This document summarizes a study that reviewed 11 meta-analyses on the effects of sex offender treatment programs. The main findings are: 1) Sex offender treatments that utilize cognitive behavioral therapy and relapse prevention, such as with multisystemic therapy, can be considered "proven" or "promising" in reducing recidivism according to the criteria used. 2) Younger sex offenders may be more responsive to treatment, as cognitive behavioral approaches were found to be most effective for juvenile sex offenders in reducing recidivism. 3) While hormonal treatments can reduce recidivism, cognitive behavioral therapy tends to have higher completion rates and may be more advantageous as a treatment approach.

1. Article
Sex Offender Recidivism Revisited: Review of
Recent Meta-analyses on the Effects of Sex
Offender Treatment
Bitna Kim
1
, Peter J. Benekos
2
, and Alida V. Merlo
1
Abstract
The effectiveness of sex offender treatment programs continues
to generate misinformation and disagreement. Some literature
reviews conclude that treatment does not reduce recidivism
while others suggest that specific types of treatment may
warrant
optimism. The principal purpose of this study is to update the
most recent meta-analyses of sex offender treatments and to
com-
pare the findings with an earlier study that reviewed the meta-
analytic studies published from 1995 to 2002. More importantly,
this study examines effect sizes across different age populations
and effect sizes across various sex offender treatments. Results
of
this review of meta-analyses suggest that sex offender
treatments can be considered as ‘‘proven’’ or at least
‘‘promising,’’ while age

2. of participants and intervention type may influence the success
of treatment for sex offenders. The implications of these
findings
include achieving a broader understanding of intervention
moderators, applying such interventions to juvenile and adult
offenders,
and outlining future areas of research.
Keywords
offenders, sexual assault, recidivism, intervention
Introduction
The topic of sex offenders generally elicits fear and anxiety
from the public and contributes to punitive policies aimed at
harsh, exclusionary punishments. The perspective that commu-
nities need to be protected from sex offenders through incar-
ceration and surveillance often overshadows the prospects
that treatment can also provide public safety. In their study,
Kernsmith, Craun, and Foster (2009) found that citizen respon-
dents who reported higher levels of fear of sex offenders were
more supportive of registration requirements for sex offenders.
Levenson, Brannon, Fortney, and Baker (2007) also reported
that public perceptions of sex offenders reflect public anxiety
and support for community protection.

3. Although negative attitudes toward sex offenders are not
reflective of all countries, cultural differences and historical
context can account for less punitive public responses. For
example, McAlinden (2012) found that therapeutic interven-
tions for sex offenders were more prevalent in European coun-
tries than in England and Wales. She attributes this to a more
scientific and medical approach to sex offending across Europe
and less emphasis on ‘‘sexual abuse as a moral, legal, and social
problem’’ (p. 170). Nevertheless, the sex offender problem has
become more serious across Europe and policies reflect a shift
toward more punitive attitudes and sanctions (McAlinden,
2012). Not only in European countries but also in the United
States, one of the misgivings about how to respond to sex
offenders concerns the effectiveness of treatment.
In this article, the authors address the treatment issue by
updating the meta-meta-analytic study of Craig et al. (2003)
on sexual offender treatment. This study augments the original
work of Craig et al. by incorporating more recent meta-analytic

4. studies in the analysis. In this research, all salient meta-analytic
sex offender treatment studies from 1995 to 2010 were
included. The purpose of this study is to systematically review
what is known about the effectiveness of sex offender treat-
ments based on results of extant meta-analyses of different
types of treatment for sex offenders.
Furthermore, the study examines the issue of treatment spe-
cificity and which treatment strategies are effective for adult
versus juvenile offenders. Juvenile offenders who commit sex
offenses can evoke more alarm and fear among the public and
prosecutors because age is viewed as an aggravating character-
istic that can contribute to reoffending. When the prosecutors
emphasize public safety, this not only reinforces fears, but also
justifies more punitive rather than therapeutic responses.
Michels reports that prosecutors can take the position that
1
Department of Criminology, Indiana University of
Pennsylvania, Indiana, PA,
USA

5. 2 Criminal Justice Department, Mercyhurst University, Erie,
PA, USA
Corresponding Author:
Bitna Kim, Department of Criminology, Indiana University of
Pennsylvania,
Indiana, PA 15705, USA.
Email: [email protected]
TRAUMA, VIOLENCE, & ABUSE
2016, Vol. 17(1) 105-117
ª The Author(s) 2015
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juvenile sex offenders are the ‘‘worst of the worst’’ because
they
are more prone to reoffending and ‘‘therefore too dangerous to
release’’ (2012, { 9). This demonizing of juvenile sex offenders
reflects a concern that this population cannot be effectively
treated, that they are at greater risk of recidivism, and that they
present a threat to public safety. Although these views are gen-

6. erally inaccurate, they do impact public reaction and
prosecutor-
ial responses (Chaffin, 2008; Letourneau & Miner, 2005).
This study assesses the effectiveness of sex offender treat-
ment programs and includes 11 meta-analytic studies, 6 of
which were included in the Craig et al. (2003) study and 5 of
which are more recent. Cohen’s d was reported to aid in the
interpretation of effect sizes. Definitions of small (d ¼ .20),
medium (d ¼ .50), and large (d ¼ .80) effects were based on
Cohen’s (1988) guide and based on effect sizes encountered
in the behavioral sciences (Cooper, 2010). These guides are
most appropriately employed ‘‘when no better basis for esti-
mating the effect size is available’’ (Cohen, 1988, p. 25).
Two other descriptors of research results related to program
evaluations that have recently received attention among some
social scientists are ‘‘proven’’ and ‘‘promising’’ (Cooper,
2010). Among different guides for magnitude labels of proven
and promising, the Promising Practices Network (PPN) is con-
sidered as credible by associating the terms such as proven and

7. promising with the solid evidence criteria (e.g., type of out-
comes affected, substantial effect size, statistical significance,
comparison groups, sample size, and availability of program
evaluation documentation (Cooper, 2010; PPN, 2007).
According to the PPN (2007), in order for a program to be
labeled proven, the associated evidence must meet the follow-
ing criteria: ‘‘(1) the program must directly affect one of the
indicators of interest; (2) at least one outcome is changed by
20%, d ¼ .25, or more; (3) at least one outcome with a substan-
tial effect size is statistically significant at the 5% level; (4) the
study design used a convincing comparison group to identify
program impacts, including studies that used random assign-
ment or some quasi-experimental designs; (5) the sample size
of the evaluation exceeds 30 in both the treatment and compar-
ison groups; and (6) the report is publicly available’’ (Cooper,
2010, p. 209). An intervention would be labeled promising if it
measured the outcomes of most interest and used rigorous
designs and revealed a smaller effect size (e.g., an associated
change in outcome of more than 1%) that PPN requires for a
program to be considered proven (Cooper, 2010, p. 209). One

8. purpose of this study is to determine whether the current evi-
dence supports a conclusion that sex offender treatment is pro-
ven or promising. This study utilizes both Cohen’s (1988)
guide and the PPN (2007) guide to convey proven and promis-
ing findings of sex offender treatments.
Sex Offender Treatments
Cognitive Behavioral Therapy
The treatment foundation that is used in many sex offender pro-
grams is cognitive behavioral therapy (CBT) and relapse
prevention (Baker, 2012; Brandes & Cheung, 2009; Center
for Sex Offender Management, 2006; McGrath, Cumming,
Burchard, Zeoli, & Ellerby, 2009; Worling & Langton, 2012).
Based on their survey of 1,379 programs in the United States
and Canada, McGrath et al. (2009) reported that the cognitive
behavioral model was in the top three choices for most adult
and adolescent programs (86%) and relapse prevention was
in the top two choices for 50% of the programs.
CBT combines two psychotherapies to address thoughts and

9. beliefs as well as behaviors and actions (Development Services
Group, Inc., 2009). The cognitive focus is on assumptions and
attitudes that contribute to dysfunctional thinking that rein-
forces patterns of unacceptable or inappropriate behaviors. The
behavioral component emphasizes actions and settings that
contribute to patterns of behavior. This problem-focused
approach helps sex offenders learn new skills and develop com-
petencies in maintaining appropriate behaviors. CBT confronts
rationalizations about behavior and provides skills to control
sexual impulses. Similarly, relapse prevention is also a cogni-
tive approach that helps sex offenders regulate their own beha-
viors by recognizing internal and external risks and learning to
manage their behaviors.
In his review of CBT, Greenwald (2009) described struc-
tured intervention strategies that improve interpersonal
problem-solving skills and facilitate more effective communi-
cation skills. By developing self-management skills that recog-
nize social cues and maladaptive behaviors, treatment provides

10. more constructive ways of thinking and understanding the con-
sequences of behavior. Corson (2010) also noted that social and
life skills training and cognitive restructuring are characteris-
tics of CBT. Essentially, treatment programs include various
strategies that focus on correcting thoughts, feelings, and beha-
viors that promote inappropriate behaviors and replacing them
with self-directed behavioral skills that maintain prosocial
beliefs and behaviors.
As previously noted, CBT presents strategies that are effec-
tive in cognitive restructuring that improve victim empathy and
complement relapse prevention (Craig, Browne, & Stringer,
2003; Hanson, Bourgon, Helmus, & Hodgson, 2009). Galla-
gher, Wilson, Hirschfield, Coggeshall, and MacKenzie
(1999) noted that cognitive behavioral treatment is not only
broadly supported in the literature, but also in their meta-
analytic study of 25 studies, in which they found that ‘‘ . . .
cognitive behavioral programs are effective in reducing the
recidivism of treated offenders’’ (p. 27). In addition, Marshall
and McGuire (2003) found supporting evidence that treatment

11. of sex offenders is effective. In reporting that recidivism among
sexual offenders is lower than among other offenders, Mann,
Hanson, and Thornton (2010) observe that this contradicts
common beliefs.
CBT is also the most prevalent treatment approach for ado-
lescent sex offenders and has wide support. For example, in
their
meta-analytic study, Reitzel and Carbonell (2006) found that
cognitive behavioral approaches were the most effective for
juvenile offenders. The cognitive behavioral treatment–relapse
prevention (CBT-RP) approach to treatment underscores
106 TRAUMA, VIOLENCE, & ABUSE 17(1)
changing ‘‘thoughts, behaviors, and arousal patterns of juvenile
sex offenders’’ (Fanniff & Becker, 2006, p. 273).
Generally, programs that use CBT-RP to work with adoles-
cent sex offenders motivate them to reject their thinking errors
and to identify situations and ideations that precipitate inap-

12. propriate behaviors. In addition, adolescents learn to recognize
the connection between their emotions and behaviors. (Bourke
& Donohue, 1996; Hall, 1995; Hunter & Santos, 1990; Lipsey,
2009; Marques, Wiederanders, Day, Nelson, & van Ommeren,
2005). Since juveniles are still maturing, developing, and
experimenting, there is an expectation that they are more
responsive to cognitive restructuring and skills development.
This is consistent with findings that juvenile sex offenders who
receive treatment have low rates of reoffending (Baker, 2012;
Center for Sex Offender Management, n.d.; Reitzel & Carbo-
nell, 2006).
Multisystemic Therapy
Another promising approach for treating sex offenders is multi-
systemic therapy (MST) (Borduin, Schaeffer, & Heiblum,
2009; Fanniff & Becker, 2006; Henggeler, 2012; Huey, Heng-
geler, Brondino, & Pickrel, 2000; MST Associates, n.d.). MST
was originally developed by Scott Henggeler as a family-based
treatment program for antisocial children and serious delin-

13. quent offenders. The emphasis of MST was on working with
families to improve monitoring, supervising, and disciplining
youth, and on reducing deviant peer affiliations (MST Services,
n.d.). MST has been adapted and has demonstrated effective-
ness in treating adolescent socialization issues and interperso-
nal relations (Crime
Solution
s, n.d.; Henggeler, 2012). The
intervention is provided at home or in the community and
focuses on interrupting the sexual assault cycle by working
with the offender and his family to develop a safety plan, by
empowering the family with skills and resources to more effec-
tively parent, and by targeting treatment toward individual
and family risk factors for sexual and nonsexual delinquency

14. (Fanniff & Becker, 2006; Henggeler, 2012).
Borduin et al. (2009) reported that juvenile sexual offenders
treated with MST had lower recidivism rates than offenders
receiving ‘‘usual’’ community services. Multiple randomized
controlled trials of MST provided to juvenile sex offenders
have found reductions in recidivism, problematic sexual beha-
vior, and out-of-home placements (Letourneau et al., 2009). In
their meta-analytic study, Walker, McGovern, Poey, and Otis
(2004, p. 289) found that MST appeared promising and they
recommended that future research on adolescent sexual offen-
der treatment ‘‘test the effectiveness of CBT against that of
multisystemic therapy.’’
Using their findings from a meta-analysis and distinguishing

15. between specialist and generalist sex offenders, Pullman and
Seto (2012) recommended both MST and CBT in order to
achieve more effective treatment outcomes. They concluded
that using MST and CBT to focus on sexual self-regulation
results in lower recidivism for specialist adolescent sex offen-
ders than using MST alone.
Additional Sex Offender Treatments
Sex offender therapy can also include medical interventions
that are either physical or chemical. Surgical procedures denote
mechanical castration, and chemical castration refers to hormo-
nal drugs such as antiandrogen, which are used to reduce sexual
arousal (Pray, 2002, p. 99). Gallagher et al. (1999) reported that

16. cognitive behavioral treatment (or other psychological treat-
ment) is sometimes used in conjunction with hormonal treat-
ment such as Depo-Provera, which reduces physiological
drive to engage in deviant behavior (Gallagher, Wilson,
Hirschfield, Coggeshall, & MacKenzie, 1999, p. 25).
In his study of hormonal treatments, Hall (1995) found that
effect sizes in studies that used a cognitive behavioral approach
were not significantly different from those that employed hor-
monal treatments. Hall performed a meta-analysis of 12 pri-
mary studies and found that both cognitive behavioral and
hormonal treatments were effective. However, the refusal and
discontinuation rates of hormonal treatment participants is con-
siderably higher compared to cognitive behavioral treatment

17. participants, and Hall suggests that this may indicate that cog-
nitive behavioral treatment is more advantageous (p. 807).
More recently, Rice and Harris (2011) also considered the
effectiveness of androgen deprivation therapy (ADT) to reduce
sexual recidivism. In describing the outcomes of surgical and
chemical treatment, the authors acknowledge that voluntary
subjects and weak methodology limit confidence in the out-
comes. Although some studies comparing volunteers with refu-
sers report favorable outcomes using pharmacological ADT,
the authors identify sufficient concerns to conclude that ‘‘ADT
cannot serve as a guarantee against sexually violent recidi-
vism’’ (p. 325). In the cases of men who volunteer and request

18. ADT, sexual recidivism may be reduced but this may be more
indicative of the characteristics of volunteers rather than the
effects of ADT (p. 328).
In addition to qualified conclusions about the effectiveness
of ADT, the authors recognize legal and ethical issues that sur-
round the use of castration. For example, long-term effects of
ADT on health, sexual behavior, and sexual recidivism remain
a concern among researchers and therapists. In spite of the sup-
port that androgen reduction therapy receives from some thera-
pists, the differential effects experienced by sex offenders and
the methodological limitations of many studies lead Rice and
Harris to conclude that ‘‘Clearly, much more research is needed
before ADT has a sufficient scientific basis to be relied upon as

19. a principal component of sex offender treatment’’ (p. 328).
Although it is more controversial, surgical castration can be
used in concert with other types of treatment, including psycho-
logical approaches. Although the operation is performed infre-
quently, it has been utilized in Western Europe and in the
United States. In one study of German offenders, Wille and
Beier (1989) found that the surgically castrated offenders
(volunteers) were more likely to refrain from further sexual
offending than offenders who had applied for the surgery but
were denied approval or withdrew their request (Gallagher
et al., 1999, p. 25). Due, in part, to the dearth of studies on this
Kim et al. 107

20. treatment approach and the lack of a similar control group in
the Wille and Beier study, researchers are reluctant to embrace
its effectiveness (Eher & Pfäfflin, 2011).
Current Study
Although several narrative reviews of sex offender interventions
exist, the most useful are meta-analyses that quantitatively
synthesize the literature. Meta-analyses are characterized by a
number of strengths, including (1) exhaustive literature
searches, (2) an ability to synthesize large literature, (3) a focus
on precise effect sizes rather than solely on statistical signifi-
cance, and (4) an ability to empirically test moderators of study
outcomes and help understand why certain studies had stronger

21. effects than others (Noar, 2008). Given that the literature of sex
offender treatment has continued to grow at a rapid pace, these
more recent meta-analyses have taken advantage of more
sophisticated analyses that larger literature permit (Noar, 2008).
Craig et al. (2003) previously reviewed six meta-analytic
studies that were published from 1995 to 2002 (Alexander,
1999; Aos, Phipps, Barnoski, & Lieb, 2001; Gallagher et al.,
1999; Hall, 1995; Hanson et al., 2002; Polizzi, MacKenzie,
& Hickman, 1999) and concluded that there were positive
treatment effects in reducing sexual offense recidivism. The
principal purpose of this study is to update the most recent
meta-analyses of sex offender treatments and compare the

22. findings with those of Craig et al. (2003). This is a replication
of the earlier Craig et al. (2003) study with an expanded sample
of meta-analyses. In addition, this study extends the earlier
review by examining and comparing: (1) effect sizes across the
meta-analytic literature, (2) effect sizes across different target
populations (adolescents vs. adults) in order to examine how
sex offender treatments have performed across populations, and
(3) effect sizes across different types of sex offender
treatments.
Method
Search Strategy and Inclusion Criteria
To comprehensively identify meta-analysis studies on sex
offender treatment, the authors conducted a search of a number

23. of online databases in which criminal justice-related meta-
analyses might plausibly be reported. The intent was to locate
all meta-analyses of sex offender treatments published in peer-
reviewed journals that were available (in print or electronic
form) or in dissertation databases and met criteria for this
review (Noar, 2008).
The search looked for any mention in the title, the abstract,
or the keyword list of the words ‘‘meta-analysis,’’
‘‘quantitative
review,’’ and ‘‘systematic review,’’ paired with any of the fol-
lowing terms: sex offender treatment or sex offender interven-
tion. The specific databases used were: Criminal Justice
Abstracts, Sociological Abstracts, PsychINFO, MEDLINE,

24. Social Science Abstracts, Psychology and Behavioral Science
Collections, and Current Contents. In addition, computer and
manual searches identified listings of unpublished materials
(Dissertation Abstracts International, ERIC). The reference
lists of those articles retrieved from each of the databases were
scanned to identify additional studies that may have used
meta-analytic procedures (Lundahl, Taylor, Stevenson, &
Roberts, 2008). The abstracts of likely references were
reviewed to confirm that they used meta-analysis, and an
attempt was made to obtain copies of each of the likely candi-
dates (Wells, 2009).
Meta-analyses were included in the review if they: (1) con-
ducted a meta-analysis (quantitative research synthesis) of

25. formally developed and evaluated sex offender treatments tar-
geting recidivism; (2) were focused on a defined target popu-
lation of adolescent and adult sex offenders; and (3) examined
outcome variables of sexual recidivism, violent recidivism, or
any recidivism. As a result of these search strategies and
inclusion criteria, a final set of 11 meta-analyses were
included in the current review. Of the 11 meta-analyses, 5
studies were published since 2002 and not included in Craig
et al. (2003).
Effect Size Conversion
Effect size essentially refers to the magnitude of the ‘‘effect’’
of
the program on recidivism (Cohen, 1988). Bigger program

26. effects (impacts) imply that the program had a greater effect
than smaller effect sizes. The meta-analyses included in this
review used differing effect size indicators. In order to provide
a common metric for interpretation and comparison across all
meta-analyses, effect sizes and confidence intervals in the odds
ratios and r meta-analyses were converted to d using the fol-
lowing equations (Ellis, 2010):
d ¼
2r
ffiffiffi
1
p
�r2
and d ¼ log odds ratio�
ffiffiffi

27. 3
p
p
Negative effect size indicates recidivism reduction among
intervention participants. One arbitrary criterion used to
determine what constitutes a big effect size as opposed to a
smaller one is that effect sizes of .20 are small, .50 are
medium, and .80 or higher are large (Polizzi et al., 1999).
Cohen (1988) suggests that a small effect of d ¼ .20 is typical
of those found in personality, social, and clinical psychology,
while a large effect as d ¼ .80 is more likely to be found in
sociology, economics, and experimental or physiological psy-
chology (Cooper, 2010).
Although d is probably one of the best known effect size

28. indexes, a more compelling way to provide a translation of the
effects of discrete interventions on dichotomous outcomes
(e.g., success or recidivism) is to present the results in a bino-
mial effect size display (BESD) (Cooper, 2010). Developed by
Rosenthal and Rubin (1982), the BESD is a 2 � 2 contingency
table where the rows correspond to the independent variable
(e.g., treatment and control) and the columns correspond to any
dependent variable that can be dichotomized (e.g., success or
recidivism). For any given correlation (r), the success rate for
the treatment group is calculated as (.50 þ r/2), while the suc-
cess rate for the control group is calculated as (.50 � r/2).
108 TRAUMA, VIOLENCE, & ABUSE 17(1)

29. In this study, to use the BESD for a standardized mean dif-
ference effect size of d, the effect size of d was converted into
the correlational equivalent using the formula, r ¼ d=
p
4 þ d2
(Lipsey & Wilson, 2001). For example, d ¼ .60 is converted to
the correlation effect size of .30. So, the value in the success-
treatment cell is .65 (or .50 þ .30/2) and the value in the
success-control cell is .35 (or .50 � .30/2). The BESD shows
that success was observed for nearly two thirds of the people
who undertook treatment but only a little over one third of
those in the control group (Ellis, 2010). The difference between
the two groups is 30 percentage points, meaning that those who
took the treatment saw an 86% improvement in their success
rate (representing the 30 percentage point gain divided by the
35-point baseline; Ellis, 2010). It is easier to comprehend the

30. magnitude of a relationship if it is expressed as a difference
between a 65% and a 35% success rate than if it is expressed
as a correlation effect size of .30 or a standardized mean effect
size of .60.
Results
Table 1 lists characteristics for each of the 11 meta-analyses.
As can be seen, to date three meta-analyses (Gallagher et al.,
1999; Hanson et al., 2002, 2009) included studies conducted
both inside the United States and outside the United States, and
the remaining eight meta-analyses included only American
studies on sex offender treatment. Six meta-analyses included
in Craig et al. (2003) examined the research on sex offender
treatments from as early as 1943 (Doshay, 1969/1943) and as

31. late as 2000 (Borduin, Schaeffer, & Heiblum, 2000; Hanson
& Nicholaichuk, 2000; Looman, Abracen, & Nicholaichuk
2000; McGuire, 2000; Nicholaichuk, Gordon, Gu, & Wong,
2000; Walker, 2000), while the newly added five meta-
analyses in the current review have examined the research as
late as 2009 (Borduin et al., 2009). In the current review, the
term ‘‘study’’ (represented by the letter k) is used to refer to the
primary intervention trials. This set of meta-analyses typically
treated each research trial as one study (deriving one effect size
from each report), although in some cases trials only reported
data in subgroups (e.g., separately for adolescents and adults),
leading meta-analysts to treat those separate groups as different

32. ‘‘studies’’ (deriving multiple effect sizes from a single report;
Noar, 2008). Using this definition, these meta-analyses have
included as few as 9 studies with a cumulative N ¼ 2,986 (Reit-
zel & Carbonell, 2006) and as many as 79 studies with a cumu-
lative N ¼ 10,988 (Alexander, 1999), with a median of k ¼ 22
primary studies.
Efficacy of Sex Offender Treatment
Table 2 is a summary of effect size indices across study out-
comes in the meta-analyses. The effect sizes for the recidivism
measures are listed in the third and fourth columns of the table.
Results from all meta-analyses favored the treatment group. All
effect sizes reported are from fixed effects analyses except for
Gallagher et al. (1999); Hanson, Bourgon, Helmus, and Hodg-
son (2009); and Lösel and Schmucker (2005).

33. Results indicated that every meta-analysis (Alexander,
1999; Aos et al., 2001; Gallagher et al., 1999; Hall, 1995; Han-
son et al., 2002; Polizzi et al., 1999) examined in Craig et al.
(2003) found significant effects, and the mean effect size was
d ¼ �.20 (range �.11 to �.43), suggesting the sex offender
treatments produced an overall 10% reduction in recidivism.
The weakest effect was found in Aos et al. (2001), which
synthesized the outcomes of the cognitive behavioral treatment
(k ¼ 25), psychotherapy (k ¼ 6), behavioral treatment (k ¼ 5),
chemical treatment (k ¼ 3), and surgical treatment (k ¼ 2) for
adults in the United States (see Table 1). The strongest effect
size was found in Gallagher et al. (1999), which synthesized the
outcomes of both psychological therapies (k ¼ 20) and surgical
castration (k ¼ 1) and chemical castration/supplemental com-
ponent (k ¼ 4) for adolescents and adults in the United States
(k ¼ 14), Canada (k ¼ 10), and Germany (k ¼ 1; see Table 1).

34. The more recent five meta-analyses (Hanson et al., 2009;
Lösel & Schmucker, 2005; Pray, 2002; Reitzel & Carbonell,
2006; Walker, McGovern, Poey, & Otis, 2004) were included
in the current review. Results of these five meta-analyses indi-
cated that every meta-analysis found significant effects, and the
mean effect size was d ¼�.36 (range �.15 to �.80), suggest-
ing that the sex offender treatments produced an overall 22%
reduction in recidivism. This average effect size of the updated
sample of meta-analyses is 1.77 times bigger than the average
effect size of Craig et al.’s (2003) sample. The weakest effect
size was found in Pray’s (2002) dissertation that synthesized
the outcomes of psychological treatments (k ¼ 10; see Table
1). The strongest effect size was found in Walker et al.
(2004), which synthesized the outcomes of both the psycholo-

35. gical interventions including MST (k ¼ 1), CBT (k ¼ 3), psy-
choeducational therapy (k ¼ 1), and satiation therapy (k ¼ 1)
and vicarious sensitization (k ¼ 1) for American adolescents
(see Table 1).
Although Craig et al. (2003) found that sexual offender
treatment programs appear to reduce recidivism, what is not
clear is whether this is specific to ages of sex offenders (adult
or adolescent offenders) or particular types of treatments.
Figures 1–4 present heterogeneous information. As shown
in Figures 1 and 2, there appears to be some variability on this
outcome according to target population of sex offender treat-
ments. Three meta-analyses (Aos et al., 2001; Hanson et al.,
2009; Lösel & Schmucker, 2005) that provide the effect sizes
of sex offender treatments of adults in Figure 1 found signif-

36. icant results, but the grand mean effect size was only d ¼�.15,
suggesting that the sex offender treatments for adults pro-
duced an overall 5% reduction in recidivism.
As can be seen in Figure 2, five meta-analyses (Aos et al.,
2001; Hanson et al., 2009; Lösel & Schmucker, 2005; Reitzel
& Carbonell, 2006; Walker et al., 2004) that provide the effect
sizes of sex offender treatments of adolescents found signifi-
cant results, and the grand mean effect size was d ¼�.51, sug-
gesting that the sex offender treatments for adolescents
produced an overall 24% reduction in recidivism, which is
Kim et al. 109
Table 1. Description of Basic Meta-analytic Study
Characteristics by Target Population.

37. Study Specific Sex Offender Treatment Specific Target
Population Years k N
Alexander
(1999)
� Relapse prevention
(N ¼ 713); group/behavioral
(N ¼ 6,616); unspecified
(N ¼ 2,054)
� Institutions (N ¼ 2,220);
hospital (N ¼ 3,668);
community (N ¼ 1,563);
unspecified or mixed (N ¼
1,932)
Male adolescents (N ¼
1,025); male adults (N ¼
9,963)
1943–1996 79 10,988
Aos, Phipps,
Barnoski, and

38. Lieb (2001)
� Cognitive behavioral with (or
without) relapse prevention
(k ¼ 25); psychotherapy
(k ¼ 6); behavioral (k ¼ 5);
chemical treatment (k ¼ 3);
surgical treatment (k ¼ 2)
Adult sex offenders 1977–2000 41 6,139 (T);
8,854 (C)
Aos et al. (2001) Juvenile sex offenders
treatment—primarily
cognitive behavioral
Juvenile sex offenders 1990–2000 11 392 (T);
424 (C)
Gallagher,
Wilson,
Hirschfield,
Coggeshall,
and
MacKenzie

39. (1999)
� Behavioral (k ¼ 2);
augmented behavioral
(k ¼ 2); cognitive behavioral/
relapse prevention (k ¼ 10);
cognitive behavioral (k ¼ 3);
surgical castration (k ¼ 1);
chemical castration/
supplemental component
(k ¼ 4); other psychological
treatment (k ¼ 3)
� Treatment delivered after
1970
Sex offenders;
exhibitionists (k ¼ 8);
incest offenders (k ¼ 6);
pedophiles (k ¼ 16);
rapists (k ¼ 13);
unspecified mix (k ¼ 5)
� Canadian (k ¼ 10);
Americans (k ¼ 14);

40. Germany (k ¼ 1)
� Adolescents (k ¼ 3);
adults (k ¼ 22)
� Males (k ¼ 15)
1975–1999 25 NR
Hall (1995) � Cognitive behavioral (k ¼ 5);
hormonal (anti-androgen
drug or castration; k ¼ 4);
group psychotherapy (k ¼ 1);
behavioral (k ¼ 4); family
therapy (k ¼ 1); individual
psychotherapy (k ¼ 1)
� Adolescents (k ¼ 1);
adults (k ¼ 11)
1988–1994 12 812 (T);
799 (C)
Hanson et al.
(2002)

41. Psychological treatment (e.g.,
group therapy, aversive
conditioning)
� Institutions (k ¼ 23);
community (k ¼ 17); both
settings (k ¼ 3)
� Treatment delivered
between 1965 and 1999 (80%
after 1980)
Sex offenders receiving
psychological treatment
(note that this study
includes sex offenders
receiving no treatment
or a form of treatment
judged to be inadequate
or inappropriate)
� American (k ¼ 21);
Canadian (k ¼ 16); UK
(k ¼ 5); New Zealand

42. (k ¼ 1)
� Adult males (k ¼ 42);
adult female (k ¼ 1)
1977–May, 2000 43 5,078 (T);
4,376 (C)
Polizzi,
MacKenzie,
and Hickman
(1999)
Prison-based sex offender treat-
ment (k ¼ 8); non-prison-
based sex offender treatment
(k ¼ 5)
Sex offenders 1988–1997 21 5,542
(continued)
110 TRAUMA, VIOLENCE, & ABUSE 17(1)

43. Table 1. (continued)
Study Specific Sex Offender Treatment Specific Target
Population Years k N
Hanson,
Bourgon,
Helmus, and
Hodgson
(2009)
a
Psychological treatments:
specialized treatment
programs for sex offenders
(k ¼ 19); programs designed
for general offenders (k ¼ 4)
� Institutions (k ¼ 10);
community (k ¼ 11); both
settings (k ¼ 2)
� Treatment delivered

44. between 1965 and 2004 (90%
after 1980)
� Canadian (k ¼ 12);
American (k ¼ 5); UK
(k ¼ 3); New Zealand
(k ¼ 2); Holland
(k ¼ 1)
� Adolescents (k ¼ 4);
adults (k ¼ 19)
� Male (k ¼ 20); female
(k ¼ 3)
1980–2009 23 3,310 (T);
3,672 (C)
Lösel and
Schmucker
(2005)a
Treatment did NOT have to be
specifically tailored for sexual
offenders

45. � Specialized treatment
programs for sex offenders
(k ¼ 56)
� Institutions (k ¼ 21); hospital
(k ¼ 8); community (k ¼ 27);
combination (k ¼ 10)
� Cognitive behavioral (k ¼
35); classic behavioral (k ¼ 7);
insight oriented (k ¼ 5);
therapeutic community (k ¼
8); other psychological,
unclear (k ¼ 5); hormonal
medication (k ¼ 6); surgical
castration (k ¼ 8)
Sex offenders receiving
psychological treatment
(note that this study
includes sex offenders
receiving no treatment)
� Adolescents only

46. (k ¼ 7); adults only
(k ¼ 36)
1959–2003 69 22,181
Pray (2002)ab Psychological treatments Sex offenders receiving
psychological treatment
(note that this study
includes sex offenders
receiving no treatment)
1980–2000 10 924 (T);
695 (C)
Reitzel and
Carbonell
(2006)
a
Juvenile sexual offender
treatment
� Average length of treatment
¼ 13.22 months (SD ¼ 4.92);
range ¼ 5–18 months

47. � Institutions (k ¼ 3);
community (k ¼ 3);
court-based (k ¼ 2);
Combination (k ¼ 1)
� Cognitive behavioral/relapse
prevention (k ¼ 1); classic
cognitive behavioral (k ¼ 2);
psychosocial-educational
(k ¼ 1); multi-systematic
therapy (k ¼ 2); unspecified
treatment (k ¼ 1);
combination (k ¼ 2)
Juvenile sexual offenders
� Male (N ¼ 2,604);
female (N ¼ 121)
� mean age ¼ 14.6
(SD ¼ .62)
� 41% ¼ a minority race
1975–2003 9 1,301 (T);

48. 1,331 (C);
354 (CT)
Walker,
McGovern,
Poey, and
Otis (2004)a
� Multisystemic therapy (MST;
k ¼ 1); Cognitive behavioral
therapy (CBT; k ¼ 3);
psycho-educational therapy
(Psychoeducational; k ¼ 1);
satiation therapy (ST; k ¼ 1);
vicarious sensitization (VS;
k ¼ 1)
Male adolescent sexual
offenders
10 644
Note. k ¼ cumulative number of studies; N ¼ largest cumulative
sample size reported; NR ¼ not reported; T ¼ treatment group;

49. C ¼ comparison group without
treatment; CT ¼ comparison treatment.
aStudies not included in Craig et al. (2003).
bDissertation.
Kim et al. 111
Table 2. Summary of Meta-analytic Effect Sizes (d) and
Standard Error.
Study Population Any Recidivism Sexual Recidivism K
Alexander (1999) Adolescents and adults �.19 (.04) — 79
Aos, Phipps, Barnoski, and Lieb (2001) Adults �.11 (.05) — 7
Aos et al. (2001) Adolescents �.12 (.10) — 5
Gallagher et al. (1999) Adolescents and adults �.43 (NA)a —
25
Hall (1995) Adolescents and adults �.25 (.07) — 12
Hanson et al. (2002) Adults �.12 (.04) — 38
Polizzi, MacKenzie, and Hickman (1999) Adolescents and
adults — Treated ¼ 13b
Control ¼ 21

50. 21
c
Hanson, Bourgon, Helmus, and Hodgson (2009) Adolescents
and adults �.27 (.08)a 13
cHanson et al. (2009) Adolescents and adults �.229 (.084)a 22
c
Lösel and Schmucker (2005) Adolescents and adults �.28 (.06)a
49
cLosel and Schmucker (2005) Adolescents and adults �.293
(.064)a 74
c
Pray (2002) Adolescents and adults �.15 (.09) 10
cReitzel and Carbonell (2006) Adolescents �.47 (.07) Treated
¼ 7.37b
Control ¼ 18.93
9
cWalker et al. (2004) Adolescents �.80 (.09) 10
aRandom Effect Model.
bRates of sexual recidivism (%).

51. cStudies not included in Craig et al. (2003).
Figure 1. Forest plot of meta-analytic effect sizes and 95%
confidence intervals for recidivism of sex offender treatment for
adults.
Figure 2. Forest plot of meta-analytic effect sizes and 95%
confidence intervals for recidivism of sex offender treatment for
adolescents.
112 TRAUMA, VIOLENCE, & ABUSE 17(1)
almost 3.8 times bigger than the grand mean effect size of sex
offender treatments for adults.
Lösel and Schmucker (2005, p. 121) suggest that sex offender
treatments are not restricted to a certain therapeutic paradigm
but combine strategies from different ‘‘schools in an eclectic
manner’’ and they provide seven modes of sex offender treat-

52. ment, including cognitive behavioral (including MST), classical
behavioral, insight oriented, therapeutic community (TC),
hormonal medication, surgical castration, and general psycho-
logical treatments (e.g., not specifying a certain psychological
therapeutic paradigm). As can be seen in Figure 3, three meta-
analyses (Aos et al., 2001; Hanson et al., 2009; Lösel &
Schmucker, 2005) that examined nine effect sizes over seven
different types of sex offender treatments found significant
effects for all treatment approaches except insight oriented,
gen-
eral psychological, and TC interventions. The weakest effect
size was found in insight-oriented treatment (d ¼ .01), followed
by cognitive behavioral (d ¼ �.14), and psychological treat-
ment (d ¼�.15). The strongest effect size was found in surgical

53. castration (d ¼�1.51) and hormonal medication (d ¼�.62).
Figure 4 shows the comparison of effect sizes between com-
munity treatments and institutional treatments for sex offenders.
As illustrated in Figure 4, three meta-analyses (Hanson et al.,
2002, 2009; Lösel & Schmucker, 2005) that provide three effect
Figure 3. Forest plot of meta-analytic effect sizes and 95%
confidence intervals for recidivism according to the types of sex
offender treatment.
Figure 4. Forest plot of meta-analytic effect sizes and 95%
confidence intervals for recidivism according to the types of sex
offender treatment.
Kim et al. 113
sizes for each treatment type found significant results, except
the

54. effect sizes of community treatment from Hanson et al. (2002)
and institutional treatment from Lösel and Schmucker (2005).
The grand mean effect size of community treatments was d ¼
�.33, suggesting that the sex offender treatments occurring in
the community produced about an overall 17% reduction in
recidivism, while the grand mean effect size of institutional
treatments was smaller, d ¼ �.20, suggesting about a 10%
reduction in recidivism.
Conclusion
The purpose of this study was to review and synthesize
meta-analyses of sex offender treatments designed to reduce
recidivism. One of the most promising findings is that every
meta-analysis in this review found significant recidivism
reduction outcomes. Compared to the Craig et al. (2003) study,
the current review of more recent meta-analyses of sex offen-

55. der treatment efficacy demonstrated a larger and more robust
sex offender treatment effect in reducing recidivism.
Given PPN’s recommendation, sex offender treatments can
be considered as proven or at least promising. For six meta-
analyses (Alexander, 1999; Aos et al., 2001; Gallagher et al.,
1999; Hall, 1995; Hanson et al., 2002; Polizzi et al., 1999)
examined in Craig et al. (2003), the mean effect size was
d ¼ �.20, suggesting the sex offender treatments produced
an overall 10% reduction in recidivism, which meets the pro-
mising criteria. The most recent five meta-analyses (Hanson
et al., 2009; Lösel & Schmucker, 2005; Pray, 2002; Reitzel
& Carbonell, 2006; Walker et al., 2004) did find significant
effects, and the mean effect size was d ¼ �.36, suggesting a
22% reduction in recidivism. Thus, it appears that sex offender

56. treatments included in the most recent five meta-analyses are
proven to reduce recidivism. Specifically, the current review
reveals that sex offender treatments for adolescents (d ¼�.51)
compared to adults (d ¼�.14), surgical castration (d ¼�1.51),
and hormonal medication (d ¼�.62) compared to psychological
treatment (d ¼ �.15), and community treatment (d ¼ �.33)
compared to institutional treatments (d ¼ �.20) have a larger
effect in reducing recidivism.
As indicated in Table 3, this study revealed that there are
effective treatments available for sex offenders, both juvenile
and adult, which reduce recidivism. However, sex offender
treatment appears to be more successful with adolescent rather
than adult offenders. Although the study conclusions are tenta-
tive, they suggest that we now have greater knowledge about
sex offender treatments.

57. The data reported in this study included recent studies and
updated the published research of Craig et al. (2003) to illus-
trate the effectiveness of treatment approaches for adolescents
and adults. This kind of research is intended to inform treat-
ment programs and to provide data on program effectiveness,
which can be utilized in designing, implementing, and evaluat-
ing new and existing programs. As noted earlier, there are var-
iations in both adolescent and adult sex offenders. Concluding
that their treatment needs are identical suggests a lack of
knowledge about the research on offenders, their backgrounds,
and their behavior.
The current review found that surgical castration and hor-
monal medication have significantly larger effects compared

58. to the psychological treatments that show significant but small
effect size. Consistent with prior research in this area, the
authors also note the need for more rigorous studies with better
research designs (Hanson et al., 2009). Therefore, these results
must be interpreted cautiously.
As illustrated in Table 4, there are a number of implications
from this study’s conclusions. Most importantly, meta-analytic
evidence demonstrates that there are successful interventions
for
adolescent and adult sex offenders. These findings offer support
for existing strategies and strengthen advocates’ request for
their
continuation and expansion. The good news is that the five most

59. recent meta-analyses studies found significant effects
suggesting
a 22% reduction in recidivism. Nonetheless, additional research
on adolescent and adult sex offender populations is warranted.
This study included a comprehensive array of treatment
techniques that have been employed in the United States and
other countries and compared their effectiveness across the
types of the interventions. Meta-analytic study affords an
opportunity to determine which treatment modalities are most
successful, which allows resources to be allocated to those pro-
grams most likely to reduce recidivism. It is more desirable
than simply treating offenders as though they are homogeneous
and all fit into one treatment program or modality. Based on the
results, sex offender treatments for adolescents compared to

60. adults have a larger effect in reducing recidivism. These find-
ings suggest that while sex offender treatment should continue
to be supported for juveniles, treatment for adults also needs to
be refined and further developed.
Even if research indicates that specific treatments are effec-
tive in reducing recidivism, ethical considerations or feasibility
might prevent their use. In this study, surgical castration and
hormonal medications were found to be more effective than
psychological treatments. However, there is a reluctance to
endorse them. According to del Busto and Harlow (2011), the
American Medical Association (AMA) is opposed to physi-
cians participating in surgical castration or engaging in medical

61. practices that serve to punish rather than treat (p. 551). Con-
cerns also focus on whether the treatments violate offenders’
human rights (del Busto & Harlow, 2011, p. 552).
When Daly (2008, p. 206) surveyed state practices for treat-
ing sex offenders, she noted ethical considerations that pre-
clude researchers from randomly assigning offenders to
hormonal treatments that could be intrusive or cause harm as
one of the reasons for the limited research in this area. Only
a few states reported drug use to treat sex offenders, and this
decision was based on a review of individual cases. These con-
cerns suggest that CBT is the preferable treatment modality,
even if it might not be as effective as hormonal medications.
In addition, the most recent meta-analyses demonstrate that

62. community-based treatments compared to institutional treat-
ments have a larger effect in reducing recidivism. The findings
seem to support legislative reforms that would authorize more
114 TRAUMA, VIOLENCE, & ABUSE 17(1)
sex offender treatments in the community rather than relying
on institutional treatments. Given the punitive approaches that
have characterized the criminal justice system, these changes
may be unlikely. Nonetheless, the evidence demonstrates that
if the public and elected officials were committed to reducing
recidivism, community treatment rather than institutional treat-
ment is proven to reduce recidivism.

63. This study has some limitations. First, like Craig et al.
(2003), the present review did not include meta-analysis pub-
lished in languages other than English, abstracts from confer-
ence proceedings, or books. The inclusion of unpublished
studies may allow for the investigation of publication bias.
When researchers engage in meta-analysis, they are dependent
on the work of other researchers to a much greater degree than
if they are designing the study and collecting original data. As a
result, interpretations and conclusions are somewhat tentative
(Kim, Merlo, & Benekos, 2013).
Despite these limitations, this study may prove useful to sex
offender treatment practice that seeks to develop a more
evidence-based approach. Specifically, practitioners should

64. endeavor to treat both juveniles and adults, but recognize that
there is a greater likelihood of reductions in recidivism with
ado-
lescents. In terms of recidivism, surgical castration and
hormonal
medications have been proven to be effective, but there are seri-
ous ethical issues with them. As a result, there will be more
reli-
ance on the psychological approaches like CBT and MST that
were found to be significant in reducing recidivism but had
small
effect size when compared to surgical castration and hormonal
medications. The research indicates that treatment in the
commu-
nity is more effective than treatment in institutions. Although

65. there may be obstacles to changing existing exclusionary
policies,
evidence demonstrates that sex offenders, both adolescent and
adult, can be treated successfully in community settings.
Finally, additional primary research on various treatment
approaches is required for future meta-analysis to identify
which target groups respond best to specific techniques and
which combination of treatments is most effective. Research
can compare institutional versus community treatments for
adolescent and adult offenders and highlight approaches that
are most likely to reduce recidivism in these settings. Further
study can look at specific age-groups within the target groups.
For example, research could compare younger and older ado-

66. lescents and adults. The influence of characteristics of each sex
offender treatment approach such as length and frequency of
treatment sessions, materials, and instructors on the effective-
ness of treatment should be addressed in future analyses. With
an emphasis on evidence-based strategies, it is essential to con-
duct more research using meta-analytic techniques to help
inform policy and practice.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,

67. author-
ship, and/or publication of this article.
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