Generic Treatment - Sex Offenders are not all Created Equal

I just finished reading a March 6, 2007 New York Times article on adult sex offenders that indicates dismal outcomes (high recidivism or repeat offending) among individuals who participate in sex offender programs. The article appears to relate this failure (in part) to our failure to complete research on treatment programs and effective interventions (when I thought that the major cause of sex offending was due to the presence of perpetrators). Sometimes I feel like a broken record... but my belief is that one of the major problems in the area of sex offender treatment programs is that the programs tend to treat "sex offenders" using "programs". There is not a thing that is a "sex offender"... only individuals who engage in sexually inappropriate behaviors... and a as a result, any “program” that treats sex offenders is bound to be associated with limited results.

About twenty years ago, I had the wonderful opportunity to experience and be mentored by Dr. Jan van Eys in the Dept. of Pediatrics at M.D. Anderson Hospital and Tumor Institute (who mentored everyone who had the good fortune to be near him). During one of our discussions, he indicated that existing treatments for ALL (acute lymphocytic leukemia) were not 60% effective (which is what I recall the literature stated at that time), but that the existing treatment was probably 100% effective for 60% of the children and 0% effective among 40% of the children. Wow… the thought changed my life. The task in cancer treatment… like ADHD treatment… like sex offender interventions… is to learn to identify those individuals who benefit from specific treatments and to develop alternative interventions among individuals who do not respond to specific treatments. The critical factor to this type of undertaking? …perform evaluations that provide data to allow us to differentiate among responders and non-responders for treatment.

My experience with child & adolescent sex offenders has really been enlightening, maybe 30-40% (I'm making up these numbers... but an estimate) are Asperger's Syndrome / Nonverbal Learning Disabled adolescent males who are unable to engage peers in social (or sexual) relationships and, as a result, tend to drop down to engage with younger children (i.e. the 16 year-old Asperger's male who cannot "get" the 16 year-old girl and drops down to engage with 10-12 year old females and proceeds to act out 16 year old sexual behaviors with a 10-12 year old female); another 20-30% may be low IQ - low frontal lobe processing - very disorganized, poor planning, failure to perceive consequences of actions, failure to identify with the victim or see the world from the perspective of others and violations of social rules/norms in the service of personal needs/wants and as a result act out more primitive drives; maybe 30-40% have a history of early sexual experiences and abuse that results in early sexualization, sort of like they "taste" sexual experiences/pleasures before they are in a position to appropriately channel it, they often attach sexual drives to children (since they were sexualized as a child) and subsequently as they become older repeat the attachment. They also tend to internalize or identify with their perpetrators and act out the sexual abuse they experienced. For another maybe 10%, sexual offending is about dominance, same-sex offending to dominate other males. This group tends to have high scores on the Psychopathy Checklist - YV. Generally "scary" to the community… repeat offenders who will use other means of domination including bullying, aggression, threats, etc. While I recognize that children / adolescents who are sexual predators have a high rate of exposure to sexual abuse, this exposure does not affect each child the same. Some become sexual offenders (maybe if they have other risk factors like Asperger's Syndrome, limited frontal lobe processing, etc.) some do not.

I’m not sure about the percentages (above), but in our practice, we have some prototypes that we tend to see as recurring and the interesting fact is that each group (and each child) is different and requires an equally individualized treatment plan that addresses their specific needs. I don't mean to criticize others for classification of all sex offenders in one group, and then embark on my own classification that simply has several groups, but I thought I would share some of my experiences & perceptions (since if I reviewed each individual child that we have seen, this blog would be even more cumbersome than I already have made it). Anyway, I feel like we embark on interventions, treatments or programs for individual children & adolescents before we have completed the evaluation to identify the cause…and the result?… catch the NY Times article… read your own local papers…