There are few crimes which evoke more horror and loathing than sexual abuse, especially when the victim is a child. Yet in the late 1960s, when I first began a residency in psychiatry, there were also no established evaluation and treatment programs for the sexual offender.
While exploring strict behavior therapy for overeating and tobacco use, which was almost a fad at the time, we came across a few men who had committed sexual crimes against children or had raped adult women, yet had been released from prison and had nowhere to turn for treatment, let alone assessment. While our efforts to combat obesity and smoking were less than perfectly successful, we believed we could employ those same behavioral techniques to combat an attraction to prepubescent girls and boys as well as to overly aggressive sexual behavior. We were, initially at least, wrong.
Nonetheless, throughout the past decades, much progress has been made in the assessment and treatment of all forms of sexual offenders. This has been aided by the realization that the majority of sexual offenders cannot be placed within the same categories; many are situational offenders while others are aggressive and predatory pedophiles or repeat rapists for whom sexual gratification has been welded to sexual gratification, a particularly harmful association, as I explain in my book Sexual Abuse and the Sexual Offender: Common Man or Monster? Indeed, there exist a host of categories in which sexual offenders should be placed, many of whose borders cannot be definitively drawn. This text reveals the possible genesis of some sexual crimes, their prevalence (now thankfully declining), how professionals evaluate the sexual offender, and, of utmost importance, not only how sexual offenders are being provided treatment to reduce or eliminate the prospect of their re-offending in the future but, of utmost importance, how to prevent the majority of sexual crimes from occurring in the first place.
There exist a number of principles this book will emphasize and explain that counter the common myths so often misrepresented in the public, and even the pseudo-scientific media. These stem from our published research and experience (and that of others) in assessing and treating over 10,000 sexual offenders over a period exceeding 40 years. They can be briefly summarized here:
- Most sexual offenders are not strangers lurking in the dark or enticing children with treats or gifts, but are those we know, those in our very own families, those we live with, those we live next door to, and, indeed, even those we love; they do not fit into one neat personality type and cannot be stereotyped any more than can the general population. Those believing they can tell a sexual offender from a distance are in error.
- The path from psychobabble to misunderstanding and mistreatment of the sexual offender within our judicial system is a short one that, hopefully now is beginning to change to a more scientifically enlightened view and practices; the economics of dealing with the sexual offender are at play here.
- Many sexual offenders are upstanding citizens who have accomplished much good in their communities, in their jobs, and even within their families, but who also have committed unspeakable crimes against children or adults; crimes which may scar their victims for life.
- Although we are unaware of the genesis of all these antisocial acts, we can trace some of them to their primate and evolutionary beginnings; we can accurately assess who the most dangerous of these offenders are, who will require institutional treatment to start, and who is safe to be treated at large in their communities. Sexual and general impulse control can be a key in evaluating such offenders and there is a possibility that the potential for abuse may reside, under extraordinary circumstances, within each of us.
- Sexual offenders present to us with many different patterns of behavior but can generally be differentiated into two main groups: the situational and the predatory offender. (Please see Table on ‘Differences between Situational and Predatory Sexual Offenders’, below).
- Of crucial import, we can successfully treat over 90% of situational sexual offenders so they will never molest again; the same cannot be claimed for predatory offenders but even amongst these, our success rates over as long as 40 years hover around 75 – 80%, defined as the lack of any sexual recidivism over that period of time.
- Assessment and treatment techniques are far from idiosyncratic; they have been honed over a half-century, proven to be valid and reliable, and have been standardized with help from the international Association for the Treatment of Sexual Abusers and often published in Sexual Abuse: A Journal of Research and Treatment.
- Of utmost significance, we can take simple steps to produce primary prevention of sexual abuse employing common-sense precautions, guided by the principles gleaned from the research and experience built up over many years of dealing with sexual offenders. These steps are laid out in the text in a format most people can easily follow.
- This text is written in, hopefully, clear English, minus the jargon of our field and within the scope of understanding of a lay audience, such as parents, teachers, guidance counselors, corrections personnel, coaches, university administrators and others who work with both children and adults; however, it also offers sufficiently detailed information for the general counselor, psychologist and social worker, all of whom may encounter sexual offenders in their various practices.
Over the years, assessment techniques for the sexual offender have been refined to the extent that we can be almost 95% accurate in predicting who will re-offend absent treatment and regardless of incarceration. Unfortunately, we cannot be so precise, or even come close, to predicting when a re-offence might occur. However, evaluation techniques, including pen and paper assessments, criminal history, penile plethysmography (PPG: the measurement of erection in a laboratory setting), and computerized viewing time tests have all added immensely to our ability to predict recidivism.
We have added to our assessment toolkits not only these static factors, but dynamic aspects of behavior as well, during incarceration (if any) and treatment, such as improvements in many of the tests mentioned above and explained more fully in the text. We have also achieved limited but certified progress in the physiological tests commonly utilized, such as the plethysmograph and viewing time tests. Moreover, gains in treatment not so easily measured statistically but nevertheless of importance, include improvements in self-disclosure, trust and follow-through on workbook assignments, as well as, of course, absence of any sexual misbehaviors. These are all taken into account in the evaluation of progress in treatment.
It has become apparent through the years, that, although sexual offenders can be grouped in many differing ways, the standard bilateral grouping of situational vs. predatory (or in some expositions, preferential) offender has stood the test of time. Some case examples, while egregious, should explain some of the differences:
Glenn, a 43 year-old construction worker, had recently moved into his girlfriend’s apartment. While a good provider, he had difficulty not noticing his girlfriend’s 12 year-old daughter’s development and, because it was a close setting, he had often seen her half-dressed. Glenn tried but could not control his sexual arousal, now focused on the girl, and he began to fantasize and masturbate to images of having sexual activity with her. On several nights, when Glenn believed everyone was asleep, he stole into her bedroom and fondled her breasts and genital areas underneath her nightgown. Once, as she awoke, Glenn whispered to her “This will be our little secret”. After several such incidents, the girl finally developed the courage to tell her mother, who wisely took the girl into her physician for an examination and booted Glenn out of the apartment and out of her life as well. Glenn was referred to a behavioral and cognitive treatment program following adjudication (probation only) and, following successful graduation after several years of treatment, has remained offense-free over the last 24 years. Although he has now married, he has never been allowed to live with a young girl in his household.
Stuart, a 29 year-old unmarried accountant, had entertained sexual fantasies about boys in the age range of 5-11. His habit was to identify boys in his neighborhood who might be having trouble in their home life or who were living with a single mother. He would then befriend such a youth, offering at first to play games, then plying him with gifts and offering to babysit for him or take him to the movies while his beleaguered mother was at work or on a date. When alone with the boy at his house (always stocked with candy and ice cream) he would show him videos for kids but “inadvertently” slip in video porn and gauge his reaction. This would lead to frank talk about sexual matters, then “instructions” in how to masturbate, then end in frank sexual activity, including anal penetration with the boy. Rumors circulated in several of these neighborhoods, prompting Stuart to make several moves before he was caught by a community watch group. He served 9 years of a 20-year sentence and is now in treatment. We cannot be certain, however, his outcome will be as sanguine as that of Glenn’s.
Thus, Glenn would be classified as a situational offender while Stuart would fall into the predatory offender group. While there are certainly overlaps, these twin distinctions have been of great help in classifying the two types of sexual offender we have treated over more than the past 45 years. The table below presents, in abridged form, the differences between situational and predatory offenders.
The assessment techniques used, and more importantly, the treatment techniques employed stemmed from our own research and that of others over the decades and have comprised the contents of over 30 peer-reviewed publications in the scientific literature, several texts on the treatment of the sexual offender, and countless chapters in volumes devoted to this unpleasant, but necessary topic. A bibliography is provided in an Appendix but references are not given for each fact in the text as they can easily be located in the bibliography and I wished to make the book as readable as possible, especially for the non-specialist in this field.
The treatment of the sexual offender stems not so much from the etiology of the offenses as from their history and epistemology of the offenses themselves. We wish we knew more about the origins of sexual offending, and in some cases we can link childhood events to later offending behavior. In addition, a few such cases stem from a damaged central nervous system, producing inadequate sexual impulse control. In fact, the case of Glenn, above, might be thus linked. We do know that genetics is but a minor factor except in the realm, again, of impulse control. We also know, and review in the text, animal examples (primarily in primates) of deviant sexuality. However, lacking an unobstructed insight into the genesis of most sexual offending, we have developed a range of cognitive and experiential techniques to treat the harmful behaviors themselves, which include not only offenses against children but exhibitionism, rape, and a variety of less common sexual crimes.
Included among these therapies are, at first, trust-building, followed gradually by confrontation of denial (the offenders’ best friend), role-playing, and relapse prevention, along with the construction of safety plans. Much of this work can productively occur in group, but individual therapy must also be applied as each offender’s modus operandi and victim choice will differ. Techniques, fully explained in the text, include covert sensitization, “assisted” covert sensitization (utilizing foul odors which induce nausea, thus directly de-conditioning sexual arousal), vicarious sensitization, direct aversive de-conditioning, plethysmograpahic biofeedback and aversive behavior rehearsal.
These are accompanied by written assignments along with work in notebooks designed for the sexual offender. While direct punishment may seem cruel to those unfamiliar with the treatment of the sexual offender, in fact such techniques have not only proven to prevent future sexual offending in the vast majority of cases, but are rarely viewed by offenders as unduly harsh. Contrary to popular belief, most offenders wish to be relieved of their deviant attractions and behaviors.
There remain a handful of offenders (about 2% in our sample) who are so hardened in their deviant attractions that no amount of outpatient therapy can guarantee that no further deviant sexual activity will recur. These unfortunate individuals may well require continuous inpatient treatment but our current system of incarceration or commitment can often allow such offenders to be released. For such individuals, an injectable depo-Provera program or its like may be the first and best option while, hopefully, behavioral and cognitive treatment is taking hold. Currently, this population fortunately constitutes only a small fraction of the sexual offenders presenting to treatment. Thus the cognitive and behavioral methods fully described in this volume can produce outstanding reductions in the relapses so often seen prior to the institution of these techniques. Indeed, employing such methods, we and multiple other cognitively- and behaviorally-based treatment programs have achieved success rates, defined by the absence of sexually deviant arousal or behaviors over extended periods of time (for certain clients, exceeding 35 years), of well in excess of 90% for the majority of sexual offenders who complete treatment.
Aside from the usual molesters, pedophiles (clergy are not spared here), rapists (there are several varieties within this category), and exhibitionists, others exist who abuse people sexually and for whom treatment techniques lie in waiting for more resourceful investigators and therapists to explore and discover in the future. These include the sex traveler, the mentally disabled or ill sexual offender, and the rare but increasingly recognized female offender. All these and more are explored in this text, and include the hardened repeat rapist, the female offender as mentioned above, the child or adolescent who offends, the internet offender, the foreign traveler whose purpose is to abuse children, and the hypersexual offender. All these are presented, with specialized treatment programs described, where available. The problems with the American restrictions on consenting adult prostitution are also examined.
Chapters herein also deal with the practical matters of the supervision of the sexual offender after a term in prison, generally by parole or probation officers, the new but essential study of who might become a sexual offender in the future, the common statistics of sexual offending in America (and its likely extension to other similar cultures), the frequency, duration and cost of offender treatment programs, and the overriding scientific rationale of the differing types of treatment programs available.
There thus remains work to be done: Better treatment techniques need to be researched for the hardened pedophile and repeat rapist who has bonded sexual pleasure with the infliction of pain on their victims. In addition, improved objective measures than the penile plethymosgraph and Viewing Time Tests must be investigated. More therapists and researchers must focus on therapy as opposed to assessment techniques or demographic trends, as the literature remains sparse on the objective measures of treatment successes. This text would also not have been complete without some objective measures of how common various forms of sexual offending exist in our communities, the manner in which offenders are handled by the justice system in the U.S., and speculation on more enlightened legal changes suggested not only by the sparse population of treatment providers but by newly-enlightened law-makers, and not just in this country but abroad as well. Offenders in prison are rarely afforded adequate treatment due to lack of resources.
The final, and perhaps most important chapter, deals with the primary prevention of sexual abuse. This task is just as, if not more, difficult than ridding our societies of all types of sexual criminal activity. Here, advice, guarded but honed from many decades worth of studying, and more importantly, dealing directly with the evaluation and treatment of all manner of sexual offenders, has led the most prominent in our small field to generalizations well worth considering. These offerings are aimed at not just the treatment professional but, of more importance, at the parents, teachers, nurses and all others whose charge is to nurture and protect our young and most vulnerable.
In sum, this book not only highlights the current problems our legal systems have in dealing with sexual offenders but provides ways in which most such offenders can be successfully treated without the cost of incarceration. It details case examples (not all with positive outcomes), the methods currently in common use in the cognitive and behavioral therapy of sexual offenders, and provides the results of these treatment techniques in thousands of such “criminals”. Surprisingly, and against common opinion, the majority of sexual offenders, particularly of the situational sort, can be treated so as to never commit another sexual crime. These results are time-tested, the outcomes of over 40 years of working with such offenders, and have been repeatedly represented in the peer-reviewed literature by ourselves and in clinics world-wide. Hopefully, this text will provide both insights into the mechanisms of sexual offending, the evaluation techniques of its perpetrators, and the results of modern treatment techniques honed over almost a half-century of dealing with these most unfortunate of individuals who have committed the most heinous of crimes yet who also deserve our treatment in place of generally useless punitive incarceration and condemnation. Perhaps we can, in time, thus learn to judge not the actor as much as the act itself.
Dr Barry Maletzky graduated from Columbia University with a BA and from Stony Brook Medical School with an MD. He completed a residency in psychiatry at the Oregon Health Sciences University in 1971. Following two years of service in the military, he entered the practice of psychiatry in Portland, OR in 1973. Dr Maletzky began specializing in several fields in psychiatry, including the treatment of severe depression, the use of electroconvulsive therapy, and the assessment and treatment of sexual offenders. In 1978 he founded the Sexual Abuse Clinic to treat sexual offenders and their victims. Since that time, the clinic has become one of the largest and most established such clinics in the world. His latest book, Sexual Abuse and the Sexual Offender: Common Man or Monster?, is published this week by Karnac.
Reviews and Endorsements
“Sexual crimes might well be among the most difficult of patients to treat. Drawing upon almost four decades of clinical experience with sexual offenders of all varieties, Maletzky dispels many of the myths about pedophiles and other sexual criminals, and underscores some of the complex realities about providing psychological treatment…Full of useful clinical wisdom acquired from a lifetime of psychiatric practice, Barry Maletzky’s book on the sexual offender patient provides mental health workers of every professional background and every theoretical orientation with a clearer, fuller, and more balanced portrait of the complex and vexing realities of day-to-day work with this highly troubled and troubling patient population.”
— Professor Brett Kahr, PhD, Series Editor, Forensic Psychotherapy Monograph Series, Karnac Books
‘I cannot think of any person better suited to write a book for the public about sexual offenders than Dr. Barry Maletzky. Without in any way dismissing the harmful effects of sexual offending, Dr. Maletzky shows that the proper treatment and management of these offenders is in the best interest of society. He shows quite clearly that treating these offenders and managing them appropriately not only reduces future victimization, it also saves society a considerable amount of money. When governments and their agents act responsibly in accordance with evidence, then we and our families and friends will be safer. Dr. Maletzky has, in this book, provided the public a significant and valuable service. I hope other readers will enjoy this book as much as I did.’
— William Marshall, OC, PhD, FRSC, Emeritus Professor of Psychology and Psychiatry, Queen’s University, Canada; Former Director, Rockwood Psychological Services