Few issues in the mental health field are capable of stirring more controversy than the psychiatric treatment of sex offenders. Recent legislation in a growing number of states providing for civil commitment and preventive detention of sexually violent persons (1,2) has fueled long-standing debates on the diagnosis of paraphilias, the nature of mental illness, and the treatability of sex offenders (3).
Regarding treatment, a body of literature has evolved steadily over the past two decades that addresses the effectiveness of treatment programs for sex offenders, but it remains specialized and unfamiliar to many general psychiatrists (4,5,6,7). It is commonly assumed, and even argued in support of public policy, that disorders involving aggressive sexual behaviors are unlike other mental illnesses because they are untreatable. The purpose of this paper is to examine this assumption more closely by reviewing the research on the effectiveness of treatment for sex offenders, focusing primarily on adult males.
Background
Recent research has suggested that more than half of all women and one-fifth of all men in the United States will be sexually assaulted at some point. One study estimated that by the time rapists enter treatment, they had assaulted an average of seven victims and that nonincestuous pedophiles who molest boys had committed 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 by more than two-thirds in the last decade, leading to increasing burdens on public budgets (9). The number of treatment programs has grown, although some programs have closed due to limited funds (9).
Identified on the basis of sexual behavior sufficiently aberrant and aggressive to bring the perpetrator to the attention of law enforcement officials, sex offenders as a group include a variety of types of individuals. Although it has been suggested that the vast majority of rapists have no mental disorder other than antisocial personality disorder (3), many offenders meet diagnostic criteria for paraphilias, especially pedophilia, and may also suffer from comorbid anxiety, depressive, or psychotic disorders.
Some treatment programs have attempted to assess the outcomes of their interventions. However, little is definitively known about the efficacy of many of the treatments currently in use, and research necessary to produce such knowledge must confront particularly difficult problems. Before discussing the nature of sex offender treatment and its outcome, we will review the major difficulties this type of research must face.
Psychological andbehavioral treatment
Psychological treatment of sex offenders showed little success until the advent of cognitive-behavioral techniques (7), which have undergone rapid development over the past two decades. The goal of these treatments is to change sex offenders' belief systems, eliminate inappropriate behavior, and increase appropriate behavior by modifying reinforcement contingencies so that offensive behavior is no longer reinforced. Techniques aimed at eliminating deviant arousal include aversion treatment, covert sensitization, imaginal desensitization, and masturbatory reconditioning. Cognitive-behavioral treatment for sex offenders often includes cognitive restructuring, that is, modification of distorted cognitions used to justify paraphilic behavior (75), social skills training, victim empathy training, lifestyle management, sex education (76), and relapse prevention (77).
Cognitive-behavioral techniques
Aversion therapy and covert sensitization
Both aversion therapy and covert sensitization pair deviant sexual fantasies with punishments. In aversion therapy, deviant fantasies are paired with physical punishment (37,76). Patients work with therapists to develop a series of fantasies about the patients' preferred deviant acts. These fantasies are presented verbally to the patient accompanied by an aversive experience such as a harmless but painful self-administered electrical shock or a noxious odor. Alternately, the therapist presents visual depictions involving the deviant fantasy—for example, depictions of young children—and the patient receives a shock or odor when viewing them. Appropriate visual stimuli such as depictions of adults are also presented, without an accompanying shock or odor.
Covert sensitization pairs deviant sexual fantasies with mental images of distressing consequences. In this technique, offenders verbalize a detailed deviant fantasy. When they become aroused, they discontinue the deviant fantasy and begin verbalizing an equally detailed fantasy of highly aversive consequences, such as being arrested. This technique requires them to focus attention on negative consequences that they find upsetting.
During treatment, offenders identify and focus on the chain of events leading up to the sex offense. This process enables them to insert fantasies of aversive consequences at progressively earlier phases of the predatory behavior leading to a sexual offense. The procedure is thought to teach offenders that their behavior is under their own control and can be interrupted by them at any stage.
Sometimes sex offenders are required to subject themselves to a noxious odor to augment the negative impact of the fantasized aversive consequences. When they become anxious from this fantasy, they are required to begin to fantasize that they "escape" the aversive scene by imagining a nondeviant sexual scene, such as consensual adult sex.
Imaginal desensitization
Imaginal desensitization is a technique in which offenders are trained in deep muscle relaxation (54). When they have learned the relaxation technique, they fantasize the first scene from the chain of events they have previously identified as leading to an act of sexual offense. After they can visualize the first scene and remain relaxed, they are asked to imagine the next scene, and to proceed through the chain, while remaining relaxed. This technique is thought to teach offenders that they can tolerate the feelings associated with their deviant sexual urges, without acting on them, until the urges recede.
Masturbatory reconditioning
Masturbatory reconditioning involves the use of the naturally reinforcing properties of orgasm to change behavior. Various techniques have been proposed to change masturbatory fantasies by requiring the sex offender to change from deviant to nondeviant fantasies at the point of ejaculation (79). Another type of masturbatory reconditioning, satiation, attempts to eliminate deviant sexual arousal by removing its reinforcing properties or supplanting them with aversive properties. Two forms are generally used—verbal satiation and masturbatory satiation (80,81).
In verbal satiation, offenders verbalize deviant sexual fantasies for a prolonged period, until these fantasies become tedious. In masturbatory satiation, offenders masturbate to orgasm while verbalizing nondeviant fantasies, and they then continue masturbating during the refractory period for a prolonged time while verbalizing deviant fantasies. This technique pairs the pleasure of orgasm with appropriate fantasy material, and the pain or boredom of prolonged masturbation without ejaculation with deviant fantasies.
Cognitive restructuring
Cognitive restructuring is based on the theory that sex offenders develop numerous distorted beliefs to justify their deviant sexual behavior. These distortions help such individuals to relieve feelings of guilt or shame associated with their offenses (14,75,83). For example, child molesters may assert that children enjoy sex with adults or that sex with adults is good for children.
Cognitive restructuring involves confronting and changing such distorted beliefs. It requires the sex offender to define his cognitions and then discuss the ways he uses these distorted beliefs to rationalize deviant behavior. The therapist challenges his beliefs and suggests new formulations. Role playing in which the therapist plays the role of the offender and the offender plays the role of the police or of an abused family member is often included (13). In this way, the offender must dispute his own beliefs.
Social skills training
Social skills training has been attempted on the theory that deficits in skills necessary for successful interaction in social and nondeviant sexual situations may be involved in sexually deviant behavior. This theory has been debated in the literature (84,85). Social skills training focuses on skills involved in social conversations using role playing, modeling by the therapist, and identification of irrational fears deriving from social conversations. Some programs focus on social anxiety, conflict resolution, and anger management (86). Assertiveness training has also been used to help patients express themselves more effectively (13). Some clinicians believe sex education in conjunction with social skills training is helpful (13).
Victim awareness or empathy
Many offenders minimize the consequences of their deviant sexual behaviors by developing cognitive distortions that allow them to believe their victims were not injured by them or enjoyed the event. Victim awareness or empathy techniques attempt to increase sex offenders' understanding of the impact of their deviant sexual behaviors on their victims. This may involve offenders' viewing videotapes of victims' descriptions of their own experiences, role playing, and receiving feedback from therapists, other offenders, or victims (77).
Relapse prevention
A central feature of many therapies is relapse prevention involving maintenance strategies to anticipate and resist deviant urges (77,87). Relapse prevention is based on the view that relapse occurs in predictable sequences that offenders can avoid if they can identify and interrupt them. The essential components of relapse prevention involve the offender's identification of high-risk situations and the decisions he makes that lead him closer to relapse. He must learn skills to cope with the high-risk situations so as to prevent relapse.