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10.9: Treatments for Sexual Deviations

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    Learning Objectives
    • Examine psychological perspectives and treatment methods for sexual deviations
    • Describe and evaluate the conventional and controversial treatments provided for sex offenders and rapists

    Treatment for Sexual Deviations

    The treatment and management of paraphilias and paraphilic disorders pose extreme difficulty due to a multitude of factors. Despite the egosyntonic and egodystonic dual nature of paraphilias in general, the overall majority of patients rarely seek treatment voluntarily. Many individuals may feel indignity, culpability, or discomfiture, while others focus on the difficulty and lack of desire to halt efforts of achieving intense sexual pleasure and ultimate satisfaction. Furthermore, many may fear the legal repercussions of coming forward for treatment. Those patients in treatment or seeking treatment are most often either mandated legally or convinced by family, friends, or sexual partners.

    6 chairs placed in a circle and facing inward.
    Figure \(\PageIndex{2}\): Psychotherapy combined with group therapy may be particularly useful for patients with a paraphilic disorder.

    The management of paraphilic disorders falls into two main categories, incorporating both psychological and biological constituents. The psychological approach, which includes psychotherapy, but more importantly, CBT, yields an overall positive outcome in terms of efficacy, regardless of the type of diagnosed paraphilic disorder.

    Treatments within the psychological perspective seem most effective when combining individual with group therapy. The cognitive-behavioral perspective is particularly useful in helping clients recognize their distortions and denial. At the same time, these clients benefit from training in empathy, so that they can understand how their victims are feeling. Adding to the equation within the psychological perspective, clinicians may also train clients in learning to control their sexual impulses. [2] However, due to the patient’s reluctance to seek treatment or the legal obligation to obtain treatment, psychiatrists are often forced to focus efforts on protection against potential victimization and limit focus on the reduction of distress in the patient. The predisposition of committing sexual offenses demonstrates the significance of biological treatments for paraphilic disorders for not only the suffering individual, but also for the greater good of society. However, specialized management, with a comprehensive treatment plan encompassing both psychological and pharmacological components, proves to be the optimal therapeutic option overall.

    The three main classifications of pharmacological agents used in the management of paraphilic disorders involve selective serotonin reuptake inhibitors (SSRIs), synthetic steroidal analogs, and antiandrogens. The therapeutic choice is dependent upon previous medical history and medication compliance, along with the intensity of both the sexual fantasy and the risk of sexual violence.

    Literature suggests that each of the three drug categories mentioned above help to target diverse physiological pathways and subsequent psychological attributes through their unique mechanism of action. Studies have shown SSRIs to be particularly useful in the adolescent population and milder paraphilias, including exhibitionism, as well as in patients suffering from comorbidities of obsessive-compulsive disorders (OCD) or depression. SSRIs have also been used in the attempted alleviation of hypersexuality, but strong evidence of actual efficacy has yet to be established. Antiandrogens, with emphasis on gonadotropin-releasing hormone (GnRH) analogs, have shown to considerably reduce the frequency and intensity of both deviant sexual arousal and behavior. Gonadotropin-releasing hormone (GnRH) analogs are also considered to be among the most promising pharmacological management for those sex offenders at high risk of particularly violent acts, particularly serial rapists or those individuals with pedophilic disorder. Of note, informed consent is obligatory before initiating antiandrogenic therapy.

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    Treatment for the Sexually Violent

    Sexually violent men have been shown to be more likely to consider victims responsible for the rape and are less knowledgeable about the impact of rape on victims. Such men may misread cues given out by women in social situations and may lack the inhibitions that act to suppress associations between sex and aggression. They may have coercive sexual fantasies and overall are more hostile towards women than are men who are not sexually violent. In addition to these factors, sexually violent men are believed to differ from other men in terms of impulsivity and antisocial tendencies. They also tend to have an exaggerated sense of masculinity.

    The research on convicted rapists has found several important motivational factors in the sexual aggression of males. Those motivational factors repeatedly implicated are having anger at women and having the need to control or dominate them. A study by Marshall et al. (2001) found that male rapists had less empathy toward women who had been sexually assaulted by an unknown assailant and more hostility toward women than non-sex-offenders and nonoffender males/females. Meta-analyses indicate that convicted rapists demonstrate greater sexual arousal to scenes of sexual coercion involving force than do non-rapists.

    Psychotherapy can also be helpful in treatment, though research is unclear about its effectiveness for long-term prevention.[3]

    Applied criminal psychology

    The effect of psychological and social factors on the functioning of our brain is the central question forensic or criminal psychologists deal with due to the fact it is the seed of all our actions. For forensic psychiatry, the main question is, “Which patient becomes an offender?” or “Which offender becomes a patient?” Another main question asked by these psychiatrists is, “What came first, the crime or the mental disorder?” Psychologists also look at environmental factors along with genetics to determine the likeliness (profiling) of a particular person to commit a crime.

    Criminal and forensic psychologists may also consider the following questions:

    1. Is a mental disorder present now? Was it present during the time of the crime?
    2. What is the level of responsibility of the offender for the crime?
    3. What is the risk of reoffending and which risk factors are involved?
    4. Is treatment possible to reduce the risk of reoffending?

    Accordingly, individual psychiatric evaluations are resorted to measuring personality traits by psychological testing that have good validity for the purpose of the court.

    A barbed wire fence
    Figure \(\PageIndex{3}\): Incarceration alone does not guarantee that offenders won’t commit acts of sexual violence again.

    Therapists use various methods to assess individual sex offenders’ recidivism risk. Risk assessment tools consider factors that have been empirically linked by research to sexual recidivism risk. Researchers and practitioners consider some factors as static, such as age, the number of prior sex offenses, victim gender, relationship to the victim, and indicators of psychopathy and deviant sexual arousal, and some other factors as dynamic, such as an offender’s compliance with supervision and treatment. By examining both types of factors, a more complete picture of the offender’s risk can emerge, compared with static or dynamic factors used alone.

    Recidivism is a major concern, in the treatment of paraphilia, especially in pedophilia. Most people recognize that incarceration alone will not solve sexual violence. Treating the offenders is critical in an approach to preventing sexual violence and reducing victimization.

    Behavior modification programs have been shown to reduce recidivism in sex offenders. Often, such programs use principles of appliedbehavior analysis (ABA), also called behavioral engineering, which is a scientific technique concerned with applying empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. Two such approaches from this line of research have promise. The first uses operant conditioning approaches(which use reward and punishment to train new behavior, such as problem-solving) and the second uses respondent conditioning or classical conditioning procedures, such as aversion therapy (a form of treatment in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort). Many of the behaviorism programs use covert sensitization (eliminating the unwanted behavior by creating a profound and lasting association between the behavior and a highly disturbing covert, i.e., imagined, stimulus or consequence) and/or odor aversion: both are forms of aversion therapy, which have had ethical challenges. Such programs are effective in lowering recidivism by 15–18%. The use of aversion therapy remains controversial, and is an ethical issue related to the professional practice of behavior analysis. Previous research in the early 1990s has shown covert conditioning to be effective with sex offenders as part of a behavior modification treatment package. Clinical studies continue to find it effective with some generalization from office to natural environment with this population.

    Castration as a treatment for men with paraphilic disorder, particularly pedophilic disorder, is intended to destroy the body’s production of testosterone through surgical castration (removal of the testes) or chemical castration, in which the individual receives medications that suppress the production of testosterone. Chemical castration is also used in some countries, including the United States, to treat male sex offenders. Unlike physical castration, it is reversible by stopping the medication. For male sex offenders with severe or extreme paraphilias, physical castration appears to be effective, although more radical. It results in a 20-year re-offense rate of less than 2.3% (versus 80% in the untreated control group), according to a large 1963 study involving a total of 1,036 sex offenders by the German researcher A. Langelüddeke. This rate was much lower than otherwise expected compared with overall sex offender recidivism rates.

    Programs for Perpetrators

    There are few programs outside of the criminal justice system that target perpetrators of sexual violence. They are generally aimed at men convicted of male-on-female sexual assault, who form a significant portion of criminal cases of sexual violence. A common response of men who commit sexual violence is to deny both that they are responsible and that what they are doing is violent. These programs work with male perpetrators to make them admit responsibility. One way of achieving this admittance is for programs that target male perpetrators of sexual violence to collaborate with support services for victims, but this could potentially be a revictimization of rape victims and be a poor choice of action unless the rape perpetrator is highly apologetic.

    In 2007, the Texas State Auditor released a report showing that sex offenders who completed the Texas Sex Offender Treatment Program (SOTP) were 61% less likely to commit a new crime.[4] Oftentimes psychological treatment programs are mandated in sentences, but unlike the successes shown in this Texas report, their efficacy is contested.[5]

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    Glossary

    applied behavior analysis (ABA): also called behavioral engineering, is a scientific technique concerned with applying empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance

    aversion therapy: a form of treatment in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort.

    behavior modification: used to change behavior or reduce maladaptive behavior by means of techniques that include negative and positive reinforcement, imposing environmental limitations, goal setting, and conditioning

    castration: a treatment intended to destroy the body’s production of testosterone through the removal of the testes

    chemical castration: a treatment in which the individual receives medications that suppress the production of testosterone

    covert sensitization: eliminating the unwanted behavior by creating a profound and lasting association between the behavior and a highly disturbing covert” (i.e., imagined) stimulus or consequence

    dynamic factors: include an offender’s compliance with supervision and treatment.

    respondent conditioning: known also as classical conditioning or Pavlovian, conditioning that occurs when we link or pair a previously neutral stimulus with a stimulus that is unlearned or inborn, called an unconditioned stimulus

    static factors: include age, number of prior sex offenses, victim gender, relationship to the victim, and indicators of psychopathy and deviant sexual arousal

    1. Thibaut, F., De La Barra, F., Gordon, H., Cosyns, P., & Bradford, J. M. (2010). The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World Journal of Biological Psychiatry, 11, 604–655. ↵
    2. Hall, R. C. (2007). A profile of pedophilia: Definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues. Mayo Clinic Proceedings, 82, 457–471. ↵
    3. Thibaut, Florence, Flora De La Barra, Harvey Gordon, Paul Cosyns, John M. W. Bradford, and the WFSBP Task Force on Sexual Disorders. “The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Paraphilias.” The World Journal of Biological Psychiatry 11, no. 4 (January 2010): 604–55. https://doi.org/10.3109/15622971003671628. ↵
    4. "An Audit Report on Selected Rehabilitation Programs at the Department of Criminal Justice (Report No. 07-02)". Texas State Auditor. March 2007. Retrieved October 20, 2009. ↵
    5. Brooks-Gordon, B., & Bilby, C. (2006). Psychological interventions for treatment of adult sex offenders. BMJ (Clinical research ed.), 333(7557), 5–6. https://doi.org/10.1136/bmj.333.7557.5↵
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    • Modification, adaptation, and original content. Authored by: Sonja Ann Miller for Lumen Learning. Provided by: Lumen Learning. License: CC BY-SA: Attribution-ShareAlike
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