Sex Offender Treatment

Accomplishments, Challenges and Future Directions

Edmond J Coleman, Michael Miner

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317787631
• Edition: 1
• Topic: Law
• Subtopic: Law Theory & Practice
• Index: Law

Examine the major advances in sexual offender treatment over the last decade and promising new concepts in treatment, supervision, and research Sex Offender Treatment: Accomplishments, Challenges, and Future Directions points the way toward humane, dignified, effective treatment regimes for sexual offenders. In addition to providing an essential overview of the current state of sex offender treatment, this book examines vital areas of service provision and research and points to future directions for the field. On the medical/psychological front, this volume explores the importance of recognizing comorbid psychiatric factors in treatment and of exploring central nervous system function's role as a cause of sexually inappropriate behavior. In the legislative/justice arena it illustrates a "Circles of Support" proposal that mobilizes community resources to aid the adjustment of released offenders rather than branding them as dangerous to the community. And in the area of service provision, this book presents a treatment approach for residential programs that is inspired by research on childhood behavioral problems and special education. This book will increase your effectiveness with:

• a model of multisystemic treatment for juvenile sex offenders
• a restorative justice approach for reintegrating adult offenders into the community
• a study of the physical/mental correlates of organic brain dysfunction
• a case report on the use of a pharmaceutical treatment (leuprolide acetate) for pedophiles

Advances in Sex Offender Treatment and Challenges for the Future

Michael H. Miner, PhD

Eli Coleman, PhD

Michael H. Miner is Assistant Professor and Coordinator, Sexual Offender Treatment Program at the Program in Human Sexuality, and Eli Coleman is Professor and Director, Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota Medical School.
Address correspondence to: Dr. Michael H. Miner, Program in Human Sexuality, 1300 S. 2nd Street, Suite 180, Minneapolis, MN 55454 USA (E-mail: [email protected]).

SUMMARY. This paper describes what the authors believe to be the major advances, the areas of debate, and the future direction of sexual offender treatment as we leave the 20th century and enter the new millennium. In the area of sex offender treatment, the modification of relapse prevention for use with sex offenders has had a profound effect on the way that therapy is done. Additionally, the development of the selective serotonin reuptake inhibitors and other pharmacotherapies has moved the field more toward a bio-psycho-social model of etiology and treatment, and focused more attention on co-morbid psychiatric disorders in the treatment of sexual offenders. The late 1990s saw major advances in the development of actuarial prediction tools for recidivism, and a concerning move toward phallometric stimuli with unclear reliability and validity. Additionally, the development of the Abel Screen for Sexual Interest has provided a promising, but as yet unvalidated, alternative to phallometry. The 1990s were also a period of considerable growth in the application of sexual offender treatment to special populations, such as adolescents, the developmentally disabled, women and children. The major challenge for the future is to develop methodologically sound research on which to base our decisions about the treatments to apply, the unique needs of special populations, and the assessment of dangerousness. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2001 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Sexual offender treatment, SSRIs, assessment, risk, phallometry, reoffending, relapse prevention

The publication of the Furby, Weinrott and Blackshaw (1989) review in Psychological Bulletin began a debate about the effectiveness of sexual offender treatment that extended well into the 1990s and is still active today. Furby et al. (1989) concluded, after an exhaustive review of the literature at that time, that there was no scientifically valid evidence to suggest that psychotherapeutically-based sexual offender treatment was effective in reducing criminal behavior. This article set the stage for the 1990s, which have been a period of major advances and considerable growth, but also significant stagnation and retrenchment.

This paper will describe what the authors believe are the major advances, the areas of debate, and future directions of sexual offender treatment as we leave the 20th Century and enter into the new millennium. This will not be an exhaustive literature review, nor will we present a meta-analysis. Rather, this paper will highlight the major contributions to our understanding of sexual offender treatment process, procedures, and techniques.

[Haworth co-indexing entry note]: “Advances in Sex Offender Treatment and Challenges for the Future.” Miner, Michael H., and Eli Coleman. Co-published simultaneously in Journal of Psychology & Human Sexuality (The Haworth Press, Inc.) Vol. 13, No. 3/4, 2001, pp. 5-24; and: Sex Offender Treatment: Accomplishments, Challenges, and Future Directions (ed: Michael H. Miner, and Eli Coleman) The Haworth Press, Inc., 2001, pp. 5-24. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: getinfo@ haworthpressinc.com].

Advances in Sexual Offender Treatment

Relapse Prevention

In 1983, two students of Alan Marlatt published a book chapter that described the application of Relapse Prevention (RP) to sexual offender treatment (Pithers, Marques, Gibat, & Marlatt, 1983). This model is based on the assumption that important similarities exist between sexual offending and other “indulgent” behaviors (e.g., substance abuse, overeating, compulsive gambling); specifically, that sexual offending behaviors are defined as leading to a state of immediate gratification, followed by delayed negative consequences (Nelson, Miner, Marques, Russell, & Achterkirchen, 1989). Additionally, RP assumes that there are common behavioral, affective, and cognitive components associated with the relapse process itself (Nelson et al., 1989). This intervention model has been so influential in the field of sexual offender treatment that virtually all treatment programs involve RP or some variant (Laws, Hudson, & Ward, 2000).

In 1984, the State of California (USA) chose to discontinue its state hospital-based sexual offender treatment programs, citing their lack of effectiveness. In so doing, the State Department of Mental Health began a randomly controlled study of the use of RP with incarcerated sexual offenders, the Sex Offender Treatment and Evaluation Project (SOTEP: Marques, Day, Nelson, & Miner, 1989; Miner, Marques, Day, & Nelson, 1990). To date, SOTEP has yet to have the major impact on the field that was expected at its inception. Part of this is likely due to the results of this study, which initially were quite promising (Miner et al., 1990), but have proven to be less impressive with subsequent analyses (Marques, 1999). In the most recent publication of SOTEP findings, there are no significant differences between those who completed the RP-based treatment program and those in the two control groups, non-volunteers and volunteers assigned to no treatment (Marques, 1999), although the trend is toward fewer re-offenses in the treatment group. To date, SOTEP researchers have not published the results of their extensive post-release interviews, which provide outcome measures other than officially reported re-offenses, nor have they published their in-treatment data, other than two very preliminary analyses of re-offense predictors (Marques, Day, Nelson, & West, 1994; Marques, Nelson, West, & Day, 1994). While SOTEP has not had the impact that was expected, the study was just completed in January, 2000. It is likely that the final results of this study will be very informative, if the researchers publish the wealth of data they have accumulated.

As mentioned earlier, the 1990s dawned with skepticism about the effectiveness of sexual offender treatment, at least those interventions based in psychotherapy. Marshall and his colleagues have more recently argued that the accumulating evidence points to the effectiveness of comprehensive cognitive-behavioral programs (Marshall, 1996; Marshall & Barbaree, 1990; Marshall, Jones, Ward, Johnston, & Barbaree, 1991; Marshall & Pithers, 1994). However, Quinsey and his colleagues have argued that the evidence is, at best, sketchy and based on inadequately designed studies (Quinsey, Harris, Rice, & Lalumière, 1993; Quinsey, 1998).

Hall (1995) conducted a meta-analysis on the outcomes studies published after the Furby et al. (1989) review. This study found that there were few studies that met minimal standards for scientific quality, but those identified (n = 12) indicated that cognitive-behavioral and hormonal treatments were effective. In a more recent meta-analysis, Alexander (1999) used more liberal inclusion criteria than Hall (1995), and reached similar conclusions. That is, that “data from multiple studies suggest that treatment may lower recidivism rates, at least in some sexual offenders” (p. 112).

So, as we enter the 21st Century, there is still conflict over what evidence is sufficient for determining that interventions for sexual offenders are effective. Some authors argue that without random assignment, our conclusions will always be questionable (Miner, 1997; Quinsey, 1998), while others argue that random assignment is impractical and unethical (Marshall, 1993; Marshall & Anderson, 2000; Marshall et al., 1991; Marshall & Pithers, 1994). So, in the year 2002, we are still challenged to develop practical, scientifically valid studies that will advance our understanding of effective treatment. This, we believe, requires a recasting of the question from “is sexual offender treatment effective?” to “which components of sexual offender treatment are effective, with which populations, delivered by which modalities?” (Marques, 1999; Miner, 1997).

Pharmacological Agents

The 1990s saw an increase in the focus on psychopharmacology in treatment of sexual offenders–in particular the use of selective serotonin reuptake inhibitors (SSRIs) and LHRH agonists. In general, early pharmacological intervention focused on the use of antiandrogens (mydroxyprogesterone acetate (MPA) and cyproterone acetate (CPA) which reduce plasma testosterone, thus resulting in decreased erections and ejaculation, reduced spermatogenesis, and sexual fantasies, along with a general reduction in sexual interest (Bradford, 1983, 1985). The research on the effectiveness of these agents has generally been limited to case studies and single group designs. There have been very few placebo-controlled designs (e.g., Cooper, 1981; Bradford & Pawlak, 1993). These studies have indicated that treatment with antiandrogens does decrease subjective reports of sexual arousal and sexual interests, as well as leading to a decrease in the frequency of sexual behavior. However, while the research indicates that taking antiandrogens decreases re-offending to almost zero, the drop-out rate is extremely high and re-offense rates have been found to exceed 65% of those who discontinue antiandrogen treatment (Grossman, Martis, & Fichtner, 1999).

In the 1990s, the search for more palliative and effective pharmacotherapies increased. Some clinicians turned to the use of leuprolide acetate–a synthetic analog of luteinizing hormone-releasing hormone (LHRH) which is one of the gonadotropin-releasing hormones (GnRH) (Dickey, 1992; Thibaut, Cordier, & Kuhn, 1993, 1996; Cooper & Cernovsky, 1994). Leuprolide acetate initially stimulates the release of production of testosterone and other testicular steroids but with chronic administration testicular steroidogenesis is suppressed. Thus, androgen production is suppressed and this medication functions similarly to other antiandrogens and reduces sexual fantasies and drive. The advantage of leuprolide acetate is that it works at a higher level of the hypothalamic pituitary axis and, as a result, has a lower side effect profile compared to medroxyprogesterone acetate or cyproterone acetate. The antiandrogenic effects are equal to MPA and in some cases has been used effectively when MPA and CPA have failed (e.g., Dickey, 1992). As a result, there has been initial enthusiasm and some clinicians are now favoring this antiandrogenic approach over the traditional MPA and CPA. Or certainly, they are turning to leuprolide acetate when antiandrogens have failed. Obviously, more systematic study of the effectiveness of leuprolide acetate is necessary.

During the 1990s, there has been much more interest in other pharmacotherapies beyond the use of antiandrogens. In particular, there has been a great deal of interest in the use of the newer antidepressant selective serotonin reuptake inhibitors (SSRIs) in the treatment of sexual offenders. The use of such agents is based on the pharmacological action of such agents and on case reports, which have indicated decreased paraphilic fantasies and urges (Coleman, 1991; Bradford, 1997). It has not been clear whether these medications have been effective because of their known sexual side effects or the improved control of anxiety, obsessionality, and depression. It has been speculated that paraphilias may be best understood as part of obsessive-compulsive spectrum disorders (Coleman, 1991). There have been a few open trials which have shown positive results for the use of SSRIs (Kafka, 1991; Coleman, Cesnik, Moore, & Dwyer, 1992; Stein, Hollander, Anthony, Schneider, Fallon & Liebowitz, 1992; Kafka, 1994; Kafka & Prentky, 1992; Bradford et al., 1996), but to date there have been no published double-blind, placebo controlled studies.

The use of SSRIs has increased our armamentarium of pharmacotherapies beyond the antiandrogens. They have given us more tools in which to treat sexual offenders. The general advantage of the SSRIs over the antiandrogens has been the ease in administration, lowered side effect profile, and the ability to address other psychiatric comorbidity– especially anxiety and depression which seem to be significant triggers in an offender’s offense cycle. In general, today, the SSRIs have replaced the antiandrogens as a first-line treatment of paraphilias. In general, however, our knowledge of the usefulness of pharmacotherapy is similar to that for other forms of intervention. That is, the research has shown some promise, but there has not been sufficient scientific rigor in the studies to draw definitive conclusions. We are obviously in need of more double-blind, placebo-controlled studies analyzing the effectiveness of these medications. The problem seems to be the lack of interest by federal agencies or the pharmaceutical industry to support this type of research. There are also ethical issues that make placebo-controlled studies difficult.

Conclusions

While there have been other advances in our underst...

Table of contents

• Cover
• Original Title
• Title
• Copyright
• Contents
• Introduction: Sex Offender Treatment: Accomplishments, Challenges, and Future Directions
• Advances in Sex Offender Treatment and Challenges for the Future
• Multisystemic Treatment of Juvenile Sexual Offenders: A Progress Report
• Collaborative Treatment for Sexual Behavior Problems in an Adolescent Residential Center
• Circles of Support: A Restorative Justice Initiative
• Treatment of Pedophilia with Leuprolide Acetate: A Case Study
• A Comparison Between Exclusively Male Target and Female/Both Sexes Target Child Molesters on Psychometric Variables, DSM-IV Diagnoses and MTC:CM3 Typology
• Somatic and Mental Symptoms of Male Sex Offenders: A Comparison Among Offenders, Victims, and Their Families
• Standards of Care for the Treatment of Adult Sex Offenders
• Index