandrogens with placebo, using each subject ashis own control. These studies all showed that during the activephase of medication, patients reported decreases in some aspectsof their sexual behavior, including deviant sexual thoughts,fantasies, and frequency of masturbation. However, in all threestudies, plethysmography did not consistently support patients’self-report. Indeed some patients showed increased deviant arousalwhile on antiandrogens and decreased deviant arousal duringthe placebo phase. Bradford and Pawlak (63) suggested that anendogenous sex hormone rebound effect associated with androgenreceptor sensitivity during the placebo phase might explainthe lack of positive findings in some comparisons between placeboand active agent.
| | Table 2. Placebo-controlled double-blind crossover studies of sex offenders treated with antiandrogens |
Previously, direct comparisons of MPA and CPA were not donebecause the two drugs were not available in the same country.In 1992 Cooper and associates (62) provided the first directcomparison of the two agents. The results suggested that MPAand CPA performed equally in decreasing sexual thoughts andfantasies, frequency of masturbation, and erection.
Thus outcome studies of antiandrogen treatment appear promising.However, certain cautions apply:
• The drugs must be used cautiously in treating patientswith migraine, asthma, or cardiac dysfunction and are contraindicatedfor patients with diseases affecting testosterone production(53).
• They may produce side effects, including weight gain,depression, hyperglycemia, hot and cold flashes, headaches,muscle cramps, phlebitis, hypertension, gastrointestinal complaints,gallstones, penile and testicular pain, and diabetes mellitus(50,53). CPA can cause feminization (45).
• As with many other forms of treatment, antiandrogen medicationis associated with high dropout rates (50,57,58).
• Antiandrogen treatment requires a level of medical managementthat can be costly, reducing its availability to broad populations.
• The long-term consequences of use of these drugs arenot known; some clinicians recommend using them for only shorttime periods (52).
Newer hormonal therapiesand serotonergic agents
Several case reports have suggested that analogues of gonadotropin-releasinghormone may be useful either alone or in combination with antiandrogens(64,65,66). These agents inhibit the secretion of luteinizinghormone with a resulting decrease in plasma testosterone levelsand libido (45). Dickey (59) described the use of a long-actingdepot-injectable luteinizing-hormone-releasing hormone (LHRH)agonist in treatment of a patient with multiple paraphiliaswho had shown a poor response to both MPA and CPA. The patientwas reported to have complete cessation of deviant sexual behaviorafter one month of treatment and decreased frequency of masturbation.The use of LHRH agonists apparently avoids unwanted side effectsseen with MPA and CPA (59).
In a recent open study, Rosler and Witztum (65) treated 30 menwith severe longstanding paraphilias with monthly injectionsof triptorelin, a long-acting agonist analogue of gonadotropin-releasinghormone, for eight to 42 months. The results indicated thatall men showed a decrease in deviant sexual fantasies, desires,and abnormal sexual behavior. These effects persisted in allof the 24 men who continued in treatment for one year. Treatmentwas associated with suppression of serum testosterone. Furtherstudy is needed before conclusions can be drawn about the efficacyand safety of these agents. However, gonadotropin-releasinghormone analogues and related agents may provide alternativehormonal therapy in cases where antiandrogens fail (59).
A number of small studies and case reports (67,68,69,70,71,72)have found treatment with antidepressants helpful for patientswith paraphilias. These studies have included patients for whomtricyclics or lithium was used (70). However, most of the morerecently reported successes have been with selective serotoninreuptake inhibitors (SSRIs) (67,68,69). Many patients in theseseries were reported to have concurrent mood or anxiety disorders.The anxiolytic buspirone, a 5-HT1A partial agonist, has alsobeen reported effective in reducing paraphilic fantasies (67,68,73,74).
These reports have noted that the serotonergic agents, includingbuspirone, appear to have specifically antiobsessional effectsin patients with paraphilias and related sexual obsessions;such clinical observations are consistent with the demonstratedefficacy of SSRIs for obsessive-compulsive disorder. Althoughthese findings are mostly anecdotal, further research couldconfirm a role for SSRIs, other antidepressants, or other serotonergicagents in the treatment of paraphilias. Clearly, in the presenceof comorbid anxiety or depressive disorders, a trial of theseagents may be indicated.
| Psychological andbehavioral treatment |
Psychological treatment of sex offenders showed little successuntil the advent of cognitive-behavioral techniques (7), whichhave undergone rapid development over the past two decades.The goal of these treatments is to change sex offenders’ beliefsystems, eliminate inappropriate behavior, and increase appropriatebehavior by modifying reinforcement contingencies so that offensivebehavior is no longer reinforced. Techniques aimed at eliminatingdeviant arousal include aversion treatment, covert sensitization,imaginal desensitization, and masturbatory reconditioning. Cognitive-behavioraltreatment for sex offenders often includes cognitive restructuring,that is, modification of distorted cognitions used to justifyparaphilic behavior (75), social skills training, victim empathytraining, lifestyle management, sex education (76), and relapseprevention (77).
Cognitive-behavioral techniques
Aversion therapy and covert sensitization
Both aversion therapy and covert sensitization pair deviantsexual fantasies with punishments. In aversion therapy, deviantfantasies are paired with physical punishment (37,76). Patientswork with therapists to develop a series of fantasies aboutthe patients’ preferred deviant acts. These fantasies are presentedverbally to the patient accompanied by an aversive experiencesuch as a harmless but painful self-administered electricalshock or a noxious odor. Alternately, the therapist presentsvisual depictions involving the deviant fantasy—for example,depictions of young children—and the patient receives ashock or odor when viewing them. Appropriate visual stimulisuch as depictions of adults are also presented, without anaccompanying shock or odor.
Covert sensitization pairs deviant sexual fantasies with mentalimages of distressing consequences. In this technique, offendersverbalize a detailed deviant fantasy. When they become aroused,they discontinue the deviant fantasy and begin verbalizing anequally detailed fantasy of highly aversive consequences, suchas being arrested. This technique requires them to focus attentionon negative consequences that they find upsetting.
During treatment, offenders identify and focus on the chainof events leading up to the sex offense. This process enablesthem to insert fantasies of aversive consequences at progressivelyearlier phases of the predatory behavior leading to a sexualoffense. The procedure is thought to teach offenders that theirbehavior is under their own control and can be interrupted bythem at any stage.
Sometimes sex offenders are required to subject themselves toa noxious odor to augment the negative impact of the fantasizedaversive consequences. When they become anxious from this fantasy,they are required to begin to fantasize that they “escape” theaversive scene by imagining a nondeviant sexual scene, suchas consensual adult sex.
Imaginal desensitization
Imaginal desensitization is a technique in which offenders aretrained in deep muscle relaxation (54). When they have learnedthe relaxation technique, they fantasize the first scene fromthe chain of events they have previously identified as leadingto an act of sexual offense. After they can visualize the firstscene and remain relaxed, they are asked to imagine the nextscene, and to proceed through the chain, while remaining relaxed.This technique is thought to teach offenders that they can toleratethe feelings associated with their deviant sexual urges, withoutacting on them, until the urges recede.
Masturbatory reconditioning
Masturbatory reconditioning involves the use of the naturallyreinforcing properties of orgasm to change behavior. Varioustechniques have been proposed to change masturbatory fantasiesby requiring the sex offender to change from deviant to nondeviantfantasies at the point of ejaculation (79). Another type ofmasturbatory reconditioning, satiation, attempts to eliminatedeviant sexual arousal by removing its reinforcing propertiesor supplanting them with aversive properties. Two forms aregenerally used—verbal satiation and masturbatory satiation(80,81).
In verbal satiation, offenders verbalize deviant sexual fantasiesfor a prolonged period, until these fantasies become tedious.In masturbatory satiation, offenders masturbate to orgasm whileverbalizing nondeviant fantasies, and they then continue masturbatingduring the refractory period for a prolonged time while verbalizingdeviant fantasies. This technique pairs the pleasure of orgasmwith appropriate fantasy material, and the pain or boredom ofprolonged masturbation without ejaculation with deviant fantasies.
Satiation has received support from several studies (11,79,80,81),but further controlled studies are needed to validate the technique.Approximately 20 hours of masturbatory satiation are estimatedto be generally required for treatment efficacy (82).
Cognitive restructuring
Cognitive restructuring is based on the theory that sex offendersdevelop numerous distorted beliefs to justify their deviantsexual behavior. These distortions help such individuals torelieve feelings of guilt or shame associated with their offenses(14,75,83). For example, child molesters may assert that childrenenjoy sex with adults or that sex with adults is good for children.
Cognitive restructuring involves confronting and changing suchdistorted beliefs. It requires the sex offender to define hiscognitions and then discuss the ways he uses these distortedbeliefs to rationalize deviant behavior. The therapist challengeshis beliefs and suggests new formulations. Role playing in whichthe therapist plays the role of the offender and the offenderplays the role of the police or of an abused family member isoften included (13). In this way, the offender must disputehis own beliefs.
Social skills training
Social skills training has been attempted on the theory thatdeficits in skills necessary for successful interaction in socialand nondeviant sexual situations may be involved in sexuallydeviant behavior. This theory has been debated in the literature(84,85). Social skills training focuses on skills involved insocial conversations using role playing, modeling by the therapist,and identification of irrational fears deriving from socialconversations. Some programs focus on social anxiety, conflictresolution, and anger management (86). Assertiveness traininghas also been used to help patients express themselves moreeffectively (13). Some clinicians believe sex education in conjunctionwith social skills training is helpful (13).
Victim awareness or empathy
Many offenders minimize the consequences of their deviant sexualbehaviors by developing cognitive distortions that allow themto believe their victims were not injured by them or enjoyedthe event. Victim awareness or empathy techniques attempt toincrease sex offenders’ understanding of the impact of theirdeviant sexual behaviors on their victims. This may involveoffenders’ viewing videotapes of victims’ descriptions of theirown experiences, role playing, and receiving feedback from therapists,other offenders, or victims (77).
Relapse prevention
A central feature of many therapies is relapse prevention involvingmaintenance strategies to anticipate and resist deviant urges(77,87). Relapse prevention is based on the view that relapseoccurs in predictable sequences that offenders can avoid ifthey can identify and interrupt them. The essential componentsof relapse prevention involve the offender’s identificationof high-risk situations and the decisions he makes that leadhim closer to relapse. He must learn skills to cope with thehigh-risk situations so as to prevent relapse.
Outcome studies ofcognitive-behavioral treatment
Table 3 and Table 4 summarize the methods and results of institutionaland outpatient treatment programs, respectively.
| | Table 3. Studies of psychological and behavioral treatment programs for sex offenders offered within institutions |
| | Table 4. Studies of psychological and behavioral treatment programs for sex offenders offered in outpatient settings |
As Table 3 shows, recidivism rates from cognitive and behavioraltreatment programs that have been offered in institutional settingsrange from 3 to 31 percent for sex crimes, depending on thestudy (78,87,88,89,90,91). Of the studies that compared treatedto untreated subjects, two programs presented lower recidivismrates for treated subjects (87,89,90), and two programs showedno differences (78,91).
It is possible that the lack of treatment efficacy in the studiesby Rice and associates (78) and Hanson and colleagues (91) reflectsthe fact that neither of these programs offered modern innovationssuch as cognitive techniques or relapse prevention. In addition,the lack of treatment efficacy in the Rice study may be a functionof the characteristics of the sample, which included patientswith very poor prognoses. In the Hanson study, lack of efficacymay be a function of this study’s extremely long follow-up period.
Table 4 summarizes studies of outpatient psychological and behavioraltreatment programs. These studies provide promising data fortreatment efficacy. Recidivism rates ranged from 6 to 39 percentfor treated subjects (10,92,93,94), with one sample of nearly3,000 heterosexual pedophiles showing a recidivism rate of only6 percent over a very long period of time (93). Treated subjectsall showed lower recidivism rates than did their untreated counterparts.
| Overview of treatment efficacy |
Several investigators have compiled the data from treatmentoutcome studies, despite variation in types of treatment, patientstreated, and research design. Furby and colleagues (95) amasseddata from numerous studies of sex offenders that included atleast ten subjects and used criminal justice records for outcomemeasures. The review covered almost 7,000 men. The authors concludedthat their review failed to provide any convincing evidencethat treatment is effective in reducing recidivism of sexualoffenses. They further stated that their data did not permitevaluation of the relative effectiveness of treatment for differenttypes of offenders. In fact, the authors reported difficultydiscerning any patterns relating treatment to recidivism, includingthe expected pattern that longer follow-up periods would producehigher recidivism rates.
When these authors compared treated patients to untreated patients,they found that untreated patients had recidivism rates below12 percent, while treated sex offenders in two-thirds of thestudies had recidivism rates above 12 percent. The authors suggestedthat treatment outcome studies may monitor subjects more closelyduring the follow-up period, leading to a greater likelihoodof detection of subsequent arrests. Further, they suggestedthat pre-existing differences between treated and untreatedsex offenders—apart from whether they received treatment—maymean that any conclusions to be drawn must remain tentative(95).
Marshall and Pithers (6) criticized the Furby review, arguingthat its findings are no longer applicable since they are basedon studies mostly published before 1978, before the use of thecognitive-behavioral techniques so prevalent today. Indeed mostof the programs reviewed by Furby and colleagues no longer exist.Further, Marshall and Pithers argued that the samples reviewedby Furby and colleagues overlap in at least one-third of thestudies reviewed, which biases the results against positivefindings. Thus Marshall and Pithers concluded that the findingsof the Furby review are inappropriately pessimistic.
The best methodology for integrating the sex offender treatmentdata is meta-analysis. Until recently, this procedure was precludedby the inadequate descriptions in many studies of sampling techniquesor outcome measures, differences in sample sizes, types of subjectsassessed, types of treatment, and length of follow-up. However,a meta-analysis by Hall (96)—although limited to only 12studies—provided an overall estimate of the results oftreatment for sex offenders. This analysis included all publishedstudies since the Furby review that compared samples of morethan ten offenders who had completed a treatment program withothers who had completed a comparison program or no treatmentprogram, and that used arrest records for sexual offenses asoutcome data. The mean length of treatment in the studies was18.5 months, and the mean follow-up period was 6.9 years. Overall,the analysis found that the recidivism rate for treated offenderswas 19 percent, compared with 27 percent for nontreated offenders.
The meta-analysis found that cognitive-behavioral treatmentand antiandrogen treatment were comparable in their treatmenteffects and significantly more effective than behavioral treatmentalone (96). It is noteworthy that effect sizes—indexesof the strength of treatment outcome—were significantlygreater in studies of outpatients than in studies of institutionalizedpatients and were greater in studies with follow-up periodsof longer than five years. Effect sizes did not differ betweenstudies that included rapists and those that did not.
Larger effect sizes were also found for patients with higherbase rates of recidivism, which according to the author couldreflect greater difficulty demonstrating statistically significanttreatment effects in groups with low base rates of recidivism.Although the use of arrest records as recidivism criteria mayunderestimate recidivism, differences related to treatment shouldnot be invalidated by this limitation because any underestimationshould apply equally to treated and untreated groups.
When considering whether a sex offender is a candidate for antiandrogentreatment or cognitive-behavioral therapy, Hall (96) pointedout that although the two forms of treatment are equally successful,the dropout rates for hormonal therapy are greater. Two-thirdsof participants refused hormonal treatment (50,58), and 50 percentof patients who began this type of treatment discontinued itbefore completing the program (57). In contrast, dropout andrefusal rates for cognitive-behavioral treatment were aboutone-third (92). In addition, hormonal treatments impose potentialadverse medication effects and possible longer-term health risks.Obviously, cognitive-behavioral treatment avoids these problems.On the other hand, for patients who can tolerate hormonal treatment,this form of intervention may prove particularly effective.The cost-effectiveness of different treatments deserves furtherstudy.
In a large recidivism study of 408 sex offenders followed upover a mean of four years and in some cases up to ten years,Bench and colleagues (9) used discriminant analysis to identifyfactors predictive of recidivism. Of most interest, the totalnumber of felony convictions was the strongest predictor ofrecidivism involving sex-related offenses. Failure to completetreatment was a weaker but significant predictor as well. Whena broader definition of recidivism that included nonsex offensesand probation or parole violations was used, failure to completetreatment emerged as the strongest predictor of recidivism.
A recent meta-analysis of factors predicting recidivism basedon 61 follow-up studies of 23,393 sex offenders found that failureto complete treatment was associated with higher risk of recidivismof sex offenses (97). Perhaps surprisingly, variables not associatedwith higher risk of recidivism of sex offenses included denialof responsibility, low motivation for treatment, length of treatment,and empathy with victims. The strongest predictor of sexualreoffense in this meta-analysis was sexual interest in childrenas measured by plethysmography. When the definition of recidivismwas broadened to include any crime, increased risk was associatedwith premature termination of treatment, denial, and low motivationfor treatment. Taken together, these meta-analyses suggest thatfailure to complete treatment is a significant predictor ofcriminal recidivism, including sexual reoffense, in this population.
| Conclusions |
Although some forms of treatment for sex offenders appear promising,little is known definitively about which treatments are mosteffective, or for which offenders, over what time span, or inwhat combinations. What emerges from the literature is a strongsuggestion that a comprehensive cognitive-behavioral programshould involve components that reduce deviant arousal whileincreasing appropriate arousal and should include cognitiverestructuring, social skills training, victim empathy awareness,and relapse prevention. In addition, patients should be consideredfor antiandrogen medication if they are at high risk of reoffending.
In general, results from biological and cognitive-behavioraltreatment programs strongly suggest that treatment decreasesrecidivism of sexual crimes. In evaluating whether the ameliorationproduced by treatment is clinically significant, Hall’s meta-analysis(96) suggested that antiandrogen and cognitive-behavioral treatmentlead to a decrease in recidivism from a baseline rate of 27percent in untreated individuals to a rate of 19 percent inpatients who receive treatment. Hall summarized these findingsas an outcome of eight fewer sex offenders per 100.
However, the results of his meta-analysis may be viewed in anotherway: from a baseline recidivism rate of 27 percent, a decreasein recidivism among treated patients to a level of 19 percentamounts to a 30 percent remission rate as a result of treatment.When viewed from this perspective, the analysis suggests anoutcome of 30 fewer sex offenders per 100, and it reflects afollow-up period of nearly seven years. This outcome is nota negligible impact from the standpoint of clinical treatment.
By comparison, lithium prophylaxis of bipolar disorder—astandard treatment for a well-established psychiatric illness—wasfound in a recent five-year prospective study to be associatedwith complete remission in approximately 38 percent of patientsstill taking lithium (98). Because a number of other patientsdropped out of this study due to perceived lack of efficacyof lithium, this percentage may actually overestimate lithium’smedical effectiveness.
Zonana (3) has suggested, however, that the consequences ofrecidivism in sex offenders are so detrimental to society thata recidivism rate of zero is the only acceptable risk level.Such an assumption could lead to the conclusion that indefiniteconfinement is the only conceivable effective intervention withor without medical treatment. But the demonstrated reductionin recidivism that emerged in the meta-analysis of researchon treatment of sex offenders is a robust finding and suggeststhat treatment for patients in this population improves outcomeand may protect potential sexual assault victims.
Recent legislation in an increasing number of states focusingon the preventive detention of sexually violent persons hasstimulated vigorous legal and policy discussion and debate (1,2,3). This newer legislation may have significant impact on publicmental health systems because the proceedings involve civilcommitment rather than criminal prosecution and are associatedwith mandates for medical evaluation and treatment. Clinicianshave not traditionally regarded sex offenders as falling withinthe target population of severely and persistently mentallyill persons considered appropriate for civil commitment.
Yet although it may be true that, in general, public mentalhealth programs have little to offer by way of a service linetailored to this population, it is far less clear that individualsexhibiting chronic, repeated sexually aggressive behaviors donot suffer from mental illnesses. Nor is it clear that psychiatrictreatment is without benefit for this patient population, despitefrequent anecdotal references to the lack of effective treatments.To the contrary, research provides evidence of a robust treatmenteffect that has the potential to reduce sexually aggressivebehavior.
Although the conclusion that sex offenders are untreatable isunwarranted, caution must be exercised in unfolding the implicationsof the positive treatment findings in the literature. It isworth underscoring the finding of Hall’s meta-analysis (96)that treatment of outpatients was associated with a larger treatmenteffect than treatment of institutionalized individuals. Further,in the discriminant analysis of Bench and colleagues (9), failureto complete treatment was a weak predictor of sex-offense-specificrecidivism in comparison with the extent of the felony convictionrecord.
These findings appear to suggest, unfortunately, that the morea sex offender needs confinement, the less confident we canbe that treatment will have lasting benefits. Paradoxically,however, it is precisely the more dangerous subset of patientsthat psychiatry is being called to treat based on the new legislation.Civil commitment of sex offenders is based on the problem ofperceived persistent dangerousness.
Precautions must be taken to ensure that treatment environmentsare appropriate for the risk level presented by these patients.Psychiatrists, other mental health professionals, and publicadministrators are concerned about the potential for predatorybehavior by sex offenders who are mixed with the currently definedpopulation of patients with serious and persistent mental illness.Criteria must be developed to determine which sex offendersare more appropriate for outpatient programs and to providea rational basis for transitioning patients from institutionalto outpatient care. Civil commitment to outpatient treatmentmay provide a more appropriate level of care for many patientsthan psychiatric hospitalization in traditional general inpatientsettings.
Finally, from a scientific standpoint, there remain significantproblems with the available data from sex offender treatmentstudies. An optimistic perspective must be entertained cautiouslyand accompanied by a commitment to the advancement of scientificknowledge in the field. This perspective is not new to psychiatry,where gains in knowledge about treatment of chronic illnessessuch as schizophrenia have been gradual and hard earned. Yetas Bradford (66) recently pointed out, support for the scientificstudy of deviant sexual behavior has not kept pace with theapparent—or at least official—public sentiment aboutthe management of sexual aggressors. It would be informativefor such research to include a focus on sex offenders from additionalpopulations, such as women and adolescents.
Treatments for sex offenders do exist, and the outcome dataare not uniformly discouraging. They are, however, complex,difficult to interpret, and cause for cautious optimism at best.If mental health professionals and society at large are to acceptthe challenge of promoting treatment for sex offenders, vigorousongoing research efforts are mandatory.
| Footnotes |
Dr. Grossman is director of training in psychology and professorof psychology and Dr. Martis is a psychiatric resident in thedepartment of psychiatry at the University of Illinois at Chicago,912 South Wood Street (M/C 913), Chicago, Illinois 60612 (e-mail,lgrossman@psych.uic.edu). Dr. Fichtner is medical coordinatorfor mental health services with the Illinois Department of HumanServices and associate professor in the department of psychiatryand behavioral sciences at Finch University of Health Sciences/ChicagoMedical School.
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