Seminar on Child Sexual Abuse
Ralph C. Underwager
VII. Treatment for Perpetrators
A. Psychological characteristics of child sexual abusers
1. Child sexual offenders must be differentiated from pedophiles.
a. A child sexual offender has committed a criminal act. He may or may or may not be a
pedophile. It is adult/child sexual contact that is against the law.
b. A pedophile has an anomalous sexual preference. If a pedophile never acts on his
impulses, he is not a sex offender.
c. Pedophiles are an heterogeneous group and many do not fit the stereotype of the
dirty old man lusting after little \children.
2. There is no single child sexual offender personality type, although there are some
characteristics that many child sexual abusers have.
3. It is often claimed that abusers were themselves abused as children.
a. However, most of the studies of this suffer from problems with control groups and no
really good study with appropriate controls has yet been done. With the current knowledge
it is a mistake to think that an abuser must have been abused in the past or that an
abused child will grow up to be an abuser.
b. Even if it could be established that many abusers were abused themselves, this does
not mean that most persons who were abused as children will later become abusers. Most
abused children do not become abuse perpetrators in later life
4. Some characteristics of sexual offenders that are often reported include:
a. Inadequate and immature with low self-esteem and poor social skills.
b. Poor impulse control.
c. Hostile, aggressive, psychopathic.
d. Manipulative and lacking in empathy.
e. Many rationalizations and cognitive distortions.
5. Child sexual abusers generally do not have normal MMPIs.
a. The pathology is most likely to be seen in the elevation of the scales which reflect
poor impulse control, antisocial behavior, poor judgment, a history of acting out, lack of
self-esteem, feelings of inadequacy, a schizoid social adjustment, much time spent in
fantasies, and/or thought disorders and confusion. Scale 4 in various combinations is the
b. However, Erickson, Luxenberg, Walbek, and Seeley (1987) report that 19% of their
convicted sex offenders had within normal limits profiles.
c. The more aberrant the behavior of the abuser, the more likely it is that he will
have a pathological MMPI.
6. Female child sexual abusers (see Wakefield & Underwager, 1991a).
a. Although awareness about female sexual abusers has greatly increased in recent
years, most sexual abusers are males.
b. Female child sexual abusers are less likely than men to fit the psychiatric
definition of "pedophile."
c. There are widely different circumstances in which females may engage in behavior
that is defined as "child sexual abuse" and the circumstances that lead women to
sexually abuse children can often be differentiated from those causing men to do so. One
example of this is sexual abuse which occurs in conjunction with a dominant male and in
which the woman plays a secondary role. Another is found by the retrospective surveys of
college men in which many of the boys reported that they had engaged in the incidents
voluntarily and did not feel victimized.
d. Many studies depict women who sexually abuse children as being loners, socially
isolated, alienated, likely to have had abusive childhoods, and apt to have emotional
problems. However, most are not psychotic.
B. Assessment of child sexual abusers
1. Perform a clinical interview, which includes a careful social and sexual history
along with details of the offense.
2. Include detailed information about the offenders' sexuality and sexual fantasies.
Knight, Prentky, & Cerce (1994) report that sexual offenders have more sexual
preoccupation, deviance, compulsiveness, and inadequacy than is evident in their clinical
3. Include standardized tests, such as the Minnesota Multiphasic Personality
Inventory-2 (MMPI-2), the Millon Clinical Multiaxial Inventory-II (MCMI-II),
and the California Psychological Inventory (CPI) for personality. Get some measure
of general intelligence. Use other tests as indicated.
4. Penile plethysmograph
a. The penile plethysmograph assesses physiological arousal in response to different
b. It is widely used to assess male sexual arousal and preference for various sexual
c. There are problems with it however, and its use is controversial.
d. It cannot be used to assess whether an individual who denies the offense has, in
fact, sexually abused a child.
5. Multiphasic Sex Inventory (Nichols & Molinder, 1984)
a. This a test developed for assessing sexual offenders and developing treatment
b. It cannot be used on a person who denies the offense.
6. On the basis of the assessment, develop an individualized treatment plan.
C. Three general types of treatment approaches
1. Organic, biological approach
2. Psychotherapeutic approach (individual, group, and family counseling)
D. Treatment and Recidivism
1. There has been controversy over the effectiveness of treatment for sex offenders.
a. Some reviewers have concluded that there is little evidence that treatment reduces
recidivism (Furby, Weinrott, & Blackshaw, 1989; Quinsey et al., 1993).
b. More recent reviews have reported positive effects when the treatment is
cognitive-behavioral (Lösel, 1995; Nagayama Hall, 1995).
c. Marshall et al. (1991) concludes that comprehensive cognitive-behavioral programs
(for child molesters, incest offenders and exhibitionists, but not for rapists) are most
likely to be effective.
2. Treatment must include attending to the cognitive distortions, be comprehensive, and
be individually designed to meet individual needs (Marshall &
Pithers, 1994; Marshall,
Eccles, & Barbaree, 1993; O'Donahue & Letourneau, 1993).
3. A June 1996 report by the United States General Accounting Office sees the research
as inconclusive but concludes that cognitive behavioral treatments are the most promising
(U. S. GAO, 1996). This is based on an analysis of 22 review articles on sexual offender
4. The clinician cannot wait for the research to produce definitive answers. There is
sufficient support now to conclude that cognitive behavioral procedures are the treatment
5. Sexual offender recidivism is lowest for incest offenders.
E. Traditional offenders programs
1. In the past, the most common treatment approach in the United States was group
therapy that relies heavily upon punitive and hostile confrontation and a nonsystematic
blend of psychoanalytic concepts and traditional talking therapy.
2. Most required a threshold requirement of admission of guilt before being admitted
into the program. All in prison treatment programs that we are aware of still require an
admission of guilt for successful completion. When probation or parole are dependent upon
completing a program, this creates great difficulty for the many innocent persons who have
been wrongfully convicted.
3. The expression of feelings is absolutely required in the traditional
psychotherapeutic approach. Common treatment goals include bringing the perpetrator to the
point where he admits all of his abusive behaviors, expresses guilt and remorse for them,
and is willing to admit and apologize to the victim.
4. There is no evidence for the effectiveness of this type of treatment to cure sexual
abuse and prevent recidivism.
F. Biological treatment
1. This includes surgical castration, hormonal/pharmacological, and psychosurgery. The
rationale is that if the sex drive is reduced, sexual offenses will be prevented.
2. The United States General Accounting Office (1996) states that no program in the
United States reports using these methods alone as the basis for treatment.
3. Some researchers report that there is some effectiveness with hormonal treatments,
but there is no consensus about a particular drug being most effective or about the
duration of positive effects (United States General Accounting Office, 1996).
4. Surgical castration in widely used in Europe (United States General Accounting
Office, 1996). Over 10,000 men were castrated in Zurich alone in the years between 1910
and 1961 according to one report (Quinsey & Marshall, 1983).
5. Quinsey and Marshall (1983) report that there is no research supporting the efficacy
of castration on sexual misbehavior and state that sexual potency is not reduced in many
castrated men who continue to engage in some form of sexual behavior.
6. Nagayama Hall (1995), however, reports on a study in Germany were castration was
reported to lower recidivism.
G. Treatment directions with research support.
1. Treatment should be cognitive-behavioral and include relapse prevention
1996a, 1996b; Marques et al., 1994; Miner et al., 1990).
a. Cognitive behavioral treatment seeks to change the offenders' distorted sexual
cognitions and perceptions, reduce deviant sexual arousal, and increase arousal to
appropriate behaviors or partners.
b. The goal is to get offenders to understand and take responsibility for their actions
and to learn skills to help control their deviant behaviors.
c. Cognitive-behavioral treatment includes a wide variety of treatment methods and
combines behavior control techniques with some type of individual, group, and/or family
d. This approach is now used by most treatment programs in the United States.
2. Treatment should be individually-tailored and include careful assessment of the
situation along with the capacities, personality, and behaviors of the individual and a
therapy program that uses a broad mix of learning theory-based treatment techniques.
Different treatment interventions must be planned for different types of child molesters.
3. Treatment should address the level of self-confidence. Low self-esteem both may be a
major factor in causing the sexual behavior and an obstacle to any behavior change. To
change, persons must believe they are capable of change (Marshall, 1996).
4. Treatment should address social skills and intimacy deficits.
5. Behavioral techniques for strengthening the person's arousal pattern to appropriate
behaviors or partners while weakening the deviant arousal pattern may include aversion
therapy, covert sensitization, satiation, and directed masturbation.
6. Cognitive-behavioral techniques such as aversive conditioning, cognitive
restructuring, thought stopping, covert sensitization, satiation, contracts, covert
reinforcement, modeling, role playing, social skills training, and relaxation training may
7. With pedophiles, it may not be possible to change the arousal pattern. Langevin and
Lang (1985) maintain that "sexual preference is a powerful and persistent feature of
human behavior and there is no evidence that therapy in any form can change it" (p.
a. Therefore the goal of therapy for a pedophile must be to help the pedophile manage
his urges for sexual contact with children.
b. A key factor in the success in any treatment of pedophiles will be motivating them
to change; most pedophiles are resistant to giving up a sexual behavior pattern which they
perceive as positive and rewarding.
8. Treatment should involve material and homework assignments that respond to what has
been learned about the individual.
a. Use didactic materials, bibliotherapy, structured assignments, and individualized
therapy sessions that are aimed at reattribution and cognitive restructuring.
b. Wherever possible, use behavioral homework assignments that are part of ongoing
interpersonal relationships or will guide the individual through the development of new
8. Group treatment should be cognitive-behavioral rather than confrontational.
9. Treatment should help the person understand the potential harm done to children by
reinforcing and teaching a genitalized view of sexuality.
10. When a satisfactory level of response to the initial cognitive restructuring has
been reached, move to a relapse prevention approach.
a. Relapse prevention is a self-control program designed to teach individuals who are
trying to change their behavior how to anticipate and cope with the problem of relapse. It
is based on social learning theory and combines behavioral and cognitive interventions.
There is an emphasis on self-management. It is not an isolated treatment; relapse
prevention was developed as a maintenance strategy and is intended to preserve gains in
whatever treatment preceded it (Laws, 1989; Maletzky, 1996b).
b. The relapse prevention program is individually developed following a careful
assessment of the individual. Offenders learn to identify and anticipate high risk
situations, control their urges, develop more effective coping skills, maintain a more
balanced lifestyle and gain a sense of control and self-efficacy. Through this process, it
is hoped that they will be less apt to relapse and recommit a sexual offense.
c. Offenders learn that there offense is the result of a chain of events involving
cognitions and emotions that trigger a sequence of behaviors that end with the commission
of the sex offense. In relapse prevention, they learn skills that avoid or interrupt the
H. Court-ordered sex offender treatment.
1. Probation with mandated treatment and perhaps some jail time is a common disposition
in the United States. Also, a person accused of sexual abuse may be offered a choice of
therapy in place of punishment as part of a plea bargain.
2. There may be a negative effect on therapy when it is court-ordered. The therapist
must make regular reports to parole officers, judges, and child protection workers and
information given by the sex offender about other victims or offenses must be reported.
Langevin and Lang (1985) comment that a therapist who serves both as helper-therapist and
as informer for the law becomes a "double agent."
3. However, few sex offenders voluntarily seek treatment.
I. Treatment for deniers.
1.The requirement of a threshold admission of guilt may prevent both actual
perpetrators and innocent people from being able to progress in resolution of their
2. An indeterminate number of people found by the family or criminal courts to be child
sexual abusers are, in fact, innocent.
3. When an accused person who is actually innocent enters treatment with the hope of
eventually having a relationship with his children or of benefiting from therapy, it can
4. Failure to admit abuse can result in termination of parental rights in the United
5. Therefore, it is important to find a way to provide treatment to individuals who
6. Maletzky (1996a) developed a cognitive-behavioral group and individual program for
a. Just over 60% who entered treatment completely denying admitted something by the end
of their program.
b. Group was more effective at producing this verbal change than was individual.
c. The men who made this verbal change were somewhat more successful in treatment than
those who did not.
d. Men who admitted crimes at entry into treatment were more successful than those who
e. The vast majority of men who did not admit, yet completed the program were
successful at not relapsing.
f. Men in total denial who completed the program were overwhelmingly safer to be at
large than those who admitted but did not complete treatment.
The experience of the United States in pursuing the noble goal of reducing the
frequency of adults savaging little children can be of assistance to other nations. The
flaws and mistakes in the system developed in the US can be avoided and the strengths
demonstrated can be expanded and increased.