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State of the Art Treatment Options for Actual and Potential Sexual Offenders and New Prevention Strategies

GIBBELS, CHARLOTTE MS; KNEER, JONAS DIPL-PSYCH; HARTMANN, UWE DIPL-PSY; KRUEGER, TILLMANN H.C. DR MED

Journal of Psychiatric Practice®: July 2019 - Volume 25 - Issue 4 - p 242–257
doi: 10.1097/PRA.0000000000000395
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Sexual violence is a significant and devastating issue for men and women throughout the world. Its consequences are not only disastrous for victims of sexual violence but are also extremely costly (estimated cost of $41,000 per rape) for society. Successful treatment of sexual offenders is therefore an important goal for society as well as for victims and offenders themselves. Over the years, multiple treatment approaches for sex offenders have been developed. Treatment programs range from the risk-need-responsivity (RNR) model, which focuses on providing tailored treatment for high-risk and low-risk offenders, to psychodynamic models. This article presents an overview for clinicians of state-of-the-art offender treatment, describing the most common treatment approaches, in particular the RNR model, cognitive-behavioral programs (relapse prevention programs, sexual offender treatment programs), psychodynamic approaches (transference-focused psychotherapy, mentalization-based therapy), the Good Lives Model, as well as pharmacological options. In addition, it provides an evaluation of the various treatment programs. However, given the fact that most acts of sexual violence will never be reported to the police, the question arises if treating convicted perpetrators is enough. Do we need rather—in terms of preventive work—a program for potential sexual offenders and men with delinquent sexual fantasies? Given the prevalence of sexual violence and its impact on victims, society, and the medical community, it would be remiss not to try to reach potential/unconvicted perpetrators. This article offers novel ideas and a project the goal of which is to prevent sexual offenses against women by introducing the “I CAN CHANGE” program from Hannover Medical School.

GIBBELS, KNEER, HARTMANN, KRUEGER: Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany

The authors declare no conflicts of interest.

Please send correspondence to: Charlotte Gibbels, MS (Psychology), Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany (e-mail: gibbels.charlotte@mh-hannover.de).

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EPIDEMIOLOGY OF SEXUAL OFFENDING

Prevalence of Sexual Offending

Sexual violence is a significant issue for men and women throughout the world. The World Health Organization defines sexual violence as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.”1 Numerous studies have shown a positive association between being a victim of sexual violence and the risk of developing a wide range of behavioral problems (eg, suicidal behavior),2 psychological problems (eg, depression, anxiety disorders, drug dependence),3 sexual problems (eg, sexual pain),4 and immense costs for society (estimated at $41,000 per rape).5 The prevalence of posttraumatic stress disorder among women who have experienced sexual assault is ~50%.6 In 2010, it was estimated that 7.2% of women worldwide had experienced nonpartner sexual violence at some point in their life.7 In the United States, 43.9% of women and 23.4% of men have reported having experienced some form of sexual violence during their lifetime, including being made to penetrate a perpetrator, sexual coercion, unwanted sexual contact, and unwanted sexual experiences without contact.8 Nearly a fifth of women (19.3%) and 1.7% of men have been raped during their lifetime.8 In Germany, a representative study found that 12% of women had experienced some form of sexual violence and 58% of women had experienced sexual molestation at some point in their lives.9 In nearly half of the cases, the perpetrator was a partner or ex-partner, which may explain the gap between reports of rape and estimates of the actual number of rapes in Germany. Hellmann10 explained that between 85% and 95% of women who were raped do not report it to the police and fewer than a quarter of reports lead to an actual conviction. In Germany, unreported cases are referred to as the “Dunkelfeld” (dark field) and reported cases as the “Hellfeld” (light field), respectively.

The estimated number of perpetrators in the dark field is alarming. When asked about sexual violence, almost 14% of 21,313 Swiss army recruits admitted they had perpetrated sexual violence during the last 12 months. Furthermore, 1.7% of them confessed that they had had nonconsensual sex >20 times in the last 12 months.11 In a sample of 2513 subjects, Allroggen et al12 found evidence that 1.5% of men and 1.0% of women had been sexually aggressive in some way during the past 12 months.

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Psychiatric Characteristics of Sexual Offenders

Several studies have found that most sexual violence is committed by males.8,13,14 Identifying the psychiatric characteristics of sexual offenders is challenging on various levels. It is well established that sexual offenders show high psychiatric comorbidity, especially with respect to mood disorders (6.6% to 43.8%), personality disorders (27% to 76%), and alcohol and drug dependence (19% to 67%).15–18 In addition, certain psychiatric disorders are associated with an increased hazard ratio for violent reoffending (adjusted hazard ratio: 1.63, 95% confidence interval: 1.57-1.70).19 In a longitudinal cohort study of 47,326 prisoners, Chang et al19 found that up to 20% of violent reoffending in men was attributable to a diagnosed psychiatric disorder. It is clear from this evidence that tailored treatment programs are essential, especially for sexual offenders who suffer from psychiatric disorders.

Since it is crucial to establish valid clinical diagnoses in order to offer the best possible treatment, it is essential to have a closer look at the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)20 and its new approach to diagnosing paraphilias. There was a great debate concerning how DSM-5 should integrate paraphilias in the new edition.21–27 But even though pedohebephilia, hypersexual disorder, and paraphilic coercive disorder were diagnoses proposed for inclusion in DSM-5,28 none of them was included in the final version of the manual.20 Instead, 3 significant changes were made concerning paraphilias in DSM-5: (1) a differentiation between paraphilia and paraphilic disorders (paraphilia is only regarded as a disorder when it causes distress or dysfunction or when its satisfaction has entailed personal harm, or risk of harm, to others); (2) introducing criteria that allow paraphilic disorders to be in remission (when they no longer cause distress or dysfunction and the individual has not acted on the urges with a nonconsenting person for at least 5 years while in an uncontrolled environment); and (3) clarifying the relationship between behavior and paraphilia.29 Hence, paraphilic disorders have been included in the DSM-5 but paraphilic preference is no longer a clinical diagnosis itself.

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TREATMENT OF SEXUAL OFFENDERS: OVERVIEW OF CURRENT APPROACHES

Many treatment programs for sexual offenders have been developed. Marshall and Hollin30 described the history of sex offender treatment in the United Kingdom and the United States from early approaches, such as the use of aversive conditioning to reduce deviant sexual interests in the 1960s, to more recent developments such as the Good Lives model (GLM),31 which uses aspects of positive psychology to reduce the risk of recidivism. Given the variety of sexual offender treatments, it is impossible to mention them all. Therefore, in this article, we will only describe and discuss the most common sexual offender programs in the United States, the United Kingdom, and Germany, with a particular focus on the psychological foundations of the programs and treatment outcomes.

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Difficulties in the Evaluation of Sexual Offender Treatment

Given that the treatment of perpetrators is in the hands of the legal system, various difficulties arise in evaluating sexual offender treatments. To evaluate a treatment program, it is necessary to compare 2 groups that do not differ a priori or a posteriori in all variables.32 First, since decisions about who receives treatment are made by the legal system, offenders who receive treatment are not necessarily internally motivated to stop offending and it is possible that perpetrators who would benefit from treatment are not included in the treatment group,32 either because they are deemed too difficult to treat or because their problems are not deemed serious enough to warrant specialist treatment. In addition, many perpetrators are not internally motivated to work on their problems, which may lead to nonresponse or “false positives” in the form of socially desirable answers to questions, given in the hope of extracting advantage (eg, a reduced period of incarceration) rather than because the perpetrator’s attitude or behavior has genuinely changed.

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THEORETICAL FRAMEWORKS AND TREATMENT APPROACHES FOR SEXUAL OFFENDING

Risk-Need-Responsivity (RNR) Model

According to the RNR approach,33 treatment should be based on 3 main principles: (1) estimation of the risk of reoffending after the first offense (risk), (2) assessment and targeting of criminogenic features (need) and tailoring of treatment to the offender’s learning style, and (3) motivation and abilities (responsivity).34 There are general and specific aspects to responsivity. In general, treatment should be cognitive and behavioral, but it should be modified to reach those offenders who would benefit most from treatment and treatment should be facilitated by focusing on the 3 main principles.

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Evaluation of the RNR Model

The RNR model assumes that perpetrators with a high risk of reoffending are likely to benefit the most from treatment programs, yet they are also the group least likely to complete such programs.35 Therefore, applying the RNR model when treating sexual offenders not only provides specific help for those who are likely to benefit the most from these programs, it could also provide the opportunity to tailor a treatment program precisely and specialize it for those offenders who are at high risk. Moreover, there is some evidence that risk-related in-treatment improvements are associated with a reduction in posttreatment recidivism.35–38 Overall, there is good empirical evidence for the RNR mode.32

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Good Lives Model (GLM)

Unlike other offender treatment programs, the GLM31 focuses on primary “goods” (certain states of mind, personal characteristics, and experiences) that every human being values. These goods are life (including healthy living and functioning), knowledge (how well informed one feels about things that are important to oneself), excellence in play (hobbies and recreational pursuits), excellence in work (including mastery experiences), excellence in agency (autonomy, power, and self-directedness), inner peace (freedom from emotional turmoil and stress), relatedness (including intimate, romantic, and familial relationships), community (connection to wider social groups), spirituality (in the broad sense of finding meaning and purpose in life), pleasure (feeling good in the here and now), and creativity (expressing oneself in different ways). While all human beings value these goods, the weighting and priority of them differ between individuals. Ward’s GLM31 assumes that criminal behavior develops when individuals are not able to attain the goods that they value through prosocial means. Subsequently, offenders need to learn to achieve the goods that are important to them by different and prosocial means or, if goods are not achievable, to shift their focus to other attainable goods. Writing on the GLM has highlighted its strengths-based approach and emphasis on the personal growth and development of participants.

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Evaluation of the GLM

The theoretical foundations of the GLM are sound,39 but unfortunately there is a lack of studies evaluating the program. Andrews et al40 found that GLM did not produce better results than RNR, but, according to Harkins et al,39 both facilitators of and participants in the GLM program reported that the impact of the Good Lives approach module is positive and future focused, whereas participants in the RNR program did not report such improvements. It should be noted, however, that neither Andrews et al40 nor Harkins et al39 found any differences between the outcomes of the GLM and RNR. It is possible that the positive approach of the GLM means that participants, especially those at high risk of reoffending, are more motivated to participate and to complete the program.

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Self-regulation Model of Offending (SRM)

The treatment program based on the SRM, a model that was originally introduced by Ward and Hudson,41,42 provides an alternative to relapse prevention. Being developed specifically for sexual offenders and taking into account the diversity evident in sexual offending behavior, the program focuses on internal and external processes that allow individuals to engage in goal-directed behavior.42,43 By taking into account the variability of offense-related goals, the model is able to differentiate among 4 pathways. Those pathways differ between individual offenders and within an individual offender at various points in the progression to sexual offending.44 They include the individual’s goals with respect to sexual offending (approach vs. avoidance) as well as the individual’s attempts to achieve the goal (passive vs. active).44 While offenders with avoidance goals desire to refrain from offending, offenders with approach goals are more likely to actively seek out opportunities to offend. In addition, achieving those goals is based on individual capacity of self-regulation and the ability to control behavior. According to SRM, offenders will follow one of the following 4 pathways45: avoidant-passive pathway (desire to refrain from sexual offending but lack of awareness/ability to control behavior); avoidant-active pathway (implementing strategies to cope with desire to offend but strategies are ineffective); approach-automatic pathway (neither desire to prevent offending nor to refrain from offense-related goals); and approach-explicit pathway (intact self-regulation and a goal to approach offending).45 The goal of SRM is to take a more individualized and comprehensive approach to treatment that addresses individual risk-factors and is tailored to offense pathways.45

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Evaluation of the SRM

As Yates45 described in her paper, there is evidence for the validity of SRM, especially with regard to the existence of the pathways of sexual offending, offense characteristics (offense planning and victim type), variability in pathways across different types of offenders, and treatment participation, compliance, motivation, progress, and outcome.44,46–52 Furthermore, the different pathways have been associated with static and dynamic risk factors, offense specialization, and psychopathy.45 Nevertheless, different pathways have been found to be linked differently with recidivism.48,53,54 Hence, SRM has been supported by research and could be applied in the treatment of sexual offenders.

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SPECIFIC TREATMENT PROGRAMS AND MANUALS FOR SEXUAL OFFENDING

Cognitive Behavioral Programs

According to Cullen and Gendreau,55 cognitive behavioral programs have 2 aims: (1) restructuring the distorted or erroneous cognitions of the individual and (2) trying to help him or her to learn new, more adaptive cognitive skills. Offenders’ cognitive distortions might include thoughts and values that justify antisocial behavior. Techniques such as cognitive reconstruction, modeling, positive reinforcement, and role playing play an important part in cognitive behavioral programs such as the German Treatment Program for Sexual Offenders.56,57

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Relapse Prevention Programs

Originally developed for addictive patients,58,59 relapse prevention programs are cognitive behavioral programs that teach participants to avoid or manage situations that threaten their commitment to abstinence.60 Pithers et al61 transferred this approach to sexual offender treatment. During treatment, participants are taught how risk situations may develop and how to defuse such situations.62 Gradually, additional techniques targeting other cognitive behavioral factors have been added to programs for sexual offenders.62 The programs developed by Pithers et al61 and Laws63 especially have been widely adopted, and relapse prevention programs such as these remain the most popular types of interventions in the United States.62

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Sexual Offender Treatment Program (SOTP)

The SOTP was introduced in prisons in the United Kingdom in 199262 and is based on the relapse prevention model.58 It focuses on the long-term risk of reoffending and therefore on offenders’ personal risk factors for reoffending, ranging from broad lifestyle factors and cognitive distortions to deviant sexual arousal patterns and deficits in coping skills.64 The program includes a variety of cognitive, behavioral, and skill-training elements.64 The aims of the SOTP are to increase offenders’ sense of personal responsibility and decrease their use of justifications for sexual deviance as well as to decrease deviant sexual behavior, to improve their ability to identify high-risk situations, and to give them skills to avoid and cope with high-risk situations.64 The treatment is offered in weekly, highly structured 90-minute group sessions. Further groups focus on sex education, human sexuality, relaxation training, stress and anger management, and social skills.64 The SOTP also includes a prerelease course designed to prepare offenders for “life on the streets.” This consists of weekly individual sessions with an assigned clinician and nursing staff. If necessary, special programs can be offered for groups of alcohol and drug abusers.64

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German Treatment Program for Sexual Offenders (Behandlungsprogramm für Sexualstraftäter, BPS)

The BPS,56,57 which has become the most widely used SOTP in Germany,65 consists of 2 parts. The first is a non–offense-related educational component and the second part involves cognitive-behavioral interventions. Like the relapse prevention model, the second part concentrates on offense-specific factors.66 The BPS is based on a theoretical model that assumes basic relations between social and psychological factors on the one hand and sexual assault on the other. It focuses on experiencing distress and holding attitudes or beliefs that are supportive of sexual aggression.66

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Evaluation of Cognitive Behavioral Programs

The literature suggests that cognitive behavioral therapy and medical interventions are the most effective forms of treatment for sexual offenders.46,55,65,66 Programs such as relapse prevention programs, the BPS and the SOTP are cognitive behavioral programs and could therefore be considered a good treatment option for sexual offenders.67–70 However, a randomized controlled trial (RCT) of the SOTP64 found no difference in recidivism between treated and untreated offenders after 8 years, although closer analysis did reveal other group differences. Offenders with a high risk of reoffending were less likely to have reoffended if they were in the treatment group than if they were in the control group.64 Therefore, it seems appropriate to include the RNR model among the treatments for sexual offenders.35,64

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Psychodynamic Programs

After years during which treatment for sexual offenders in forensic settings was dominated by behavioral programs, there has recently been a shift to psychodynamic therapies in German forensic hospitals.71 Modern manualized therapies, such as transference-focused psychotherapy (TFP) as well as mentalization-based therapy (MBT), are gaining acceptance.71

TFP is a manualized psychodynamic treatment program used particularly in the treatment of borderline personality disorder. Although it was not originally developed for sexual offenders, it has been used to treat sexual offenders in German forensic hospitals.72 TFP takes the view that the current difficulties of the participants in the program are the result of pathologic internal relationships in the past.73 Unlike other psychodynamic therapies TFP actively tries to reduce self-harm, using confrontational and clarifying techniques.72 The program aims to improve participants’ mentalization in order to help them interpret their own and others’ behavior by understanding their mental state.74 In this context, transference relates to therapeutic tasks and explanations in the present.72

MBT is rooted in attachment and cognitive theory and aims to strengthen patients’ capacity to understand their own and others’ mental states in attachment contexts. MBT assumes that participants will be able to address their difficulties with affect, impulse regulation, and interpersonal functioning, which act as triggers for acts of suicide and self-harm.75

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Evaluation of Psychodynamic Treatment

Unfortunately, little research has evaluated psychodynamic approaches to sexual offender treatment. To the best of our knowledge, only 1 study exists,72 which examined a sample of 44 sex offenders who were in a German forensic hospital due to an addiction. The authors reported that, after 18 months of treatment, the patients in the TFP group (n=24) showed positive changes in dimensional personality scores and global psychopathology indices compared with the control group (n=20) who received treatment as usual.

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INTERVENTION AND PREVENTION PROGRAMS SPECIFIC TO PEDOPHILIA

Although this paper focuses on treatment programs for sexual offenders against women rather than children, we felt we could not ignore 2 programs designed to treat pedophilia, as they were the first programs ever designed to prevent people from committing a sexual crime against children and therefore represent milestones in the treatment of potential sexual offenders.

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The Berlin Dissexuality Therapy Program (BEDIT)

BEDIT is a specific program for self-identified, self-referring pedophiles who are not known to the legal system, that is, in the so-called “dark field.”76 Designed as a group therapy, the program consists of 12 modules and covers topics such as motivational work, emotion regulation, coping strategies, problem-solving, and protective measures.76 The program uses cognitive behavioral techniques to reduce the risk that clients will become perpetrators (again). It was developed as part of the Berlin prevention project “Dunkelfeld” (Don’t Offend) and is the first program that has ever attempted to prevent child sexual abuse and consumption of child pornography in people who are not known to the legal system. It is used by the “Don’t offend” network in Germany, which currently has 11 sites.

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Evaluation of BEDIT

Beier et al77 showed that, after participating in the BEDIT program, participants had lower levels of emotional deficits and offense-supportive cognitions and better sexual self-regulation. However, although these results seem promising, 5 of the 25 child sexual abuse perpetrators and 29 of the 32 consumers of child pornography reported ongoing offending behavior during therapy. Because of strict confidentiality laws in Germany, therapists are forbidden to report these incidents to the police so that these participants remain “in the dark field” because they are not known to the police. Further evaluation of BEDIT is necessary to demonstrate whether it can prevent child sexual abuse and consumption of child pornography.

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Prevention of Sexual Abuse

This program was developed by Schulz et al78 and resembles BEDIT fairly closely, but it is the first prevention program for self-identified, self-referring pedophiles in Germany. It uses a cognitive-behavioral approach that integrates need-oriented and resource-oriented concepts and is based on the SOTP, GLM, BPS, and several other established programs for sexual offenders. Like BEDIT, the program aims to prevent child sexual abuse and consumption of child pornography in people who have had no contact with the legal system yet.

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Evaluation of Prevention of Sexual Abuse

The Prevention of Sexual Abuse Program was only introduced in 2017, so that there has not yet been any systematic evaluation of its impact. Schulz et al78 have published 2 case reports on clients who participated in the program. Both clients improved on several outcome measures (such as self-efficacy and life satisfaction) and reported reductions in child abuse behaviors. However, 2 case reports are not enough to determine whether or not the program is effective.

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PHARMACOLOGICAL OPTIONS FOR PREVENTION AND TREATMENT OF SEXUAL OFFENDING

The World Federation of Societies of Biological Psychiatry (WFSBP) released guidelines for the biological treatment of paraphilias in 2010,79 as well as for the treatment of adolescent sexual offenders with paraphilic disorders in 2016.80 While these algorithms may be very useful for the clinician,79,80 one needs to keep in mind that the scientific quality of the underlying studies was usually weak, involving about 7 small trials (total N=138), all of which were published >20 years ago. Furthermore, newer drugs currently in use, such as selective serotonin reuptake inhibitors (SSRIs) and gonadotropin‐releasing hormone (GnRH) analogues, were not evaluated in those trials.81 Although some findings and our subjective clinical experience may be encouraging, the limitations noted above do not allow reliable conclusions to be drawn about the efficacy of pharmacological treatments for reduction of first or repeated sexual offending. Also, many safety issues remain unclear, as the studies that have been done were usually underpowered and of too short duration to carefully assess side effects. Nevertheless, the WFSBP guideline algorithms discussed below provide a useful tool for clinicians when initiating a pharmacological intervention in men with paraphilias and/or who have sexually offended or are at risk of offending. As part of shared decision-making, we strongly recommend that clinicians conduct a detailed discussion on the desired effects and all known side effects of any pharmacological treatment and obtain written informed consent.

The 2010 WFSBP guideline on biological treatment of paraphilias79 suggests a 6-level algorithm; this may seem complex for less experienced clinicians and the distinction between the different levels is not always well defined. The level of evidence for each of these steps varies between C and D or no level of evidence (level of evidence C: minimal research based evidence, eg, 1 randomized, double-blind study with a comparator treatment and 1 prospective, open-label study/case series or at least 2 prospective, open-label studies/case series; level of evidence D: evidence was obtained from expert opinions supported by at least 1 prospective, open-label study/case series). The goal of all of the treatment levels in the algorithm is to control paraphilic sexual fantasies, compulsions, and behaviors with different degrees of reduction or suppression of conventional and/or deviant sexual drive and activity. Usually if 1 level is not sufficient, the next higher level should be chosen. The levels are as follows:

  • Level 1: Psychotherapy (preferentially cognitive behavioral therapy) is suggested.
  • Level 2: As a suggestion for all mild cases (“hands off” paraphilias with a low risk of sexual violence, such as exhibitionism) and when level 1 actions have not been satisfactory, SSRIs can be prescribed.
  • Level 3: As a means of substantial reduction of sexual drive and activity and in cases of moderate and high risk of sexual violence (“hands on” paraphilias without penetration), adding a low-dose antiandrogen [eg, cyproterone acetate (CPA) 50 to 100 mg/d] to SSRIs is suggested.
  • Level 4: In case of moderate and high risk of sexual violence and when level 3 has not been satisfactory, a full dosage of CPA 200 to 300 mg/day orally or 200 to 400 mg IM once weekly or every 2 weeks is recommended. Where CPA is not available, medroxprogesterone acetate (MPA) 50 to 300 mg/day is an alternative. When comorbid affective disorders (eg, anxiety, depression, obsessive-compulsive symptoms) are present, the antiandrogen can be augmented with an SSRI.
  • Level 5: As a means of almost complete suppression of sexual desire and activity and in cases of high risk of sexual violence (eg, sexual sadism fantasies and/or behavior or physical violence), long-acting GnRH analogues can be used (ie, triptorelin or leuprolide acetate 11.25 mg every 3 mo). If necessary, this intervention can be monitored by measurement of testosterone levels. Please note that CPA (or MPA) should be given 1 week before and during the first months of treatment with a GnRH analogue to prevent an initial flare up effect from the GnRH analogue.
  • Level 6: A complete suppression of sexual desire and activity may be achieved by administration of an antiandrogen treatment, that is, CPA (50 to 200 mg/d orally or 200 to 400 mg once weekly or every 2 wk IM) or MPA (300 to 500 mg/wk IM if CPA not available) in addition to GnRH agonists.). An SSRI may also be added.

A similar algorithm has been proposed for pharmacological treatment of adolescent sexual offenders with paraphilic disorders (for details, see Thibaut et al80), even though the scientific support is even sparser in juveniles and the developmental stage of younger individuals may limit the use of certain drugs due to their potential side effects.

Side effects should be monitored regularly in all patients. Careful physical, laboratory, and instrument-based diagnostics (eg, electrocardiogram, osteodensitometry) are recommended. In our clinic, all patients who receive long-term treatment have regular visits every 4 to 12 weeks and check-ups (eg, electrocardiogram, laboratory tests) at least every 6 months. For most of our patients, we provide all relevant information on pharmacological treatment during a group psychoeducational intervention and in a one-to-one appointment. For educational purposes, we use a more simplified schema which basically incorporates psychological interventions and an optional 3-level pharmacological treatment which allows for the same steps and combinations as described in the 6 level algorithm (Fig. 1).

FIGURE 1

FIGURE 1

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CASE REPORT

A 28-year-old participant in the “Don’t Offend” project with a pedophilic disorder asks for pharmacological options to reduce his pedophilic sexual fantasies and sexual drive. He reports a masturbation frequency of 5 times per day and regularly uses child pornography. His degree of suffering is estimated as high. Symptoms worsen during episodes of stress such as interpersonal conflicts with family members. He has a lifetime diagnosis of a major depressive disorder, but currently the patient does not report suffering from a depressive episode. He has a homosexual orientation with a pedophilic preference. The severity of his sexual symptoms was 65/100 on a visual analogue rating scale (Fig. 2). Although the patient did not indicate suffering from current depression, his initial score on the Beck Depression Inventory was 32, possibly as a sign of general mental burden due to his pedophilic urges. After initiation of pharmacological treatment with CPA (50 mg twice a day), his symptom severity score on the visual analogue rating scale and his Beck Depression Inventory score decreased dramatically. His scores on the Massachusetts General Hospital Sexual Functioning Questionnaire (MGHSFQ) indicated the development of sexual dysfunction as a typical side effect (impairment of erectile function) which, however, was perceived as tolerable by the patient.

FIGURE 2

FIGURE 2

Despite the current guidelines that are available, there is a strong need for additional clinical trials,81 because the evidence supporting treatment recommendations is still weak. According to the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use Guideline for Good Clinical Practice (ICH-GCP), RCTs are either not feasible for incarcerated subjects for legal reasons (as is the case in Germany) or are extremely expensive. Registry studies are an alternative and can also be used to evaluate important clinical parameters (efficacy, safety, adherence, sexual function, risk factors). Previous studies, meta-analyses, and general clinical experience indicate that antiandrogen treatment can be a powerful tool for reducing sexual offending recidivism, with odds ratios as high as 3 for hormonal castration and 14 for surgical castration (for an overview, see Bickley and Beech46). But, as mentioned above, the existing research suffers from many methodological flaws.15,82 It is also extremely difficult to carry out research on the effectiveness of antiandrogens as a preventive treatment, for both ethical (eg, control groups would be persons at risk receiving no treatment or placebo) and practical (longitudinal or prospective studies with large samples are needed) reasons.

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OVERALL EVALUATION OF SEXUAL OFFENDER TREATMENT

Despite many difficulties, several attempts have made to evaluate treatment programs for sexual offenders.39,68,83–87 The very limited number of RCTs of SOTPs is one of the main limitations in examining research on the effectiveness of sexual offender treatment.35 Schmucker and Lösel68 found that the results of RCTs were heterogenous, which reduced the statistical power of their meta-analysis. Treatment for people who have committed serious crimes is mandatory in various countries, which makes it difficult to form a randomized control group for RCT designs.68 Nevertheless, some conclusions can be drawn from current data. Overall, there is some evidence that participation in SOTPs is associated with a reduction in sexual offending recidivism and recidivism in general.67,68,84,88–90 However, several studies have failed to find differences in recidivism between treated and untreated sexual offenders.64,83,85 The meta-analysis by Schmucker and Lösel68 reported mean weighted sexual recidivism rates of 10.1% for treated offenders and 13.7% for controls as well as 26.4% less general recidivism of any crime in treated offenders. In addition, Hanson et al84 found a sexual recidivism rate of 10.9% in their treatment group, compared with 19.2% in the comparison group. The most robust risk factors for sexual recidivism included sexual deviance, antisocial orientation, sex offender attitudes, and intimacy deficits, whereas potentially misleading factors are denial, victim empathy deficits, low self-esteem, and loneliness.91 Olver and Wong35 were able to show that intensive treatment of moderate-risk to high-risk offenders was associated with more substantive reductions in recidivism than a briefer treatment program for lower risk offenders. This is consistent with Schmucker and Lösel’s68 conclusion that medium-risk and high-risk groups benefit from treatment, whereas low-risk participants do not. There is also evidence that in-treatment improvements that are related to risk factors may be linked to a reduction in posttreatment recidivism.36–38 Overall, one could give a positive answer to the question of whether treatment of sex offenders has a positive impact,48 but the questions of when, why, and for whom it works best remain open.48,92

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GUIDELINES FOR PRACTITIONERS

Even though criminal behavior and sexual crime are not psychiatric diagnoses per se, it is noticeable and well-established that sexual offenders show high levels of comorbid psychiatric conditions,15–18 which in turn can represent risk factors for offending.19 Therefore, the risk of undetected sexually deviant patients in regular treatment might be underestimated. Addressing questions about sexuality and sexual behavior in therapy might not only help practitioners clarify whether or not patients might have deviant fantasies but also is helpful in meeting patients’ therapeutic needs and, therefore, in the long term improving quality of treatment and life for patients. In addition, when patients mention deviant sexual fantasies or admit that they have already sexually offended, it is important to know that there are treatment programs and medical options for those patients. Only by knowing about those programs and integrating this knowledge into our health care system, can we attempt to decrease the risk of sexual offending. Moreover, it is essential for practitioners to know that multiple projects, such as “Stop it now!” (United Kingdom, Ireland, and Netherlands),93 “Don’t Offend” (Germany),76 and “Troubled Desire” (worldwide)94 provide information, advice, and guidance to anyone concerned about child sexual abuse and anyone at risk of offending. Those programs address practitioners as well as relatives of people at risk of sexual offending.

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PREVENTION OF SEXUAL OFFENDING

Programs for Prevention of Sexual Offending

In recent years, the focus has been primarily on treatment of sexual offenders, whereas relatively little is known about prevention of sexual crimes. Most prevention programs provide general help by training teachers, school children, college students, and adults to recognize the signs of sexual abuse95 or are designed to help potential victims, such as children and women, by strengthening their self-esteem.96,97 Even if one accepts that this is a reasonable approach to prevention, it ignores an important part of the problem, namely potential sexual offenders who already fantasize about sexual offending or have problems with regulating their sexual drive but are (as yet) unknown to the legal and health care systems.

In the United Kingdom, Ireland, and the Netherlands, the project “Stop it now!” provides information, advice, and guidance to anyone concerned about child sexual abuse.93 Like the programs described above, this project offers help to professionals, parents, and people who are at risk to offend children and people who have committed child sexual offenses. In addition, it aims to raise awareness of child sexual offending.

In Germany, the introduction of the “Don’t Offend” prevention program has marked a shift in perspective, at least when it comes to prevention of child molestation. The high number of men participating in this program (8479 contacts in September 2017, with 804 receiving psychotherapy) highlights the importance, need, and acceptance of such preventive support for potential offenders. There is no analogous preventive program for potential adult sex offenders.

Since not all countries have such strict rules of confidentiality as Germany, treatment programs for offenders in the dark field might be considered as problematic on an international level. Therefore, the website “Troubled Desire” (https://troubled-desire.com/en/), which is available in English and German, offers help to people attracted to children, and to their relatives. It also provides support for health care professionals who are confronted with patients with pedophilia.

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Projects for Prevention of Sexual Offending Against Adults

To date, the prevention of rape and sexual violence against adults has been focused primarily from the perspective of victims. Given that a high proportion of sexual violence against women is not reported to the police, this may not be sufficient. As Keller et al98 showed, simple interventions such as educational programs can have an enormous impact on participants’ attitudes to women and the likelihood that they will intervene when they witness violence against women. However, it is also necessary to develop additional prevention programs that are specific to the needs of men who are at risk of committing a sexual crime. With regard to the effects of offender treatments all over the world, the next step seems to be to address those who report intrusive, excessive, and uncontrollable sexual urges involving threatening or raping. Working on risk factors is one of the most important elements of offender treatment; hence, targeting risk factors before a crime has been committed seems to be a promising new although challenging approach for prevention of sexual offences.

Before such prevention programs are implemented, multiple issues should be carefully considered:

  • Are there participants who would want to take part in such a prevention program? The number of men participating in the “Don’t Offend” project suggests that the answer to this question is likely to be a clear “yes.” These are men who have not been convicted of child molestation yet are willing to participate in anonymous therapy that is free of charge. However, given the differences between pedophiles and rapists of adults noted above, in particular the difference in cultural perceptions of pedophilia and violence against women, it is unclear whether potential rapists are as distressed by their fantasies and sexual preoccupation as pedophiles are. Due to the lack of prevention programs for potential sex offenders against adults, there is as yet no empirical evidence about how willing those potential offenders would be to participate in such programs. One factor that might encourage them to attend a program could be fear of the punishment for committing a sexual crime. Awareness of the severity of punishments for sexual crimes might be higher in Germany following the “No means no!” campaign and the reinforcement of criminal law relating to sexual offences. Because of the change in climate that has indeed taken place, it may now be easier to reach the target group with such a prevention program.
  • How can we reach potential sexual offenders? Having sexual fantasies of violence and rape is not something that anybody wants to admit. This makes it very difficult to reach potential prevention program participants. Experience with “Don’t Offend” suggests that it is realistic to expect that potential offenders who are distressed by their sexual drive and fantasies would participate in such a program. Internet forums and the media may offer ways of obtaining access to potential participants.
  • Who would sign up for a preventive program? As mentioned above, we know a lot about comorbidity and the problems of sexual offenders who are in prison or forensic psychiatric hospitals, but little is known about the numerous offenders who have not been charged with their crimes. It is highly probable that this population differs from the population of convicted offenders in some ways. It might be that perpetrators who evade conviction are less likely to have a comorbid psychiatric disorder. Therefore, they could be superior in concealing their criminal behavior and are probably better integrated into society. It is also possible that there are some other, less obvious reasons why sexual crimes go undetected. The fact is that we do not know anything about the social, sexual, or even educational background of unconvicted sexual offenders. Studies of unconvicted sexual offenders have been done, but so far none of them has focused on the psychological background of such offenders. The opportunity to analyze differences between convicted sexual offenders, unconvicted sexual offenders, and those who have sexual fantasies about illegal acts or feel a drive to offend but have not yet done so would be an additional benefit of prevention programs.
  • Ethical issues such as self-indictment. Finally, adjusting existing treatment programs to meet the potentially different needs of unconvicted perpetrators and potential perpetrators is an issue of particular importance. As argued above, it is highly likely that these groups differ from convicted sexual offenders in some ways and so it is important to adjust the programs to reflect their different needs. Almost all offender treatment programs focus on a concrete type of crime, but it may be more sensible for prevention programs to concentrate on addressing cognitive bias, emotional deficits, and a lack of sexual self-regulation. Subsequently, programs such as GLM and emotion-focused therapy might be good alternatives or supplements to treatment as usual. In addition, some parts of the SOTP and some cognitive behavioral techniques could be incorporated into a prevention program focusing on cognitive bias, rape myths, emotional deficits, and sexual self-regulation.

In summary, the take-up and outcomes of such a prevention program cannot be foreseen, but, given the prevalence of sexual violence and its impact on victims, society, and the medical community, it would be remiss not to try to reach unconvicted and potential perpetrators.

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I CAN CHANGE: A New Preventive Treatment Approach

Given these unmet needs, Hannover Medical School has recently introduced a program, called “I CAN CHANGE.” Participants receive psychological treatment, medical care and—if they wish—couples therapy. In addition and to avoid stigmatization, labeling, and “witch hunting,” the project provides information about sexual offending and its various facets to health care professionals and the German population by giving educational talks and sensitizing on the topic. The project aims to extend the understanding that most sexual crimes are not committed by a stranger but occur in the context of a relationship and that they vary in severity. It is clearly communicated that the crime should be condemned but not the human being that committed it.

While the therapy focuses on topics related to sex crimes, such as rape myths, sex education, and development of an emergency action plan, it also covers more general psychotherapeutic topics such as coping strategies, handling emotions, social interaction, and communication. By including general psychotherapeutic techniques and lessons learned from treatment programs for sexual offenders in the “I CAN CHANGE” program, the project is aiming to represent a new approach to “dark field” prevention and thus to reduce the number of sexual assaults. The authors admit that measuring a “reduced number of sexual assaults” and associating that finding with the project raises difficulties. Nevertheless and with regard to projects such as “Stop it now!” and “Don’t Offend,” the authors wholeheartedly believe that preventive work is crucial to reduce the risk of sexual violence.

Because the program is designed especially for sexual offenders in the dark, ethical questions arise concerning how to handle self-indictment and confidentiality. The legal system in Germany forces physicians, psychologists, and psychotherapists to handle already committed crimes with confidentiality. Therefore, patients who mention crimes committed in the past do not have to fear any risk of being incarcerated for something they tell their therapist. Nevertheless, therapists may sometimes find it difficult to handle knowing about crimes such as rape and not being allowed to report to the legal system. Hence, a weekly supervision/intervision is incorporated into the program to help therapists handle such information. In addition, the question of whether or not to support self-indictment is very present in the program. German law handles rape as a so called “official delict” that forces the prosecution and police to investigate as soon as they know about the crime. Therefore, self-indictment should be handled with care, especially with regard to the victim of the crime and possible re-traumatization. For that reason, the aspect of self-indictment is always an individual procedure that requires special supervision and attention.

The program uses elements of GLM as well as cognitive behavioral strategies. Patients usually get in contact with our therapists via telephone calls. After a brief telephone screening, patients are either included or excluded. Exclusion criteria are pedophilia as a sexual preference and/ or ongoing investigation(s) concerning a sexual crime. After the screening, patients are invited to Hannover Medical School for a preliminary talk to gain information about motivation and discuss possible treatment options. In subsequent sessions, patients are assessed in a broad diagnostic process that includes the Structured Clinical Interview for DSM,99 the Wechsler Adult Intelligence Scale,100 and several questionnaires to measure empathy and impulsiveness and collect sociodemographic data and data on past criminal behavior. The therapeutic program includes individual therapy for each patient. Treatment provides medical options as well as cognitive behavioral therapy and elements of GLM. A treatment manual for the program will be published as soon as it is validated. Hopefully this will be the first step in establishing a preventive intervention for potential sexual offenders against adults. By implementing the “I CAN CHANGE” program as a preventive approach, the authors feel confident about reducing the number of victims in the long-term. Furthermore, the project supports data acquisition and scientific research with regard to the “dark field” of sexual offending against adults. Since little is known about offender characteristics in this area, “I CAN CHANGE” as one of the first prevention programs specifically developed for this field will play a crucial role in gaining more information about potential perpetrators. A subsequent goal of the project is to support the further development of more effective prevention programs for people with a high risk of sexual offending. First scientific outcomes are expected in the near future.

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Keywords:

sexual violence; offender treatment; treatment program; prevention of sexual violence; I CAN CHANGE project

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