Are Sex Offenders Treatable? Research Overview (Psychiatr Serv 50:349-361, March 1999)

  Although some forms of treatment for sex offenders appear promising, little is known definitively about which treatments are most effective, or for which offenders, over what time span, or in what combinations. What emerges from the literature is a strong suggestion that a comprehensive cognitive-behavioral program should involve components that reduce deviant arousal while increasing appropriate arousal and should include cognitive restructuring, social skills training, victim empathy awareness, and relapse prevention. In addition, patients should be considered for antiandrogen medication if they are at high risk of reoffending.

In general, results from biological and cognitive-behavioral treatment programs strongly suggest that treatment decreases recidivism of sexual crimes. In evaluating whether the amelioration produced by treatment is clinically significant, Hall's meta-analysis (96) suggested that antiandrogen and cognitive-behavioral treatment lead to a decrease in recidivism from a baseline rate of 27 percent in untreated individuals to a rate of 19 percent in patients who receive treatment. Hall summarized these findings as an outcome of eight fewer sex offenders per 100.

However, the results of his meta-analysis may be viewed in another way: from a baseline recidivism rate of 27 percent, a decrease in recidivism among treated patients to a level of 19 percent amounts to a 30 percent remission rate as a result of treatment. When viewed from this perspective, the analysis suggests an outcome of 30 fewer sex offenders per 100, and it reflects a follow-up period of nearly seven years. This outcome is not a negligible impact from the standpoint of clinical treatment.

By comparison, lithium prophylaxis of bipolar disorder—a standard treatment for a well-established psychiatric illness—was found in a recent five-year prospective study to be associated with complete remission in approximately 38 percent of patients still taking lithium (98). Because a number of other patients dropped out of this study due to perceived lack of efficacy of lithium, this percentage may actually overestimate lithium's medical effectiveness.

Zonana (3) has suggested, however, that the consequences of recidivism in sex offenders are so detrimental to society that a recidivism rate of zero is the only acceptable risk level. Such an assumption could lead to the conclusion that indefinite confinement is the only conceivable effective intervention with or without medical treatment. But the demonstrated reduction in recidivism that emerged in the meta-analysis of research on treatment of sex offenders is a robust finding and suggests that treatment for patients in this population improves outcome and may protect potential sexual assault victims.

Recent legislation in an increasing number of states focusing on the preventive detention of sexually violent persons has stimulated vigorous legal and policy discussion and debate (1,2, 3). This newer legislation may have significant impact on public mental health systems because the proceedings involve civil commitment rather than criminal prosecution and are associated with mandates for medical evaluation and treatment. Clinicians have not traditionally regarded sex offenders as falling within the target population of severely and persistently mentally ill persons considered appropriate for civil commitment.

Yet although it may be true that, in general, public mental health programs have little to offer by way of a service line tailored to this population, it is far less clear that individuals exhibiting chronic, repeated sexually aggressive behaviors do not suffer from mental illnesses. Nor is it clear that psychiatric treatment is without benefit for this patient population, despite frequent anecdotal references to the lack of effective treatments. To the contrary, research provides evidence of a robust treatment effect that has the potential to reduce sexually aggressive behavior.

Although the conclusion that sex offenders are untreatable is unwarranted, caution must be exercised in unfolding the implications of the positive treatment findings in the literature. It is worth underscoring the finding of Hall's meta-analysis (96) that treatment of outpatients was associated with a larger treatment effect than treatment of institutionalized individuals. Further, in the discriminant analysis of Bench and colleagues (9), failure to complete treatment was a weak predictor of sex-offense-specific recidivism in comparison with the extent of the felony conviction record.

These findings appear to suggest, unfortunately, that the more a sex offender needs confinement, the less confident we can be that treatment will have lasting benefits. Paradoxically, however, it is precisely the more dangerous subset of patients that psychiatry is being called to treat based on the new legislation. Civil commitment of sex offenders is based on the problem of perceived persistent dangerousness.

Precautions must be taken to ensure that treatment environments are appropriate for the risk level presented by these patients. Psychiatrists, other mental health professionals, and public administrators are concerned about the potential for predatory behavior by sex offenders who are mixed with the currently defined population of patients with serious and persistent mental illness. Criteria must be developed to determine which sex offenders are more appropriate for outpatient programs and to provide a rational basis for transitioning patients from institutional to outpatient care. Civil commitment to outpatient treatment may provide a more appropriate level of care for many patients than psychiatric hospitalization in traditional general inpatient settings.

Finally, from a scientific standpoint, there remain significant problems with the available data from sex offender treatment studies. An optimistic perspective must be entertained cautiously and accompanied by a commitment to the advancement of scientific knowledge in the field. This perspective is not new to psychiatry, where gains in knowledge about treatment of chronic illnesses such as schizophrenia have been gradual and hard earned. Yet as Bradford (66) recently pointed out, support for the scientific study of deviant sexual behavior has not kept pace with the apparent—or at least official—public sentiment about the management of sexual aggressors. It would be informative for such research to include a focus on sex offenders from additional populations, such as women and adolescents.

Treatments for sex offenders do exist, and the outcome data are not uniformly discouraging. They are, however, complex, difficult to interpret, and cause for cautious optimism at best. If mental health professionals and society at large are to accept the challenge of promoting treatment for sex offenders, vigorous ongoing research efforts are mandatory. Psychiatr Serv 50:349-361, March 1999