A Project of the Office of Justice Programs, U.S. Department of Justice

Long Version
Section 3: An Overview of Sex Offender Treatment for a Non–Clinical Audience
Elements of Sex Offender–Specific Treatment
4 hours, 30 minutes

(30 minutes)

Use SlideUse Slide #21: Sexual Interests—The First Domain of Treatment


You will recall that we identified four domains that are important to address in sex offender treatment: sexual interests, distorted attitudes, interpersonal functioning, and behavior management. We’ll look at some very specific interventions in each of these domains in order to give you examples of what occurs in cognitive–behavioral sex offender treatment. In each case, we’ll examine the rationale for the intervention, its goals, and the specific methods that treatment providers use. Let’s start with some treatments directed toward the reduction of deviant sexual arousal.

Use SlideUse Slide #22: For Offenders with Deviant Sexual Arousal

As we discussed before, some but not all sex offenders are motivated to commit sexual assaults in part because they are sexually aroused to activities—such as rape or types of people such as children—where to act on these arousal patterns constitutes criminal behavior. If this deviant arousal could be diminished, the motivation to commit sexual assaults also would be diminished. There are two principal ways this can be accomplished: through the use of behavioral interventions and through medications that reduce sexual arousal and/or control of deviant inclinations. Let’s first look at an example of behavioral treatment to reduce deviant sexual arousal, one that is called masturbatory satiation.

Use SlideUse Slide #23: Behavioral Intervention to Reduce Deviant Sexual Arousal

Behavioral Intervention to Reduce Deviant Sexual Arousal

The primary goal of behavioral treatments to reduce deviant sexual arousal is just that—to diminish deviant sexual arousal. In order to do this, we have learned that it is much more difficult for men to reduce deviant sexual arousal alone than it is for them to replace that arousal with non–deviant arousal. Therefore, behavioral treatments involve substituting non–deviant erotic fantasies as a replacement for deviant fantasies (see, e.g., Abel and Blanchard, 1974; Abel, Blanchard, and Becker, 1978; Berlin, 2000; Dougher 1995; Laws, 1995; Laws and Marshall, 1991; Laws and Osborn, 1983; Maletzky, 1991; Marshall, et al., 1999; Marshall and Eccles, 1995; Marshall and Laws, 2003; Quinsey and Marshall, 1983). Another component of this intervention is to have sex offenders react to their deviant behaviors in the way that most people do, namely to have no arousal and even to find the deviant thoughts repugnant.

Before proceeding with a discussion about how to affect deviant sexual arousal, it is important to note the range of severity of sexual interest problems evidenced by sex offenders. In particular, some sex offenders’ deviant sexual interests are so exclusive and ingrained that they are destined to struggle with controlling them for the rest of their lives (see, e.g., Berlin, 2000; Laws and O’Donohue, 1997). For example, men who have an overarching, primary, and exclusive sexual interest in pre–pubescent boys are referred to as fixated male pedophiles. Even state–of–the–art behavioral and medication treatments will, at best, only help these men control their deviant urges, not eliminate them. In addition, although social learning theory seems to be the most effective way to think about the etiology (or cause) of sexual offending and how to treat sex offenders, some researchers posit that sexual interests may have some biological basis and consequently are very resistant to long–term change.28 These are important caveats to keep in mind as we move on to discuss methods we use to reduce deviant sexual arousal.

So how do we do this? We’ll describe what is involved with the technique known as masturbatory satiation (see, e.g., Dougher, 1995; Laws and Marshall, 1991; Maletzky, 1991; Marshall, et al., 1999; Marshall and Laws, 2003). It is based on behavioral learning principles that suggest that deviant sexual arousal is, to some degree, learned behavior and that arousal can be reduced by “unlearning” the deviant thoughts and behaviors, and replacing them with non–deviant thoughts and behaviors. This method is one of the clearest examples of behavioral conditioning in sex offender treatment, the “behavioral” part in the “cognitive–behavioral” sex offender treatments.

When teaching this technique, the treatment provider starts by explaining to the offender that he will be involved in a treatment method to reduce his deviant sexual arousal and, to some extent, increase his arousal to non–deviant stimuli. The treatment method will involve his performing some very specific homework in private. It is important that the offender understand the intervention well in order to consent to it, increase his compliance and motivation, and ensure that he does the treatment properly. The offender records the homework on an audiocassette so that it can be performed at home, in private, yet can be monitored later by the treatment provider.

The general idea of this technique is to pair the intense physical pleasure of orgasm with healthy sexual fantasies, followed by pairing discomfort and boredom with deviant fantasies (see, e.g., Laws and Marshall, 1991; Maletzky, 1991; Marshall, et al., 1999). Typically, attempting to masturbate during the refractory period (i.e., the period of time following the initial orgasm in which continued physical arousal and orgasm are generally not physically possible) causes boredom and in some instances, a degree of physical discomfort. Therefore, the purpose of this second aspect of the exercise is to have the offender experience negative reactions to his deviant fantasies—namely to find them non–erotic, boring, and physically uncomfortable. Ideally, the attractiveness of the previously erotic (and deviant) stimulus is substantially diminished. By focusing on one aspect of his deviant arousal pattern, he pairs physical discomfort and extreme boredom with what typically would be arousing and pleasurable to him. Taken together, the pairing of healthy fantasies with the intense and positive experience of an orgasm is designed to strengthen healthy sexual interest and arousal patterns, while the pairing of discomfort, boredom and deviant fantasy can assist him in reducing deviant fantasies and interests.

The offender is instructed to make about three audiotapes per week consisting of one hour homework assignments. The purpose of his making the audiotapes is for the treatment provider to monitor his compliance and ensure that he is doing the exercise properly. The audiotapes are to be submitted during weekly therapy sessions for a period of about seven weeks for a total of about 20 hours of homework.

Offenders typically find this exercise to be awkward to do at first, but relatively quickly become accustomed to it. Their cooperation is less of a problem than one might expect, especially when the purpose of the intervention is well understood, the method is well described, and it is clear that other offenders are completing their homework.

Use SlideUse Slide #24: Common Questions

Commonly Asked Questions

The question sometimes arises as to whether or not it is easy for offenders to sabotage this intervention, such as by pretending to go through the motions as instructed, but actually continuing to engage in their deviant fantasies even while supposedly doing their homework properly. The answer is that, of course, they can. However, these matters are discussed very openly in treatment. The treatment provider can ask the group, “What if someone wants to fake the exercise in some way? Could he do it? Who would he be harming, or fooling?” Invariably, group members will articulate the self–defeating nature of such attempts as treatment sabotage, often more pointedly than treatment providers might. For example, a group member might say, “Sure, you could pretend to do this and not really do it. But you’d be the fool, because when you get caught for your next offense, it won’t be the treatment provider who gets sent to jail, it will be you.”

Another frequent question is whether or not sexual arousal patterns can really be changed, by this or other methods (see, e.g., Berlin, 2000; Laws and Marshall, 1991; Laws and O’Donohue, 1997; Marshall, et al., 1999; Marshall and Laws, 2003). Some professional opinion in this regard is that a mechanism that underlies sexual interest other than gender orientation is primarily one mediated by learning or experience, and the preponderance of professional opinion in this regard is that the mechanism that underlies sexual interest other than gender orientation is primarily one mediated by learning, and principally by learning that occurs during critical periods in development, perhaps around puberty or a bit before (see, e.g., Marshall, et al., 1999; Marshall and Laws, 2003; Sieger and Ward, 2003 (in Ward, Laws, and Hudson, 2003). This is exactly what the mechanism of behavioral treatment is attempting to mimic, only this time the stimulus of the intended arousal is purposefully chosen to be non–deviant.

Who is this behavioral intervention best suited for? For sex offenders whose offenses are most strongly motivated by deviant sexual arousal. As we’ve discussed, not all sex offenders commit offenses because they have deviant arousal. For example, most incest offenders who molest post–pubescent children have normal, non–deviant sexual arousal. Like normal heterosexual men, they are most aroused by adult women, followed by adolescent girls, followed by female children. The incest offender who fondles his 14–year old stepdaughter as she sleeps is responding—obviously very inappropriately—in part to his attraction to the child’s adult female secondary sexual characteristics. What motivates his sex offending likely is not deviant sexual arousal as much as it is extremely poor judgment, poor impulse control, lack of awareness or concern for the child’s welfare, those sorts of things. Had he done the same things to a six–year–old girl, this would suggest deviant sexual arousal, because a six–year–old child doesn’t look like a young version of an adult, whereas a 14–year–old may very well look like a young version of an adult.

Another frequently asked question is whether or not this behavioral technique is essential to sex offender treatment? In fact, it is not. However, what is essential is that some interventions be included that address issues of deviant sexual interests in offenders who have such arousal. The most extensive description of the various behavioral methods used to reduce deviant sexual arousal in sex offenders is found in a book by Maletsky (1991), “Treating the Sexual Offender.”

Sometimes training participants ask whether or not offenders can be treated successfully using this behavioral method alone. The answer to that question is “No.” Because the reasons that people have for committing sexual assault are varied and are almost never accounted for by a single explanation, it is important that any approach to treatment combine techniques, each addressing the domains we have mentioned earlier—sexual interest being only one of those.29

For example, there are people who have deviant sexual arousal and never act on that arousal because of their use of self–control, their concern about people they might victimize, and so forth. Other people might get better control over their deviant sexual arousal, but being unconcerned for others or uninformed about the harm sexual assault causes victims, they might commit offenses even though their sexual arousal was fairly minimal.

Use SlideUse Slide #25: Pharmacological Interventions to Address Deviant Sexual Arousal

Pharmacological Interventions to Address Deviant Sexual Arousal

An entirely different treatment approach for reducing or helping sex offenders manage their deviant sexual arousal is through the administration of prescription medications (see, e.g., Association for the Treatment of Sexual Abusers, 2005; Becker and Murphy, 1998; Berlin, 2000; Bradford and Greenberg, 1998; Craissati, 2004; Glaser, 2003; Greenberg and Bradford, 1997; Grubin, 2000; Harris, Rice, and Quinsey, 1998; Kafka, 1994, 2000; Prentky, 1997). Very few sex offender treatment providers are physicians. Thus, treatment providers must collaborate with physicians to obtain appropriate medication for offenders who might benefit from it.

Note: Elicit answers from audience, focusing on offenders for whom sexual preoccupation is a salient feature of their personality and offending.

Ask QuestionsCan you think of examples of sex offenders who might have the greatest likelihood of benefiting from medications that reduce sex drive? What about types of sex offenders for whom medication likely would have no benefit?

Use SlideUse Slide #26: Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors

One class of medications commonly used for reducing or helping sex offenders manage their deviant sexual arousal is referred to as Selective Serotonin Reuptake Inhibitors, or SSRI’s.30 These are medications that are very commonly prescribed for the treatment of depression and obsessive–compulsive disorders. Although SSRIs are quite effective with these mental health problems, they also can be helpful in the treatment of sex offenders.31 This is because these medications reduce libido—sexual urges—in most patients and they also reduce aggression. For many patients they decrease deviant sexual fantasies. They often empower people to better manage their behavior in general, and they reduce the intensity of compulsive aspects of sex offending that are a part of many offenders’ patterns.32 SSRIs are the medications most frequently used with sex offenders because of these treatment effects. Because they are very commonly prescribed medications, physicians typically have considerable experience with them, and, therefore, doctors have little reluctance to prescribe them when deemed appropriate. The therapeutic dose for sex offenders is the same dose that is used for depression and obsessive–compulsive disorders, again something that physicians are familiar and comfortable with.

Use SlideUse Slide #27: Anti–androgen Medications

Anti–androgen Medications

Other medications that are commonly thought of in the treatment of sex offenders are hormonal agents known as anti–androgens.33 These are the medications often referred to in the popular media as “chemical castration,” because they reduce the male sex hormone, testosterone, in men, much as physical castration does when a man’s testicles are removed.34 These medications may be thought of as “sexual appetite” suppressants. They don’t remove all appetite; they just make it easier for the offender to manage his behavior, because the intensity of his appetite is diminished.35 Offenders who are taking anti–androgen medications such as Provera or Lupron continue to get aroused and have erections and orgasms, but they are less highly motivated. But like diet pills, although they can be quite effective, they only are effective with people who otherwise are motivated to lose weight or in the case of sex offenders, not to commit further sexual assaults. As is the case with behavioral interventions to reduce deviant sexual arousal, these medications should be administered in conjunction with cognitive–behavioral sex offender treatment.36

Unlike SSRIs, Provera and Lupron are medications physicians are quite reluctant to prescribe and manage.There are two reasons for this. First, there are many side effects associated with these medications.37 You can see on the slide what these side effects are, and the percentage of patients who experience each of these effects.

Following are the side effects experienced by patients using anti–androgens:38

Use SlideUse Slide #28 and Slide #29: Incidence of Side Effects with Anti–androgen Medications

Slide #28
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Slide #29
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  • Erectile dysfunction
  • Decrease amount of ejaculate
  • Decrease sex drive
  • Decrease in size of sexual organs
  • Weight gain
  • Lethargy
  • Headaches
  • Hot/cold flashes
  • Nightmares
  • Hyperglycemia
  • Insomnia
  • Nausea
  • Muscle cramping
  • Irritability
  • Shortness of breath

Use SlideUse Slide #30: Some Physicians are Reluctant to Prescribe Anti–androgens

The other reason physicians may be reluctant to prescribe Provera and Lupron is that they are not approved by the FDA for the treatment of sex offenders.39 Although this also is the case with the SSRIs, their very common use renders this less of an issue. But anti–androgens are medications that are relatively rarely prescribed to men and doctors consider themselves going much further outside normal clinical practice to use them, especially when they have not been approved for use with sex offenders. It is not improper, unethical, or even especially unusual for physicians to prescribe medications that have not been approved for a particular use, but doctors understandably feel there is greater risk when there is not FDA approval for the use for which they are employing the medication.

Use SlideUse Slide #31: Methods of Administration and Costs: Anti–androgens

The particulars of prescribing these medications are described on this slide. You will note neither medication is inexpensive, but Lupron is especially costly at about $400 per month. Many sex offenders simply cannot afford this medication.

Compliance can be an important concern to keep in mind when it comes to medication. Although offenders may reliably report to the clinic or to their doctor for their medication, the effects of the medication can essentially be neutralized by steroid hormones that can be purchased on the street. In essence, someone may appear to be taking his medication regularly and at the same time offsetting the effects of the medication by taking hormones that he buys on the street. The only way to examine this possibility is with random urine tests.

Note: Elicit answers from audience, focusing on offenders for whom sexual preoccupation is a salient feature of their personality and offending.

Ask QuestionsWe’ve reviewed the use of prescription medications with sex offenders. Although the notion of a pill or an injection to solve the problem of sex offending is very attractive to the general public, why, upon closer examination, is this intervention so far from being the complete answer for all sex offenders?

We have, of course, already discussed the answer—that the motivations for sexual offending are influenced by a complex set of issues that go beyond the realm of sexual interests. Those issues include distorted attitudes, poor behavior management, and lack of interpersonal skills. In the following sections of this training, we will treat each of those topics in turn. Before we leave the topic of psychopharmacological interventions, we should note that often the question is raised, “If we have a medication–based therapy, why waste our time with other types of treatment that seem costly and lengthy?” In fact medication only addresses the issue of sexual arousal—which is one domain of treatment.40 When prescribed in a manner that complements the cognitive–behavioral model of treatment—which addresses the other domains of treatment (distorted attitudes, interpersonal functioning and behavior management), it can be very helpful in facilitating treatment.

If our goal is to reduce recidivism, and medication will help maintain an individual long enough to help him assimilate the cognitive–behavioral response, we are impairing our effectiveness if we don’t use it with those for whom it would be beneficial. Conversely, given the current body of evidence, it would be irresponsible only to medicate and not include a cognitive–behavioral treatment component.