Article

A 25-Year Follow-Up of Cognitive/Behavioral Therapy With 7,275 Sexual Offenders

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Outcome data are presented, grouped into 5-year cohorts, for 7,275 sexual offenders entering a cognitive/behavioral treatment program. Assessment variables included treatment completion, self-admission of covert and/or overt deviant behaviors, the presence of deviant sexual arousal, or being recharged for any sexual crime (regardless of plea or conviction). It proved possible to follow 62% for the cohort at 5 years after initiating treatment, but follow-up completion rates decreased with time. Outcomes were significantly different based on offender subtype, with child molesters and exhibitionists achieving better overall success than pedophiles or rapists. Prematurely terminating treatment was a strong indicator of committing a new sexual offense. Of interest was the general improvement of success rates over each successive 5-year period for many types of offenders. Unfortunately, failure rates remained comparatively high for rapists (20%) and homosexual pedophiles (16%), regardless of when they were treated over the 25-year period. Implications for clinical practice and future research are drawn.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Those who attended a CBT/RP program re-offended at a lower rate (8.1%) than those who attended a 'group/behavioral/other' program (18.3%), an 'unspecified' program (13.6%), and untreated offenders (25.8%). Maletzky and Steinhauser (2002), in a study looking at treatment outcome over a 25-year follow-up of a CBT program for sex offenders (N = 7275), reported that child abusers had a better response to treatment (6.3% for those with female victims, 9.4% for those with male victims), than either exhibitionists (13.5%), or rapists (21.2%). Lösel and Schmucker (2005), in a meta-analysis of 69 studies (N= 22,181) found positive effects of treatment for extra-familial child abusers (most likely to be pedophilic) in nine studies (Odds Ratio (OR) = 2.15, Confidence Limits (CL) 1.11-4.16), ...
... Alexander (1999) found positive treatment effects (N = 331), in a meta-analysis of sex offender treatment, in that no exhibitionists (typically without a formal DSM diagnosis) who attended a CBT/RP program had recidivated, compared to 21% of those who attended a group/behavioral/ other program, and 57% of untreated samples. Maletzky and Steinhauser (2002), in a study looking at treatment outcome over a 25 year follow-up from a CBT program (N = 7275), reported that exhibitionists (13.5%) had a comparatively worse response to treatment, in terms of subsequent recidivism, than child abusers with female child victims (6.3%), and child abusers with male child victims (9.4%); but at a much lower rate than rapists (21.2%). ...
... The majority of treatment outcome evaluations do not examine the separate impact on rapists. However, Maletzky and Steinhauser (2002), in a study looking at treatment outcome over a 25-year follow-up for a CBT program for sex offenders (N = 7275), reported that rapists (21.2%) had a comparatively worse response to treatment than child abusers (6.3% for those with female child victims; 9.4% for those with male child victims) and exhibitionists (13.5%). Alexander (1999) reporting data on 528 rapists found no significant difference between the recidivism rates of treated (20.1%) and untreated rapists (23.7%). ...
Article
The aim of this chapter is to review the literature to determine whether there is support for evidence-based practice for paraphilias and sexual offending. The first section gives an overview of each of the DSM criteria plus an overview of offenses not well defined or covered in DSM (i.e., child molestation, rape, and Internet sexual offending). This is followed by material covering demographic criteria and impact of these problems on the individual and their victims. The second section examines the effectiveness of current treatments (behavioral, pharmacological, cognitive behavioral treatment, systemic) for (illegal) DSM paraphilias, and sexual offending more generally, taking account of whether these criteria meet the Chambless & Hollon (1998) criteria for evidence-based practice. There are currently too few well-designed studies to provide support for evidence-based practice with any of the paraphilias. There is, however, a growing body of evidence for the effectiveness of sex offender treatment from meta-analyses. In particular, support is provided for CBT approaches in each of the meta-analyses examining treatment outcome studies with mixed groups of sex offenders, and for child abusers alone, fulfilling Chambless and Hollon (1998) criteria. Keywords: paraphilias; sexual offenders; treatment; evidence-based practice
... There is no uniform agreement on how best to categorize sex offenders but most use some pragmatic combination of variables of interest, usually involving sex and/or age of victim (Bard et al., 1987;Bickley & Beech, 2001). While the research is not definitive, it suggests that rapists have higher rates of recidivism than child molesters and incest offenders (Alexander, 1999;Hanson et al., 2003;Langan et al., 2003;Maletzky & Steinhauser, 2002;Sample & Bray, 2006;Weinrott & Saylor, 1991). For example, Hanson and Bussiere (1998) conducted a metaanalysis of 61 sex offender recidivism studies and reported the mean sex re-offense rate over an average period of 4 to 5 years was approximately 13%; however, nearly 19% of rapists compared to 13% of child molesters committed recidivated sexually. ...
... This variation in recidivism rates between different types of sex offenders may be a reflection of how child molesters are categorized. Studies that further sub-divide child molesters by the sex of the victim have found that male victim child molesters sexually re-offended at a higher rate than rapists and female victim child molesters (Hanson & Harris, 2004;Maletzky & Steinhauser, 2002). ...
... As previously noted, evidence suggests variation in the recidivism rates of different types of sex offenders (Maletzky & Steinhauser, 2002;Serin et al., 2001). The study sample, although com prised primarily of child molesters, was nevertheless a mixed-group of sex offenders. ...
... As for response to treatment, Alexander (1999) found positive effects with exhibitionists (N = 331) in a metaanalysis of sex offender treatment, in that no exhibitionists (typically without a formal DSM diagnosis) who had undertaken cognitive-behavioral therapy (CBT) had recidivated, compared to 21% of those who attended a group/behavioral/other program, and 57% of untreated samples. In contrast, Maletzky & Steinhauser (2002) investigated outcome over a 25-year follow-up from a CBT program (N = 7,275) and reported that exhibitionists (13.5%) had a comparatively worse response to treatment in comparison with child molesters with female child victims (6.3%) or with male child victims (9.4%), but the response was better than that found in rapists (21.2%). ...
... However, many studies have examined treatment outcome for men who have sexually abused children (e.g., Hanson et al. 2002, Lösel & Schmucker 2005. For example, in a study looking at treatment outcome over a 25-year follow-up of a CBT program for sex offenders (N = 7,275), it was reported that child abusers had a better response to treatment (6.3% for those with female victims, 9.4% for those with male victims) than either exhibitionists (13.5%) or rapists (21.2%) (Maletzky & Steinhauser (2002). A meta-analysis of 69 studies (N = 22,181) found positive effects of treatment for extrafamilial child abusers (most likely to be pedophilic) in nine studies but not for intrafamilial molesters in 10 studies (Lösel & Schmucker 2005), which is an indication of treatment efficacy for those diagnosed with pedophilic disorder. ...
Article
Full-text available
This review summarizes and critically examines the changes in how the Diagnostic and Statistical Manual of Mental Disorders (DSM) characterizes paraphilias. Attention is paid to the diagnostic options that were included in DSM-5, the decision not to include criterion sets for two additional disorders (paraphilic coercive disorder and hypersexual behavior disorder), and the further decision not to modify the diagnosis of pedophilic to pedohebephilic disorder. The three most significant changes are (a) the move to distinguish paraphilias from paraphilic disorders (allowing unusual sexual interests to be studied by researchers but only regarded as disorders when they cause distress or dysfunction), (b) introducing criteria describing paraphilic disorders as being in remission (when they no longer cause distress or dysfunction), and (c) clarifying the relationship between behavior and paraphilias. Concerns are noted about the forensic use of diagnoses and the lack of funding for field trials in this revision of the DSM. Suggestions are given for future directions in order to further research efficacy and clinical diagnosis. Expected final online publication date for the Annual Review of Clinical Psychology Volume 12 is March 28, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
... Sexual offender maintenance programs appear to be necessary, especially given that a deterioration of an offender's awareness of his risk factors and relapse prevention strategies have been described as risk factors to reoffending (Craig, Brown, & Stringer, 2003). Studies often note that the highest risk period for some sexual offenders is the first few years after release (Harris & Hanson, 2004;Maletzky & Steinhauser, 2002). Despite recognition that sexual offending can be a lifelong issue for some of these offenders, there is little research or experience to guide clinicians and correctional agencies in deciding what is sufficient input to maintain treatment gains. ...
... The question regarding whether or not child molesters and rapists should be together within a group still remains debatable despite most sex offender treatment programs including both types of offenders (Lösel & Schmucher, 2005). Research has indicated that there are several key differences between child molesters and rapists, including: different offense pathways (Polaschek, Hudson, Ward, & Seigert, 2001), cognitive distortions (Ward, Hudson, & McCormack, 1997), deviant sexual arousal (Allam, Middleton, & Browne, 1997;Eher, Neuwirth, Fruehwald, & Frottier, 2003), attachment styles (Polaschek & King, 2002), and rate of recidivism (Harris & Hanson, 2004;Maletzky & Steinhauser, 2002;Pithers & Cumming, 2005). ...
Article
While optimism regarding the treatment of sexual offenders has increased over the past couple of decades, research into the factors that assist offenders in maintaining therapeutic changes remains in the dark. Maintenance programs for offenders, while theoretically appearing to have a solid place in offender rehabilitation, surprisingly have not been explored in detail with very little information or research examining the operationalization of such programs. The present article briefly reviews the literature available and poses some of the outstanding conceptual and practical issues regarding maintenance programs, such as program duration, intensity, content, and format.
... For example, in a recent study of sexuality, 9 % of 363 men surveyed anonymously disclosed having sexual fantasies about children, while 4 % indicated having engaged in sexual contact with a child (Beier et al. 2006). Despite the limited body of research investigating the offending rates of MAPs, multiple studies have indicated that the majority of those who have committed child sexual abuse are not MAPs; these studies have found that only 30-50 % of those who have committed a sex offense against a child are minorattracted (Blanchard et al. 2001;Seto et al. 2003;Maletzky and Steinhauser 2002;Seto and Lalumière 2001). ...
... This is no different in criminal justice and criminology: MAPs have traditionally been focused on by these fields exclusively as sex offenders. Numerous articles have detailed offending patterns, recidivism rates, treatment outcomes, and risk levels of those MAPs who have committed offenses against children (e.g., Beier 1998;Finkelhor 1991;Firestone et al. 2000;Hall and Hall 2007;Maletzky and Steinhauser 2002;Prentky et al. 1997;Rösler and Witztum 1998;Schober et al. 2005;Vandiver 2006). Even work by McDonald (2016) examining pedophilia in a queer context makes the assumption that pedophiles are all child molesters, which illustrates dominant conceptual frames. ...
Article
Full-text available
Despite a cultural tendency to sexualize youth, individuals who are primarily attracted to minors are subject to suspicion and stigma across society, extending into criminology and criminal justice. The prevailing assumption is that minor-attracted persons (MAPs) are mentally ill and predatory. However, there exists evidence that minor attraction is a sexual orientation, and the parallels between the treatment of MAPs and LGBT populations are striking. Employing queer criminology’s use of deconstructionist techniques, we address the current state of criminology and criminal justice, which sees MAPs as a suspect population warranting formal control. We then argue for the use of queer criminology as a framework for future research with minor-attracted populations, which could have important implications for criminal justice practice and policy.
... Not all child sexual offenders (CSO) have paedophilic disorders; similarly not all paedophilic men necessarily commit child sexual abuse. The proportion of paedophilic disorders among CSO is about 40-50% (Maletzky and Steinhauser 2002;Seto 2008). Conversely, the proportion of men with paedophilia who sexually abused children is about 43% . ...
... The efficacy of CBT for sex offenders is such as to indicate a modest reduction in recidivism (Losel and Schmucker 2005), but this is challenged by studies with more extended follow-up periods (Kenworthy et al. 2004;Maletzky and Steinhauser 2002) and recent reviews (Dennis et al. 2012;Walton and Chou 2015;Grønnerød et al. 2015;Gannon et al. 2019) (Level C/D of evidence). The other approaches (insight-oriented treatment, therapeutic communities and other psychosocial programmes) do not seem to reduce recidivism (Level E of evidence). ...
... Not all child sexual offenders (CSO) have paedophilic disorders; similarly not all paedophilic men necessarily commit child sexual abuse. The proportion of paedophilic disorders among CSO is about 40-50% (Maletzky and Steinhauser 2002;Seto 2008). Conversely, the proportion of men with paedophilia who sexually abused children is about 43% . ...
... The efficacy of CBT for sex offenders is such as to indicate a modest reduction in recidivism (Losel and Schmucker 2005), but this is challenged by studies with more extended follow-up periods (Kenworthy et al. 2004;Maletzky and Steinhauser 2002) and recent reviews (Dennis et al. 2012;Walton and Chou 2015;Grønnerød et al. 2015;Gannon et al. 2019) (Level C/D of evidence). The other approaches (insight-oriented treatment, therapeutic communities and other psychosocial programmes) do not seem to reduce recidivism (Level E of evidence). ...
Article
Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care. Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990−2018 for SSRIs) (1969−2018 for hormonal treatments), supplemented by other sources, including published reviews. Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders. Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.
... Even if pedophilia is known as the major risk factor for committing CSO, pedophilia is neither sufficient nor necessary for CSO (Seto, 2008;Seto et al., 2006). Investigations among convicted child sexual abusers show that about 50% of all offenses are committed by non-pedophilic CSO (Maletzky and Steinhauser, 2002). Reliable authoritative numbers are a pressing need, currently there are only speculations about the proportion of non-preference specific CSO, as most CSO are not reported (Hanson et al., 1999). ...
Article
Background Child sexual abuse and neglect have been related to an increased risk for the development of a wide range of behavioral, psychological, and sexual problems and increased rates of suicidal behavior. Contrary to the large amount of research focusing on the negative mental health consequences of child sexual abuse, very little is known about the characteristics of child sexual offenders and the neuronal underpinnings contributing to child sexual offending. Methods and sample This study investigates differences in resting state functional connectivity (rs-FC) between non-pedophilic child sexual offenders (N = 20; CSO-P) and matched healthy controls (N = 20; HC) using a seed-based approach. The focus of this investigation of rs-FC in CSO-P was put on prefrontal and limbic regions highly relevant for emotional and behavioral processing. Results Results revealed a significant reduction of rs-FC between the right centromedial amygdala and the left dorsolateral prefrontal cortex in child sexual offenders compared to controls. Conclusion & recommendations Given that, in the healthy brain, there is a strong top-down inhibitory control of prefrontal over limbic structures, these results suggest that diminished rs-FC between the amygdala and the dorsolateral prefrontal cortex and may foster sexual deviance and sexual offending. A profound understanding of these concepts should contribute to a better understanding of the occurrence of child sexual offending, as well as further development of more differentiated and effective interventions.
... Pedophilia, i.e. the sexual preference disorder, is one of the most important risk factor for actual child sexual offending (CSO) (Seto, 2008). However, only about half of all sexual offenses against children are being committed by pedophiles and it is estimated that only about 50% of pedophiles engage in CSO throughout their lifetime (Maletzky and Steinhauser, 2002). Thus, pedophilia and CSO are interrelated but distinct phenomena. ...
Article
Pedophilia is a sexual preference that is often associated with child sex offending (CSO). Sexual urges towards prepubescent children and specifically acting upon those urges are universally regarded as immoral. However, up until now, it is completely unknown whether moral processing of sexual offenses is altered in pedophiles. A total of 31 pedophilic men and 19 healthy controls were assessed by using functional magnetic resonance imaging (fMRI) in combination with a moral judgment paradigm consisting of 36 scenarios describing different types of offenses. Scenarios depicting sexual offenses against children compared to those depicting adults were associated with higher pattern of activation in the left temporo-parietal-junction (TPJ) and left posterior insular cortex, the posterior cingulate gyrus as well as the precuneus in controls relative to pedophiles, and vice versa. Moreover, brain activation in these areas were positively associated with ratings of moral reprehensibility and negatively associated with decision durations, but only in controls. Brain activation, found in key areas related to the broad network of moral judgment, theory of mind and (socio-)moral disgust - point to different moral processing of sexual offenses in pedophilia in general. The lack of associations between brain activation and behavioral responses in pedophiles further suggest a biased response pattern or dissected implicit valuation processes.
... Even if pedophilia is known as the major risk factor for committing CSO, pedophilia is neither sufficient nor necessary for CSO (Seto, 2008;Seto et al., 2006). Investigations among convicted child sexual abusers show that about 50% of all offenses are committed by non-pedophilic CSO (Maletzky and Steinhauser, 2002). Reliable authoritative numbers are a pressing need, currently there are only speculations about the proportion of non-preference specific CSO, as most CSO are not reported (Hanson et al., 1999). ...
... Indirect evidence suggests that there is a significant prevalence. Among sexual offenders, Seto and Lalumière (2001), in a sample of 1113 sex offenders, reported that 40% showed equal or greater arousal to stimuli depicting children as compared with adult stimuli (suggesting pedophilia), and Maletzky and Steinhauser (2002) reported that 43% of 5223 sex offenders in their sample were diagnosed as being pedophiles. National surveys report a significant occurrence of child sexual abuse. ...
Chapter
This chapter reviews the major paraphilic disorders included in DSM-5. Voyeurism and exhibitionism are among the most common paraphilic disorders in clinical studies. The study of neurobiological factors and paraphilic disorders is in its infancy, but it is clear that they play a significant role in paraphilic behavior and paraphilic disorders. Treatment of individuals with paraphilic disorders varies greatly according to whether or not the legal system is involved. Given the large variety of potential paraphilic disorders and the many comorbid conditions associated with them, treatment must be tailored to the specific individual. Therapist “burnout” is clearly an issue, and clinicians need to continue to monitor their transference towards their patients. Constant attention needs to be paid to the risks posed for the patient of harming self or others and plans made to act accordingly. Clinicians should be aware of the child abuse-reporting statutes in their jurisdiction.
... Research suggests that treatment effects vary in proportion to the severity of offences committed, on a continuum ranging from "situational child molesters" to "predatory paedophiles and rapists" (Maletzky & Steinhauser, 2002). In the papers reviewed, the lack of disaggregation of outcome data for different types of offenders leaves the data difficult to interpret. ...
Article
Background: Despite considerable advance and growth in the evidence base for psychological interventions as treatment for sex offenders with intellectual disabilities (ID), there remains limited evidence to support their effectiveness. This systematic review seeks to evaluate the effectiveness of psychological interventions on reducing reoffending rates for sex offenders with ID. Methods: A search of ten electronic databases, grey literature and reference lists was conducted using PRISMA methodology. Results: A number of studies appeared to establish positive treatment outcomes, demonstrated by improvements in attitudinal change, victim empathy and sexual knowledge. However, reductions in sexual reoffending during the follow-up period were not consistent across the studies. No studies with an adequate control comparison were identified during the search. Conclusions: The current review provides limited evidence on the effectiveness of psychological interventions for sex offenders with ID, while also highlighting the need for further research.
... Of course, child molestation and pedophilia do not equate. However, previous research has established that some child molesters have clinically significant deviant sexual interests, including pedophilia and paraphilias (Blanchard, Klassen, Dickey, Kuban, & Blak, 2001;Maletzky & Steinhauser, 2002). The present study will examine the constructs related to sexual impulsivity and compulsivity among four different groups of offenders: general offenders, child molesters, rapists, and mixed offenders. ...
Article
It is suspected that rapists, child molesters, and offenders with both child and adult victims (mixed offenders) may have different motivations and offending patterns—that they are heterogeneous. A central difference between these groups of offenders may be their propensity toward sexually impulsive behaviors and compulsive behavior. Analyses were conducted to assess the mean differences between the various offender types across four measures related to sensation seeking and compulsivity as well as several other proxy behavioral measures. Results suggest that there are differences in sexual impulsive and compulsive behavior among the different types of offenders. Treatment implications are discussed.
... As already mentioned, the term pedophilia is problematic, since it is often used to describe all sexual offenders against children, including those who do not meet the diagnostic criteria. Individuals committing sexual crimes against children are criminals, but estimates for the proportion of pedophilic people involved in the overall number of sexual offenses range between 12-20% [20] and 50% [7,[9][10][11][12]. Based on a biopsychosocial model of disease-which is composed of the individual, the disease and the crime-fundamental insights into aspects of pedophilia have been obtained. ...
Article
Sexual abuse of children is an important societal problem: up to 20% of children have been approached by an adult in a sexual context or have been victims of sexual abuse. Approximately half of sex offenses against children are perpetrated by individuals with a diagnosis of pedophilia. The identification, management and treatment of sexual offenders with pedophilia are key tasks in forensic psychiatry. Pedophilia can be divided into several subtypes, based on factors such as the age of the preferred target. Recent research has begun to elucidate possible psychological and neurobiological mechanisms underlying pedophilia. Neuroimaging studies have identified abnormalities in the emotional processing of sexual stimuli in pedophilic offenders. In the future, findings such as these may assist forensic psychiatrists in classifying sexual offenders, and perhaps in developing therapeutic interventions and assessing treatment response.
... Of course, child molestation and pedophilia do not equate. However, previous research has established that some child molesters have clinically significant deviant sexual interests, including pedophilia and paraphilias (Blanchard, Klassen, Dickey, Kuban, & Blak, 2001; Maletzky & Steinhauser, 2002). The present study will examine the constructs related to sexual impulsivity and compulsivity among four different groups of offenders: general offenders, child molesters, rapists, and mixed offenders. ...
Article
It is suspected that rapists, child molesters, and offenders with both child and adult victims (mixed offenders) may have different motivations and offending patterns—that they are heterogeneous. A central difference between these groups of offenders may be their propensity toward sexually impulsive behaviors and compulsive behavior. Analyses were conducted to assess the mean differences between the various offender types across four measures related to sensation seeking and compulsivity as well as several other proxy behavioral measures. Results suggest that there are differences in sexual impulsive and compulsive behavior among the different types of offenders. Treatment implications are discussed.
... las personas que abusan de un menor puedan ser diagnosticados de pedofilia. La prevalencia del diagnóstico de pedofilia en muestras de abusadores de menores es de aproximadamente del 50% (Maletzky y Steinhauser, 2002;Seto y Lalumière, 2001). En usuarios de pornografía infantil este porcentaje se eleva a un 60% (Seto, Cantor y Blanchard, 2006). ...
Article
Full-text available
El interés sexual hacia menores ofrece numerosas dificultades para su evaluación, principalmente, la motivación para ocultarlo en contextos forenses. Su asociación con la reincidencia en delitos sexuales y su utilidad como medida del éxito terapéutico han impulsado el desarrollo de distintas técnicas de evaluación. En este artículo se revisan los autoinformes, la pletismografía peneana y varias medidas cognitivas basadas en la latencia de respuesta. Aunque todas las técnicas presentan limitaciones en cuanto a su manipulación y a su capacidad discriminativa, las baterías multimétodo parecen ofrecer la mejor alternativa y son una vía de investigación futura.
... Even if pedophilia is known as the major risk factor for committing CSO, pedophilia is neither sufficient nor necessary for CSO (Seto, 2008;Seto et al., 2006). Investigations among convicted child sexual abusers show that about 50% of all offenses are committed by non-pedophilic CSO (Maletzky and Steinhauser, 2002). Reliable authoritative numbers are a pressing need, currently there are only speculations about the proportion of non-preference specific CSO, as most CSO are not reported (Hanson et al., 1999). ...
Conference Paper
Introduction Pedophilia is a disorder where sexual preferences of adults are directed towards children. This disorder impacts society with 1–2 out of every 10 children being sexually approached by an adult, often resulting in prolonged negative psychological effects. Prior research reported structural and functional amygdala alterations in pedophilia. As the neurophenomenological model of sexual arousal suggests the importance of the amygdala in the emotional component, we focused on amygdala functional connectivity in pedophilia. Aims To investigate amygdala functional connectivity (FC) modulated by expectancy and salient stimuli in pedophilic patients. Methods Thirteen pedophilic patients and 13 matched healthy controls underwent a salience expectancy task in a 7T ultra high fMRI study. Subjects perceived pictures of naked adults and children. Half of the pictures were preceded by an expectancy cue. Participants were instructed to actively expect the picture depending on the cue. We conducted psychophysiological analysis (PPI) to examine amygdala FC changes in two amygdala sub-regions for child/adult stimuli during the expectancy period and the visual stimuli consummation period using as seed regions the basolateral (BLA) and central nucleus of the amygdala (CeA). Results Healthy controls, relative to patients showed significant stronger left CeA to right post-central gyrus FC during expectancy of adult > child picture. For picture condition (adult > child picture) we found significant stronger left CeA to left dorsolateral prefrontal cortex FC in patients compared to healthy controls. Conclusion These findings add to the recent literature by indicating that amygdala dysfunctional connectivity is involved in development of deviant sexual behavior.
... In both cases, the offender does not necessarily have a primary sexual interest in children. In fact, half of child sex offences are perpetrated by individuals who do not meet diagnostic criteria for paedophilia (Blanchard et al. 2001, Maletzky andSteinhauser 2002). Other mental illnesses, psychological conditions or learning difficulties can have an influence on whether or not someone will engage in a sexual relation with a child (Bickley andBeech 2001, Howitt 1995). ...
Article
Full-text available
Responsible Research and Innovation (RRI) is a science policy concept that gained traction from 2000 onwards in the EU and US, in which alignment on purposes and values between different stakeholders is a key aspect. This thought experiment problematizes this particular notion: ethically acceptable and societally desirable outcomes are not necessarily achieved when alignment is a consequence of early closure. To argue this point, we took the example of the potential development of scanning technology for the detection of paedophilia among job applicants, for which indicators of broad societal support were found in an RRI project on neuroimaging. We analysed this case by looking through several lenses, obtained by structured and non-structured literature searches. We explored how facts and values are masked when a taboo topic is considered. This results in the black boxing of the problem definition, potential solutions and development trajectories. Complex unstructured problems can thus be perceived as manageable structured problems, which can in turn lead to irresponsible policies surrounding technology development. Responsible processes of research and technology development thus require the involvement of a critical reflector who is alert to signs of early closure and who prevents foreclosure of ongoing reflexive deliberation. There is an important role for ethical, legal and societal aspect studies within the framework of RRI. This paper shows that the concepts of “value/fact diversity masking” and “early discursive closure” are new avenues for RRI research.
... The DSM-5 (APA, 2013), however, no longer classifies pedophilia as a mental disorder but instead defines pedophilic disorder, in which either the sexual urges must cause marked distress or interpersonal difficulty in the individual or the individual must have acted on these sexual urges. Depending on the sample characteristics and diagnostic criteria, between 30% and 70% of all convicted child sexual offenders are diagnosed with pedophilia (Kingston, Firestone, Moulden, & Bradford, 2007;Maletzky & Steinhauser, 2002;Seto & Lalumière, 2001;Wilson, Abracen, Looman, Picheca, & Ferguson, 2011). ...
Article
Child sexual offenders have been found to have a lower average IQ than the general population. Several studies indicate that they also exhibit executive dysfunction, but the specificity of this dysfunction is unclear; the inconclusive results have been attributed to methodological problems and the heterogeneity of the population. Our study aimed to describe the neuropsychological profiles of convicted child sexual offenders with pedophilia (n = 15). To control for IQ-related effects on neuropsychological performance, we compared the sample with an IQ-matched control group (n = 15). Test scores in both groups were significantly lower than the norms, but we did not find significant differences between the two study groups. The findings of our pilot study indicate that the neuropsychological deficits of pedophilic sexual offenders are unspecific rather than the result of a pedophilia-specific brain dysfunction.
... 268 Nevertheless, adult survivors of CSA who have overcome some of these barriers have found they may have a tort action in some jurisdictions against passive parents in the cases of incestuous families. 269 Some reformers have suggested that developments in the science of CSA over the past twenty or more years 270 have set the stage for drafting a restatement of CSA law. 271 Still, others suggest that enacting criminal statutes that hold institutional decision-makers criminally liable for their roles in instances of clergy CSA would help to prevent such episodes from going forward. ...
Article
Full-text available
I. Introduction II. Defining and Attempting to Understand Pedophilia III. Delays in Reporting Childhood Sexual Abuse by Victim IV. Institutional Protection for Sexual Abusers of Children V. Politicians and Sexual Scandals VI. Differentiating Accusations from Convictions VII. Statutes on Child Molestation VIII. Presidential Support for Electing an Accused Pedophile IX. Conclusion
... While there are currently no estimates of the percentage of MAPs who have committed sexual offenses against a child, due at least in part to the stigma associated with attractions to children and the hidden nature of the population of MAPs (Hall & Hall, 2007), research does indicate that the number of individuals who are attracted to minors is greater than the number of individuals likely to commit an offense (Beier, Alhers, Schaefer, andFeelgood, 2006, as cited in Seto, 2008;Briere & Runtz, 1989;Cantor & McPhail, 2016;Okami, 1994, as cited in Levine, 2002). Additionally, various studies have shown that between 50 and 70% of individuals who do commit sexual offenses against children are not MAPs-these individuals are not preferentially attracted to minors (Blanchard, Klassen, Dickey, Kuban, & Blak, 2001;Maletzky & Steinhauser, 2002;Seto & Lalumière, 2001;Seto, Murphy, Page, & Ennis, 2003). This research suggests most sex offenders who target minors do so for opportunistic reasons: power dynamics existing in modern society make children easier potential targets of sexual victimization than adults, and individuals who offend against children in the absence of pedophilia or hebephilia may be taking advantage of this rather than acting because of a persistent attraction to minors. ...
Article
Largely based on an erroneous belief that individuals who are preferentially attracted to minors are necessarily sex offenders, queer communities have distanced themselves from this population over the past several decades. There are now those who object to the use of labels such as “gay” and “queer” by minor-attracted people (MAPs), raising the question, “to whom do queer-spectrum identity labels belong?” I engage with this question using data from my research with 42 MAPs, exploring their uses of queer-spectrum identity labels and the conflicts they have encountered regarding their use of these terms. I then discuss the potential consequences of accepting the use of these labels by MAPs.
... 35 Based on a detailed interview, all of these cases were considered to meet ICD-10 diagnostic requirements for a paraphilic disorder, with nearly three-quarters meeting requirements for pedophilia. Although these figures are generally consistent with the figures from other studies, 36,37 they are also likely influenced by other factors. First among these is the much greater likelihood of prosecution, conviction, and incarceration for sexual behavior involving children, for which prison sentences are mandatory, as compared with other types of sexual crimes in Mexico. ...
Article
Introduction: The World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), recently approved by the World Health Assembly. The most important is to limit paraphilic disorders primarily to persistent and intense patterns of atypical sexual arousal involving non-consenting individuals, manifested through persistent sexual thoughts, fantasies, urges, or behaviors, that have resulted in action or significant distress. Aim: To analyze the legal, regulatory, and policy implications of the changes in the ICD-11 classification of paraphilic disorders for forensic practice, health systems, adjudication of sex offenders, and the provision of treatment in Mexico. Methods: An expert Mexican advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO. Main Outcome Measures: The WHO assessment guide covered (i) laws related to sexual behaviors; (ii) the relationship between legal and clinical issues for non-forensic health professionals; (iii) implications of mental disorder classification for forensic practice; (iv) other implications of ICD-11 paraphilic disorders proposals; and (v) contextual issues. Results: A variety of factors in Mexico make it highly unlikely that appropriate, evidence-based treatments for paraphilic disorders will be provided to those who need them, even if they seek treatment voluntarily and have not committed a crime. Mexican law focuses on the punishment of specific sexual behaviors rather than on underlying disorders. A paraphilic disorder would not be considered sufficient grounds for exemption from criminal responsibility. The application and scope of mental health evaluations in Mexican legal proceedings are quite limited, and individuals who commit sexual crimes almost never undergo forensic evaluations to establish the presence of paraphilic disorders. Psychiatric services may be mandated for sex offenders in highly specific circumstances but cannot exceed the duration of the criminal sentence. Clinical Implications: Evaluation and treatment guidelines should be developed based on international evidence and standards and promulgated for use with individuals with paraphilic disorders in forensic and non-forensic poopulations. The much greater specificity and operationalization of the ICD-11 guidelines as compared with the ICD-10 guidelines provide a better basis for identification and case formulation. Strengths & Limitations: Major strengths of this analyses were that it was conducted to facilitate international comparability across several participating countries and the fact that it was conducted by a diverse multidisciplinary group representing various relevant legal, forensic and and clinical sectors. A limitation was that it was only possible to examine relevant federal laws and those of Mexico City rather than those of all 32 Mexican states. Conclusion: The descriptions of paraphilic disorders in the ICD-11 could support substantial improvements in the treatment of individuals with paraphilic disorders and the adjudication of sex offenders in Mexico, but specific changes in Mexican law would be required.
... In the media and amongst the general public, the terms are often used synonymously, but a large portion of child sex offenders do not have a sexual preference for children (Seto 2008). In fact, only 40% to 50% of individuals who sexually offend against children are thought to meet the clinical diagnosis for pedophilia (Maletzky & Steinhauser 2002;Seto 2008). Further, meeting the clinical diagnosis for pedophilia, including exhibiting sexual urges towards children as well as interpersonal difficulties controlling those urges, does not always result in an individual acting upon those urges (Ames & Houston 1990). ...
Chapter
Full-text available
This chapter explores how structural and functional neuroimaging research on brain abnormalities observed in individuals with pedophilia might potentially influence orthodox legal perspectives on retribution and rehabilitation concerning pedophilic sex offenders in the justice system. Knowledge regarding the neural abnormalities associated with pedophilic disorder could possibly reduce retributive sentiments of judges and juries toward diagnosed sex offenders and, most importantly, lead to more receptive attitudes toward rehabilitative punishments and treatments for these offenders in order to better combat pedophilic sexual offending. Three nascent treatments that seek to target affected brain regions in pedophilic individuals, which may one day serve as viable rehabilitative punishment options to deter sexual offending, are also discussed.
... Blandt personer, som er dømt for seksualkriminalitet mod børn, er 30-50% (inklusive danske dømte) diagnosticeret med ICD/DSM-paedofili [2, [18][19][20][21][22]. Variationen afspejler forskelle i samples og diagnostik. ...
Article
Full-text available
In this review, we discuss paedophilia, which is a persistent and intense sexual interest in prepuberty children. Paedophilia is related to but not identical to sexual offending. Valid and reliable identification of paedophilia is complicated. In Denmark there is a need for intensifying primary and secondary preventive interventions aimed at increasing the number of individuals with paedophilia seeking treatment. Paedophilia has the same or a higher prevalence than other severe psychiatric disorders. Yet, in Denmark, this research field is delayed in comparison to research into other psychiatric disorders.
... Nevertheless, future studies should recruit a larger sample of PP participants and control participants with matched sexual gender preference. This would allow a more systematic examination of the influence of the sexual preferred age and gender, which is important, as male offenders with pedophilic interest and male victims have been identified as a risk factor for recidivistic offenses [64][65][66][67][68]. Third, the control group comprised individuals with moderate to pathological consumption of video gaming or media use. ...
Article
Full-text available
Child sexual abuse offences (CSOs) represent a severe ethical and socioeconomic burden for society. Juveniles with a sexual preference for prepubescent children (PP) commit a large percentage of CSOs, but have been widely neglected in neurosci-ence research. Aberrant neural responses to face stimuli have been observed in men with pedophilic interest. Thus far, it is unknown whether such aberrations exist already in PP. A passive face-viewing paradigm, including the presentation of child and adult faces, was deployed and high-density electroencephalography data were recorded. The study group comprised 25 PP and the control group involved 22 juveniles with age-adequate sexual preference. Attractiveness ratings and evoked brain responses were obtained for the face stimuli. An aberrant pattern of attractiveness ratings for child vs. adult faces was found in the PP group. Moreover, elevated occipital P1 amplitudes were observed for adult vs. child faces in both groups. At longer latency (340-426 ms), a stronger negative deflection to child vs. adult faces, which was source localized in higher visual, parietal and frontal regions, was specifically observed in the PP group. Our study provides evidence for enhanced neural processing of child face stimuli in PP, which might reflect elevated attention capture of face stimuli depicting members from the sexually preferred age group. This study expands our understanding of the neural foundations underlying sexual interest in prepubescent children and provides a promising path for the uncovering of objective biomarkers of sexual responsiveness to childlike body schemes in juveniles.
... The conventional wisdom seems to support the view that most sex offenders are strangers and that all sex offenders are uncontrollable pedophiles that cannot be rehabilitated. Past research tells us that very few people actually convicted of a sexual offense are diagnosed as pedophiles (Kingston, Firestone, Moulden, & Bradford, 2007;;Maletzky & Steinhauser;Seto &Lalumière, (2001; Kristen M. Zgoba et. al 2008) Empirical data also tells us that overall sex offenders sexually recidivate at relatively low levels, anywhere from seven to fourteen percent (Hanson & Morton-Bourgon, (2005) and Hanson & Bussiere (1998). ...
... In a recent self-report study, 8.4% of men with sexual attractions to children reported being arrested or convicted of a contact offense against a child, while 15.2% reported arrest or conviction of any sexual offense against a child, including a pornography offense (Bailey et al., 2016). In addition, most research on this subject indicates that a large proportion to the majority of people who do commit sexual offenses against children do not fit the diagnostic criteria for pedophilia (Kingston et al., 2007;Maletzky & Steinhauser, 2002;Seto et al., 2003Seto et al., , 2017Seto & Lalumiére, 2001; for a review, see Seto, 2018). It may be that the majority of individuals who commit sex offenses against children do so for opportunistic reasons rather than because they are preferentially attracted to them. ...
Article
This study explores future mental health providers’ assumptions about minor-attracted people, using data from a survey of 200 students preparing for entry into social service professions at a public university in the state of Utah. Survey results show that more than half of the students believe clients who identify themselves as pedophiles must be automatically reported to the police, which has implications for providers’ understandings about the term “pedophile,” as well as their knowledge of guidelines for when clinicians may break client confidentiality. This belief was not significantly affected by taking ethics courses, nor courses that discussed mandated reporting guidelines. Despite this finding, 91% of students did not believe that they would need to report a client who had attractions to children, but who had never committed a sexual offense against a child. The majority of students indicated a willingness to work with minor-attracted clients, and commonly indicated in comments that they wanted more information about MAPs and when to break client confidentiality in their programs of study. Study results indicate a need for education among social service students about these issues.
... Working with a different population, Maletzky and Steinhauser (2002) examined treatment failure rates of 7,275 sex offenders who entered cognitive-behavioral treatment. ...
Article
The Static-99 is an established risk assessment instrument designed for use with adult male sex offenders. This instrument demonstrates significant utility, but because of the importance of making accurate decisions regarding the dangerousness of sex offenders, improving the accuracy of the instrument is critical. The current study examined whether the addition of data from the Antisocial Features and Aggression scales of the Personality Assessment Inventory (PAl) would improve the predictive power of the Static-99 in a sample of 72 adult male sex offenders evaluated at a community clinic. Neither the Static-99 nor any of the modifications incorporating the PAl scales significantly predicted sexual rearrest or sexual reconviction during the follow-up period, which averaged 5.2 years. Implications of these findings are discussed in the context of the sample characteristics.
... Therefore, CSOs can be grouped in those: (1) without a sexual preference for children that have sexually abused children (e.g., sexually inexperienced adolescents seeking a surrogate; persons with antisocial personality disorders or perpetrators within general traumatizing family constellations; Seto, 2008), and, (2) with a sexual preference for children (e.g., paedophilia and/or hebephilia). The proportion of paedophiles in CSOs is about 40-50% (Maletzky and Steinhauser, 2002;Seto and Lalumiere, 2001;Seto, 2008). Conversely, the proportion of paedophiles who sexually approach children seems to be similarly high with about 43% (Seto et al., 2006). ...
Chapter
Elles constituent un élément fondamental dans la stratégie de prise en charge du patient. Cependant leur efficacité dans la réduction à long terme du risque de récidive de crimes et délits sexuels demeure discutée. Certains auteurs insistent sur l’importance d’associer des traitements pharmacologiques aux psychothérapies chez les sujets pédophiles [1, 2].
Article
Cynicism about treatment of sex offenders pervades both professional and lay literature. A Cochrane review of randomized controlled trials concluded there is no evidence to support any psychological intervention for sex offenders, but RCT design has limitations for evaluating sex offender treatment. Rarely has a qualitative approach been used to explore perceptions of offenders themselves about their psychotherapy experiences. The purpose of this study was to discover the meaning of therapy experiences to 11 community-dwelling perpetrators of child sexual abuse. They had received therapy during incarceration or after release, or both. Secondary analysis was conducted of phenomenological interviews about participants’ early life, during which they spontaneously revealed insights gleaned during therapy in adulthood. Rigor of the analysis was enhanced by reading transcripts aloud and thematizing them in an interdisciplinary interpretive group. Five interrelated themes constituted a gestalt comprising the essence of the therapy experience: “This treatment, it’s just totally changed my whole world.” Themes included: “It just stripped away all the pretense, all the lies, all the manipulation;” “I didn’t understand myself; I found out all about myself through this;” “Nobody knew any of my secrets; that (therapy) was the first time that I got to tell my story;” “The group has become a family for me;” and “I’m very ashamed of what I’ve done; this treatment has really helped me, gave me a second chance.” These findings stand in contrast to cynicism about sex offender therapy and lend support to the increased optimism expressed by several contemporary scholars.
Book
Full-text available
Руководство отражает современные методологические и методические принципы проведения судебных сексологических экспертных исследований в соответствии с теоретическими и правовыми основами экспертизы в России. Дано целостное освещение предмета комплексной сексолого-психиатрическои экспертизы и проблематики, связанной с юридически значимыми сексуальными расстройства¬ми. Изложены стратегия и тактика предметных видов сексологических исследований: экспертизы обвиняемых и потерпевших, по факту смерти и др. Детально освещены методические вопросы сексологического освидетельствования в судебной психиатрии (психофизиологическое обследование и методы направленного психологического исследования сексуальной сферы). Представлены также принципы неэкспертных видов исследования (профилирование при серийных сексуальных деликтах) и осуществления мер медицинского характера в отношении лиц с парафилиями. Целью руководства является оптимизация процедуры экспертных исследований, повышение надежности и обоснованности их выводов. Для психиатров, сексологов, психологов, криминологов и работников правоохранительных органов.
Article
Paraphilic disorders are characterized by recurrent, intense, sexually arousing fantasies, urges, or behaviors, over a period ≥6 months, generally involving nonhuman objects, suffering, or humiliation of oneself or one's partner, children, or other non-consenting persons. These fantasies, urges, and behaviors produce clinically significant distress or impairments in social, occupational, and other important areas of functioning. Only a part of paraphilic behaviors may lead to sex offenses and vice versa; not all sex offenders suffer from a paraphilia. A sex offense, a major public health concern, is defined as any violation of established legal or moral codes of sexual behavior. Current treatment interventions of paraphilic sex offenders tend to integrate psychotherapy with pharmacological therapy, using psychotropic drugs and/or hormonal approaches. © 2014 Springer International Publishing Switzerland. All rights reserved.
Chapter
The diversity of sexual urges and behaviors underlying the term “paraphilia” becomes problematic not only when defining the term, but also in attempting to create a unified etiological theory. In the paraphilia and sexual offending literature, refusing treatment or dropping out of treatment has been linked to higher recidivism rates. Medical treatments of paraphilias and sexual offenders attempt to reduce deviant sexual arousal and to inhibit acting on these deviant urges by affecting hormone and neurotransmitter levels. The relapse prevention model of sex offender treatment focuses primarily on reducing risk for future offenses. The good lives approach to offender treatment is focused on helping the offender build strengths, as opposed to the typical risk management or relapse prevention approach. Treatment consisted of one intake session and group sessions that addressed victim empathy, irrational beliefs regarding sexual abuse, sex education, and assertiveness skills.
Article
One individual in three convicted of child sexual abuse, relapses in such behaviour within fifteen years after being released from prison (Harris and Hanson, 2004). The application of cognitive-behavioural therapy protocols based on relapse prevention, empathy training and cognitive restructuring showed a 43% reduction in the relapse rate (Hanson et al., 2002). This study illustrates the application of cognitive-behavioural treatment to a 50 year-old inmate sentenced to seven years detention for repeated sexual abuse on male children outside the family environment that occurred while working as a dental technician. The treatment consists of two weekly group sessions over a six-month period aimed at correcting cognitive distortions (denial of responsibility and damage minimisation), enhancing empathic skills, in addition to building up an individuatised relapse prevention manual. The relapse prevention manual is based on the functional analysis of sexual abuse behaviour, and includes a summary of the risk situations, stimulus control prescriptions and self-instructions to cope with lapses.
Chapter
Pedophilia, now termed pedophilic disorder, has been consistently defined by mental health professionals, social scientists, and historians as sexual interest in prepubescent children. In this chapter, we review evolving professional definitions of this disorder, available information regarding the prevalence of pedophilia, as well as etiological models to explain the development and manifestation of pedophilic interests. This includes considerations of historical as well as current views of how this disorder develops. Assessment strategies are reviewed, including the importance of a pretreatment psychosexual history as well as formal and structured assessment tools that are beneficial in treatment. Important treatment models for pedophilia include cognitive-behavioral therapy, relapse prevention, psychopharmacological interventions, and use of the risk-needs-responsivity framework. The chapter further describes empirical research related to recidivism and assessment of sex offender risk among those diagnosed with pedophilia, including the identification of common risk assessment tools. Finally, we conclude with a discussion of relevant policy issues and directions for future research in this important area.
Article
Full-text available
p> On behalf of the guest editors of this special issue, leading scholars and practitioners in the therapeutic jurisprudence (‘TJ’) field in Australia, Europe, and the US, we congratulate QUT and the authors for a valuable contribution to the increasingly influential presence of TJ on the international stage. TJ had its genesis in the early 1990s as a new interdisciplinary approach to mental health law in the US, but has expanded remarkably in scope, reach and influence since then. TJ sees law as a social force which inevitably gives rise to unintended consequences, which may be either beneficial or harmful (what we have come to identify as therapeutic or anti-therapeutic consequences). These consequences flow from the operation of substantive rules, legal procedures, or from the behaviour of legal actors (such as lawyers and judges). It is in this sense that we conceive of the role of the law as a ‘therapeutic agent’. TJ researchers and practitioners typically make use of social science methods and data to study the extent to which a legal rule or practice affects the psychological well-being of the people it affects, and then explore ways in which anti-therapeutic consequences can be reduced, and therapeutic consequences enhanced, without breaching due process requirements. The jurisdiction with which TJ was most often associated in its earlier days tended to the that of the drug courts (in which the drug court team assists drug addicted offenders to break out of their cycle of offending by facilitating and supervising treatment programs as part of the court process itself) and the other so-called problem solving courts (more commonly referred to as ‘solution focussed courts’ in Australia). </p
Article
Full-text available
The World Health Organization is currently developing the 11th revision of the International Classifications of Diseases and Related Health Problems (ICD-11), with approval of the ICD-11 by the World Health Assembly anticipated in 2018. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) was created and charged with reviewing and making recommendations for categories related to sexuality that are contained in the chapter of Mental and Behavioural Disorders in ICD-10 (World Health Organization 1992a). Among these categories was the ICD-10 grouping F65, Disorders of sexual preference, which describes conditions now widely referred to as Paraphilic Disorders. This article reviews the evidence base, rationale, and recommendations for the proposed revisions in this area for ICD-11 and compares them with DSM-5. The WGSDSH recommended that the grouping, Disorders of sexual preference, be renamed to Paraphilic Disorders and be limited to disorders that involve sexual arousal patterns that focus on non-consenting others or are associated with substantial distress or direct risk of injury or death. Consistent with this framework, the WGSDSH also recommended that the ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism be removed from the classification and new categories of Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals be added. The WGSDSH’s proposals for Paraphilic Disorders in ICD-11 are based on the WHO’s role as a global public health agency and the ICD’s function as a public health reporting tool. Electronic supplementary material The online version of this article (doi:10.1007/s10508-017-0944-2) contains supplementary material, which is available to authorized users.
Chapter
Full-text available
Formålet med dette kapitel er at fremme viden om pædofili en stigmatiseret og ofte misforstået tilstand. Det sætter fokus på, hvad pædofili er, og hvad det ikke er, f.eks. hvilke kriterier der skal være opfyldt, hvor udbredt det er, og forekomsten i forhold til seksualkriminalitet.
Article
Full-text available
Background Sexual offender treatment programs to reduce reoffending have been implemented in many countries as part of a strategy in managing this offender group. However, there are still controversies regarding their effectiveness. Objectives A meta-analysis of relatively well-controlled outcome evaluations assessing the effects of treatment for male sexual offenders to reduce recidivism is conducted. The aim is to provide robust estimates of overall and differential treatment effects. Search methods We searched a broad range of literature databases, scanned previous reviews and primary studies on the topic, hand-searched 16 relevant journals, carried out an internet search of pertinent institutions, and personally contacted experts in the field of sex offender treatment. In total, we identified more than 3,000 documents that were scanned for eligibility. Selection criteria Studies had to address male sexual offenders and contain an outcome evaluation with a treated group (TG) and an equivalent control group (CG). Apart from randomized controlled trials (RCTs), also quasi-experimental designs were eligible if they applied sound matching procedures, statistically controlled for potential biases or the incidental assignment would not introduce bias. The studies had to evaluate therapeutic measures aiming at reducing recidivism. Both, psychosocial and organic treatment approaches were eligible. Case reports were not eligible and sample size had to be at least n =10. To be eligible, studies had to report official recidivism data as an outcome and provide sufficient information for effect size calculation. There were no restrictions with regard to country of origin or language and both published and unpublished documents were eligible. Data collection and analysis For each study/comparison we coded general features, characteristics of the sample, treatment variables and methodological features. As most studies reported their results in terms of recidivism rates, we chose the odds ratio (OR) as effect size measure. If results on treatment dropouts were provided, we merged them with the treatment group results (“intent to treat” analysis). All statistical analysis of effect sizes applied a random effects model. Results 29 comparisons drawn from 27 studies met our inclusion criteria. This study pool comprised 4,939 treated and 5,448 untreated offenders. A quarter of the studies were retrieved from unpublished sources. Most studies appeared since 2000 and more than half came from North America. The evaluations mostly addressed cognitive-behavioral sex offender treatment. No study on hormonal treatment met the inclusion criteria. Only about one fifth of the comparisons were RCTs and matching designs were rare as well. The follow-up periods ranged from 1 to 19.5 years (M = 5.9 years). Most frequently recidivism was defined as a new conviction and with only one exception studies presented data on sexual reoffending. Overall, there was a positive, statistically significant effect of treatment on sexual reoffending (OR = 1.41, 95% CI: 1.11 to 1.78, p < .01). The mean effect equates to 26.3% less recidivism after treatment (sexual recidivism rate of 10.1% in treated sex offenders vs. 13.7 % in the control groups). There was a comparable effect on general recidivism (26.4% less recidivism in treated groups; OR = 1.45, 95% CI: 1.15 to 1.83, p < .01). The overall effects were robust against outliers, but contained much heterogeneity. Cognitive-behavioral programs showed a significant effect. Two RCTs on Multi-Systemic Therapy (MST) which also contains many cognitive-behavioral elements revealed a particularly large effect. Other intervention types showed weaker or no effects. There was a rather clear trend for better treatment effects of more individualized programs. There was no significant difference between various settings. We found significant effects for treatment in the community and in forensic hospitals, but there is not yet sufficient evidence to draw conclusions regarding the effectiveness of sex offender treatment in prisons. The overall methodological quality of the studies was not significantly related to effect size. It should be noted, though, that we could not demonstrate a significant effect on sexual reoffending for the few RCTs in our study pool. Sample size was not linearly related to effect size but small studies with fewer than 50 participants had larger effects. This may suggest publication selection bias. However, studies from unpublished sources did not reveal weaker effects compared to published studies. The strongest methodological moderator was descriptive validity. Most studies lacked a detailed documentation of offender variables so that only few analyses could target this factor. With regard to offender characteristics we found no significant treatment effect for low risk participants. In contrast, medium and higher risk groups benefitted from treatment. Although the treatment of adolescents fared somewhat better than for adults, this difference was not significant. It made no difference whether offenders entered treatment voluntarily or on a mandatory basis. Authors’ conclusions Overall, the findings are promising, but there is too much heterogeneity between the results of individual studies to draw a generally positive conclusion about the effectiveness of sex offender treatment. However, the results reveal information that is practically relevant: For example, our review confirms that cognitive-behavioral programs and multi-systemic approaches are more effective than other types of psychosocial interventions. The findings also suggest various conditions of success such as more individualization instead of fully standardized group programs, an advantage of treatment in the community or therapeutic settings instead of prisons, a focus on medium to high risk offenders, early treatment of young sexual offenders, and measures to ensure quality of implementation. Overall, and particularly with regard to moderators, the research base on sex offender treatment is still not yet satisfactory. To enable more definite answers, more high-quality research is needed, particularly outside North America. There is a clear need of more differentiated process and sound outcome evaluations on various types of interventions (including pharmacological treatment), specific characteristics of programs, implementation, settings and participants and research methods.
Article
Full-text available
Empirical research about child sexual abuse image viewers has increased in recent years, especially regarding those who may also abuse: the so-called dual offenders. Scientific literature shows that child sexual abuse image viewers and dual offenders are dissimilar regarding psychosocial and criminological characteristics. On this basis, we present this article based on a literature review of the main studies addressing this topic in order to provide the key characteristics which discriminate between both groups, and those child sexual abuse offenders who act offline. Having evidence-based differential profiles can be a useful tool for helping legal psychologists manage the risk of a child pornography offender deciding to abuse a child. (PDF) El Perfil del Consumidor de Imágenes de Abuso Sexual Infantil: Semejanzas y Diferencias con el Agresor offline y el Delincuente Dual. Available from: https://www.researchgate.net/publication/333909353_El_Perfil_del_Consumidor_de_Imagenes_de_Abuso_Sexual_Infantil_Semejanzas_y_Diferencias_con_el_Agresor_offline_y_el_Delincuente_Dual [accessed Jun 24 2019].
Article
The Sex Offender Registration Act 2004 was introduced in Victoria to decrease recidivism and aid in future investigations and prosecutions. This article reviews literature to evaluate four assumptions inherent to the Act: (a) sexual offenders are more dangerous than non-sexual offenders; (b) sexual offenders who target children are more dangerous than those who target adults; (c) recidivism risk can be accurately assessed for sexual offenders who target adults; and (d) the Act is a useful tool for investigations and prosecutions. The findings suggest that there is little evidence that supports the assumptions. Further, given the relatively narrow scope of the Act, it is unlikely to have a positive impact on the safety of the community.
Article
The purpose of the current article is to shed light on the unique population of adolescents who have committed sexual offenses, suffering from cognitive disorders, by presenting the disorders and challenges that characterize these youngsters and discussing the issues that are relevant to the therapeutic process of sexual offenses. In our article we show the correlations and adaptations that we made to provide these boys with the most effective treatment possible, both to enable them to undergo an optimal process and to lower their risk level for recidivism.
Chapter
In this chapter we review some of the sexual behaviors that are not regarded as common or “normal.” By attempting to understand them, we hope to gain a better understanding of behaviors that are normally practiced.
Article
Identifying pedophilic sexual interest among persons who have sexually offended against children (PSOCs) is important for risk assessment because not all PSOCs are pedophilic. Existing physiological and self-report methods have several limitations. In the present study, sexual interest was assessed indirectly by means of a computer task: the Choice Reaction Time (CRT) task in 49 extrafamilial PSOCs and 25 persons without a history of sexual offences against children (control group). The results showed that PSOCs, the participants with a DSM-IV diagnosis of pedophilia or with a high score on pedophilic interest (measured by the SSPI-2) performed equally fast in the different age category stimuli. In other words, no effect of sexual orientation towards children was found. The control group however, showed longer reaction times for the adult and adolescent stimuli compared to the child stimuli, indicative that they did not have a sexual orientation towards children. The present study found only partial evidence for the validity of the CRT paradigm, as it was effective in discriminating age orientation in the control group but not in the group of PSOCs.
Chapter
Full-text available
Dette kapitel giver et overblik over, hvad der karakteriserer voksne, der begår overgreb på børn, hvad der kan være baggrunden for at begå overgreb, og hvordan der kan forsøges dæmmet op for overgreb blandt andet med behandling
Article
The authors review the literature on the prevalence of sex offenders; multiple treatment modalities; and implications of the use of hypnotic psychotherapy, coupled with cognitive behavioral treatment programs, for treating sex offenders.
Article
Full-text available
Classification is a fundamental cognitive operation. From the first perceptual contact with stimuli (Pomerantz, 1986; Treisman, 1986) through the ultimate integration and storage of information in long-term memory (Rosch & Lloyd, 1978), the identification, organization, and integration of elements that share common characteristics has been shown to be an essential component of perception and cognition. The critical function of classification in scientific investigation mirrors its central role in general cognition. Phenomenalists, realists, and con-ceptualists, despite their diverse metaphysical perspectives, all recognize the vital role of classification in science (Ghiselin, 1981). It stands as a necessary precursor and pervasive sustainer of all scientific progress (Hempel, 1965).
Article
Full-text available
The authors examined how well identified rapists could be discriminated from non-sex offenders using phallometric assessments, what variables might moderate this discrimination, and whether rapists respond more to descriptions of rape than to consenting sex. Eleven primary and five secondary phallometric studies involving 415 rapists and 192 non-sex offenders were examined using meta-analytic techniques. Study effect sizes averaged 0.82 (95% confidence interval 0.16 to 1.49). Only stimulus set was a statistically significant moderator of effect size: Stimulus sets that contained more graphic rape descriptions produced better discrimination between rapists and non-sex offenders. There was a trend for stimulus sets that contained more exemplars off rape descriptions to achieve better discrimination. Also, rapists responded more to rape than to consenting sex cues in 9 of the 16 data sets and in all 8 of those using the more effective stimulus sets.
Article
Full-text available
We examined the long-term recidivism rates of 197 child molesters released from prison between 1958 and 1974. Overall, 42% of the total sample were reconvicted for sexual crimes, violent crimes, or both, with 10% of the total sample reconvicted 10-31 years after being released. Incest offenders were reconvicted at a slower rate than were offenders who selected only boys, with offenders against girls showing a rate intermediate between these two groups. Other factors associated with increased recidivism were (a) never being married and (b) previous sexual offenses. None of the mental health and personality tests used in this study (e.g., the Eysenck Personality Inventory and the Minnesota Multiphasic Personality Inventory) was significantly associated with recidivism.
Article
Several authors have recently addressed current views of sexual offender treatment efficacy. Some maintain that offenders can gain from treatment while others argue that the vast majority cannot. Some researchers say that the field of sexual offender treatment is too new to be able to determine whether or not treatment works. This latter group notes that most studies in this field have not yet reached the point at which meta-analytic techniques can be applied; for this reason no definitive statements can be made about the utility of treatment. The present analysis examines the issues from a slightly different perspective. Data from a large group of studies are combined to identify patterns which can be examined later in more detail. More specifically, 79 sexual offender treatment outcome studies are reviewed, encompassing 10,988 subjects. Recidivism rates for treated versus untreated offenders are investigated according to age of offender, age of victim, offense type, type of treatment, location of treatment, decade of treatment, and length of follow-up. Each study is used as the unit of analysis, and studies are combined according to the number of treated versus untreated subjects who reoffended in each category. Clinical implications are drawn from these results.
Article
This study examined the impact of the psychological and pharmacological effects of alcohol on the ability of sexually coercive and noncoercive men to discriminate when a female wants a partner to stop sexual advances. In a 2 (alcohol vs. no alcohol) × 2 (expectancy vs. no expectancy) × 2 (sexually coercive vs. noncoercive status) randomized factorial design, male college students were exposed to an audiotape of a date rape. Participants who consumed, or expected to consume, alcohol took significantly longer to determine that the man should refrain from attempting further sexual contact. In addition, nonsexually coercive participants assigned to conditions in which they expected to consume alcohol responded similarly to their sexually coercive counterparts in their responses. The implications of these findings are discussed.
Article
Long-term recidivism rates of 180 male sexual offender treatment completers and almost completers (persons who had been in treatment 2 years plus and had only a few goals to complete) were compared in this study. All men in this study were followed after treatment from 6 months to 17 years by interviews, anonymous questionnaires, and/or criminal record checks. The treatment center, located in Minneapolis, checked all criminal records in Minnesota and surrounding states or country: North Dakota, South Dakota, Wisconsin, Iowa, and Canada. Seventeen men had reoffended sexually and five others had reoffended criminally (theft, DWI, etc.) but not sexually. Only those finishing treatment or nearly finishing treatment were addressed in this study, recognizing that self-selection and program screening may have contributed to the statistical success of this outpatient program. The anonymous questionnaire addressed issues regarding the offender's original offenses and the success or nonsuccess of treatment techniques as judged by them. Data regarding problematic areas still existing in their lives were collected. Of these 180 treated men, 108 men also appeared, or telephoned in, for personal interviews (using a second structured questionnaire, as opposed to the anonymous one mailed to each patient). They were interviewed six times each during the 17 years. The personal interviews yielded other aspects of data used to cross-validate the questionnaires and the criminal record checks. Total sexual recidivism was 9.0%. Data thus indicate that treatment was successful for 91% of these men. The need for more sophisticated research about what constitutes successful treatment is addressed in the discussion.
Chapter
Against the background of the maladaptive sexual approach disorders, exhibitionism stands out as unusual in several respects. As opposed to pedophiles, exhibitionists commit a significantly greater number of deviant acts and are apprehended more often, yet they are jailed less often as well (Maletzky, 1991). Perhaps this is a result of society’s view that the victims of exhibitionism are less seriously affected than victims of other sexual crimes, such as child molestation and rape. Indeed, exposure of the genitals is, by and large, a misdemeanor rather than a felony; even the judicial nomenclature sounds mild: public indecency or indecent exposure. Since these charges can stem from accidental acts—such as failure to take adequate precaution against exposure (e.g., urinating in public)—society may believe that exhibitionism is less serious than other sexual crimes and that, along with fetishism, transvestism, and bestiality, it is largely a victimless act.
Chapter
Despite the almost magical advances in the physical sciences over the past quarter century, it still seems that the most interesting disciplines are those that address the roots of human behavior. At least so it seemed to those of us participating in the early 1970s in what we naively thought to be a grand experiment in applying principles of behaviorism to the treatment of maladaptive behaviors, such as overeating or sexual compulsions. Skinner had explained it all and it was simply left to us to prove clinical utility.
Article
Because of the enormous human and financial costs society incurs as a result of sexual crimes, any reduction in the recidivism of sex offenders caused by treatment is very worthwhile. Although treatment can be valuable if this reduction is small, the reduction must nevertheless be real. Real effects are statistically significant differences between treated and untreated subjects in controlled studies. In general, statistical significance is a necessary criterion for clinical and economic significance. In the field of sex offender treatment, it is likely to be a sufficient condition as well. In the view of the authors, the effectiveness of treatment in reducing sex offender recidivism has not yet been scientifically demonstrated. To demonstrate the effectiveness of sex offender treatment, more well-controlled outcome research is required that can be evaluated with meta-analytic techniques.
Article
The best predictor of sexual offense recidivism is believed to be past sexual offending. However, clinical observations of treated individuals often contradict this view. Consequently, this relationship was evaluated, using a minimum follow-up period of 18 months. The samples were adult men and consisted of 127 treatment noncompleters who terminated treatment because of inadequate motivation/unacceptable behavior, legal transfer, or by request and 150 treatment completers who underwent a minimum of 6 months of 32–35 hours per week of therapy. Sexual offense conviction recidivism and prior sexual offense convictions were significantly related in noncompleters ( r =.31, p < .05) but were not significantly related in completers (r = .03, p > .05). These two correlations differed significantly (two-tailed p < .05). There was no difference (p > .05) in the average number of prior sexual offense convictions between completers and noncompleters. The findings are supportive of treatment interventions, although they question the validity of prior sexual offenses in treated offenders for release decisions and/or risk prediction.
Article
A retrospective review of 4381 heterosexual and homosexual pedophiles treated in a community-based program produced preliminary evidence of factors associated with success or failure in treatment. Records of these offenders revealed a number of factors of importance in predicting treatment outcome, including victim and offender characteristics, offending behavior characteristics, and penile plethysmographic findings of deviant and normal sexual arousal. Results indicated that success in treatment was often associated with a minimum number of victims, familiarity and cohabitation with victims, an absence of force or threats employed in the crimes, admission of some responsibility for the offending incidents, and a stable history of employment and relationships with others. Plethysmograph findings confirmed the general impression that low pre-treatment deviant arousal was correlated with improvement. Surprisingly, duration and frequency of offending behaviors were not consistent predictors of treatment response. Limitations of the present study are noted and caution is advised in accepting these findings until corroborated by controlled research.
Article
Preliminary results from a longitudinal study of the effectiveness of cognitive-behavioral treatment with sex offenders are presented. The study's research design includes three groups: a treatment group, a volunteer control group (those who volunteered for but did not receive treatment), and a nonvolunteer control group (subjects who refused the opportunity for treatment). Although the treatment group had the lowest reoffense rates for both sex and other violent crimes, main effects analyses did not yield conclusive results regarding the program's effectiveness. The results highlight the importance of including appropriate comparison groups, managing attrition from both treatment and methodological standpoints, examining sex and other violent offenses separately as outcome variables, employing tests with adequate statistical power, and analyzing data while taking into account time at risk for reoffense.
Article
Marshall (1971) was the first behavior therapist to add social-skills training to a treatment package which also attempted to decrease deviant interests and increase appropriate sexual desires / since that time there has been a progressive expansion of the components in behavioral programs, in particular, the inclusion of procedures aimed at modifying distorted cognitions now more commonly described as "cognitive-behavioral" and are understood to be quite comprehensive in terms of the range of problems addressed in treatment / despite the ever-growing popularity of these comprehensive cognitive-behavioral programs, until very recently there was little in the way of outcome evaluations / before we turn to the issues of the effectiveness of these programs, however, we need to describe their nature content of programs / sexual behaviors / social incompetence / cognitive distortions / format of programs (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Long-term recidivism rates of 180 male sexual offender treatment completers and almost completers (persons who had been in treatment 2 years plus and had only a few goals to complete) were compared in this study. All men in this study were followed after treatment from 6 months to 17 years by interviews, anonymous questionnaires, and/or criminal record checks. The treatment center, located in Minneapolis, checked all criminal records in Minnesota and surrounding states or country: North Dakota, South Dakota, Wisconsin, Iowa, and Canada. Seventeen men had reoffended sexually and five others had reoffendedcriminally (theft, DWI, etc.) but notsexually. Only those finishing treatment or nearly finishing treatment were addressed in this study, recognizing that self-selection and program screening may have contributed to the statistical success of this outpatient program. The anonymous questionnaire addressed issues regarding the offender's original offenses and the success or nonsuccess of treatment techniques as judged by them. Data regarding problematic areas still existing in their lives were collected. Of these 180 treated men, 108 men also appeared, or telephoned in, for personal interviews (using a second structured questionnaire, as opposed to the anonymous one mailed to each patient). They were interviewed six times each during the 17 years. The personal interviews yielded other aspects of data used to cross-validate the questionnaires and the criminal record checks. Total sexual recidivism was 9.0%. Data thus indicate that treatment was successful for 91% of these men. The need for more sophisticated research about what constitutes successful treatment is addressed in the discussion.
Article
This study examined the impact of the psychological and pharmacological effects of alcohol on the ability of sexually coercive and noncoercive men to discriminate when a female wants a partner to stop sexual advances. In a 2 (alcohol vs. no alcohol) × 2 (expectancy vs. no expectancy) × 2 (sexually coercive vs. noncoercive status) randomized factorial design, male college students were exposed to an audiotape of a date rape. Participants who consumed, or expected to consume, alcohol took significantly longer to determine that the man should refrain from attempting further sexual contact. In addition, nonsexually coercive participants assigned to conditions in which they expected to consume alcohol responded similarly to their sexually coercive counterparts in their responses. The implications of these findings are discussed.
Article
The publication of a review of the treatment outcome literature by Furby, Weinrott, and Blackshaw in 1989 raised the issue of the failure of research to support adequately the efficacy of treatment for sexual offenders. Now, many years after the publication of Furbyet al., there are still major flaws in the outcome research being conducted which have led certain researchers to conclude that we still have no empirical evidence on the effectiveness of sexual offender treatment. Specifically, the current literature has been criticized for reliance on single-group, follow-up only designs and designs that include nonequivalent treatment and comparison groups. These types of designs fail to provide adequate information about treatment outcome due to threats to internal validity and construct validity of putative causes and effects. In this paper, suggestions are made as to how to maximize experimental validity through development of program theories and questions posed about which aspects of treatment are associated with positive and negative outcomes and with whom our interventions work.
Article
The increasing recognition of the large number of people victimized by sexual assault has focused considerable attention on methods for deterring its perpetrators. In particular, law enforcement and mental health professions alike seek ways to prevent sex offenders from repeating their criminal behavior. Some evidence suggests sex offenders often continue offending even after incarceration or clinical treatment. However, recidivism rates for sex offenders are unusually hard to establish, owing to gross underreporting of sex crimes. This article presents a comprehensive review of empirical studies of sex offender recidivism. It brings together data from a wide variety of studies on both treated and untreated sex offenders of all types. Because of the variety and gravity of methodological problems in these studies, guidelines are discussed for sample selection and description, study design, criterion assessment, and data analysis. With these methodological principles in mind, the results of some 42 studies are examined for what they can tell us about sex offender recidivism and efforts to reduce it.
Article
Meta-analyses were performed on 12 studies of treatment with sexual offenders (N = 1,313). A small, but robust, overall effect size was found for treatment versus comparison conditions (r = .12). The overall recidivism rate for treated sexual offenders was .19 versus .27 for untreated sexual offenders. Treatment effect sizes across studies, however, were heterogeneous. Effect sizes were larger in studies that had higher base rates of recidivism, had follow-up periods longer than 5 years, included outpatients, and involved cognitive-behavioral or hormonal treatments. Cognitive-behavioral (p < .0005) and hormonal treatments (p < .00005) were significantly more effective than behavioral treatments but were not significantly different from each other.
Article
Several authors have recently addressed current views of sexual offender treatment efficacy. Some maintain that offenders can gain from treatment while others argue that the vast majority cannot. Some researchers say that the field of sexual offender treatment is too new to be able to determine whether or not treatment works. This latter group notes that most studies in this field have not yet reached the point at which meta-analytic techniques can be applied; for this reason no definitive statements can be made about the utility of treatment. The present analysis examines the issues from a slightly different perspective. Data from a large group of studies are combined to identify patterns which can be examined later in more detail. More specifically, 79 sexual offender treatment outcome studies are reviewed, encompassing 10,988 subjects. Recidivism rates for treated versus untreated offenders are investigated according to age of offender, age of victim, offense type, type of treatment, location of treatment, decade of treatment, and length of follow-up. Each study is used as the unit of analysis, and studies are combined according to the number of treated versus untreated subjects who reoffended in each category. Clinical implications are drawn from these results.
Article
To increase understanding of the relationship between sexual violence and mental illness, the authors assessed the legal histories and psychiatric features of 36 males convicted of sexual offenses. Thirty-six consecutive male sex offenders admitted from prison, jail, or probation to a residential treatment facility received structured clinical interviews for DSM-IV Axis I and II disorders. The participants' legal histories, histories of sexual and physical abuse, and family histories of psychiatric disorders were also assessed. The participants' mean +/- SD age was 33+/-8 years. They had been convicted a mean of 1.8+/-1.4 times (range, 1-9 times) for sexual offenses and incarcerated a mean of 8+/-6 years (range, 0-22 years). Participants displayed high rates of lifetime DSM-IV Axis I disorders: 30 (83%) had a substance use disorder; 21 (58%), a paraphilia; 22 (61%), a mood disorder (13 [36%] with a bipolar disorder); 14 (39%), an impulse control disorder; 13 (36%), an anxiety disorder; and 6 (17%), an eating disorder. Participants also displayed high rates of Axis II disorders, with 26 (72%) meeting DSM-IV criteria for antisocial personality disorder. In addition, subjects reported experiencing high rates of sexual (but not physical) abuse and high rates of Axis I disorders, especially substance use and mood disorders, in their first-degree relatives. Compared with subjects without paraphilias, subjects with paraphilias displayed statistically significantly higher rates of mood, anxiety, and eating disorders, as well as significantly higher rates of childhood sexual abuse. Recognition and treatment of major psychiatric disorders among sex offenders may increase chances for successful rehabilitation, reduce recidivism and public victimization, and produce significant public health and economic benefits. More studies in this area appear warranted to search for more effective interventions for this severe public health problem.