Treating Sexual Offenders

An Integrated Approach

William L. Marshall, Liam E. Marshall, Geris A. Serran, Yolanda M. Fernandez

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135410117
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Through extensive consideration of current research, theory and practice, Treating Sexual Offenders provides a guide to the assessment, treatment, and evaluation of a number of different disorders.

Provides therapists with the means to have a continued positive impact on the sex offender, from assessment to post-treatment evaluation and follow-up. Includes fetishisms, transvestic fetishisms, exhibitionism, frottage, pedophilia, sexual sadism, sexual masochism, telephone scatologia, voyeurism, rape, child molestation, and incest.

The Therapist Rating Scale used and referenced throughout the text is available for download below.
Therapist Rating Scale (pdf file)

Description of Disorder

INTRODUCTION

With the emergence of sexual offending into the domain of public discourse, in the 1980s in particular, many people asked why these offenses were suddenly occurring at such an apparently rapidly accelerating rate. Some members of the public and the media questioned whether this was a real phenomenon or just the result of some overly zealous investigators prompted into action by the growing women's movement. Others suggested that perhaps sexual offending had increased in parallel with the social changes initiated in the late 1960s and 1970s around all issues of sexuality. Perhaps, some suggested, it was the result of relaxed rules governing the availability of pornography or the increasing explicitness of sex in films, television, and advertising. Numerous accounts of human sexuality, however, have pointed to the occurrence of rape and child molestation throughout recorded time (Forsyth, 1993; Foucault, 1978; Licht, 1932; Taylor, 1954). Greek mythology describes how the god Zeus raped many maidens often by disguising himself in some way (Servi, 1997). Disguised as a swan Zeus seduced the beautiful Leda and sired Helen, Castor, and Pollux. The infamous Marquis de Sade described, in his 18th century novels, practices that are clearly sadistic, and he was imprisoned for several years for administering cantharides (a supposed aphrodisiac) to unwitting prostitutes so that he could engage in various sexual acts with them. Baron Gilles de Rais, who fought valiantly beside Jeanne d'Arc in the 15th century, is said to have sexually molested and even murdered countless children. He was eventually hanged and burned after confessing to his crimes. By the late 19th century several authors had described an array of sexual practices, some of which are today seen as offenses (Krafft-Ebing, 1886; Moll, 1893).

Among the reports of sexual assaults made from the 1970s on, as well as in many social surveys, victims were speaking of offenses that occurred many years earlier. When these victims were asked why they waited so long to report the assaults, they identified various reasons, such as their assumption they would not be believed, their view that the investigative and prosecutorial process would involve attacks on them and their behaviors, as well as their belief that family, friends, and even lovers would hold them responsible and reject them. Russell (1984) reported that of the cases identified in her random sample of San Francisco residents, only 2% of incest victims and 6% of the child victims of nonfamilial offenders had reported the offense to the authorities. Even more recent data reveal that sexual offending remains remarkably underreported. For example, Henry and McMahon (2000) found that 91 % of cases of child sexual abuse had gone unreported, and Kilpatrick (1996) showed that 56% of women who were sexually assaulted as adults failed to report the crime. Whatever reasons silenced these victims at the time of the abuse, their reports, once confirmed, indicated two things very clearly: Sexual abuse is not a recent phenomenon, and the contemporaneous social climate serves to facilitate or inhibit reports of sexual abuse. It is now accepted that sexual abuse, in all its forms, has been an ongoing problem in all societies for all time. Changes to laws, and to the processes of investigation and prosecution of sexual abuse, appear to have made it more likely that nowadays these offenses will be reported and dealt with more effectively, although additional improvements in these processes are needed to make victims feel supported and not feel blamed when they bring forward an accusation.

FREQUENCY OF SEXUAL OFFENSES

Despite the above noted changes, it is difficult to estimate the frequency of sexual assaults, and it is all but impossible to estimate the number of offenders within any given society at any particular time. Epidemiological studies, like those done with most Axis 1 and Axis 2 disorders, are very unlikely to elicit reports from offenders that they are abusing. What such studies can do is elicit reports from victims about their abuse, although even here there are problems. It is no doubt difficult, given the continuing stigma attached to having mental illness, for people to report in surveys that they are suffering from depression, schizophrenia, or anxiety disorders. It is, however, likely to be far more difficult for most victims of sexual offending to indicate this within the context of an objective scientific survey. In fact, most published surveys of the incidence of sexual victimization have been less elegant than is demanded in an appropriate epidemiological study. Most such surveys have not attempted to obtain a demographically representative sample, and even where they have, there are no doubt many victims who would not divulge the facts of their abuse in such a survey; many other victims might refuse to participate at all; and perhaps other individuals might, in an attention-seeking ploy, falsely report being abused.

Indeed, the issue of possible false accusations presents an unresolved problem to investigators, prosecutors, and researchers. For example, nearly half of all reported cases of child sexual abuse in the United Kingdom have been deemed “unsubstantiated” by the investigative process (Westat, 1987), but this does not mean that an offense did not take place; it simply means the investigators could not formulate a case that they believed could be pursued to prosecution. While it is difficult to believe that half of all reported cases of child sexual abuse represent false accusations, there seems to be no doubt that some, but hopefully few, reports are untrue. One aspect of the truth or falsity of accusations of sexual abuse concerns the so-called “recovered memories” of abuse. This issue has been quite divisive with those (e.g., Fredrickson, 1992; Terr, 1994) who believe that certain therapeutic processes can uncover memories of abuse that have long been forgotten, pitted against those (e.g., Kaminer, 1992; Loftus & Ketchum, 1994) who point to evidence from memory research that belies the basis of these putative recovered memories. Both sides of this debate appear intractable and tend in our view to overstate their case (see comprehensive reviews in Lynn & McConkey, 1998). Aside from the problem of “recovered memories,” there is at present no way to tell which accusations are true or false other than by the gathering of credible evidence, its presentation in court, and the rendering of a judicial decision. Not surprisingly, this process can be fallible, as we have seen from recent cases where convictions were subsequently overturned. However, our view is that by far the majority of reports of sexual abuse, particularly those where the accuser is willing to endure the investigation and trial, are true reports.

Peters, Wyatt, and Finkelhor (1986) reviewed research on the prevalence of child sexual abuse and reported that between 6% and 62% of females and between 3% and 31% of males had been sexually abused as a child. These reported ranges are so broad as to be all but meaningless, although the reviewers suggest that the discrepancies are likely due to methodological features of the studies (e.g., different definitions of abuse, differing samples, questioning format). In considering the 1986 Peters et al. report, Conte (1991) rather surprisingly says that “even if one takes only the lowest estimates, it is clear that sexual abuse of children is a common experience of childhood” (p. 17). It is a bit hard to see how 6% or 3% can be construed as reflecting “a common experience.” Canadian national surveys, funded by a government commission, revealed that up to one-third of males and more that 50% of females reported being sexually abused as a child, with most of these assaults occurring before the victim had reached age 12 (Bagley, 1991).

In their examination of female college students in the United States, Koss, Gidycz, and Wisniewski (1987) found that 15% of these women said they had been raped and a further 12% said that they had thwarted an attempted rape. Russell (1984) interviewed a representative sample of Californian women and found that 44% reported having been raped. An international survey, reported by van Dijk and Mayhew (1992), revealed somewhat variable data, but across all countries (European, Asian, and North and South Pacific nations) the rates of rape were worrisomely high. In reviewing reports of the incidence of the sexual assault of adult females, Koss (1992) estimated that the true rate of rape was 6 to 10 times higher than the official records would indicate. Her estimate is consistent with the remarks of other researchers (Russell, 1984) and is based on the observation that very few women who indicate in surveys that they were raped, ever reported the offense. Marshall and Barrett (1990) extracted the number of rapes from the official records in Canada during the full year 1988. Taking a conservative stance, they then multiplied this rate by four, which produced an estimate of 75,000 adult female victims of rape for that year. This estimate, if even close to the true rate, reveals a frequency of rape that is startling: It indicates that a rape occurs in Canada every 7 minutes.

Very little has been reported about the rates of exhibitionism, but Rooth (1973) observed that this was by far the most commonly reported sexual crime. In addition, DiVasto, Kaufman, Jackson et al. (1984) noted that 30% of adult women reported that a male had illegally exposed his genitalia to them. Using an anonymous survey, Person, Terestman, Myers et al. (1989) reported that 4% of male university students said they had exposed themselves to an unwilling observer.

Person et al.'s (1989) report indicates another source of information on the rates of sexual crimes; that is, anonymous surveys asking whether the respondents themselves had committed such offenses. Employing a representative sample of U.S. citizens, Laumann, Gagnon, Michael, and Michaels (1994) found that 2.8% of adult males and 1.5% of adult females indicated that they had forced someone to have sex. Similarly in Ageton's (1983) U.S. sample of male adolescents, 10% of these young males said they had forced a female into having genital contact with them. Herman (1990) reported that between 4% and 17% of adult males indicated they had molested a child, and other researchers have found that approximately 15% of males reveal some likelihood of having sex with a child (Malamuth, 1989; McConaghy, Zamir, & Manicavasagar, 1993).

Clinicians working with sexual offenders have also provided evidence on the extent of sexual abuse. Abel, Becker, Mittelman et al. (1987) obtained a certificate of confidentiality from U.S. law enforcement officials that guaranteed the reports of Abel's clinical subjects would not be subject to seizure by authorities. Under these conditions, many of Abel et al.'s sexual offending clients reported having committed numerous offenses additional to those for which they had been charged. The 232 offenders against children admitted to 55,250 attempts at child molestation, of which 38,727 were successfully completed; the 126 rapists reported having 882 victims; and 142 exhibitionists had exposed on 71,696 occasions. Studies using polygraphy (which, it must be said, has dubious scientific status) have similarly reported rates of offending that are far in excess of those recorded in the official records (Ahlmeyer, Heil, McKee, & English, 2000; Heil, Ahlmeyer, & Simons, 2003).

EFFECTS ON VICTIMS

The effects of sexual abuse on victims can be extensive, long lasting, and profoundly damaging to various aspects of the person's life. It is clear, however, that not all victims of sexual abuse suffer such major consequences; some experience numerous and seriously damaging sequelae, others experience some but not such severe consequences, and some victims appear to suffer few, if any, deleterious effects. In considering the evidence reviewed here, it is well to keep in mind that the nature of the sexual assault (e.g., the degree of force used, the intrusiveness of the sexual acts, the humiliating features of the abuse) and the prior or expected relationship of trust between the offender and victim are likely to be factors that modulate the victim's response. In terms of immediate outcomes, Finkelhor (1988) proposed four elements that he believed accounted for the magnitude of effects on child victims of sexual abuse. Traumatic sexu-alization results, so Finkelhor suggested, from premature and inaccurate learning about sex that took place during the abuse. Betrayal is greatest when the offender is someone the child previously trusted. Stigmatization follows from the child's fear of being blamed. Finally, powerlessness results from the offender's use of force and threats.

Burgess and Holstrom (1974) identified what they called the “rape trauma syndrome,” which has features similar to post-traumatic stress disorder. They describe fear as the primary immediate post-assault response, which in some cases develops into full-blown phobias, panic disorders, or generalized anxiety. Flashbacks occur as do obsessional ruminations about the abuse. Various other signs of elevated emotional responding may also be evident, such as mood swings, irritability, loss of appetite, and sleep disturbances. Disturbances in sexual functioning, reduced feelings of attractiveness, withdrawal, deteriorating work or school performance, substance use problems, and rejection of prior friends can also result from being sexually victimized (West, 1991). In particular, Burgess and Holstrom (1979) note that fewer than 40% of rape victims had sufficiently recovered within several months of the attack. Conte and Schuerman (1987) examined the responses of 369 children who had been sexually abused. They found that 27% displayed immediate consequences involving at least four problematic symptoms. Among the total group, the unfortunate immediate sequelae included loss of self-worth, emotional distress, nightmares or other sleep disturbances, aggression, and problems concentrating. These observations match other reports (Browne & Finkelhor, 1986). Longer-term effects that have been reported for child sexual abuse include eating disorders (Root & Fallon, 1988), loss of sexual responsiveness (Lindberg & Distad, 1985), problematic sexual behaviors (Mac Vicar, 1979; Mc Mullen, 1987; Silbert & Pines, 1991), personality disorders (Herman & van der Kolk, 1987), and problems in emotional development (Gomes-Schwartz, Horowitz, & Sauzier, 1985).

The evidence, then, indicates that sexual offenses are likely to produce negative consequences for the victims, which in many cases will be severe and long lasting. When we combine these negative effects with the evident high occurrence of sexual offending and the countless victims involved, we can confidently declare that this is a serious social problem that requires our urgent and devoted attention. Although sexual offending has emerged from its former cloak of secrecy and denial, we still have a long way to go before we give it the attention it deserves. In our view, it is difficult to avoid the conclusion that were the victims of sexual abuse characteristically from among the privileged males of our societies, our governments would have vigorously addressed this problem long ago. Perhaps as women's voices become more powerful, and as children's rights become fully addressed, more systematic and effective processes for dealing with this blot on our societies will be established. There are many things that need to be done. Assisting, supporting, and comforting complainants through the investigation and prosecution of alleged offenses would help victims come forward, as would providing free physical and psychological support and counseling to the victims. These would seem necessary but are all too often not available.

Devoting substantially more research money to the topic, both for the victim and offender sides of the issue, is also vital if further progress is to be made. In a particularly revealing report, Goode (1994) gave details of funding provided by the U.S. National Institute of Mental Health for various problem areas. The funding sources for studies of depression in 1993 amounted to $125.3 million, while for sexual offending only $1.2 million was made available. Certainly depression causes considerable damage to many people but so does sexual offending. A particularly ironic aspect of this imbalance in funding is that depression and various other Axis 1 and Axis 2 disorders have, as part of their etiology, the experience of being sexually victimized (Firestone & Marshall, 2003). Finally, funding treatment programs for offenders in prisons or in community programs could help reduce the incidence of future assaults by identified sexual offenders. No doubt treatment programs need to be improved but even at this time there is, as we will see, evidence that treatment of sexual offenders can have the effect of reducing the future victimization of innocent people. Such reductions in reoffense rates not only reduce harm, but they also save a considerable amount of taxpayers' dollars (Prentky & Burgess, 1990).

THE CLINICAL PICTURE

There have been essentially two ways in which sexual offenders and their problems have been described: by applying diagnoses or by simply describing the problematic features associated with the offenders. We will consider the merits of both approaches, although the present chapter will deal only with paraphilic diagnoses. Additional, or comorbid, diagnoses among sexual offenders will be discussed in chapter 5, while the problematic features of these offenders will be outlined in chapter 3.

Diagnoses

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) in its various incarnations has described a category of the sexual disorders called paraphilias that include some disorders relevant to sexual offending: pedophilia, sexual sadism, exhibitionism, frotteurism, voyeurism, and a catchall category labeled “paraphilias not otherwise specified [NOS].” In the latter category there is mention of some sexual crimes such as telephone scatalogia, necrophilia, and zoophilia, but no guidance is given about the criteria necessary to apply these diagnoses. Unfortunately, the DSM has not served the sexual offender field at all well and has excluded many offenders (e.g., rapists and many child molesters) who have clear problems in need of treatment. Indeed, there is no evidence available indicating that those sexual offenders who meet diagnostic criteria for a paraphilia have any more problems than those who do meet such criteria, nor does there appear to be different etiological pathways between those who do or do not have a paraphilia. Most importantly, there is no evidence of a differential treatment response between those sexual offenders who do or do not fit into the DSM diagnostic categories. Finally, Wilson, Abracen, Picheca et al. (2003) report that a DSM-IV (APA, 1994) diagnosis of pedophilia is unrelated to subsequent recidivism.

Detailed criticisms of the relevant DSM categories of paraphilia have pointed to many problems (Marshall, 1997a, 1999,2005a; O'Donohue, Regev, & Hagstrom, 2000), not the least of which concerns the failure of the DSM authors to demonstrate satisfactory cross-diagnostician reliability for any of the paraphilias. In fact, studies of the reliability of all DSM diagnoses have been limited, and several authors have complained about this unacceptable state of affairs (Kirk & Kutchins, 1994; Meyer, 2002; Reid, Wise, & Sutton, 1992). The only field trials of the reliability of the paraphilias conducted under the auspices of the DSM committee appeared in reference to DSM-III (APA, 1980) criteria (O'Donohue et al., 2000). Despite the fact that the criteria have changed in important ways over the subsequent revisions of the DSM, the authors of the latest versions claimed there was no need to repeat field trials because the DSM-III studies had shown the paraphilias to be reliable (see APA, 1996). This claim does not match what the early trials showed. As O'Donohue et al. (2000) note, all sexual disorders (paraphilias and dysfunctions) were collapsed in the DSM-III field trials, and although the initial kappa coefficient (the index of reliability) was sufficiently high (kappa = 0.92), the second part of the trial generated a kappa of just 0.75. There were only seven cases in the first part of the trials and only five in the second part. For decisions having important consequences, and surely deciding that someone has pedophilia or sexual sadism has very important consequences, the acceptable kappa must be at least 0.90 (Hair, Anderson, Tatham, & Black, 1998; Murphy & Davidshofer, 1995). The DSM data on the reliability of the paraphilias are clearly not acceptable.

In a particularly telling study, Levenson (2004) evaluated the reliability of various diagnoses made by two independent experienced clinicians in the preparation of their reports to courts examining whether identified sexual offenders met criteria for sexual violent predator (SVP) status. Since these diagnoses are among the required criteria for civil commitment, the di...

Table of contents

• Cover
• Half Title
• Practical Clinical Guidebooks Series
• Full Title
• Copyright
• Contents
• Preface
• Acknowledgments
• Chapter 1: Description of Disorder
• Chapter 2: Overall Description of Treatment Strategy
• Chapter 3: Research Basis
• Chapter 4: Clinical Case Illustrations
• Chapter 5: Complicating Factors
• Chapter 6: Maintenance and Follow-Up Strategies
• Appendix: Therapist Rating Scale
• References
• Index