Sexual offenses

Treatment of people who commit sexual crimes is of interest to forensic psychiatrists because they often have to deal in practice with the impact of sexual crimes on children or adults who were victims of sexual abuse in childhood.

Experts hope that treating sex offenders will help prevent them from committing crimes in the future. The second reason is that clinical experience with sex offenders suggests that they have characteristic cognitions and psychological defense mechanisms. There is evidence that psychological treatments, especially cognitive behavioral therapy, can break down these defenses and change distorted cognitions.

The history of treatment of sex offenders in the UK is shorter than in the US. The issue of child sexual abuse only came into the public consciousness in the late 1980s following the Cleveland inquest. However, as the judge presiding over the inquest noted, "child sexual abuse did not begin in Cleveland - it goes back a long way." In the 1960s and 1970s, the existence of "baby beating syndrome" was recognised and accepted. It later evolved into "non-accidental injury". However, until the Cleveland inquest, much of the public was unaware that child abuse could be physical as well as sexual. It has been established that sexual offenders often have a history of childhood sexual abuse, and that among offenders at highest risk of recidivism, sexual abuse was present in all cases. Therefore, the goal of treating sex offenders is not only to prevent them from sexually abusing children, but to break the cycle of their victims becoming criminals. This phenomenon has been called the “vicious cycle of abuse.” Treating sex offenders is one way to break this cycle. It has even been suggested that incarcerating sex offenders does not solve the problem and that treatment, not incarceration, may help reduce the incidence of sexual crime. Before discussing sex offenders and their treatment, it is important to understand one distinction: not all forms of sexual disorders are crimes, and not all sex offenders meet the criteria for a sexual disorder. Some individuals may have sexual preferences toward children, but that does not mean they will commit sexual crimes.

Sexual Offense and Recidivism Rates

Almost every researcher or clinician involved in the assessment and treatment of sex offenders will admit that official conviction rates represent only a very small percentage of the actual figures for sexual offences committed in any one year. The evidence is the wide discrepancy between the rates of sexual abuse reported in studies and the rates of conviction for sexual offences. Fisher cites data from a number of studies on the prevalence of child sexual abuse. These figures range from 12% of women under 16 reporting abuse to 37% of those under 18 reporting ‘contact sexual abuse’. Despite the wide variation in the figures for child sexual abuse, even the lowest figures are never below 10%, indicating the seriousness of the problem. Official figures for conviction rates for sexual offences are provided in the Home Office Annual Report of Crime Statistics for England and Wales.

In 1996, 31,400 sexual offences were reported to the police; of these, one fifth were rapes and just over half were indecent assaults. In 1997, the number of sexual offences was 33,514, an increase of 6.8% on the previous year. This was twice the increase in the previous ten years. Sexual offences account for 9.6% of all violent crimes and 0.77% of all reported crimes.

One study of the prevalence of convictions for sex offences followed a cohort of men born in England and Wales in 1953. The researchers found that by age 40, 1.1% of these men had been convicted of a reportable sex offence. Of these, 10% committed a sex offence within the next five years. The researchers estimated that in 1993, 165,000 of the male population in England and Wales had been convicted of a reportable sex offence.

What about recidivism? Compared with other groups of criminals, such as property offenders, sex offenders have a lower recidivism rate. However, this may not be a reliable conclusion, given the short time period used to calculate recidivism rates. Most crimes are followed for up to five years, counting from the date of the previous conviction. Even this period may not be long enough for sex offenders. This is what Soothill and Gibbens pointed out in their oft-cited paper. They chose one specific group of sex offenders for their study: men who had or attempted to engage in vaginal sex with girls under the age of 13. Three crimes were associated with this behavior: rape, incest, and unlawful vaginal intercourse. Men convicted of these crimes in 1951 or 1961 were followed until 1974. The cumulative percentage of repeat offenders was calculated for the next 24 years. For standard crimes, that is, crimes of all types prosecuted by an indictment, 48% of them had committed some crime by the 22-year follow-up. But what was more important was how many of them had subsequently committed sexual or violent crimes. That turned out to be 23%, or almost a quarter. And it turned out that these were not trivial crimes. Only half of this group of repeat offenders were convicted within the first five years of follow-up. Therefore, using the usual follow-up period, we would have obtained significantly underestimated data on recidivism among sex offenders. The follow-up study should be at least ten years long, and only then can we draw conclusions about the absence of recidivism.

One possible reason for this conclusion is that the reported convictions for sex crimes represent only the tip of the iceberg. It is entirely possible that an offender was not convicted during the ten years of observation, but nevertheless committed crimes. They just were not caught. This view is supported by data from a study conducted in the United States. Their sample of sex offenders admitted to committing significantly more crimes and with significantly more victims than the number of cases for which they were convicted. For example, pedophiles who committed crimes outside their families admitted to an average of 23 sexual acts with girls and 280 sexual acts with boys. Not surprisingly, the figures for pedophiles committing crimes within the family were lower - an average of 81 sexual acts with girls and 62 sexual acts with boys. Rapists admitted to an average of seven crimes, and exhibitionists - more than 500. However, the results of this study should be approached with caution, since very high crime figures were only reported by a very small number of offenders. Recidivism rates vary from study to study. However, a certain pattern is observed: the lowest recidivism rate is observed among individuals who committed crimes against girls within their own families - up to 10%, compared with 30% of sexual abuse of girls outside their own families. The highest recidivism rates are noted among individuals who committed crimes against boys outside their own families - up to 40%. At the same time, Marshall (cited in Barker & Morgan) showed that these figures may also be underestimated. According to him, when working with unofficial sources, the true recidivism rates among sex offenders were 2.4-2.8 times higher than the official ones. Other researchers have shown the highest risk of recidivism among men who committed crimes against boys outside their own families. Grubin & Kennedy interviewed 102 men convicted of sex crimes, and they clearly identified a group of individuals who committed crimes against boys. This group was characterized by the following: their victims were more often boys they did not know, they had previous convictions for sexual crimes, and they had more than one victim. They were also characterized by separating pedophilia from paraphilias.

A meta-analysis of 61 studies involving nearly 29,000 sex offenders identified recidivism rates for different groups of sex offenders. Recidivism rates for subsequent sexual offenses were 19% for convicted rapists and 13% for child sex offenders, with an average follow-up of 4 to 5 years. Nonsexual recidivism rates were significantly higher for rapists than for child sex offenders. These rates are likely underestimated by the short follow-up period. The authors attempted to identify predictors of sexual recidivism. Among demographic variables, only young age at offense and no stable partner were found to be predictive. Antisocial personality disorder and a higher number of previous offenses were found to be predictors. However, the most powerful predictors of sexual recidivism were elevated levels of sexual deviance, particularly sexual interest in children, as measured by penile plethysmography. Overall, the predictors of sexual offending were the same as those in the population of non-sexual offenders.

Assessing the risk of recidivism among sex offenders

Assessing the risk of reoffending in a sex offender is different from assessing the risk of reoffending in a mentally ill person. The obvious difference is that although a mentally ill person will not be convicted of serious crimes, the characteristics of his or her illness may serve to classify him or her as having an increased risk of causing bodily harm to himself or herself or others. Assessing the risk of reoffending in sex offenders typically requires that the person have committed at least one sexual offense. Consequently, it is relatively easy to classify known offenders into high-risk and low-risk categories. One study found that reconviction rates for two-offenders were 15 times higher than for those with only one offense. In serious cases of violent sex offenders, there is no guarantee that they will never reoffend, even though the risk of reoffending may in reality be low. In this case, even if the risk of reoffending is low, the severity of the offense and its consequences will be high. The risk of recidivism is lower for individuals who have sexually abused children within their own family than for individuals who have committed the crime outside their own family. The risk of recidivism is increased for individuals who have committed crimes against children of both sexes, both prepubescent and postpubertal. These individuals are described as "polymorphously perverse."

Marshall analyzed reconviction rates and prior criminal history in a random sample of 13,000 prisoners released from prison in 1987. He found that 402 offenders in the sample (3%) had been convicted of sexual offenses. Of the subgroup with prior convictions for sexual offenses, 12% subsequently committed a sexual offense within four years of release, compared with 1% of offenders who had never committed a sexual offense. The author suggests that a history of sexual offenses predicts an increased risk of future crime. Grubin countered that such an actuarial prediction of risk based solely on past criminal history is of limited value. And the main reason is that any prediction about a rare event (i.e., less than 1% of all crimes) has too high a false positive rate to be accurate. Obviously, such an actuarial prediction tells us nothing about which criminals are curable and which are at increased risk of committing crime.

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Case Description

Mr. B is 40 years old, married, and has two children. In his early 20s, B.'s job involved working with young children and he sexually assaulted prepubescent girls three times. B. was given a short prison sentence but was not offered any treatment. Thirteen years later, he was convicted again, this time of sexually abusing two prepubescent girls who were part of the family's close social circle. Following his conviction for indecent assault, he began attending a treatment group for sex offenders. In addition, he received individual treatment for his sexual fantasies. Over the course of three years of treatment, he admitted to other crimes against young girls but denied being sexually attracted to boys. Then a young boy, who belonged to the same family as the girls who had been B's victims, admitted that he had also been sexually abused by B four years earlier. B then admitted that he was also sexually attracted to boys and that he had committed crimes against boys. Despite being offered treatment in the community as part of a sex offender treatment program, he was sent back to prison for three years. During B's three years of treatment, both in the group and individually, he had been assessed as being at significant risk for recidivism. However, this risk was greatly increased when it was discovered that, in addition to girls, he had also committed crimes against prepubescent boys, even though this had not happened recently. This new information moved him into the highest risk category. This case demonstrates that risk is not a static concept and that new information can significantly change the level of risk even if the offender does not reoffend.

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Risk factors

Any clinician or researcher who has been involved in the assessment or treatment of sex offenders knows about the extreme levels of denial that offenders display in the face of overwhelming evidence. It is not uncommon for them to deny having committed a crime even after being convicted of a sex crime, pleading guilty, and serving a prison sentence. Of course, denial among sex offenders is a defense mechanism to avoid consciously admitting that their behavior was wrong, which naturally allows them to reoffend. Denial also comes in many forms and degrees, from absolute denial of the crime to denial of the seriousness of the crime to statements about the need for treatment. Another risk factor that is common among sex offenders is abnormal levels of emotional congruence. This is their distorted emotional attachment to their children. There are some differences between offenders who are fathers and offenders who are not. Fathers who sexually offend show lower levels of emotional congruence than fathers who do not offend. Conversely, non-fathers who are sexually offending show elevated levels of emotional congruence compared to non-offending, non-fathers. It is hypothesized that non-fathers who are sexually offending may have had an earlier developmental disorder in which they were stuck at a childlike level of emotional development, which accounts for their high emotional congruence. This means that they may relate to their children in a way that makes it easier for them to commit crimes against them. Among fathers who do not offend against children, levels of emotional congruence are adequate, allowing them to empathize with their children and understand their emotional needs. The key point is that fathers who offend against children do not have this ability.

As noted earlier, Grubin also proposed clinical risk factors based on an understanding of the phenomenology of sadistic sex offenders. Other risk factors include cognitive distortions, which will be discussed in more detail below.

One of the actuarially predictive rating scales was developed by Thornton and subsequently used by Hampshire Constabulary. This assessment involves two primary stages and a third stage if the offender has completed a treatment programme. The scale describes three levels of risk: low (1 point), medium (2-3 points) and high (4+). Each point is added according to the following scheme:

1. This crime has a sexual component.
2. Committing crimes of a sexual nature in the past.
3. This crime includes a violent crime of a non-sexual nature.
4. History of violent non-sexual crimes.
5. Having more than three previous convictions for committing sexual crimes.

The second stage assesses the presence of various aggravating factors: sexual offenses against males, non-contact sexual offenses, stranger sexual offenses, never married, treatment history, substance abuse, a score of 25 or higher on the Hare Psychopathy Checklist, and a history of deviant arousal on penile plethysmography. If two or more aggravating factors are present, the risk category is increased by one level. If the offender is in prison, the risk may be increased or decreased depending on his response to treatment, especially if there is some improvement in his risk factors and his behavior in prison. An analysis of this scale showed that of 162 low-risk offenders, 9% subsequently committed sexual offenses; of 231 medium-risk offenders, 36%; and of 140 high-risk offenders, 46%.

The STEP report divided offenders into high-risk and low-risk groups. It cited five factors, identified through psychometric testing, that differentiated the two groups. High-risk offenders were found to have:

1. increased levels of social inadequacy;
2. a greater lack of empathy towards victims;
3. distorted thinking;
4. increased levels of sexual obsessions;
5. abnormal emotional congruence.

As with other violent crimes, the presence of a drug addiction may significantly increase the risk of recidivism. On the other hand, the presence of a mental disorder was not associated with future recidivism. West suggested that sexual offenders are not common among mentally ill or mentally disordered individuals, but they may be overrepresented in the criminal justice system because the presence of a mental disorder increases the likelihood of being caught.

Classification of sexual disorders and gender identity disorders

Classification is usually based on behavioral patterns. The ICD-10 classification of mental and behavioral disorders lists the following patterns of disorder:

Gender Identity Disorders (P64)

• R64.0 Transsexualism.
• R64.1 Dual role transvestism (temporary wearing of clothing of the opposite sex for pleasure without desire to change gender and without sexual arousal).
• P64.2 Gender identity disorder of childhood.

Disorders of sexual preference (I65)

• R65.0 Fetishism.
• R65.1 Fetishistic transvestism (wearing clothing of the opposite sex in order to create the impression of belonging to the other sex and to achieve sexual arousal).
• P65.2 Exhibitionism.
• R65.3 Voyeurism.
• R65.4 Pedophilia.
• R65.5 Sadomasochism.
• P65.6 Multiple disorders of sexual preference (more than one).
• P65.8 Other disorders of sexual preference (inappropriate telephone calls, frotteurism (rubbing against other persons in crowded public places), sexual acts with animals, use of asphyxiation or anoxia to enhance sexual arousal, preference for a partner with an anatomical anomaly).

Psychological and behavioral disorders related to sexual development and orientation (P66)

Sexual orientation itself is not considered a disorder, but in some cases it can create problems for the individual and thus be a cause of distress.

• P66.0 Puberty disorder: uncertainty about one's own sexual orientation causes anxiety and depression.
• R66.1 Egodystonic sexual orientation: distress arises from the subject's desire to have a different sexual orientation.
• P66.2 Sexual relationship disorder: distress resulting from difficulties in forming relationships related to gender identity or sexual preference.
• P65.9 Disorder of sexual preference, unspecified It is clear from the classification given that some of the listed behaviors may lead to the commission of crimes of a sexual nature, such as exhibitionism and pedophilia, and some may not, such as fetishism.

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Treatment of Sex Offenders

Cognitive behavioral therapy

Behavioural treatment of sex offenders used to focus on changing sexual preferences and was based on classical conditioning theory. Early, often infancy, experiences were thought to shape and condition the subsequent development of paraphilias such as pedophilia. Behavioural therapy involved reducing deviant arousal, for example through aversion therapy or by using unpleasant stimuli such as electric shock or nausea, which could then be combined with deviant sexual fantasies. The ethical shortcomings of this approach have largely eliminated its use. Some forms of aversion therapy still exist, for example in association with shame in exhibitionists. In this treatment, the individual stands with exposed genitals in front of an audience, who speak their thoughts out loud. It has been suggested that it may be more effective not to try to reduce deviant arousal but to try to increase non-deviant arousal. This can be achieved through the substitution of a conditioned reflex by masturbation or through covert sensitization. Both of these methods will be described below.

Finkelhor's work has had a major influence on the development of cognitive behavioral therapy for sex offenders in the United States and Britain. His 4-stage model of crime is described by Fisher.

1. Motivation for committing sexual abuse. As clinical experience shows, individuals who frequently commit crimes consistently deny the sexual motive for their crime, although they readily admit to the crime itself.
2. Overcoming internal inhibitions. Given that not all individuals experiencing deviant arousal and fantasies commit crimes, and that most sex offenders do recognize their behavior as illegal, they appear to develop cognitive distortions that enable them to overcome their own inhibitions to committing crimes.
3. Overcoming external constraints. The next stage involves the individual creating a situation in which he or she can commit a crime. For example, a pedophile may offer to be a nanny for a child.
4. Overcoming the Victim's Resistance. The final stage involves overcoming the victim's resistance, such as bribing a child with gifts or threatening violence. It is generally accepted that some perpetrators deliberately select vulnerable victims who are unable to offer significant resistance.

Finkelhor's theory is that a sex offender will only be able to commit a sex crime after going through the four stages described above.

This theory of crime leads naturally to treatment, since it involves therapeutic intervention at all four stages. The basic components of cognitive behavioral therapy for sex offenders are described in the STEP report, for both group and individual work. It describes the following treatment strategies:

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The Cycle of Crime

The offender describes in detail the events that led to the crimes. This work should be done early in treatment, as it allows the offender to acknowledge responsibility, that is, that the crime did not, as is often claimed, “just happen.” It is at this stage that the offender is most effectively confronted with the various levels and variations of denial of the crime, often by a member of the sex offenders’ therapy group.

Challenging Distorted Thinking

Psychological defense mechanisms that allow the criminal to continue criminal activity involve excusing and justifying their actions (cognitive distortions). For example, pedophiles often claim that they were simply satisfying a child's need for sexual experience. Rapists may believe that a man has the right to have sex with a woman if she comes to him on a date and he pays for her dinner. Changing such a stereotype of thinking is most successful in a group setting, when criminals point out cognitive distortions to each other.

Understanding the harm caused to victims

This goal is often achieved by showing offenders videos of victims of sexual crimes describing how the crime affected them. This often evokes emotions in the offenders themselves, due to their own experiences of being victims of sexual abuse in the past. Offenders may also write apology letters to their victims, which are not sent but discussed in the group. However, the STEP report cautions that too much time should not be devoted to such work, lest offenders begin to feel humiliated, which in turn can have a negative impact and ultimately increase rather than decrease the risk of recidivism. Caution is also needed in using this technique with sadistic sex offenders, who may learn how to cause long-term damage to their victims. This, in turn, may lead to an increase in deviant arousal and an increased risk of reoffending.

Modification of fantasies

It is generally accepted that criminals' deviant fantasies are reinforced through simultaneous masturbation. We have mentioned techniques for changing such fantasies earlier. One method is covert sensitization, in which the criminal is asked to imagine in detail one of his deviant fantasies, and then asked to imagine an unpleasant consequence in the form of the police appearing. Another method is to replace the conditioned reflex through masturbation. There are two ways:

• A thematic shift in which deviant fantasies are replaced by non-deviant fantasies during masturbation.
• Guided masturbation, where the offender records an audio tape of his preferred non-deviant fantasy and then masturbates to that fantasy until ejaculation occurs.

This work is best done individually rather than in a group. It is often done after the group.

Social Skills and Anger Management

It has long been established that sex offenders have poor social skills. However, if this were the only problem, there would be a danger that the outcome would be therapy instead of reduced crime - sex offenders with improved social skills. Anger is also a relevant factor, especially in rape.

Work on relapse prevention

This approach has been developed in analogy with the prevention of substance abuse. First, the offender identifies his risk factors for committing a crime. Next, he must learn to recognize, avoid, and overcome situations that may contribute to his reoffending. He must understand that the first stage of a possible relapse is the renewal of deviant fantasies. Work in this direction implies that the offender recognizes certain high-risk situations that should be avoided in the future. For example, a pedophile should avoid children's playgrounds on his route, even if this is his daily route to work. These decisions are referred to in the literature as "seemingly insignificant." The starting point is that in everyday life, sex offenders may make decisions that may seem unimportant, such as choosing a route to work. However, if such a decision leads him to a high-risk situation, such as a children's playground, he will consciously acknowledge this and choose a different route, even if it takes longer. The basis of relapse prevention work is the offender's conscious recognition of his own risk of committing a repeat offense, the need to change his lifestyle and develop strategies applicable to a particular situation in order to avoid increasing the risk of relapse. Psychoanalytic psychotherapy

Before cognitive behavioral therapy was recognized as the most effective treatment for sex offenders, group therapy with offenders was often based on psychoanalytic theory. Much of the work in this area was done at the Portman Clinic. There, individual and group analytic therapy had been used to treat individuals suffering from social and sexual deviations since the late 1930s. Individual psychoanalytic psychotherapy for sex offenders is described by Zachary. As with all psychoanalytic psychotherapy, much attention is paid to the issues of transference and countertransference. Zachary acknowledges that the effect that occurs in professionals working with sex offenders is certainly countertransference. Group psychotherapy at the Portman Clinic treated victims as well as incest offenders within the same group. Pedophiles and incest offenders are not grouped together, as this may lead to a breakdown in the group dynamics. However, as described above, the distinction between child sexual abuse within and outside the family may not be as clear-cut as previously assumed.

Most of the studies on the outcome of treatment of sex offenders with psychoanalytic therapy have been conducted in the United States. The most positive outcome of treatment of the offender in a psychoanalytic group or individually is the ineffectiveness of the therapy, and the most negative outcome is represented by some data from the United States, according to which sex offenders treated with psychoanalytic psychotherapy had higher recidivism rates than sex offenders who did not receive any treatment.

Physical treatment

Other treatments for sex offenders are physical, mostly hormonal, treatments. This is often referred to as "chemical castration." This therapy is based on the hypothesis of a direct causal relationship between the commission of a sexual crime and the offender's testosterone levels. This relationship has never been proven. There is some evidence that hormonal treatment does reduce sexual desire, and therefore it has been suggested that such treatment may be more effective for individuals with elevated sexual desire levels. However, hormonal therapy does not affect the sexual fantasies that are thought to be at the core of the criminal cycle. Another problem with this therapy is that all forms of sexual desire are reduced, including normal ones. This will prevent a pedophile from having normal sexual relations with his wife, although this is what the therapist will recommend. Side effects of this therapy are not very common, but their severity is such that it makes this therapy unsuitable for long-term use. In Britain, the most common libido-lowering drugs are cyproterone acetate and medroxyprogesterone acetate. Both drugs reduce testosterone levels.

Other drugs that work differently include progesterone, benperidol, and goserlin. While it may seem logical to some to castrate sex offenders, the fact is that when this has been done, it has not deterred them from reoffending. Some argue that these drugs are appropriate for use in the rare cases where sexual criminality is combined with hypersexuality and high testosterone levels. But there are serious ethical concerns, especially regarding consent and coercion, when such treatment is a condition for speeding up the prison system or even parole.

Treatment effectiveness

Nagayama-Hall performed a meta-analysis of twelve different studies to evaluate the effect of therapy on recidivism and to identify the most effective treatments. The study found that among sex offenders who completed a full course of treatment, 19% subsequently committed sexual offenses, compared with 27% in the control group who did not receive treatment. Studies that followed offenders for more than five years showed slightly larger treatment effects than studies with less than five years of follow-up. It was suggested that the more effective treatments overturned the results of the Soothill & Gibbons study, which found that only 50% of recidivism occurred within the first five years of follow-up. Treatment was more effective in community-based programs compared with institutional programs. The best results were seen among adolescents who had committed sexual offenses. The most effective therapies were cognitive behavioral and hormonal treatments. However, up to two-thirds of study participants refused hormonal treatment, and 50% of those who started it subsequently dropped out of treatment. With cognitive behavioral therapy, the number of refusals and dropouts was one third. In this regard, it is concluded that cognitive behavioral therapy is superior to taking hormones. These figures are even higher if we take into account the side effects of hormone therapy. According to the study, purely behavioral programs were ineffective.

The effectiveness of cognitive behavioural therapy was also assessed in the STEP study, where sex offenders were referred to seven different treatment programmes. Only 5% of the treated sample committed sexual offences in the subsequent two years, compared with 9% of the untreated sex offenders who were placed on probation supervision in 1990. It should be noted that the follow-up period is not long enough to draw conclusions about the effect of the treatment, and follow-up studies will be carried out after five and ten years. The study concludes that cognitive behavioural therapy has an effect on sexual offending behaviour.

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Treatment Programs for Sex Offenders

Treatment programmes for sex offenders are available locally and are often run by local probation services in conjunction with other agencies such as social health services and the voluntary sector. A number of prisons have their own treatment programmes.

Community Based Treatment Programs

The STEP project analysed a number of community sex offender programmes in England, as well as one residential programme. Outcome analyses showed that more than half of the offenders who received treatment failed to respond to treatment. However, it was worrying that a quarter of the offenders increased their victim blaming. The report described several different treatment programmes, all based on the cognitive behavioural model. Shorter programmes of up to 60 hours total duration were used with men who were more willing to admit to their offending and their sexual problems, who were less justifying and showed less distorted thinking. Longer programmes were more effective with highly deviant individuals. The 60% success rate of the short programme can be explained by characteristics of the programme population, particularly the low levels of deviance among those treated. A variety of scales were used to assess individuals in the different programmes. They measured the following characteristics:

• the degree of denial or minimization of the crime committed;
• arguments justifying the commission of a sexual assault by a person;
• the degree of empathy expressed towards one's victims;
• level of assertiveness;
• level of self-esteem;
• the degree to which blame is shifted to external factors, such as the behavior of victims or other problems in one's life (locus of control);
• the degree of development of the ability to maintain close relationships with adults (it is known that sex offenders often have difficulty coping with “emotional loneliness”);
• cognitive distortions;
• emotional congruence with children;
• the presence of a relapse prevention strategy developed by the offender during treatment;
• an attempt to measure whether the sex offender is attempting to replace his true attitude toward the target or his beliefs with socially acceptable responses.

The STEP project report makes important recommendations for the treatment of sex offenders in the community.

• The importance of systematic assessment of the person undergoing treatment is emphasized: this should be done before, during and after treatment. At the same time, the authors acknowledge that the assessment scales used require significant participation of psychologists.
• The training of specialists providing group therapy should be improved.
• Part of the program should include work on changing fantasies.
• Offenders must understand the basic ideas conveyed to them in the group, rather than simply mastering terminology and concepts.
• The goal of treatment for sex offenders is to reduce criminality by reducing denials, justifications for crimes committed, and cognitive distortions, by increasing empathy for victims, and by reducing their levels of deviant aspirations and deviant fantasies. Even more important, according to all treatment groups, is for the offender to recognize the risk they may pose in the future and in what specific situations.
• Empathy for the victim can only be worked on after it becomes clear that the offender is able to cope with the consequences of his admission of what he has done. Since these individuals have low self-esteem, they may feel worse at first: they may give defensive reactions and in anger increase the accusations against their victims. It is recommended that before working on empathy for the victims, they should work on increasing their self-esteem and teaching them coping skills (overcoming difficult situations).
• More work needs to be done towards relapse prevention.
• In the absence of the ability to increase the number of treatment programs in the country, more attention should be paid to selecting appropriate offenders for appropriate programs and priority should be given to relapse prevention work.

Other recommendations concerned the duration of the programmes and the need for maintenance treatment after completion of the programme.

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Treatment programs in prisons

The Sex Offender Treatment Programme (SOTP) was introduced into the Prison Service in England and Wales in 1992. It is based on a cognitive behavioural model of treatment and is delivered in 25 prisons. Pre-treatment assessment includes psychometric testing, clinical interviews and, in five prisons, also the SOP. The aim of the assessment is to exclude groups of sex offenders who would not benefit from such treatment in prison. These are the mentally ill, those at high risk of self-harm, those with severe paranoid personality disorder, prisoners with 10, below 80 and those with organic brain damage. The SOP consists of four parts:

• basic program,
• thinking skills program,
• extended program,
• relapse prevention program.

The basic program is mandatory for all BOTR participants. It sets the following goals:

• increase the offender's sense of responsibility for the crime he committed and reduce the level of denial;
• increase the offender's motivation to avoid committing repeat crimes;
• increase his level of empathy towards the victim;
• help him develop skills to avoid reoffending.

The basic program consists of 20 units and involves 80 hours of treatment. The thinking skills program is designed to improve the offender’s ability to see the consequences of his or her actions and consider alternative strategies for future behavior. It is believed that such skills are needed so that the offender can understand, develop, and use relapse prevention strategies to prevent future recidivism.

The expanded program is a therapeutic group that currently includes topics such as anger management, stress management, relationship skills and behavioral therapy. The latter is an individual therapy that includes work on sexual fantasies, deviant sexual arousal and victimology.

Offenders who complete the basic program and other elements of the sex offender treatment program are required to begin work in the relapse prevention program one year prior to release. This requires that they successfully complete other parts of the program or attendance at the relapse prevention groups will not be effective. During the group sessions, participants are required to suggest relapse prevention strategies that they will practice prior to release.

Because of the need for long-term follow-up, the effectiveness of the prison sex offender treatment programme will not be established until 2005. However, changes in offenders are already being noted in psychometric tests and in the activities of treatment groups. There is also some evidence of changes in levels of denial, minimisation of the crime committed and cognitive distortions. Another treatment option for sex offenders is part of the therapeutic regime at Grendon Prison.

Sex Offender Laws

In the 1990s, many pieces of legislation were introduced in response to public concerns about sex offenders. The first piece of legislation was the Criminal Justice Act 1991, which allowed for longer prison sentences for sex offenders.

Criminal Justice Act 1991

The Act significantly changed the principle of proportionality, or whether the length of a prison sentence should be proportionate to the gravity of the offence. It allowed courts to impose longer than normal prison sentences on violent and sexual offenders if this was “necessary to protect the public from serious harm caused by the offender”. Serious harm in this case meant severe psychological and physical harm. However, the length of the sentence could then reflect the perceived risk that violent and sexual offenders might pose in the future. An offender could therefore be sent to prison not for what they had actually done, but in order to protect the public in the future. The Act also imposed a statutory duty on the court to order a psychiatric report if it appeared that the defendant was “suffering from a mental disorder”. An analysis of the first 35 cases referred to the Court of Appeal in which courts had imposed longer than normal sentences showed the role of these psychiatric reports in sentencing. It appeared that the Court of Appeal paid particular attention to the psychiatrist's opinion on the offender's personality, the treatability of any disorder and his assessment of the risk of future recidivism. The researchers suggested that psychiatric reports were used to justify longer prison sentences, when they were originally requested for a completely different purpose.

The Criminal Justice Act also increased the length of supervision for sex offenders after release and made it equal in length to the prison sentence imposed by the court.

Protecting society

In 1996, the government published a strategy paper called Protecting the Public. It included sections on sentencing and supervision of sex offenders and the automatic life sentence for violent and sexual offenders. The strategy relied on custodial sentences for sex offenders to protect the public. It also advocated continuing care for sex offenders after their release from prison and increasing their periods of supervision accordingly. The paper gave rise to a number of laws, some of which were aimed at strengthening supervision of sex offenders. These included the Crimes (Sentencing) Act 1997; the Sex Offenders Act 1997; the Criminal Evidence (Amendment) Act 1997; the Protection from Harassment Act 1997; and the Sex Offenders (Closed Materials) Act 1997.

Crimes Sentencing Act 1997

As mentioned earlier, the Criminal Justice Act 1991 increased the period of statutory supervision for a sex offender sentenced to prison from three-quarters to the full term of the sentence. This Act takes the supervision further, setting the minimum at 12 months and the maximum at 10 years in all but exceptional cases. The length of supervision is determined by the sentencing judge and is based on the offender’s risk to the community. In addition, a post-release supervision order may include special conditions, such as attending a local sex offender programme and living in a probation service hostel. It may also include restrictions on leaving the home at certain times, including wearing an electronic ‘tag’. Failure to comply with these conditions may result in prosecution and imprisonment if the court considers it necessary to do so for the protection of the community.

Sexual Offenders Act 1997

This law consists of two parts. The first part obliges sex offenders to register with the police and notify them of their change of residence and new address. The second part allows the courts to prosecute those who have committed crimes against children while in another country. The law contains a list of crimes that must be registered. In principle, these are the same crimes that were mentioned at the beginning of the chapter. The length of registration with the police depends on the length of the prison sentence and varies from 5 years to life imprisonment. It is estimated that in 1993, 125,000 men with previous crimes were subject to the registration requirement.

The Home Office issued a circular providing guidance on how to handle information obtained under the Act. It included a requirement for a reoffending risk assessment to be carried out by the police before disclosing the information to a third party. The assessment must take into account the following:

• the nature and pattern of the previous crime;
• compliance with the requirements of previous sentences or court orders;
• the likelihood of committing a crime in the future;
• the anticipated harm from such behavior;
• any manifestations of predatory behavior that may indicate the likelihood of reoffending;
• potential objects of harm (including children or particularly vulnerable persons);
• the potential consequences of disclosure of information about the case for the offender and his family members;
• the potential implications of disclosure of information about the case in the broader context of law and order.

However, disclosure is a case-by-case decision and there is no general rule. In a number of cases, high-profile disclosures have forced sex offenders to leave their homes due to community pressure.

Crime and Disorder Act 1996

The Act includes a Sex Offender Order, which has been in force since 1 December 1998. This is a new civil order that is imposed by the court and enforced by the police, and only if two basic conditions are met:

1. The person must have previously been convicted or cautioned in connection with the commission of an offence of a sexual nature; and
2. The person has behaved in such a way that such an order appears necessary to protect the public from the risk of serious harm from him.

The definition of serious harm is the same as in the Criminal Justice Act 1991 mentioned above. This order is applied by magistrates' courts. The order - for the purpose of protecting the public - prohibits the offender from going to certain places. The court will specify a specific time and place, for example a children's play area at a certain place and time of day. The offender is also required to register with the police under the Sex Offenders Act 1997. The minimum duration of the order is five years. It can be applied to any offender aged 10 or over, and therefore applies to children and young people. Breach of the order is an indictable offence and is subject to arrest. The minimum sentence on conviction for breach of the order is five years' imprisonment.

The Home Office draft guidance suggests that a number of factors should be taken into account when assessing the risk of a sex offender. In principle, these are the same factors as those previously described under the Sex Offenders Act 1997, plus an assessment of the accuracy of information about the person and their compliance with treatment and the outcome of the treatment. The Home Office recommends that other services, such as probation, social care and health services, should be involved to improve the accuracy of the risk assessment.

The legislation is another step in the search for new ways to deal with sex offenders in the community. It is intended to fill a gap in existing regulations. How successful this has been will only become clear when these orders are put into effect.

Other legislative acts

Below are listed other laws that are relevant to the topic under discussion:

• The Criminal Evidence (Amendment) Act 1997 allows DNA samples, except from intimate areas, to be taken in a wide range of violent crimes, including sexual offences. The samples will be used to create a national DNA database.
• The Sex Offenders (Secret Materials) Act 1997 restricts access to evidence from victims where the offence was sexual in nature.
• The Protection from Harassment Act 1997 introduced the possibility of an injunction to prevent conduct that could be considered as harassment by a potential or actual sexual offender.

The full impact of the latest legislative changes is yet to be assessed. It is a matter of time. It will take many years to see how successful the government's efforts to protect society from sex offenders will be.

Sexual crimes from a legal perspective

Most sexual offences are punishable by indictment, with the exception of indecent exposure, which is a summary offence. Only the former are included in crime statistics and are considered reportable offences. These are anal intercourse with a man or woman (under certain conditions) or sexual intercourse with an animal (buggery), indecent assault on a male, indecency between males, rape of a female, rape of a male, indecent assault on a female, unlawful sexual intercourse with a girl under 13, unlawful sexual intercourse with a girl under 16, incest, procuring, abduction of a woman against her will with intent to marry or have unlawful sexual intercourse, bigamy and gross indecency with a child

The crimes that a psychiatrist deals with most are rape, indecent exposure, and sexual crimes against children.

Rape of men

This offence did not exist in the law until 1994. Offences of this type were classified as anal intercourse with a man (under certain conditions). The offence of rape of a man was introduced by the Criminal Justice and Public Order Act 1994. In 1997, 340 such offences were recorded by the police, although it is reasonable to assume that, as with all sexual offences, the actual figures may be considerably higher.