SEXUAL DISORDERS (JP FEDOROFF, SECTION EDITOR)
Psychological Treatment of Sex Offenders
R. Karl Hanson & Pamela M. Yates
#Her Majesty the Queen in Right of Canada 2013
Abstract This article reviews the research evidence, practice
guidelines and accreditation standards for the psychological
treatment of individuals who commit sexually motivated
crimes. Overall, the sexual offender treatment outcome re-
search is not well developed, which limits strong conclusions.
There is, however, strong research evidence concerning the
effectiveness of interventions for general (non-sexual)
offenders. Given the considerable overlap in risk factors for
sexual and general offending, the “what works” principles for
general offenders provide useful guidelines for sexual offender
treatment. Specifically, the intensity of treatment should be
proportional to the offender’s risk level (risk principle), treat-
the learning style and abilities of clients (responsivity princi-
treatment are provided.
Sexual offending is a special kind of crime. Whereas most
of us can appreciate the goals (if not the means) of bank
robbers and thieves, we can be bewildered when individuals
take serious risks in order to expose their genitals to strang-
ers or touch the buttocks of a naked boy. Consequently, it
should not be surprising that individuals convicted of sexual
crimes are frequently referred to mental health services.
Sexual crimes are also distinct in that they invoke very high
levels of public concern; even a single instance of sexual
recidivism can lead to careful scrutiny about the adequacy of
case management decisions and to restrictive legislation
Psychiatrists have an important and distinct role in direct-
ing medical interventions for sexual offenders, particularly
the use of anti-androgens. It is not unusual, however, for
psychiatrists to also conduct evaluations and provide psy-
chotherapy and counseling services to this population. The
use of psychological interventions is particularly significant
given that only a small proportion of identified sexual
offenders are appropriate candidates for hormone depriva-
tion therapy. Even for psychiatrists who restrict their clinical
role to medication, knowledge of psychological treatments
is important. Practice guidelines for the use of sex-drive-
reducing medications stipulate that such medications should
only be used for individuals who are simultaneously en-
gaged in comprehensive treatment programs [1, 2].
The purpose of this article is to review the psychological
treatments available for sexual offenders, summarize the evi-
dence for their effectiveness, and provide directions on select-
ing psychological interventions with the most likelihood of
success. Whereas the evidence base for sexual offender treat-
ment is not well developed, there is strong evidence
concerning the characteristics of effective interventions for
general (predominantly non-sexual) offenders [3, 4]; further-
more, there is some evidence that these characteristics also
apply to the effective treatment of sexual offenders [5•].
Consequently, we believe that the “what works” principles
of offender rehabilitation are a useful guide for structuring
psychological interventions for sexual offenders.
Sexual offenders will typically come to the attention of
mental health professionals because of criminal justice sanc-
tions. In Westernized democracies, sexual crimes are primarily
The views expressed are those of the authors and not necessarily those
of Public Safety Canada.
This article is part of the Topical Collection on Sexual Disorders
R. K. Hanson (*)
Corrections Research, Public Safety Canada,
340 Laurier Ave., West,
Ottawa, Ontario K1A 0P8, Canada
P. M. Yates
Cabot Consulting and Research Services, P.O. Box 38027,
1430 Prince of Wales Drive,
Ottawa, Ontario K2C 1N0, Canada
Curr Psychiatry Rep (2013) 15:348
definedbysexuallymotivatedviolationsof the rights ofothers.
In particular, sexual crimes are based on a lack of consent (e.g.,
sexual assault) or the inability to consent (e.g., child molesta-
tion). Certain sexual crimes, however, are based on indecency,
such as prostitution and consenting sexual activity in public
(involving non-consent), such as sexual assault of adults, child
molestation, and exhibitionism. The vast majority of these
offenders are men (95 %) , and given that little is known
about treatment for female sexual offenders, this article will
only concern the psychological treatment of male sexual
Individuals convicted of sexual crimes may or may not
have a diagnosable mental disorder related to their offending
behavior. The most common risk-relevant diagnoses are clus-
ter B personality disorders (narcissistic, borderline, antisocial)
and paraphilias, particularly pedophilia. Even for those with-
out formal diagnoses, there is a high likelihood that they have
risk-relevant psychological characteristics worthy of interven-
tion. These characteristics could include lifestyle impulsivity,
tolerance ofruleviolations, emotional identification with chil-
dren, and hostility toward women .
From the public’s perspective, the goal of sexual offender
treatment is to reduce the likelihood of re-offending.
Offenders typically share this goal; however, they are also
concerned about how it is achieved. Both the individual and
society concur on the merits of the reformed offender build-
ing a satisfying and productive life as a law-abiding citizen.
Given both public safety goals and the importance of
non-offending for adequate social adjustment, recidivism
is used as the major criterion for evaluating the efficacy
The rates of sexual recidivism among individuals con-
victed of sexual crimes are lower than the public generally
believes. Large-scale meta-analyses have identified sexual
recidivism rates of between 7 % and 15 % after approxi-
mately 5 years [8, 9]. In general, sexual offenders are more
likely to reoffend with a non-sexual offence than a sexual
offence . Consequently, treatment for sexual offenders
should be mindful of the risk of both sexual and non-
Sexual offenders vary in the risk they pose to the com-
munity. For some, the risk of sexual recidivism is sufficient-
ly low that it is indistinguishable from the risk of sexual
crimes among general offenders with no recorded history of
sexual crime. For example, the 5-year sexual recidivism rate
of low-risk sexual offenders (<2.4 %)  is equivalent to
the rate at which offenders convicted of other types of
offences will commit a sexual offence “out of the blue”
(1 % to 3 %) [11–13]. For such low-risk sexual offenders
(bottom 15 % of the risk distribution), interventions cannot
be expected to further reduce their risk and may even make
them worse . Consequently, treatment for low-risk
offenders should focus on goals other than sexual recidivism
reduction, such as family reintegration, intimacy deficits, or
shame. For some cases any specialized sexual offender
treatment is contraindicated, and they would be better
served by routine criminal justice interventions, such as
regular supervision while in the community.
“What Works” in Offender Treatment
During the 1970s and 1980s, there was considerable pessi-
mism concerning the ability of treatment to decrease the
recidivism risk of offenders. In response to Martinson’s 
“Nothing Works” doctrine, a group of researchers led by
Andrews and colleagues conducted a series of influential
studies that identified “what works” in offender rehabilitation
with reductions in reoffending can be identified by the extent
to which they adhered to certain basic principles. These prin-
ciples became known as the risk, need, and responsivity
(RNR) principles of effective corrections [3, 19]. The validity
of these basic principles has been demonstrated in high-
quality random assignment studies  and by meta-
analyses by independent groups [3, 21–24].
The risk principle states that the intensity of services
should be proportional to the offender’s risk for recidivism.
The most intensive services should be directed to the highest
risk offenders. For low-risk offenders, treatment can even be
iatrogenic and can increase risk. The need principle states
that treatment should be directed toward the offenders’ life
problems that are related to recidivism risk (criminogenic
needs), with only secondary attention to other life problems
(non-criminogenic needs). For example, attitudes tolerant of
law violation is a criminogenic need, whereas worry and
depression are not [25, 26]. Mental health providers have a
responsibility to address diverse psychiatric and psycholog-
ical problems; however, to the extent that treatment aims to
reduce recidivism, it is important to focus on characteristics
that are empirically associated with the persistence of crime
and violence. Finally, the responsivity principle states that
treatment should be delivered in a manner that is likely to
connect with clients. For offenders, this means cognitive-
behavioral interventions tailored to their language, culture,
and learning style.
The Effectiveness of Treatment for Sexual Offenders
The research on the effectiveness of treatment for sexual
offenders is less well developed than the research on general
offenders. Although hundreds of studies have been pub-
lished on sexual offender treatment, the conclusions remain
tentative because few high-quality studies have been con-
ducted. For example, the Swedish Council on Health
Technology Assessment  identified only eight studies
348, Page 2 of 8Curr Psychiatry Rep (2013) 15:348
of treatments for child molesters that met minimal quality
standards (based on the GRADE criteria ). They con-
cluded that there was insufficient evidence regarding the
benefits and risks of psychological treatment of adult perpe-
trators of child sexual abuse. They did find weak evidence
that multisystemic therapy (MST) could be beneficial for
adolescent perpetrators [29•].
Nevertheless, most systematic reviews have typically
found statistically significant but modest reductions in re-
cidivism rates for treated compared to untreated sexual
offenders (see the 2010 analysis of 8 systematic reviews
by the Institute of Health Economics; ). For example,
based on 74 studies, Lösel and Schmucker  found an
overall odds ratio of 0.59, which translates to sexual recid-
ivism rates of 11.1 % for the treatment groups compared to
17.5 % for the comparison groups. All reviews have identi-
fied positive treatment effects for cognitive-behavioral
Perhaps the most influential of the recent reviews has been
that of Hanson et al. [5•]. Based on 23 studies meeting study
quality criteria (Collaborative Outcome Data Committee
Guidelines [32, 33]), the researchers found that treatment for
sexual offenders was most likely to be successful when it
followed the same RNR principles shown to be effective for
general offenders. The odds ratio for sexual recidivism was
0.21 for programs following all three principles, 0.63 for
programs following one or two of the principles, and 1.17
for programs following none of the principles. In other words,
RNR-compliant programs cut recidivism rates to less than
one-quarter of the rates of the comparison group, whereas
the completely non-compliant programs were associated with
a (non-significant) increase in sexual recidivism. A similar
pattern of effects was observed for violent and general (any)
Application of the RNR Model to Sexual Offender
The RNR model is not a stand-alone treatment program.
Much more is required for treatment to be effective (e.g., a
sound model of change, adequate funding, community sup-
port; ). When stated, the RNR principles appear obvious
(e.g., treat problems related to criminal behavior); however,
it is surprising how rarely programs conform to even these
three principles. In Hanson et al.’s [5•] meta-analysis of
sexual offender treatment programs, only 3 of 23 programs
were found to meet the RNR criteria (13 %). The compli-
ance rate is similar in the general offender literature. In a
review of 374 offender treatment outcome evaluations for
general offenders, 60 (16 %) met all three principles, and
approximately one-third (k=124) met none .
The following section provides guidance for sexual of-
fender treatment providers wishing to adhere to the RNR
principles. As well, we highlight some new and promising
approaches to psychological interventions with sexual
Risk (Treatment Dosage)
The risk principle states that higher intensity interventions,
including treatment, should be used with higher risk
offenders, while lower risk offenders should receive mini-
mal or no treatment (e.g., routine supervision in the com-
munity). The next obvious question is how much treatment
is enough? Unfortunately, there is little available research
concerning the necessary dosage for different risk levels.
With respect to adult sexual offenders, Marshall, Marshall,
Serran, and Fernandez  recommended between 80 and
120 contact hours over 4 to 6 months, although this recom-
mendation was based on clinical experience and was not
empirically based. In addition, offenders in their particular
program tend to be of lower and moderate risk levels.
In practice, the program length for sexual offenders
varies considerably across jurisdictions , even among
the narrow category of accredited sexual offender programs
run by national prison services. For example, in the UK,
average treatment duration for their accredited program is
80 h, although more intensive treatment is available for
offenders with additional treatment needs . In the pro-
grams run by the Correctional Service of Canada (CSC),
treatment dosage is in the area of 300 contact hours for high-
risk offenders and ranges between 160 to 195 contact hours
for moderate-risk sexual offenders . As well, offenders
in CSC programs may receive additional programs needed
to address other criminogenic needs, such as substance
abuse or general violence .
Among adult general offenders, Bourgon and Armstrong
 conducted a comprehensive evaluation of treatment
dosage as related to level of risk and extent of criminogenic
needs. Results indicated that 100 contact hours was suffi-
cient to reduce recidivism for general offenders with mod-
erate risk and few criminogenic needs, but that 200 hours of
contact was more effective in reducing recidivism when
offenders were either high risk or had multiple criminogenic
needs (but not both). Lastly, 300 contact hours or more was
required to reduce recidivism among offenders who were
both higher risk and who had multiple criminogenic needs.
One meta-analysis of treatment for juvenile (non-sexual)
offenders  recommended at least 100 contact hours for
treatment to be effective. However, it is uncertain whether
this can be directly applied to juveniles who have committed
In summary, there is little direct research to guide clini-
cians in terms of the appropriate duration or dosage of
treatment for sexual offenders. We believe, however, that
the research on general offenders and the dosage used in the
Curr Psychiatry Rep (2013) 15:348Page 3 of 8, 348
accredited programs provide useful reference points. Until
further research is available, it would be reasonable to plan
for 100 to 200 h for moderate risk sexual offenders and for a
minimum of 300 h for sexual offenders with high risk and
high needs. Low-risk offenders may need no specialized
treatment at all. The statements above apply to risk levels
defined by percentile ranks, with low risk offenders being in
the bottom 10 % to 20 % of the risk distribution and high-
risk offenders being in the top 10 % to 20 % .
Need (Risk Factors for Sexual Recidivism)
Treatment programs are most likely to reduce recidivism
risk when they target characteristics associated with recidi-
vism risk. Characteristics that are both risk-relevant and
potentially changeable have been referred to as dynamic
risk factors, criminogenic needs , or psychologically
meaningful risk factors . The major risk factors for sexual
recidivism are listed in Table 1. These risk factors were
selected because they have been shown to have signif-
icant statistical relationships with sexual recidivism
when averaged across at least three follow-up studies
[Cohen’s d>0.10; [7, 8, 43, 44]].
The major risk factors for sexual recidivism can be
grouped into the two broad categories of general criminality
and sexual criminality. Like other offenders, sexual recidi-
vists commit serious rule violations and share common
characteristics such as lifestyle instability, negative peer
influences, and conflicts with intimate partners. There are,
however, certain risk factors that are unique to sexual
offenders, such as deviant sexual interests, sexual preoccu-
pations, and emotional congruence with children. It is also
worth noting some characteristics that do not qualify as
criminogenic needs, such as internalizing psychological dis-
orders (distress), lack of victim empathy, denial of sexual
crime, major mental illness, and low sexual knowledge, as
these are unrelated to recidivism [43, 45].
Effective treatment programs do not ignore all non-
criminogenicneeds. This would be a mistake. Basic standards
of care direct mental health professionals to address their
patients’ suffering—even if it is unrelated to recidivism risk.
Furthermore, addressingnon-criminogenicneeds isoftennec-
essary for effective engagement (see section on responsivity
below). On balance, however, interventions that reduce crim-
inalbehaviorfocus primarilyoncriminogenicneeds (e.g.,low
self-control, negative peers, sexual preoccupation).
Responsivity (Matching Treatment to the Client)
Responsivity concerns the interaction between treatment
and the client, with the delivery of treatment tailored to
specific client characteristics . Responsivity addresses
client characteristics such as personality, motivation, cul-
ture, language, literacy levels, learning styles, abilities, and
disabilities—all of which can influence successful client
engagement. Motivation is a particularly salient concern in
the treatment of sexual offenders . Similarly, offenders
with mental disorders may require adapted programming to
address their specific needs, either prior to or in addition to
sexual offender-specific treatment.
Although there are many different styles of psychotherapy,
the research has consistently supported structured cognitive-
behavioral programs for offender populations [3, 31, 47].
Consequently, the core features of cognitive-behavioral treat-
ment should be considered in the development of treatment
programs for sexual offenders. These features include a focus
on cognitive and behavioral self-regulation, skills building,
practice, and rehearsal.
Thus, treatment that effectively addresses responsivity is
both cognitive-behavioral in orientation and adapts effectively
to the client’s personal, interpersonal, and social characteristics.
Promising Programs and Future Directions
Severaljurisdictionshaveformalizedthe essential elementsof
effective correctional treatment into accreditation standards
Table 1 Established risk factors for sexual recidivism
• Any deviant sexual preference
○ Sexual preference for children
○ Sexualized violence
○ Multiple paraphilias
• Sexual preoccupations
• Attitudes tolerant of sexual assault
• Childhood behaviour problems (e.g., running away, grade failure)
• Juvenile delinquency
• Any prior offences
• Lifestyle instability (reckless behaviour, employment instability)
• Personality disorder (antisocial, psychopathy)
Social problems/intimacy deficits
• Single (never married)
• Conflicts with intimate partners
• Hostility toward women
• Emotional congruence with children
• Negative social influences
Response to treatment/supervision
• Treatment drop-out
• Non-compliance with supervision
• Violation of conditional release
Poor cognitive problem-solving
348, Page 4 of 8Curr Psychiatry Rep (2013) 15:348
[48–51]. Accreditation criteria aim to ensure that treatment is
evidenced-based, compliant with the RNR principles, and
implemented with integrity (see Table 2). Although many of
the accredited programsare cognitive-behavioral, the range of
currently operated by national correctional agencies have
evolved from the relapse prevention model . Originally
substance abuse problems, relapse prevention was adapted to
sexual offender treatment, without demonstrated success
[53–55]. In more recent years, the traditional relapse preven-
tion model has shifted toward a broader self-regulation ap-
proach [56–58]. In general, the most promising sexual
offender treatment programs aim to change cognitive, attitu-
aggression, introduce adaptive patterns, and inculcate the
skills necessary to manage the dynamic risk factors associated
with recidivism risk [35, 38, 59].
One recent development is the Good Lives Model (GLM)
found to be an important influence in approximately 30 % of
sexual offender treatment programs , whereas it was not
even an option on a similar 2002 survey . Although the
GLM shares certain features of cognitive-behavioral treat-
ment, its roots are in humanistic and positive psychology.
Specifically, the goal of rehabilitation in GLM treatment is
to assist offenders to meet their needs and goals in life in a
manner that is appropriate and prosocial. Risk factors are
considered as obstacles to achieving these goals. According
to the model, the attainment of life goals, well-being, and
psychological satisfaction will diminish the attraction for
offending  and increase motivation for treatment
[63–65]. As this model is relatively new, research into its
effectiveness is in its infancy; however, preliminary research
supports the basis of the theoretical model and its positive
impact on within-treatment targets, such as increased motiva-
tion and engagement with treatment, reduced attrition, and
progress on treatment goals [66–68].
Another promising approach is Circles of Support and
Accountability (COSA), an intervention designed for com-
munity re-integration of high-risk offenders . Unlike
other programs, COSA utilizes specially trained community
volunteers. These volunteers provide intensive support upon
release to the community and assist core members (i.e., the
offenders) to implement risk management plans and to de-
velop the basic skills for community reintegration. Several
recent evaluations have found lower than expected recidi-
vism rates among COSA core members [24, 70•, 71, 72],
although more and better quality research is needed before
strong conclusions can be made concerning its efficacy and
The Prevention Project Dunkenfeld (PPD), led by Claus
promising development. The goal of this project is to treat
individuals with pedophilic and hebephilic sexual interests
who are not subject to the controls of the criminal justice
in other settings, involving a combination of cognitive-
behavioral interventions, elements of the Good Lives
Model, and, selectively, androgen-deprivation medications
[74, 75]. What is unique is how the offenders are recruited
Beginning in 2005, patients were recruited for PPD
through mass media campaigns (television and billboards).
The specific messages were developed in consultation with
patients with pedophilia who were already in treatment. The
ads were intended to convey empathy and to minimize
discrimination and shame (“Do you like children more than
Table 2 Sexual offender treatment accreditation criteria
Empirically -demonstrated model of change
Targeting criminogenic needs/dynamic risk factors
Programs are based on a comprehensive model of change that is supported by research
Programs target criminogenic needs directly associated with offending,
particularly dynamic risk factors with strong links to sexual recidivism.
The use of specific methods (e.g., cognitive, behavioural) demonstrated to
reduce sexual aggression and that are not general psychotherapy.
Treatment focuses on development and rehearsal of new skills that alter behaviour
and cognition to reduce risk and recidivism.
Frequency of contact is tailored to match offenders’ levels of risk and criminogenic
needs, with higher levels of intervention reserved for higher risk offenders.
Treatment is flexible and responsive to offenders’ personal and social characteristics
and is adapted accordingly; treatment maximizses clients’ motivation and engagement.
Follow-up/maintenance programs and supervision are provided to reinforce skills learned
and to ensure continuity in overall management of offenders.
To ensure programs are implemented as intended and research is conducted to ensure
Use of effective methods
Continuity of care
Ongoing program evaluation and monitoring
Curr Psychiatry Rep (2013) 15:348Page 5 of 8, 348
you/they like?” “You are not guilty because of your sexual
desire, but you are responsible for your sexual behavior.
There is help! Don’t be an offender!”).
As of August 2012, 1,740 individuals had made tele-
phone contact, 719 completed a baseline assessment, and
373 were eligible for treatment . Approximately one-
half of the Dunkelfeld patients admitted to a prior contact
offence against a child, and two-thirds reported use of child
pornography . Of those who had committed sexually
motivated crimes, 43 % had been detected at some point by
the criminal justice system (current involvement was an
exclusion criterion; ). The absolute number of offenders
who have completed treatment is still small (<100), but the
project does indicate that it is possible to recruit individuals
with pedophilia into treatment without the coercion of the
criminal justice system.
Individuals who have committed sexual crimes vary in their
risk for recidivism. For some offenders who have been
convicted of sexual crimes, their risk of being convicted of
a new sexual crime is no different from the risk presented by
individuals with no history of sexual crimes. Others present
substantial recidivism risk, both in the short- and long-term.
In general, the risk for sexual recidivism increases to the
extent that individuals have problems with sexual self-
regulation (deviant sexual interests, sexual preoccupation)
and difficulties conforming to the demands and expectations
of society (antisocial orientation). We believe that useful
guidance to the development of effective treatment pro-
grams for sexual offenders can be found in the accreditation
standards developed by national prison services and by the
application of the “what works” principles for interventions
with general offenders .
Further research is needed in which strong research
designs are used to evaluate the most promising treatment
approaches for sexual offenders. Currently, there is only one
strong study examining a currently plausible treatment for
adult sexual offenders: Marques and colleagues’ evaluation
of a relapse prevention program in California . This
study found no effects; however, it is difficult to generalize
their findings to other settings, as their results could have
been influenced by any number of incidental factors (e.g.,
hospital versus prison setting, therapists’ training). Strong
evaluations are unpopular with clinical program managers
because they require experimenters (not clinicians) to assign
offenders to treatment and control conditions. As well, long
follow-up periods (typically greater than 5 years) are re-
quired to accumulate sufficient statistical power .
Nevertheless, research using strong designs is both possible
and desirable .
No potential conflicts of interest relevant to this article
Papers of particular interest, published recently, have been
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