Offenders: Characteristics and Treatment

Judith V. Becker, Ph.D.
,
is professor of psychology
and psychiatry at the
University of Arizona.
Offenders:
Characteristics and
Treatment
Judith V. Becker
Abstract
People who sexually abuse children are diverse in terms of age, occupation, income
level, marital status, and ethnic group. At one time it was believed that sex offenders
could be easily categorized along three dimensions: offending against either adults
or children; offending against either members of their families or against acquain-
tances and strangers; offending in noncontact ways (for example, exhibitionism) or
through bodily contact. There is growing evidence that a number of offenders offend
across these categories. Many child sexual abusers are themselves adolescents, and
many adult offenders first offended when they were adolescents.
A review of the literature reveals a paucity of controlled therapy outcome studies on
the effectiveness of treatment, and existing uncontrolled studies are marked by
methodological problems. This has led some to conclude that there is insufficient
evidence to prove the effectiveness of treatment for child molesters. However, there
have been major changes in treatment programs over the years, and some more
recent studies provide reason for optimism about the effectiveness of current
treatment methods for some offenders.
A
s other articles in this journal issue have noted, far too many
children in our society fall prey to individuals who use them
to fulfill their own sexual needs. The offenders can be relatives
of the child victim, or may be acquaintances or strangers. Their
activities may come to the attention of the child protection system (if
the childs parents are involved) or of the criminal justice system, or
they may escape detection. Offenders may be adults or may themselves
be minors.
This article uses the term child molester
to refer to those who choose only or
primarily child victims, and sex offender to
refer broadly to those who offend against
adult victims, child victims, or both.
Child molesters are a specific and signifi-
cant category of sex offenders. The term
incest refers to sexual acts, which may or
may not include intercourse, between
members of a family other than a hus-
band and wife. Incest may occur between
two adults, but all references to incest in
this article refer to sexual acts involving
a child.
The population of incarcerated sex of-
fenders has grown rapidly. Between 1988
and 1990, the population of sex offenders
in American prisons grew by 48%.
1
In
some states, as much as one-third of the
prison population is made up of sexual
offenders.
2
It is unknown to what extent
The Future of Children SEXUAL ABUSE OF CHILDREN Vol. 4 No. 2 Summer/Fall 1994
177
this is the result of longer sentences for
incarcerated offenders.
This article reviews what is known
about offenders and treatment of them.
First, the role of paraphilia (consistent de-
viant sexual interests) in child molestation
is discussed. Second, the article looks at
what is known about offenders, including
data on juvenile offenders and incest of-
fenders. Third, the article discusses recidi-
vism and the difficulty of determining
recidivism rates, with a summary of what is
known about recidivism of untreated of-
fenders. Fourth, the article looks at treat-
ment, including mechanisms for getting
offenders into treatment, treatment pro-
viders, goals and types of treatment, the
efficacy of treatment, and the need for
postincarceration monitoring and long-
term treatment. Finally, recommendations
are made.
The Role of Paraphilia in
Child Molestation
The universe of child molesters is broad.
A distinction could be made between (a)
those individuals with a normal pattern of
sexuality who may impulsively or opportu-
nistically perform a single deviant act, and
(b) those individuals who have a consis-
tent deviant sexual interest, known as a
paraphilism. There is some link between
the two categories: opportunistic deviance
may develop into full-blown paraphilia
over time, as described below.
For a person to be diagnosed as hav-
ing a paraphilia, it is required that a
sexual fantasy or pattern of behavior in-
volving a nonconsenting person, an ani-
mal, or nonhuman objects have existed
for at least six months, that the sexually
arousing fantasies or urges are recurrent
and intense, and that the person either
acted on the fantasies or suffered serious
distress because of them.
3
An individual
who occasionally has paraphilic fantasies
but is not markedly distressed by them
and does not act on them is not diag-
nosed as suffering from a paraphilia. In
this authors clinical experience, most,
but not all, of the offenders who come
to the attention of the criminal justice
system or child protective system have
one or more paraphilia. In some cases,
isolated acts may occur without para-
philia, usually in the context of alcohol
or substance abuse, or during stressful
situations such as psychiatric illness or
marital problems.
Paraphilic fantasies or actions involv-
ing prepubescent children as sexual part-
ners are termed pedophilia.
3
Pedophiles
may be attracted to youth of the same sex,
opposite sex, or both. While both adult
males and females have been diagnosed
with pedophilia, clearly the majority of
cases involve adult men molesting female
children. (See the article by Finkelhor in
this journal issue.)
Although at one time it was assumed
that most offenders could be simply clas-
sified as suffering from a single paraphilia,
a growing body of evidence indicates that
many or most offenders have more than
one category of deviant sexual behavior.
4
For example, it used to be assumed that
incest offenders could be clearly separated
from other child molesters, but current
evidence indicates that a substantial per-
centage of child molesters offend in both
spheres.
4
There is also some evidence that
many exhibitionists engage in additional
deviant sexual acts, rather than exhibition-
ism being an isolated category of behavior,
as was once assumed.
5,6
As will be discussed below, a substan-
tial percentage (one study suggests the
number may be as high as 30% to 50%)
7
of child molestations are perpetrated
by juveniles, and a substantial percent-
age of adult offenders may begin their
molesting behavior as juveniles.
8
While
juvenile offenders may resist treatment
as stubbornly as adult offenders, their
younger age means that a higher percent-
age of juvenile offenders will not yet
have developed full blown paraphilias
and entrenched patterns of behavior,
and may therefore be more amenable to
treatment.
178 THE FUTURE OF CHILDREN SUMMER/FALL 1994
Offenders
Until recently, most of what was known
about perpetrators of child sexual abuse
was based on incarcerated offenders.
While studies on incarcerated offenders
have added to our knowledge about this
population, these studies do not necessar-
ily represent accurately the population of
nonincarcerated offenders, which may be
substantially larger. Also, incarcerated sex
offenders are likely to conceal the exact
nature and scope of their offenses because
of fear of further prosecution or extended
incarceration.
This section discusses a major study of
nonincarcerated offenders, and summa-
rizes information from other studies, with
discussion of knowledge specific to juve-
nile offenders and incest offenders. A ty-
pology defining a range of distinct types
of nonincestuous offenders is described,
and current knowledge of the etiology of
child molestation is summarized.
Abel Study of Nonincarcerated
Offenders
From 1977 to 1985, Abel and colleagues
4
interviewed a large sample (n = 561) of
nonincarcerated male sex offenders un-
der a federal certificate of confidentiality,
which protected information provided to
the researchers by those who participated
in the study.
9
The sample was made up of 270 child
molesters, as well as 152 sex offenders who
offended against both children and adults,
an additional 92 who sexually offended
exclusively against adults, and 47 other
paraphiliacs who participated in sexual be-
havior that was not classifiable by victim
age (for example, fetishism).
Child molesters may engage in incestuous,
as well as nonincestuous, abuse and may
target children of both genders.
The subjects were recruited through
informal discussions with health care pro-
fessionals, formal presentations at mental
health, parole, probation, forensic, and
criminal justice meetings, and through ads
in the local media. Although subjects were
seen at two sites (Memphis, Tennessee,
and New York City), some of them resided
in other areas of the country. They ranged
in age from 13 to 79. The average age of
these sex offenders was 31.5 years. Eighty
percent were between the ages of 20 and
49 years of age, and 7% between the age
of 50 and 79. Because this was a study of
adult male offenders, juvenile offenders
were underrepresented and female of-
fenders were not represented at all.
These were people from every walk of
life. Forty-seven percent of the offenders
were and always had been single. Twenty-
nine percent were married, and the re-
mainder were formerly married or had, at
some point, formed a significant living
with relationship of some type with an
adult partner. All educational levels were
represented, with 40% having at least one
year of college. The majority were em-
ployed, with only 20% being either tempo-
rarily unemployed or unemployed longer
than one month.
All subjects volunteered to participate
in the study, seeking assessment and/or
treatment. Consequently, this pool of sub-
jects would have to be characterized as
self-selected. Although the subjects in-
cluded representatives of each of the cate-
gories of paraphiliacs, we cannot assume
that this group represents the normal dis-
tribution of categories of paraphiliacs in
the general population. (However, it
should be remembered that any group of
sex offenders being studied will show
some selection bias, since they will either
be self-selected or will be in the study by
virtue of having come to the attention of
the legal system.)
A major concern was that offenders
were expected to underreport their sex
crimes. Therefore, each subject first
watched a one-hour videotape describing
the study and the protection afforded by
the certificate of confidentiality. Each sub-
ject then underwent a structured clinical
interview, lasting from one to five hours,
depending upon the subjects ability to
recall and describe his deviant history and
the variety and complexity of his para-
philiac interests. In a few instances where
the subject was suspected of overreporting
his behavior, the interview was repeated
until data were consistent. If repeated in-
terviews failed to yield consistency, the
data were not included in the study.
The Abel study yielded some impor-
tant information. Child molesters may
engage in incestuous, as well as noninces-
tuous, abuse and may target children of
both genders. Of the total population in-
Offenders: Characteristics and Treatment 179
terviewed in the Abel study, 67% targeted
only females, 12% targeted only males, and
21% targeted both. While 56% engaged
only in nonincestuous behavior (molest-
ing or assaulting nonrelatives) and 12%
engaged only in incestuous behavior, 23%
engaged in both incestuous and noninces-
tuous behavior. Again, 47 subjects (8%)
engaged in activities not classifiable in this
subcategory (for example, fetishism).
Data from Other Studies of Offenders
In addition to the Abel study, a number of
other studies provide information about
characteristics of offenders. For example,
one of the most publicized characteristics
of sex offenders is a past history as a victim
of abuse, and indeed both physical and
sexual abuse histories have been noted in
many studies of offenders. Johnson and
Shrier
10
reported that 66% of a sample of
male juvenile sex offenders had been vic-
timized either physically (19%) or sexually
(49%). In this authors clinical practice,
which includes primarily less serious, non-
incarcerated juvenile offenders, about
19% report a history as sexual abuse vic-
tims.
11
Longo reported that 47% of the
adolescent sex offenders in his treatment
program had been sexually abused.
12
Some have assumed that child mo-
lesters are typically passive, unassertive
individuals who interact with children by
mutual consent. However, data indicate
that child molesters are frequently ag-
gressive. Of 250 child victims studied by
DeFrancis,
13
50% experienced physical
force, such as being held down, struck,
or shaken violently. In an unpublished
study of 38 child molesters, using self-
reports of offenders and interviews with
medical examiners, Christie, Marshall,
and Lanthier
14
found that 59% of the
child molesters used force, and in 42% of
cases the force was sufficient for the medi-
cal examiners to find noticeable injury
to the victim.
Characteristics of Juvenile Offenders
Until somewhat recently, the major focus
of research and treatment has been on
adult child molesters. However, the im-
portance of the juvenile offender is be-
coming increasingly clear. In a research
project on 411 adult offenders seen volun-
tarily at an outpatient clinic, 58% of the
adult offenders reported the onset of
deviant sexual interests in adolescence.
15
Groth reported that 60% to 80% of adult
offenders admitted that they had begun
their deviant sexual behaviors as adoles-
cents.
16
In a study of 54 incarcerated child
molesters in Florida and Connecticut, in-
quiries about the offenders age at first
offense produced a bimodal curve, with
one group whose first child molestation
offense occurred between the ages of 13
and 16, and a second group whose first
offense occurred between the ages of 31
and 35.
16
In a national sample of 863 ado-
lescent males, the rate of sexual assaults
committed per 100,000 adolescent males
ranged from 5,000 to 16,000,
17
depending
upon the definition of sexual assault and
whether arrest rates or self-report data
were used.
In a 1984 study of 401 child sex abuse
cases, 56% of the male child victims and
28% of the female child victims reported
being abused by a juvenile offender.
7
Two
other 1980s studies had similar results,
with 56% of male child sexual abuse vic-
tims reporting a juvenile offender
18
and
15% to 25% of female child victims report-
ing a juvenile offender.
19
Juveniles may offend against their peers,
against younger children, or against
adults. Many of their victims may be
children simply because the juvenile
offender lacks the means to offend
against an adult.
Juveniles may offend against their
peers, against younger children, or against
adults. Many of their victims may be chil-
dren simply because the juvenile offender
lacks the means to offend against an adult
or has more opportunity to offend against
children.
Gail Ryan at the C. Henry Kempe Cen-
ter for Prevention and Treatment of Child
Abuse and Neglect in Denver, Colorado,
has established a national data base on
1,600 youth who have been referred to 90
specialized treatment programs.
20
That
data base indicates that juvenile sexual
offenders range in age from 5 to 19 with
a median age between 14 and 15. Juvenile
sex offenders are representative of all eth-
nic, racial, and socioeconomic classes.
Ninety percent of the juvenile offenders
were male, and more than 60% of the
sexual offenses involved penetration.
Over 90% of the juvenile offenders se-
lected as a victim a person known to them
(for example, a relative or an acquain-
tance).
20
The most common scenario in-
volves a 7- or 8-year-old victim.
20
Individual characteristics prevalent
among juvenile sex offenders include a
lack of assertive and social skills.
21-23
Low
academic performance,
22
learning prob-
lems, and learning disabilities have also
been diagnosed in juvenile sex offenders.
Smith and colleagues,
24,25
in a study of
262 male adolescent offenders, found lack
of impulse control to be present in many
of their patients. Fehrenbach and col-
leagues
26
have reported that, in a sample
of 293 male adolescent offenders, 44%
committed nonsexual offenses prior to
their first sexual offense.
Depression may also be a major char-
acteristic in juvenile sex offenders. In a
study of 246 adolescent sex offenders,
Becker and colleagues
27
found that 42%
of their clients experienced major symp-
Unfortunately, controlled studies that
measure the effectiveness of different types
of treatment against different types of
offenders are lacking.
tomatology as measured by the Beck De-
pression Inventory. The mean score of the
sex offenders on this inventory was two
times higher than a random sample of ado-
lescents as reported by Kaplan and col-
leagues.
28
Most of the above-mentioned charac-
teristics are not unique to juvenile sex of-
fenders. In two studies that compared
juvenile sex offenders to other violent and
nonviolent juvenile offender populations,
no significant differences were found re-
garding neuropsychological, intellectual,
or psychological capacities.
29,30
Several characteristics of family envi-
ronment have also been described in the
research literature on juvenile offenders.
These include unstable home environ-
ments, a sexual pathology within a parent,
and the child viewing sexual interactions
between parents or parent surrogates.
24,25
Viewing or experiencing family violence
has also been suggested.
31
Parental loss or
separation may also play a role for incest
offenders.
Extensive information on juvenile of-
fenders is included in a 1993 book, The
Juvenile Sex Offender, edited by Barbaree,
Marshall, and Hudson.
32
Characteristics of Incest Offenders
Traditionally, it was thought that incest
offenders were exclusively incestuous,
and that their recidivism risk was ex-
tremely low. With newer and more com-
plete information, these assumptions are
being dropped.
Of the 159 incest offenders against fe-
male children in the Abel study, 49% had
histories of being involved in nonincest
female pedophilia, 12% in male pedo-
philia, 19% in rape, 20% in exhibitionism,
7% in voyeurism, 6% in frottage (public
sexual rubbing against nonconsenting
persons), and 6% in sadism.
4
Recidivism among incestuous mo-
lesters, especially among those whose sex-
ual offenses are exclusively incestuous, is
still generally lower than for nonincestu-
ous offenders (see discussion of recidiv-
ism, later in this article). However, free-
dom from recidivism should never be as-
sumed, and family reunification in incest
cases should be approached with cau-
tion.
33
Recidivism may not occur until
many years later, especially where the of-
fender clearly has a paraphilic sexual in-
terest in children but has better impulse
control than most sex offenders. In this
authors clinical experience, such offend-
ers may go years without offending, but
may reoffend when placed in close, fre-
quent contact with children.
Some have put forth the theory that
incestuous men tend to relate sexually to
children in response to some family dis-
ruption.
34
However, the majority (59%) of
the subjects in the Abel study had the
onset of their deviant sexual interest pat-
tern during adolescence, which indicates
a disposition to offend, predating and in-
dependent of any family disruption. A
more plausible explanation may be re-
lated to the presence of a child who resides
in the house of the age and sex to which
the perpetrator is attracted.
Typology of Child Molesters
The population of child molesters is het-
erogeneous as to the offenders motiva-
tions and the type of their sexual behaviors
with children. Efforts are ongoing to dif-
ferentiate types of molesters in order to
provide guidance for improved under-
standing of the etiology of sexual offend-
ing and to assign offenders to appropriate
treatment. The first step is to develop and
validate a typology of sexual offenders.
Knight, Carter, and Prentky
35
devel-
oped and tested a typology using the cases
of 177 nonincestuous child molesters who
had been civilly committed to the Massa-
chusetts Treatment Center for Sexually
Dangerous Persons in Bridgewater, Massa-
chusetts, between 1959 and 1981. One
goal was to create a typology which was
consistently valid, so that individual of-
fenders would be assigned to the same type
by different reviewers working separately,
and so that individual offenders would be
consistently assigned to the same type over
time. Another goal of the typology was to
separate the mass of offenders into dis-
tinct categories, based upon their behav-
ior and thought patterns and upon the
differing developmental antecedents lead-
ing to their paraphilia.
types of offenders are lacking. Even so,
many clinical programs make use of
Knights typology, often in a modified
form, in assessing offenders and assigning
them to treatment. Essential next steps
for the field are to (1) validate a typology
In all likelihood, there is not one
causative factor, but rather multiple
pathways by which a person develops
a sexual attraction to minors.
This typology is based upon a selected
population of child molesters who had
been apprehended and convicted. Offend-
ers were excluded from the typology if they
had no physical contact with their victims
(for example, if they were exhibitionists).
Also excluded from the typology were
incest-only offenders and offenders who
chose as victims both adults and children.
that applies to incest-only offenders, fe-
male offenders, offenders who chose both
adults and children as victims, and non-
contact offenders, (2) conduct controlled
studies that assess which types of treat-
ment are most effective with different types
of offenders, and (3) use current knowl-
edge of typology in developing an im-
proved understanding of the etiology of
child molestation.
Etiology
Knight found that nonincestuous child
molesters could be classified by both the
offenders degree of fixation on children
and the offenders behavior during the
molestation. The behavior history allowed
Knight to break offenders into six types
representing a range of behavior. At one
extreme are interpersonal offenders who have
frequent nonsexual contact with children
and have shown a sustained interest in an
individual child in a relationship that ex-
tends beyond sexual involvement, where
sexual contact is typically nongenital and
nonorgasmic. At the opposite extreme are
sadistic offenders who rarely have nonsexual
contact with children and who are more
likely to choose strangers as victims. Sadis-
tic offenders by definition have a history
of violent acts that are sexually arousing to
the offender and that produce physical
injury to the victim. Knight and colleagues
have recently published updated data on
the validity of the typology.
36
While a number of theories have been
proposed in an attempt to explain why
some individuals are attracted to minors,
we are lacking a theory that has been em-
pirically derived and universally agreed
upon, and that addresses the heterogene-
ity of the offender universe. In all likeli-
hood, there is not one causative factor,
but rather multiple pathways by which a
person develops a sexual attraction to
minors.
37
Biological factors have been postu-
lated as perhaps being causative in the
development of deviant sexual interest
patterns. It has also been suggested that
abnormal levels of androgens may con-
tribute to inappropriate sexual behavior.
It is important to note, however, that the
majority of studies of androgen treatment
have dealt only with violent sex offenders
and have yielded inconclusive results.
38
Psychoanalytic and psychodynamic
theories relating the cause of deviant sex-
ual behavior to conflicts or trauma expe-
rienced in early childhood have been of
limited utility in fostering effective treat-
ment for offenders (see the discussion of
treatment options that appears below).
Development and validation of a typo-
logy are important steps in differentiating
offenders. Unfortunately, controlled stud-
ies that measure the effectiveness of dif-
ferent types of treatment against different
Learning theorists propose that sexual
arousal develops when an individual en-
gages in a sexual behavior that is sub-
182
THE FUTURE OF CHILDREN SUMMER/FALL 1994
sequently reinforced through sexual fanta-
sies and masturbation.
39,40
It is thought
that there are certain vulnerable periods
(such as puberty) when this can occur. For
example, if an adolescent engages in sex-
ual activity with a small child and there are
no negative consequences to the adoles-
An additional problem with
conviction records as a measure
of recidivism is that many sex-
ual offenses are plea bargained
down to nonsexual offenses.
cent, the adolescent may fantasize about
having sex with young children and mas-
turbate to those fantasies, thereby develop-
ing arousal to younger children.
Given our largely invalidated and lim-
ited understanding of the etiology of sex-
ual abuse, some observers recommend
that analysis and research focus on the
conditions that must exist in order for
individuals to move beyond fantasy to
carry out their sexual impulses toward
children. Finkelhor
41
theorizes that four
factors are necessary before pedophilic
fantasies will turn into action: (1) the adult
finds it emotionally satisfying to relate to
children; (2) the adult experiences a
physiological response to a child, for ex-
ample, erection; (3) the adult is blocked
in his or her ability to get needs met by an
adult; and (4) the individual may have
poor impulse control or may utilize sub-
stances such as alcohol or drugs that lower
inhibitions. It is important to note, how-
ever, that alcohol, in and of itself, does not
cause a person to commit a sexual offense.
In some instances, individuals consume
alcohol or drugs to give them the cour-
age to do what they wanted to do in the
first place.
While there are numerous theories
that address the etiology of sexual offend-
ing behavior, what is needed is a compre-
hensive, integrated theory, that is em-
pirically derived. Marshall and Barbaree
42
describe such an integrated theory, which
brings together psychological, biological,
and sociological factors.
Currently, a review of the literature
reveals only two models to describe the
etiology of such behavior in juveniles.
Ryan, Lane, Davis, and Isaac
43
identify a
sexual assault cycle. This model incorpo-
rates six steps, beginning with a juvenile
having a negative self-image with an in-
creased probability of maladaptive coping
strategies; this leads to the second step
when the youth anticipates negative reac-
tion from others. To protect against this
rejection, the youth isolates and with-
draws. To compensate for feelings of pow-
erlessness, the youth fantasizes situations
in which he or she is in control and acts
on those fantasies (victimizes someone).
This leads to more negative self-imaging,
and the vicious cycle is repeated.
Becker and Kaplans
44
model pro-
poses that sexual offending and abusive
behavior by juveniles result from a combi-
nation of individual characteristics (for ex-
ample, poor impulse control, history of
victimization, lack of social interactional
skills); family variables (including poor
parent-child bonding, domestic violence,
child maltreatment, lack of boundaries);
and socioeconomic factors (cultural ac-
ceptance of violence, violent role models,
objectification of people).
While both of these models of the eti-
ology of sex offending in juveniles make
intuitive sense, neither has been empiri-
cally validated.
Screening for Pedophilia in
Volunteer Organizations
Current knowledge about offenders is
not sufficient to be used to assess the like-
ly guilt or innocence of an accused per-
son. However, efforts are ongoing to de-
velop nonintrusive testing instruments
that could aid youth-serving volunteer or-
ganizations in screening volunteers to
avoid giving pedophiles unsupervised ac-
cess to children.
45
Recidivism Among
Untreated Offenders
Recidivism (repeated offenses after con-
viction) for most serious crimes is high.
According to a U.S. Department of Justice
report,
46
of the more than 100,000 persons
released from prisons in 11 states in 1983,
an estimated 62.5% were rearrested for a
felony or serious misdemeanor within
three years. A RAND report which looked
at prison populations generally concluded
that released inmates, as a group, pose a
very serious threat to public safety, but we
cannot predict with useful accuracy which
inmates will recidivate.
47
In California,
the state Department of Justice concluded
that sex offenders do not differ signifi-
cantly in terms of overall recidivism from
most other types of offenders.
48
In understanding recidivism among
child molesters, an important question is
what level of recidivism can be expected
in the absence of treatment, and whether
any characteristics of offenders have
been identified that predict an above- or
below-average risk of recidivism. To ad-
dress these topics, we must first consider
the problem of measuring recidivism.
Measuring Recidivism
The key question in measuring recidi-
vism is whether the once-convicted of-
fender commits a second sexual offense
when returned to the community. One
source of such information would be offi-
cial arrest or conviction records, although
these would be imperfect, given that so
many offenses will never come to the atten-
tion of the system.
49
But official statistics
are extremely limited. In discussing the
shortcomings of official data sources,
Furby and colleagues
50
note the following:
The actual number of sex offenses is
grossly underestimated by official reports.
Probably less than 10% of rape assaults are
ever reported to the police (citation omit-
ted). Furthermore, of those sex offenses
reported to law enforcement authorities,
some are not recorded, and records of
others are lost. There is little indication of
how extensive this problem is at the site
of original recording. However, users of
Uniform Crime Rate statistics or Federal
Bureau of Investigation (FBI) rap sheets
should be aware that some local law en-
forcement agencies do not provide the
FBI with arrest reports. Conviction rates
for sex offenses are even lower than arrest
rates and dramatically so (e.g. of 315 rapes
reported to police in Seattle, Washington
in 1974, only 15 resulted in conviction
[citation omitted]). Furthermore, data on
dispositions are estimated at only 50%
complete.
An additional problem with convic-
tion records as a measure of recidivism is
that many sexual offenses are plea bar-
gained down to nonsexual offenses.
50
To
more accurately reflect recidivism, some
researchers include arrests or convictions
for violent nonsexual offenses.
Furby also notes that one other meas-
ure of recidivism that has been used by
some (e.g. United States Department of
Justice, 1985) is the percentage of sex of-
fenders admitted to prison in a given year
who are recidivists. . . . [This information]
is conceptually flawed as a recidivism mea-
sure: It tells us what percentage of a group
of offenders has committed previous of-
fenses, which is not necessarily the same
as the percentage of a group of offenders
who will go (or went) on to reoffend.
50
Given these serious limitations on
official crime statistics, most studies of
recidivism rely on data from multiple
sources, which generally start with arrest
and conviction records, and are sup-
plemented with interviews with the of-
fender, his parole officer, local police de-
partments, and/or the offenders family.
Marques and colleagues
51
found that
simply reviewing parole office records, in
addition to law enforcement records, pro-
duced a 33% increase in their estimates of
serious crimes committed by released sex
offenders.
Recidivism rates are most meaningful
if they cover at least a five-year period,
postincarceration. Twenty-seven percent
of recidivists in one study did not begin to
recidivate until four years or more after
their release.
52
However, it can take sev-
eral years to identify a treatment popula-
Given these serious limitations
on official crime statistics, most
studies of recidivism rely on
data from multiple sources.
tion and control group of sufficient size
to study, which must then be followed for
several more years, resulting in studies
often taking ten years or more to complete.
Studies of Recidivism Among
Untreated Offenders
Prentky and Burgess,
53
in the context of
an article comparing the costs of treating
child molesters versus not providing treat-
ment, stated that determining a recidi-
vism rate for untreated molesters was the
weakest component of their economic
analysis. Nonetheless, they concluded that
the most defensible figure from recent
research came from a control group of
53 untreated molesters in a 1988 study of
treatment impact by Marshall and
Barbaree.
54
This control group showed a
recidivism rate of 32% over four years. If
incest offenders were dropped from this
group, the recidivism rate rose to 40%.
Because it is extremely difficult to
measure recidivism and numerous of-
fenders may go several years or longer
before recidivating, no statistics on recidi-
vism for untreated offenders should be
taken as definitive. However, as discussed
below, there is support from other sources
for the reasonableness of Marshall and
Barbarees 40% recidivism rate for un-
treated nonincest offenders.
A 1988 study showed a
recidivism rate of 32% over
four years. If incest offenders
were dropped from this group,
the recidivism rate rose to 40%.
Studies of untreated molesters alone
have primarily taken place in Europe.
Christiansen and colleagues,
55
in a 1965
Scandinavian study of 2,934 sex offenders
followed for 12 to 14 years, found 24% were
sentenced for a new offense during the
observation period. Presumably a higher
percentage committed offenses for which
they were not sentenced. In England in
1978, Soothill and Gibbens
56
estimated
that 48% of their sample of sex offenders
would be reconvicted by the end of 22 years
at risk.
In Canada, Hanson and colleagues
57
used two control groups of untreated con-
victed child molesters in a treatment effec-
tiveness study. Group 1, made up of 31
untreated offenders who were released
from prison between 1958 and 1965, had
a 48% rate of reconvictions for sexual or
violent offenses. Group 2, made up of 60
untreated offenders released between
1965 and 1973, had a 33% reconviction
rate. The length of the follow-up period
varied according to when offenders were
released, but 93% were followed for 15
years or more. The authors noted that the
greatest risk period appeared to be the
first 5 to 10 years after release from incar-
ceration, but that 23% of the recidivists in
their sample were reconvicted more than
10 years after they were released.
Factors Other Than Treatment That
Affect Recidivism
McGrath
58
in a 1991 literature review of
recidivism risks for sex offenders (looking
broadly at rapists, child molesters, and ex-
hibitionists) analyzed 18 variables that
predict recidivism to varying degrees. He
found that incest offenders have the lowest
untreated recidivism rates, often less than
10%.
59
Extrafamilial offenders who molest
boys generally have higher reoffense rates
(13% to 40%) than those who molest girls
(10% to 29%).
58
Multiple paraphilias can
also be a powerful indicator.
60
In a study
of 98 treated child molesters who were
followed for one year,
61
those offenders
who targeted both males and females and
both pre- and postpubertal victims showed
a 75% recidivism rate (n = 9). This variable
alone correctly classified 84% of both re-
cidivists and nonrecidivists in the study. A
prior criminal record is also a strong predic-
tor of recidivism.
62
Romero and Wil-
liams,
52
in a 10-year follow-up study of 231
sex offenders, found the offenders num-
ber of prior sex offense arrests to be the
single best predictor of recidivism. Twenty-
seven percent of the recidivists in their
study did not begin to recidivate until the
fourth year after their release or later.
Other factors identified by McGrath as
increasing the risk of recidivism among
child molesters are sexual arousal pat-
terns, alcohol abuse, use of force, absence
of social supports, and employment status.
Treatment for Offenders
This section discusses mechanisms for get-
ting offenders into treatment, who pro-
vides treatment, common goals and types
of treatment, and what is known about the
efficacy of treatment.
Briefly, there are serious problems with
the application of scientific standards of
research to treatment of sex offenders. For
example, many in the field (including this
author) feel it is ethically questionable to
randomly assign sex offenders who are
being treated in the community to treat-
ment or to nontreatment control groups.
These and other methodological prob-
lems are discussed later in this section.
A review of the literature reveals a pau-
city of controlled therapy outcome studies
on the effectiveness of treatment. Existing
uncontrolled studies are marked by meth-
odological problems. This has led some to
conclude there is insufficient evidence to
prove the effectiveness of treatment for
child molesters.
50
The most widely cited
analysis concluding that treatment has
not been proven effective has recently
been challenged
63
for focusing on out-
dated programs. There have been major
changes in treatment programs over the
years, and more recent studies
51,64
pro-
vide reason for optimism about the effec-
tiveness of current treatment methods for
some offenders.
Many sexual offenders, whether or not
incarcerated, receive no treatment. Where
in-depth treatment is available to incarcer-
ated offenders, it is typically available to
only a very small portion of the incarcer-
ated offender population.
65-67
Any per-
son who has a sexual interest in children
should receive professional help in gain-
ing control of this behavior. This author
believes strongly that modem treatments,
which have changed and improved signifi-
cantly in the past 15 years, have a signifi-
cant impact on the recidivism rates for
many offenders. However, because of the
need to follow treated offenders for sev-
eral years in order to establish recidivism
rates, it will be some time before this per-
ception can be reliably demonstrated.
Mechanisms for Getting Child
Molesters into Treatment
The discussion below describes the most
common mechanisms by which child mo-
lesters enter treatment. Unfortunately, no
data are available on the frequency of use
of these mechanisms.
A small number of offenders voluntar-
ily seek treatment. Among offenders who
have not yet had contact with the legal
system, the majority are probably not mo-
tivated to seek treatment, and reporting
laws that require therapists to report these
individuals to authorities probably deter
most of those who might consider seeking
treatment voluntarily.
Some patients enter therapy when in-
formal agreements are made between the
offender, the victims family, and/or the
offenders employer (for example, when
the employer is a church). However, this
means of getting molesters into treatment
is probably shrinking in significance, as
victims are increasingly likely to turn to the
legal system.
If an offender is arrested, he may be
directed to a pretrial diversion program
that includes treatment. Nonparticipation
in treatment would result in criminal
charges being filed against the offender,
but participation in treatment would allow
the offender to avoid having a criminal
record.
In other cases, the offender may be
found guilty at trial or through a plea
bargain, and be sentenced to probation,
with treatment required as a condition of
probation. (This is a common outcome.
In a 1987 survey of counties in three states,
80% of convicted child molesters were
sentenced to probation, with no prison
time served.
68
) If treatment is a condition
of probation, nonparticipation in treat-
ment could result in incarceration.
Some offenders who are found guilty
at criminal trial or plead guilty are incar-
cerated where they may receive treatment
in prison. However, this is likely only in
special facilities dedicated to sex offend-
ers. Upon release from incarceration,
some sex offenders are required to partici-
pate in treatment as a condition of parole.
Noncompliance is a violation of parole
and can result in reincarceration.
Finally, some offenders may be civilly
committed to residential mental health
programs if judged to be a danger to the
community. However, standards for such
involuntary commitment are strict. Be-
tween 1937 and 1972, 25 states and the
District of Columbia passed sexual psycho-
path laws, most of which were sub-
Where in-depth treatment
is available to incarcerated
offenders, it is typically avail-
able to only a very small portion
of the incarcerated offender
population.
sequently repealed or modified when they
were found to serve only the unconstitu-
tional purpose of preventive detention.
69
The state of Washington recently passed a
law specifically allowing the civil commit-
ment of sexual predators,
70
which has
been upheld as constitutional by the Wash-
ington Supreme Court.
71
Even if commit-
ment procedures meet constitutional
standards, it is a problem in some jurisdic-
tions that standards for release from civil
commitment are vague and subjective.
Some incest offenders whose cases do
not enter the criminal system may be re-
quired by a family court judge to take part
in treatment as a condition of family re-
unification.
186
Treatment Providers
One thousand five hundred programs
that provide sex-offender assessment and
treatment programs responded to a 1992
survey for the Safer Society, a private, non-
profit national resource and referral cen-
ter.
72
This is an increase of 133% from
the 643 providers identified by the Safer
Society in 1986. The 1992 list is a fairly
complete national listing; only 194 pro-
grams nationally were identified but
failed to respond to the survey. The sur-
vey makes no distinction between pro-
grams for child molesters and programs
for sex offenders who offend against adult
victims.
Of the 1,500 identified programs,
about half (755) serve juvenile offenders
and half (745) serve adult offenders. The
1,500 listed programs include only profes-
sional mental health providers specializ-
ing in treating sex offenders; other po-
tential resources not included are self-help
programs for offenders, nonspecialized
treatment programs that include sex of-
fenders, and the several hundred groups
nationally that serve only incest offenders
in the context of the family.
About 25% of sex offender treatment
programs are in residential settings, which
includes both programs for incarcerated
offenders and residential mental health
facilities. The other 75% are community-
based outpatient programs. The private
sector accounts for the majority of all out-
patient services for juveniles (60%) and
adults (66%), but provides a smaller share
Currently only the state of Washington
requires special certification for counselors
treating sex offenders, although other states,
including Texas and Wisconsin, are considering
such a requirement.
of all residential services for juveniles
(45%) and adults (18%). Services are un-
evenly distributed geographically. The Pa-
cific states offer the greatest number of
services, and Texas alone accounts for 9%
of the total (131 programs).
Services to specialized populations are
expanding, but are still insufficient rela-
tive to the number of offenders. Sixty-five
percent of programs serving juvenile sex
offenders include treatment to preadoles-
cent children who molest. Sixty-four per-
cent of juvenile treatment facilities offer
specialized treatment for juvenile female
sex offenders; but according to the Safer
Society, the demand for services for this
population is escalating dramatically, and
the availability of treatment is not keeping
pace with the need. Similarly, services to
lower-functioning/developmentally dis-
abled sex offenders are increasing but are
still inadequate. Forty-nine percent of ju-
venile providers and 51% of adult provid-
ers offer services to the developmentally
disabled.
Counselors employed in sex offender
treatment programs may come from a va-
riety of disciplines. The Societys 1994 sur-
vey, due later this year, will include
information on the academic qualifica-
tions and training of staff members in the
surveyed programs. Currently only the
state of Washington
73
requires special cer-
tification for counselors treating sex of-
fenders, although other states, including
Texas and Wisconsin, are considering
such a requirement.
74
Goals of Treatment
Successful treatment is most frequently de-
fined as a lack of recidivism. Other treat-
ment goals include decreasing deviant
arousal, increasing nondeviant arousal,
developing functional interactional skills,
anger management, stress control, and
eliminating alcohol and substance abuse
if they exist. Therapy might also target
empathy training, sexual values clarifica-
tion, and cognitive distortions. There is
controversy over whether family reunifica-
tion should normally be a goal in incest
cases.
75,76
Clinical interviews, psychological test-
ing, and paper-and-pencil tests are often
used within treatment programs to assess
whether treatment goals have been at-
tained. However, these measures have se-
rious limitations because they may not
predict actual behavior. Measures such
as the penile plethysmograph (a physi-
ological assessment technique used to as-
sess erectile responses in males) may be
used to determine if the offender has ex-
perienced a decrease in deviant arousal
and/or an increase in nondeviant arousal.
Plethysmograph results are often used in
therapy to confront the offender who de-
nies or minimizes his deviant sexual inter-
ests. Although penile plethysmography is
the most valid measure of sexual arousal
and has been validated against an adult
non-sex-offender population,
77
both false
positives and false negatives occur, and it
cannot be used either as the sole predictor
of recidivism or to determine if a person
has committed a sex offense. The Associa-
tion for the Treatment of Sexual Abusers
has formulated a series of guidelines for
therapists in regulating the ethical use of
the plethysmograph.
78
Amenability to Treatment
McGraths 1991 literature review,
58
dis-
cussed earlier, noted that a sex offender
can be considered amenable to treatment
only if he acknowledges that he has com-
mitted a sexual offense, he considers his
sexual offending a problem behavior that
he wants to stop, and he is willing to par-
ticipate fully in treatment. These require-
ments alone indicate that many known
offenders are not good candidates for
treatment, though McGrath notes that
amenability to treatment is not a static
variable because offenders who resist
treatment at one point in time may be
amenable to treatment at a later date.
Types of Treatment
As discussed earlier in this paper, the of-
fender population is extremely diverse in
demographics, paraphilic interests, and
behaviors. A great deal remains to be done
in developing and validating typologies
that cover the full range of offenders and
in understanding which types of treatment
are most effective with which types of of-
fenders.
In general, treatment can be grouped
into five categories: biological therapies,
traditional psychoanalysis and psycho-
dynamic therapies, family therapy, behav-
ioral therapies, and relapse prevention
programs. Any of these models may be
used either for adult or juvenile offenders,
and some of these treatments may be used
in combination.
Biological Therapies
Biological therapies have been utilized for
some pedophiles with long-established of-
fense histories. At one time, surgical cas-
tration was widely used in Europe. Heim
and Hursch provide an extensive review
and critique of the literature on the surgi-
cal castration of sex offenders.
79
Although
low recidivism rates have been reported,
these authors conclude that there is no
scientific (based on methodological prob-
lems with studies conducted) or ethical
basis for the use of surgical castration in
the treatment of sex offenders.
In view of the important role andro-
gens play in the maintenance of sexual
arousal, treatments have predominantly
A sex offender can be considered amenable to
treatment only if he acknowledges that he has
committed a sexual offense, he considers his
sexual offending a problem behavior that he
wants to stop, and he is willing to participate
fully in treatment.
focused on blocking or decreasing the
level of circulating androgens.
38
Anti-
androgenic medications do not appear to
influence the direction of the sexual drive;
however, they do act to decrease the sexual
drive in general. While these medications
have proven effective with some offenders,
some antiandrogens have potential side
effects, such as hypertension, weight gain,
and mild lethargy, which at times provoke
difficulty in compliance.
80
Recent work
81
has suggested the use
of antidepressants with some sex offend-
ers, where sex offending behavior is com-
bined with poor impulse control or com-
pulsive behavior. There is no expectation
that this medical treatment alone will
eliminate sexually offending behavior,
but there are indications it may aid in
relapse prevention.
Psychoanalysis and Psychodynamic Therapies
Psychoanalysis and psychodynamic thera-
pies have been used in treating sexual
offenders. Often involving individual coun-
seling, these therapies focus on identify-
ing and resolving early life conflicts and
traumas. Evaluating results of these inter-
ventions has been somewhat complicated
because there are no common standards
of measurement. Furthermore, several re-
searchers have reported disappointing re-
sults with this form of intervention with
sexual offenders.
82
According to the Safer Societys 1992
survey,
72
98% of juvenile and adult sex
offender treatment programs prefer to of-
fer counseling in peer groups (see discus-
sion of cognitive-behavioral therapies,
below). Only 2% of juvenile and 2% of
adult programs indicate that they use in-
dividual treatment by choice, rather than
because of inadequate numbers of clients
by gender or age.
Family Therapy
A community-based treatment program
for families in which incest has occurred
has been described by Giarretto, Giarretto,
and Sgroi.
83
This treatment program com-
bines individual therapy with group ther-
apy in self-help groups. While Giarretto
reported no recidivism in more than 600
families receiving treatment,
84
unfortu-
nately no data regarding length of follow-
up have been reported. Giarretto noted
that the authority of the criminal justice
system was essential in treating incest
cases; program dropouts were largely
those men who were not under criminal
justice system supervision.
85
Cognitive-Behavioral Therapies
Perhaps the most widely available and
most widely researched forms of ther-
apy for sex offenders are the cognitive-
behavioral therapies. The goal of these
therapies is to teach individuals how to
recognize and change their inaccurate
beliefs (for example, that a victim enjoys
being victimized) and to teach specific
means to control their inappropriate im-
pulses and behaviors. These treatments
are usually multicomponent and utilize
various behavioral techniques, especially
altering maladaptive thinking, learning
control of inappropriate fantasies and
behaviors, skills building, and victim em-
pathy. Low recidivism rates have been
reported with these forms of therapy
(see discussion below regarding outcome
studies).
The authority of the criminal justice system
was essential in treating incest cases; program
dropouts were largely those men who were not
under criminal justice system supervision.
In a 1994 literature review, Marshall
and Pithers
63
note the prevalence of these
multidimensional approaches, saying,
Implementation of a single therapeutic
intervention, even by the most high
skilled practitioners, cannot be consid-
ered sufficient treatment for most sex of-
fenders, and we doubt that anyone today
would deem such an approach to be sat-
isfactory.
Relapse Prevention Programs
A model gaining in popularity is the re-
lapse prevention model.
86,87
Under this
model, therapists assist the child molester
in identifying the molesters cognitive and
behavioral patterns that are precursors to
sexual abuse. This model enhances self-
management techniques and provides su-
pervision. Techniques used to increase
self-management are based on cognitive
behavioral intervention, combined with
community-based supervision, which can
include probation or parole officers, fam-
ily members, or other designated people
in the community.
Efficacy of Treatment
Numerous serious methodological issues
limit the scientific validity of existing stud-
ies and preclude firm statements about the
efficacy of treatment of sex offenders in
general. In addition, the diversity of the
offender population and the rapid and
substantial change in treatment methods
over the past 15 years complicate our un-
derstanding of this complex topic. While
no treatment has been shown to be 100%
effective, this author believes the research
literature provides definite grounds for
optimism about the responsiveness of
some segments of the offender population
to existing treatment modalities.
Methodological Concerns
To assess recidivism rates after treatment,
it is essential to compare the behavior of
treated offenders with the behavior of
comparable untreated offenders; to cre-
ate comparable groups, ideally offenders
should be randomly assigned to treat-
ment and control groups. However, this
author and others have argued that it is
ethically questionable to randomly assign
sex offenders to treatment or control
groups. Rather, determinations regarding
community safety and offender motiva-
tion generally dictate which offenders are
placed in treatment. On the other hand,
it has been argued that the greater good
would be served by conducting efficacy
studies with maximum methodological
rigor, including random assignment, so
that effective methods could be more
quickly and clearly identified and dis-
seminated.
In addition to the lack of random as-
signment in most studies, other methodo-
logical concerns are discussed at length by
Furby and colleagues in an exhaustive lit-
erature review of treatment efficacy stud-
ies.
50
They note that sample selection
generally represents a specialized group of
offenders: some treatment programs han-
dle the most dangerous cases (judged most
likely to reoffend), while other programs
restrict themselves to the easiest cases (the
offenders most motivated to reform), but
almost no programs treat a representative
sample of all offenders, or even of incar-
cerated offenders. In addition, if clinicians
allow offenders into treatment according
to such factors as motivation for treatment
or because they presumably pose a greater
threat to the community, then substantial
differences may exist between treatment
and control groups.
According to Furby, other common
methodological limitations in the litera-
ture assessing treatment effectiveness in-
clude the problem of attrition among
treatment participants (often as high as
30%) and the often relatively short follow-
up period.
Studies of Adult Offender Treatment Programs
In 1989, Furby
50
reviewed 42 published
and unpublished sex-offender recidivism
studies (30 treatment outcome studies and
12 studies of untreated offenders) with
sample sizes over 10. The review excluded
studies in which outcomes were assessed
solely by means of self-report or physiolog-
ical or psychological measures. Within
those criteria, the review was intended to
be exhaustive. After noting the numerous
methodological challenges and varying
study results, the authors conclude de-
spite the relatively large number of studies
of sex offender recidivism, we know very
little about it. . . . There is as yet no evi-
dence that clinical treatment reduces
rates of sex reoffenses in general and no
appropriate data for assessing whether it
may be differentially effective for different
types of offenders.
More recently, Marshall and Pithers
63
have pointed out problems with the Furby
analysis. More than half of the Furby data
come from subjects at programs which are
now closed and whose treatment methods
are now considered outdated. Marshall and
Pithers note that treatment approaches of
that time (for example, milieu therapy, non-
directive group therapy) bear little resem-
blance to the present-day multifaceted
cognitive-behavioral programs that em-
ploy cognitive restructuring, masturbatory
reconditioning, role playing, skills train-
ing, desensitization, stress management,
and other techniques to target a range of
behavior, attitude, and cognitive changes.
Furbys critique of treatment efficacy
was also discussed in a 1991 literature re-
view by Marshall, Jones, and colleagues,
62
who reframed the question by stating, At
this stage in the development of our un-
derstanding of treatment and its effective-
ness, we believe that the best approach is
to ask not the categorical question Can
sex offenders be treated? but rather a
Numerous serious methodological issues limit
the scientific validity of existing studies and
preclude firm statements about the efficacy of
treatment of sex offenders in general.
more modest question such as Can we
discern grounds for optimism in the
treatment outcome literature? While ac-
knowledging that, in general, studies of
nonbehavioral psychological treatment
showed no impact on recidivism, Marshall
noted that other studies did show treat-
ment effectiveness in reducing recidi-
vism. With the exception of the Ontario
program cited in the next sentence,
none of these studies were included in
Furbys review, because they were either
in press at the time or were published after
Furbys review. An Ontario penitentiary
program
88,89
found recidivism rates of
approximately 11% (though that rate
changed to 18% to 20% in later years when
the program was revised).
90
In Vermont, a
prison-based treatment program achieved
a 3% recidivism rate over a six-year follow-
up period.
91
These results, plus the results
of Barbaree and Marshall
92
and Abel,
61
discussed below, led Marshall to conclude
that, at the least, treatment and supervi-
sion can delay recidivism in some and pre-
vent it in others.
Barbaree and Marshall,
92
in a study of
68 treated and 58 untreated child mo-
lesters followed for 1 to 11 years (average
4-year follow-up), found a recidivism rate
of 13% for the treatment group and 34%
for the untreated group. When the un-
treated group was further subdivided, re-
cidivism was 22% for incest offenders and
43% for nonincest offenders. The un-
treated group was composed of men who
admitted their guilt and requested treat-
ment but did not receive it. Treatment
consisted of electrical aversion, masturba-
tory reconditioning, self-administration
of smelling salts contingent on deviant
thoughts or urges, and skills training. Con-
flict resolution and constructive use of lei-
sure time were also taught.
Lang, Pugh, and Langevin
93
described
a multimodal treatment for 29 incest of-
fenders and 27 heterosexual pedophiles.
By the end of a three-year follow-up, 7%
of the incest offenders and 18% of the
pedophiles had reoffended.
Rice and colleagues
94
evaluated 153
nonincest child molesters, including 50
who participated in their treatment pro-
gram. Of the 50 participants, 46 received
electrical aversion therapy, and 32 were
given biofeedback training, with both
procedures aimed at reducing deviant
arousal. Progress was measured by changes
in arousal patterns, but only half of the
subjects reached the goal criterion. It
should not be surprising that this brief
intervention, involving no aftercare or
clinical follow-up for serious offenders,
had no measurable impact on recidivism.
Similarly, Hanson
57
provided short-
term treatment in the form of aversion
therapy, individual and group counseling,
and other general treatments to 106 inces-
tuous and nonincestuous child molesters.
Compared with two control groups of 31
and 60 untreated offenders, there was no
significant difference in recidivism rates.
However, there are indications that mem-
bers of the treatment group were substan-
tially more hard core than members of
the control groups. Sixty-three percent of
the treated sample had previous sexual
convictions, versus 32% and 35% for the
control groups.
A more extensive treatment program
was provided by Abel to 192 nonincarcer-
ated pedophiles.
61
This population was a
subgroup of the 561 nonincarcerated sex
offenders studied by Abel, discussed at the
beginning of this article. Treatment con-
sisted of thirty 90-minute weekly group
sessions, focusing on decreasing deviant
arousal, sex education and cognitive re-
structuring, and social and assertiveness
skills training. Of the 192 pedophiles en-
tering this voluntary treatment program,
35% dropped out. Of the 98 pedophiles
evaluated one year after treatment ended,
12 had recidivated. Recidivists were likely
to have a history of more varied offending
behavior and more varied targets than
nonrecidivists.
A methodologically superior study by
Marques and colleagues
51
(currently in
progress) compares three groups of sex
offenders: matched volunteers who were
randomly assigned to treatment or no
treatment and a matched group of un-
treated nonvolunteers. Few sex-offender
treatment studies have ever been able to
create such closely matched control
groups. Treatment refusers and treat-
ment dropouts are also being studied.
The treatment program is extensive. Par-
ticipants attend group meetings 4.5 hours
per week and receive 3 hours of individual
counseling weekly. All participants are
also provided a series of specialty groups
based on individual need, such as social
skills training, sex education, stress and
anger management, substance abuse, and
preparation for release. To preserve con-
sistency of interventions, all treatment
groups are conducted from manuals
specifying goals and methods for each
session.
Offenders: Characteristics and Treatment
191
The Marques study is still in process;
preliminary data (based on 7 years of a
planned 15-year study) do not yet yield
conclusive results regarding the pro-
grams effectiveness. Two statistically sig-
nificant findings in the preliminary data
are that (1) those who dropped out of
treatment were at higher risk for new sex
crimes than were those completing a year
or more of the program, and (2) treated
child molesters were less likely to commit
violent nonsexual crimes after release
than were molesters in the volunteer con-
trol group.
Effectiveness of Juvenile Offender Treatment
Programs
While there are more than 800 treatment
providers in the United States for youth-
ful sexual offenders, relatively few pro-
viders are systematically evaluating their
treatment and reporting their results in
the research literature. There is, how-
ever, an emphasis in the literature on two
approaches to treatment of juveniles:
cognitive-behavioral and multisystemic.
Becker, Kaplan, and Kavoussi
95
de-
scribe a cognitive-behavioral treatment
program for adolescent sexual offenders.
The components of treatment include
methods to (1) eliminate or decrease de-
viant sexual thoughts; (2) alter maladap-
tive belief systems, for example, that a
young child who complies out of fear ac-
tually enjoys the sexual contact; (3) ap-
preciate the consequences such behaviors
have to victim and offender, and learn how
to control inappropriate urges and behav-
iors; (4) increase social interactional skills;
and (5) increase sex knowledge and clarify
sex values, for example, that one should
not engage in sexual relations outside a
caring, responsible, consensual relation-
ship. Becker
96
reports an 8% recidivism
rate for a sample of 80 youths followed in
some cases for up to two years with this
treatment format. Recidivism was deter-
mined by interviewing the youths, their
families, and the referral source.
Multisystemic therapy helps the of-
fender improve his functioning in a variety
of milieus, with emphasis on cognitive
processes (changing maladaptive beliefs),
family relations, peer relations, and school
performance. Borduin and colleagues
64
compared individual therapy to multi-
systemic therapy in a small sample. At com-
pletion of therapy, each youth was fol-
lowed, on average, for 37 months. Only
12.5% of those youths receiving the mul-
tisystemic therapy reoffended, as com-
pared with 75% sexual recidivism for
youths receiving individual therapy.
More recently, Schram, Milloy, and
Row,
97
in an unpublished report, evalu-
ated the reoffending behaviors of 197
male adolescent sex offenders who had
received various types of treatment at a
number of treatment centers in their state.
States and localities vary widely in the
amount of supervision, if any, they
provide to sex offenders who are
released from incarceration.
The average length of follow-up was 6.8
years. Ten percent of the youth were re-
convicted for new sex offenses; however,
48% were convicted for nonsex offenses.
Factors associated with recidivism in-
cluded (1) having deviant arousal pat-
terns, (2) having a history of truancy, (3)
experiencing cognitive distortions, and
(4) having one prior conviction for a sex
offense.
In this authors view, parent support
and educational groups should ideally be
run concurrently with juvenile offender
treatment. According to the Safer Society
1992 survey, 90% of juvenile sex offender
programs include family therapy in their
range of services, but no information is
available on the rate or quality of parent
participation. Unfortunately, there does
not exist in the literature a description of
a controlled treatment outcome study for
parents of youthful sexual offenders.
Need for Postincarceration and
Posttreatment Services
States and localities vary widely in the
amount of supervision, if any, they provide
to sex offenders who are released from
incarceration. Some provide no supervi-
sion at all, some maintain registries of sex
offenders, and some require probation or
parole, either for all released sex offend-
ers or at the discretion of the parole board
or sentencing judge. Kim English, re-
search director of the Colorado Division of
Criminal Justice, is preparing a national
survey of local practices in this regard,
under a grant from the National Institute
of Justice.
98
192
As described earlier, a model gaining
in popularity is the relapse prevention
model. This model emphasizes the need
for a continuity of counseling and suppor-
tive services for nonincarcerated sex of-
fenders, especially those recently released
from custody, coupled with close supervi-
sion and immediate sanctions for inappro-
priate behavior, such as drug abuse or
possession of child pornography. In Ari-
zona, a 1987 law allows sex offenders to be
placed on lifelong probation, allowing
continuous supervision and sanctions for
inappropriate activities that are likely to
precede reoffending.
99
Under the Arizona law, the trial court
has discretion over whether to order life-
time probation for sex offenders. In prac-
tice, virtually all convicted child molesters
receive this sentence, either in lieu of
prison time or upon release from pri-
son.
100
Once on probation, offenders are
required to take part in 45 hours of edu-
cation over six weeks, then continue
weekly 2-hour group treatment sessions so
long as the probation office determines
there is a need.
101
In most cases, the of-
fender pays for the therapy and for peri-
odic physiologic testing. A special detail of
the probation team makes unannounced
visits on evenings and weekends to those
probationers considered at highest risk of
reoffending. Although the probation de-
partment considers their supervision of
offenders to be strict, it appears that the
sex offender unit does not return a higher
percentage of probationers to prison than
do the other units of the states adult pro-
bation office.
100
In Arizona, a 1987 law allows sex offenders
to be placed on lifelong probation, allowing
continuous supervision and sanctions for
inappropriate activities.
There are as yet no published data on
the impact of this specialized probation
program on recidivism, although evalu-
ation of the program is ongoing. However,
this model has support among profession-
als in the field. The American Bar Associa-
tion, in a report based on a telephone
survey of 100 probation departments and
extensive site visits in four jurisdictions,
reported that most officials adamantly be-
lieved that specialized, intensively trained
probation units with reduced case loads
were needed to supervise child sexual
abuse offenders on probation.
68
Recommendations
n Empirically derived typologies need to
be developed for incest-only offenders, fe-
male offenders, offenders who chose both
adults and children as victims, and non-
contact offenders.
n There is a lack of empirically derived
theory on the etiology of sex-offending
behavior. Current knowledge about typo-
logy should be used in developing an im-
proved understanding of the etiology of
child molestation.
n We need controlled treatment outcome
studies with long-term follow-up that assess
which treatments are most effective with
different categories of offenders.
n While the mental health profession has
progressed at developing treatment pro-
grams for juvenile offenders, the wider
community and, in particular, the justice
system have not made much progress to-
ward better understanding and control of
inappropriate juvenile sexual behavior.
Community membersincluding parents,
teachers, police, child protective work-
ers, and juvenile court judgesare in need
of education regarding what constitutes
age-appropriate versus age-inappropriate
sexual behaviors. They are greatly in need
of information as to how to respond to
youth who abuse sexuality, and the con-
sequences of young offenders inadver-
tently receiving the message that their
behavior is acceptable. The community
also needs to be informed of the availabil-
ity and the success of various treatment
strategies.
n A continuum of care should be made
available so that individuals can receive
treatment if they are incarcerated or
placed in residential treatment, followed
by coordinated services after release. We
are in need of specialized group homes,
therapeutic foster care, specialized day
treatment, and community-based treat-
ment for both individuals and groups.
n Both civil commitment and incarcera-
tion programs that make use of indeter-
minate sentencing need to implement
clear and objective criteria for releasing
offenders.
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99. Ariz. Rev. Stat., 13-902 (D).
100. Telephone call between Donna Terman, Center for the Future of Children, and Laurie
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101. See note no. 5, Scott. This chapter describes the Maricopa County, Arizona, sex offender
program in detail, including special behavioral rules limiting paroled sex offenders con-
tact with children.

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