Chapter 8 - Treatment

Here below: (10 Summary, (2) Some Quotes


This chapter has identified many questions about the effective treatment and
management of persons with pedophilia and sex offenders against children. These
questions include the irrelevance of common treatment targets, such as acceptance of
responsibility and expressions of remorse and victim empathy; whether changes in
pedophilic sexual arousal because of behavioral conditioning or antiandrogen
treatment translate to long-term changes in sexual behavior involving children; and
the relative importance of general versus specific treatments for pedophilic sexual

Methodologically rigorous evaluations are needed to answer these important
questions, and theoretically informed treatment models that draw from general
offender intervention research and specific research on pedophilia are needed to
develop empirically supported treatments to reduce child sexual abuse.
Until the results of such research are available, how should clinicians proceed? I
believe a conservative approach is warranted, guided by the scientific knowledge
that is available. Based on the research reviewed here, some recommendations are
summarized in Table 8.1 and Exhibit 8.1.

  • Table 8.1 (p. 220)
    This table gives 6 levels of suppression [on sexual impulses], from
    • Level 1 = No suppression > Recommendation = Cognitive behavior therapy,
    • Level 2 = Minimal suppression > SSRI medication
    • Level 3 = Moderate suppression > Low dose of anti-androgen or SDRI
    • Level 4 = Substantial spuppr > Full dose of crypterone or medroxyprogesterone acetate or SSRI
    • Level 5 = Almost complete suppression: id risk is high > gonadotropin-releasing hormone agonists; cyproterone acetate; monitor testosterone level
    • onto Leven 6 = Complete suppression > antiandrogen or medroxyprogesterone acetate; can add SSRIs
  • all followed by a Recommendation of medication of several medicines in several doses, according to the World federation of Societies in Biological Psychiatry Guidelines.
  • Exhibit 8.1 (p. 236)
    Recommendations for Treatment Pedophilic Sex Offenders
    • 1. Risk assessment using a well-supported measure, for the purpose of triaging individuals in terms of placement, security, and intensity of any treatment and supervision.
    • 2. Education of the client, his spouse or partner, family members, and close friends regarding risky situations and potential precursors for sexual offenses against children (e.g., the offender being alone with a child or consuming alcohol).
    • 3. Behavioral treatments targeting pedophilic sexual arousal, when applicable, with “booster" sessions as needed on an ongoing basis.
    • 4. Monitoring of access to child pornography, unsupervised contacts with children, and alcohol or drug use.
    • 5. Anti-androgen treatments targeting sexual drive for higher-risk individuals who are not suitable for incapacitation. Though the evidence for such treatments is not strong, compliance with the regimen is a positive treatment-related indicator and could be used to adjust the intensity of other interventions.
    • 6. Cognitive-behavioral and behavioral treatments targeting dynamic risk factors for general criminal behavior such as antisocial attitudes and beliefs, association with antisocial peers, and substance abuse.
    • 7. lncapacitation of high-risk pedophilic sex offenders, especially those who have committed many sexual offenses against children or who have committed violent sexual offenses.

Intervention for sex offenders should be preceded by an actuarial or structured risk
assessment, to prioritize cases according to risk to reoffend and to guide subsequent
decisions. For sex offenders against children, the options range from minimal
intervention for the lowest risk individuals to long-term incapacitation for the
highest risk individuals. The clinician should also monitor potentially worrisome
behaviors, such as access to child pornography, unsupervised contacts with children,
and alcohol or drug consumption that leads to disinhibition of behavior (…).

Ongoing assessment with validated dynamic risk measures is needed to monitor
changes in imminent risk. Clinicians and other professionals should rely on sources
of information other than self-report whenever possible.

Behavioral treatments targeting pedophilic sexual arousal have some support.
Because the long-term effects are unknown, ongoing follow-up and “booster”
sessions may be necessary. This is not a sufficient treatment on its own, but learning
to control their sexual arousal may help individuals who are motivated to refrain
from offending.

The use of drug therapies has modest empirical support, but treatment using antiandrogens might be justified for high-risk individuals who are not suitable for
incapacitation, for two reasons.

  • First, for individuals who believe they need assistance to control their pedophilic sexual interests, administration of these agents can activate a placebo expectancy response that may in fact contribute to their ability to do so.
  • Second, administration of these agents can be viewed as a strict behavioral test of the individual’s motivation and commitment to avoid sexually offending against children, because noncompliance with medication appears to be associated with a worse prognosis.
  • (A similar logic applies for the provisional recommendation regarding the use of behavior therapy, while researchers await longer-term follow-up results).

These agents may also possibly reduce sex drive, and this reduction in sex drive may
lead to a reduction in likelihood to sexually offend against children for some

Finally, for pedophilic sex offenders who are at higher risk of antisocial behavior and
thus for acting upon their sexual interest in children, cognitive behavioral and
behavioral treatments drawn from the correctional literature could have a significant
impact on general risk factors, such as antisocial attitudes and beliefs (including
permissive attitudes about sex with children), association with antisocial peers
(including other persons with pedophilia who endorse and reinforce permissive
attitudes about sex with children), and substance abuse (which can lead to
disinhibition of behavior).

It is unlikely such treatments will be helpful to self-referred pedophilic individuals,
who would tend to be low in antisociality because those who are more antisocial
are less likely to come forward for help.

Important advances have been made in the understanding of what can reduce the persistence of sexual offending, including treatment that adheres to the RNR [Risk-
] framework (Hanson et al., 2OO9), has a cognitive behavioral
orientation, and targets empirically established dynamic risk factors.

They need to be responsive to individual learning styles, and they possibly need to do more than target deficits — they need to also build on strengths and offering more prosocial options.

When possible, social-ecological factors need to be targeted, which can include parents for adolescents who have sexually offended and possibly partners/spouses and other close people for adult offenders (although little is known about the latter).

The encouraging, if not methodologically strong, evidence from Circles of Support and
is in line with the importance of social ties.

Some Quotes from Chapter 8


Page 204
Sex offender treatment was not widely provided before the 1980s, when the relapse
prevention approach
was adopted from the addictions field, along the lines that both types of behavior could be experienced as compulsive, that it could persist despite negative consequences, and that powerful motivations to approach problematic situations needed to be regulated.
Relapse prevention quickly became the dominant model, until the null results reported by the widely followed [SOTEP] Sex Offender Treatment Evaluation Project in California (Marques, e.o. 2005).

Although many programs still identify their approach as relapse prevention (…), more programs now identify as espousing a self-regulation or good lives model (GLM), reflecting the emergence of a self-regulation and then pathways model from Ward and colleagues (2002 & Stinton e.o. 2008) describing a therapy that is also based on  enhancing self-regulation.

Relapse Prevention

Marlatt and Gordon (1985) described the relapse prevention approach, which is based on cognitive behavior principles, as

  • (a) identifying situations in which the individual is at a high risk for relapse;
  • (b) identifying lapses, that is, behaviors that do not constitute full-fledged relapses butapproximate drug-taking and that may be a precursor to a relapse (e.g., spending time in bars as a precursor to drinking alcohol);
  • (c) developing strategies for avoiding high-risk situations or triggering cues; and
  • (d) developing coping strategies, which are used in high-risk situations that cannot beavoided and in responding to lapses that occur.

In the context of sexual offending against children, lapses might include behaviors such as

  • masturbating to sexual fantasies about children, and
  • high-risk situations might include spending time alone with a child.

In the previous edition, I reviewed the results of the Sex Offender Treatment Evaluation Project (SOTEP) in more detail, as it was a big deal in the field with the publication of the final evaluation results in Marques al. (2005).

SOTEP’s distinctive features include

  • random assignment of volunteers to treatment and no-treatment conditions after being matched for age, criminal history, and type of offense;
  • an intensive, 2-year cognitive behavioral treatment program based on relapse prevention principles;
  • a one-year after-care program in the community; and a program evaluation that included both proximal (within-treatment) and ultimate outcomes.

The final SOTEP report found that the program had the desired effects on within-treatment goals, such as greater acceptance of responsibility and reduced atypical sexual arousal, but it had no impact on recidivism.

The SOTEP report was a watershed moment because the sexual offending treatment field had to figure out what to do next. Some responded by adopting a skeptical or even
pessimistic view on the possibilities of sex offender treatment. Others focused on criticizing details about SOTEP, even though it was carefully designed, comprehensive, and impressive in its scope and intensity, or even going so far as to suggest that randomized clinical trials were not necessary (W. L. Marshall & Marshall, 2007), to which I and others responded with some heat (Seto et al., 2OO8).

Marques et al. (2OO5) discussed reasons that the SOTEP program did not have the desired impact on recidivism and suggested several ways in which they would change the program if it was offered again. These changes included recruiting more high-risk offenders, conducting pre-treatment assessments on all sex offenders and regularly monitoring treatment progress to ensure that participants ‘were learning the concepts and skills being taught.

Other problems with the evaluation, in hindsight, included that relapse prevention was
designed to assist individuals who had completed treatment and who needed assistance to avoid relapse (using substances again). It was therefore designed to be a maintenance intervention rather than treatment to reduce risk.

Also, the relapse prevention model is predicated on the person being motivated to refrain from relapse; it did not speak to someone who was not genuinely motivated to change. In response to these criticisms and to preliminary results from evaluations of relapse prevention programs, other approaches to sex offender treatment have emerged:

  • Self-regulation (pages 205 & 2006) [This model] views offendeers as following different pathways to committing their crimes.
  • [GLM =] Good Lives Model (pages 2006 ev) … How can the goals could be satisfied in pro-social ways? … build on the positive psychology movement … positive factors … a more holistic approach … it considers the context … and the human needs … more attention to the therapeutic relationship and individualization …
  • [RNR =] The Risk Need Responsivity model (page 207) … do more in terms of explicitly recognizing strengths and building up protective factors …

Page 208
The intervention response can also take place outside of the criminal justice system, even though that is now where most sex offender treatment is provided. As I discuss in the next chapter, programs have emerged for individuals who have offended but are mostly unknown to the criminal justice system (Dunkelfeld Prevention Project) or for individuals who self-identify concerns about their risk to offend against children (Dunkelfeld, Stop It Now!).

People concerned about their child pornography use can find online resources (, and peer support groups for persons with pedophilia
committed to not offending (Virtuous Pedophiles).

Last, the response cannot encompass only treatment but can also comprise the many
opportunities for education, skills training, and environmental changes to reduce sexual
offending against children.

Page 210
Perkins (1987) … found a large negative effect of [cognitive behavioral] treatment.

Page 211
Anderson-Varney (1992) randomly assigned 60 sex offenders against children to cognitive behavior therapy or no treatment conditions; the outcome measures were sexual attitudes, knowledge, and self-reported behavior, social avoidance and empathy. Overall, Kenworthy et al. concluded there was no significant impact of [this kind of] treatment on these … targets.

Page 2012
Gro[/]nnerod et al, (2015) … meta-analysed 14 studies … These studies included 1,421
adult offenders receiving treatment and 1,509 untreated controls, followed for a maximum of 3 years. Most studies were methodologically weak, and the overall effect sixe was small, suggesting no significant positive impact.

Page 232
Table 8.2: Examples of Dynamic Risk Factors and Some Corresponding Indicators