Assessment & Treatment of Sexual Offending

Sexual Offending: Assessment and Treatment

Sexual Offending Definition

• Sexual offending is defined as engaging in sexual behavior that would constitute a criminal sexual offense, regardless of whether it resulted in criminal prosecution (McGrath, Livingston, & Falk, 2007).
• In the UK, these behaviors are covered by the Sexual Offences Act (2003).

Types of Sexual Offending

• Exhibitionism
• Voyeurism
• Frottage
• Rape (stranger, acquaintance, multi-perpetrator)
• Child sexual abuse (extrafamilial and intrafamilial victims)
• Sexual homicide

Sexual Reoffending/Recidivism

• After a 5-year follow-up (Hanson & Morton-Bourgon, 2003):
  • 13.5% sexual recidivism (N = 23,494)
  • 25.5% any violent recidivism (N = 13,427)
  • 35.5% any recidivism (N = 18,167)

Sexual Recidivism by Victim Type (Harris & Hanson, 2004)

• Follow-up = 15 years
  • Adult Victims (N = 1,038): 24%
  • Intrafamilial Victims (N = 1,099): 13%
  • Extrafamilial Victims (N = 2,798): 25%
  • Girl Victims (N = 1,572): 16%
  • Boy Victims (N = 706): 35%
• There is significant variation among sexual offenders.

Risk-Need-Responsivity (RNR) Principles

• Risk: Match treatment intensity with risk level.
• Need: Target relevant criminogenic risk factors.
• Responsivity: Tailor treatment to ensure maximum benefit.

Risk Assessment

• Informs about the level of risk (of reoffending) posed by the individual.
• Informs on treatment needs.
• Provides strategies for supervision to promote effective risk management.
• Involves identifying and measuring risk factors.
• Risk factors are individual characteristics that increase or decrease the probability of reoffending.

Types of Risk Factors

• Two categories:
  • Static Risk Factors
  • Dynamic Risk Factors

Static Risk Factors

• Largely ‘historical’ factors.
• Non-changeable aspects of the individual.
  • Young when first offended
  • Prior sex offenses
  • Prior non-sex offenses
  • Never been in a committed relationship
  • Stranger victims
  • Male victims

Static Risk Assessment

• Examples:
  • Young age (cut-off = 25)
  • Never married
  • Non-sexual violence in index offense
  • Prior non-sexual violent convictions
  • Prior sexual offenses
  • Prior sentencing dates
  • Non-contact sexual offenses
  • Stranger; Unrelated; Male victims.
• Most widely used measure = the STATIC-99 (Hanson & Thornton, 1999).

Sexual Reconviction by STATIC-99 Score

The risk of sexual reconviction increases with STATIC-99 score over time (5, 10, and 15 years).

Dynamic Risk Factors

• Factors that are amenable to change or fluctuation.
• Issues addressed in treatment.
  • Stable: Enduring (but changeable) characteristics linked to the offending behavior.
  • Acute: Rapidly changing characteristics. Indicate a re-offense may occur within a short period.
• Some dynamic factors may be both stable and acute.

Examples of Dynamic Risk Factors

• Sexual interest in children
• Relationship conflict
• Emotional congruence with children
• Poor problem-solving
• Lack of intimate adult relations
• Hostility toward women
• Employment instability
• General self-regulation problems
• Sexualized violence
• Grievance/hostility
• Sexualized coping
• Sexual preoccupation
• Offense-supportive beliefs/attitudes
• Impulsivity, recklessness
• Multiple paraphilias

Dynamic Risk Domains (Thornton, 2002)

• DOMAIN 1: Sexual Deviance
• DOMAIN 2: Distorted Cognition
• DOMAIN 3: Socio-affective Issues
• DOMAIN 4: Self-management Issues

Dynamic Risk Assessment Tools

• STABLE-2007 and ACUTE-2007 (Hanson et al., 2007) were developed to assess dynamic risk factors.
• Most powerful acute factors include:
  • Hostility
  • Sexual Preoccupation
  • Victim Access
  • Rejection of Supervision
• Assessments including these tools give judges greater confidence.

Reliability and Validity of Dynamic Risk Factors

• Each dynamic risk factor needs a reliable and valid measure of assessment.
• If sexual deviant interests cannot be reliably assessed, measures like STABLE-2007 become less reliable.

Deviant Sexual Interest

• A predisposition to respond sexually to an illegal or non-consensual category.
• According to the DSM-V:
  • If enduring, persistent, and necessary for sexual enjoyment, then the interest can be regarded as a paraphilia.
  • If it causes significant distress or impaired functioning, it’s considered a paraphilic disorder (APA, 2013).
  • Deviant sexual interests are not necessarily pathological (Baur et al., 2016).

Sexual Arousal Definition

• “The psychological, physiological, and behavioral responses to an internal or external target of sexual interest” (Rullo et al., 2010, p. 874).
  • External
  • Internal

Sexual Arousal & Assessment

Self-Report Assessment (Direct)

• Directly ask an individual how much (or whether) they are sexually interested in various sexual categories.
• Most come in the form of a questionnaire.
• Examples:
  • Multiphasic Sex Inventory (Nichols & Molinder, 1984)
  • Sexual Fantasy measures (e.g., Wilson, 1978)

Self-Report: Critique

• Pros:
  • Easy to administer and analyze
  • Rich and detailed information
• Cons:
  • Assumes the information is consciously accessible – sexuality is complex!
  • Sensitive topic, so prone to socially desirable responding.
  • Easily faked (Meston et al., 1998) – Sex offenders have an incentive to distort the truth!

Phallometric Assessment (Direct)

• Penile Plethysmography (PPG) - Measures volumetric changes of a man’s penis in response to sexual stimuli.
• Stimuli can be visual, auditory, or fantasy-based.

Phallometry: Critique

• Pros:
  • One of the best measures for distinguishing child abusers from non-sex offenders (Barsetti, Earls, Lalumière, & Bélanger, 1998; Freund, Watson, & Dickey, 1991; Marshall & Eccles, 1991) and rapists (Looman & Marshall, 2001) - But see Babchishin, Curry, Fedoroff, Bradford, and Seto (2017)
  • The current ‘gold standard’ in sexuality research (Fromberger et al., 2012)
• Cons:
  • Very invasive
  • In some countries (e.g., Germany) it is seen as unethical and so is prohibited (Babchishin et al., 2013)
  • Assumes erection equates to sexual arousal - not always the case, esp. in older men (Janssen et al., 2008)
  • Prone to faking behaviors and inhibition/suppression (Trottier et al., 2014)

Indirect Measures

• Most are reaction time-based computer tasks - sometimes referred to ‘latency-based indirect measures’.
• Drawn from the socio-cognitive literature.
• The outcome (e.g., reaction times) is used to infer (indirectly) whether a sexual interest is present or not.
• Most are based on the idea that automatic responding evokes more ‘genuine’ indications of an interest.

Types of Indirect Measures

• Task Relevant:
  • Viewing Time (VT; Harris et al., 1996)
  • Implicit Association Test (IAT; Greenwald et al., 1998)
  • Go/No-Go Association Task (GNAT; Nosek & Banaji, 2001)
• Task Irrelevant:
  • Emotional Stroop (E-Stroop; Smith & Waterman, 2004)
  • Choice Reaction Time (CRT; Wright & Adams, 1994)
  • Rapid Serial Visual Processing (RSVP; Broadbent & Broadbent, 1987)
  • (See The Wiley Handbook on the Theories, Assessment and Treatment of Sexual Offending (Boer, 2016))

Viewing Time (VT)

• Oldest indirect measure in the forensic field and commonly used.
• Records how long an image is viewed while it’s being rated on a sexual attractiveness scale.

Very attractive Very unattractive

Viewing Time (VT) - Findings

• In a recent meta-analysis (Schmidt, Babchishin & Lehmann, 2016):
  • VT showed a moderate ability to discriminate child abusers from comparison groups ($d = 0.60$).
  • Correlated with self-reports, PPG, and file-based measures.
• VT can also assess interest in sexual violence (Larue et al., 2014).

Implicit Association Test (IAT)

• The IAT assesses the strength of associations between:
  • (1) Target categories (e.g., children vs. adults) and
  • (2) Attribute categories (Sexy vs. Not sexy)
• Example design:
  • Stage 1: Adult / Child - 20 trials
  • Stage 2: Not Sexy / Sexy - 20 trials
  • Stage 3: Adult+Not Sexy / Child+Sexy - 60 trials
  • Stage 4: Child / Adult - 20 trials
  • Stage 5: Child+Not Sexy / Adult+Sexy - 60 trials

IAT Mechanism Explained

• If they associate children and sexy, they will be faster pressing this key (than Adult-Sexy key in the other stage).

Implicit Association Test (IAT) - Findings

• In a meta-analysis (Babchishin, Nunes, & Hermann, 2013)
  • Child–Sex IATs can distinguish child abusers from comparison groups ($d = 0.63$).
  • Correlates with other measures of sexual interest, such as PPG and self-report
• Some evidence that IATs can assess interest in sexual violence (Larue et al., 2014)

IAT & VT Limitations

• VT can be easily faked once you know how it works.
• The IAT can only assess relative associations.
• So if someone shows a bias for child-sex, this could be due to:
  • Strong Child-Sex associations
  • Weak Adult-Sex associations
  • Strong Adult-Not Sex associations
  • Weak Child-Not Sex associations

Go/No-Go Association Task (GNAT)

• Is essentially an IAT variant.
• Addresses the issues just mentioned.
• Involves participants responding to target stimuli and withholding responses to non-target stimuli.
• It can measure associations towards a single target.
• It can measure absolute associations (rather than just relative ones).

Indirect Measures: Critique

• Pros:
  • Responses typically based on uncontrollable, automatic processes
  • Less prone to faking
• Cons:
  • Rich and detailed information not obtained
  • Possibly assesses consciously inaccessible preferences

Treatment Approaches Over Time

• Early days (60-70’s) - focused almost exclusively on trying to change deviant sexual interest using behavioral techniques.
• 80’s - Marques (1982) proposed framing sex offender treatment around the relapse prevention approach used with drug and alcohol problems. It became instantly popular.
• 90’s - Saw the beginning of using evidence-based risk assessment to identify relevant needs to target in treatment. This was led by the RNR model.
• 2000+ - Saw a move towards strengths-based treatment, such as the Good Lives Model

Sexual Offending Treatment - Current Standards

• Based on behavioral strategies, including cognitive-behavioral, social learning, modeling, and skill building, along with psycho-education.
• Goals of Treatment:
  • To address the dynamic risk factors
  • To understand the progression to the offense
  • To develop a self-management plan
• Typically delivered as group therapy.

Treatment of Dynamic Factors

• Deviant interest
  • Aversive reconditioning
  • Fantasy management
  • Chemical castration
• Distorted cognition
  • Cognitive restructuring
  • Schema therapy
  • Behavioral experiments
• Intimacy / relationship issues
  • Cognitive-behavioral techniques
  • Role-playing
• Anger & hostility
  • Anger management therapy
  • CBT
• Self-regulation issues
  • Identifying new coping strategies
  • Mindfulness

Reconditioning Techniques

• Reduce arousal
  • Ammonia aversion
  • Olfactory aversion
  • Covert desensitization
  • Satiation
• Increase arousal
  • Masturbatory reconditioning
  • Directed masturbation

Dual-Process Model of Sexual Thinking (Bartels, Beech, & Harkins, 2021)

With repeated use, sexual imagery becomes encoded as a cognitive script.

Elaborative Process

• Involves Working Memory!
• Targeting these processes underlying sexual fantasising may help reduce the use of problematic fantasies

Bilateral Eye-Movements (EMS)

• Negative memories (Gunter & Bodner, 2008; Hout et al., 2001)
• Traumatic imagery in PTSD patients (Jongh et al., 2013)
• Social anxiety imagery (Homer & Deeprose, 2018)
• Anxious imagery about the future (Engelhard et al., 2010)
• Food craving mental imagery (McClelland et al., 2006)
• Cigarette craving mental imagery (Littel et al., 2016)
• Gaming craving imagery (Brandtner et al., 2020)
• Positive memories (Hornsveld et al., 2011)
• All based on the ‘Working Memory Hypothesis’ of EMDR (Andrade et al., 1997)

Behavioral Progression

• A series of events & situations, combined with cognitive & emotional states, that lead to sexual offending.
• Sometimes referred to as an offense-chain.
• Can help devise a case formulation.
• A case formulation aims to describe a person's presenting problems and use theory to make explanatory inferences about the causes and maintaining factors (which informs treatment).

Self-Regulation Plan

• Establish goals promoting an offence-free life.
• Develop management & coping strategies for internal & external risk factors.
• Ensure cognitive & emotional aspects are present.
• Include a support network.
• Be concrete but generalizable.

Good Lives Model (GLM) (Ward & Stewart, 2003)

• GLM is a strengths-based approach to treatment and is highly influential.
• Theoretical Assumptions
  • All humans are goal-directed organisms that seek to acquire a set of ‘primary human goods’
  • Primary goods are actions, experiences, and activities that are intrinsically beneficial to human beings and are sought for their own sake
  • Secondary (or instrumental ) ‘goods’ refers to the ways people go about acquiring primary goods

The Primary Human ‘Goods’

• Life (healthy living and functioning)
• Knowledge (learning new skills, personal insight)
• Excellence in work and play (inc. mastery)
• Excellence in agency (i.e., sense of autonomy)
• Inner peace (i.e., free from emotional turmoil and stress)
• Relatedness (e.g., intimate, romantic, & family relationships)
• Community
• Spirituality (i.e., meaning and purpose in life)
• Creativity

GLM & Sexual Offending

• Like all humans, offenders are goal-directed and predisposed to seek the same set of primary ‘goods’ as everyone else
• Sexual offending occurs when individuals lack the internal and/or external resources to achieve their ‘primary goods’ using pro-social means (i.e., problematic secondary goods)
• Dynamic risk factors are internal obstacles (e.g., distorted cognitions; sexual deviance) that affect the prosocial acquisition of primary ‘goods’

GLM of Rehabilitation (Ward et al., 2006)

*Helping offenders to live better lives, not simply targeting isolated risk factors.

Research Evidence on Treatment Effectiveness

• Hanson et al. (2002):
  • Significant reductions for sexual recidivism (12.3% treated vs. 16.8% untreated)
  • Specialized treatments produced the best effects
  • Treatment effects were comparable across institutions and community settings.
• Lösel and Schmucker (2005):
  • Significant reductions for sexual recidivism (11.1% treated vs. 17.5% untreated),
  • Biological treatments produced strongest effects.
  • Of the psychological treatments, only CBT and behavioural approaches were effective.
• Mews, Di Bella, and Purver (2017) - Ministry of Justice
  • Found that sexual recidivism for treated individuals INCREASED by an absolute value of 2% and a relative value of 25% (10% treated vs. 8% untreated).
• Gannon, Olver, Mallion, James (2023)
  • Treatment was associated with recidivism reduction (32.6% reduction)
  • TREATED = 9.7% risk VS UNTREATED = 14.6% risk

In Summary

• Research and theory reveal specific factors are linked to recidivism risk in men who have sexually offended.
• Specialized, research-supported measure are needed to accurately assess these factors (and risk levels).
• Factors associated with offending should be targeted in treatment using evidence-based strategies
• Cognitive-behavioural sex offender treatment reduces sexual recidivism
• But - we must continue to research efficacy further!