ArticleSex Offender Recidivism Revisited Review ofRecen.docx

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

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.

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

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

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
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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-

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

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

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

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

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

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-

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-

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

(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

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

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

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

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

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

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

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

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

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,

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

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

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

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

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)

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

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

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

‘‘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).

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).

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 …

Sexual Abuse: A Journal of
Research and Treatment
2016, Vol. 28(4) 340 –359
© The Author(s) 2014
Reprints and permissions:
DOI: 10.1177/1079063214535819
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Article
Adverse Childhood
Experiences in the Lives
of Male Sex Offenders:
Implications for Trauma-
Informed Care
Jill S. Levenson1, Gwenda M. Willis2,
and David S. Prescott3
Abstract

This study explored the prevalence of childhood trauma in a
sample of male sexual
offenders (N = 679) using the Adverse Childhood Experience
(ACE) scale. Compared
with males in the general population, sex offenders had more
than 3 times the odds
of child sexual abuse (CSA), nearly twice the odds of physical
abuse, 13 times the
odds of verbal abuse, and more than 4 times the odds of
emotional neglect and
coming from a broken home. Less than 16% endorsed zero
ACEs and nearly half
endorsed four or more. Multiple maltreatments often co-
occurred with other types
of household dysfunction, suggesting that many sex offenders
were raised within
a disordered social environment. Higher ACE scores were
associated with higher
risk scores. By enhancing our understanding of the frequency
and correlates of
early adverse experiences, we can better devise trauma-
informed interventions that
respond to the clinical needs of sex offender clients.
Keywords

adverse childhood experiences, sexual offender treatment,
trauma-informed care
1Barry University School of Social Work, Miami Shores, FL,
USA
2The University of Auckland, New Zealand
3Becket Family of Services, Falmouth, ME, USA
Jill Levenson, PhD, LCSW, Associate Professor, Barry
University School of Social Work, 11300 NE, 2nd
Ave, Miami Shores, FL 33161 USA.
535819 SAXXXX10.1177/1079063214535819Sexual
AbuseLevenson et al.
research-article2014
14535819&domain=pdf&date_stamp=2014-05-28
Levenson et al. 341
Over the past few decades, researchers have established that the
prevalence of early

traumatic experiences such as child maltreatment and family
dysfunction is far greater
than previously recognized (Centers for Disease Control and
Prevention [CDC],
2013b). Multiple types of adversity are often present and
research has demonstrated
that cumulative experiences of childhood trauma lead to
alarming increases in the risk
for a range of health and social problems (Anda, Butchart,
Felitti, & Brown, 2010;
Felitti, 2002; Felitti et al., 1998). Emerging evidence also
suggests that early traumatic
experiences are common in the lives of sexual offenders
(Jespersen, Lalumière, &
Seto, 2009; Reavis, Looman, Franco, & Rojas, 2013). A clear
understanding of the
scope and impact of early adversity is important in the
development of treatment inter-
ventions and social policy (Anda et al., 2010; Anda et al., 2006;
Felitti et al., 1998).
Trauma, by definition, is any extraordinary event (experienced
or witnessed) that
threatens an individual’s physical or psychological well-being
and challenges his or

her coping skills (American Psychiatric Association, 2000,
2013; Whitfield, 1998).
The Adverse Childhood Experiences (ACE) study, a
collaborative research project
between the U.S. CDC and Kaiser Permanente (a network of
health care organiza-
tions), produced staggering evidence of the pervasive and
enduring nature of early
trauma (CDC, 2013b). Beginning in 1997, the ACE study
collected data about child-
hood adversity and its relationship to adult health outcomes
from 17,337 participants
who sought health services from Kaiser Permanente (Felitti et
al., 1998).
Notwithstanding an underrepresentation of ethnic minorities and
lower socioeconomic
classes, the results of this project were remarkable for their
revelation of the frequency
and negative correlates of child maltreatment and household
dysfunction. More than
28% of the participants reported childhood physical abuse, 11%
were emotionally
abused, and 21% had been sexually abused. Women were more
likely to report sexual
(25%) and emotional (13%) abuse than men (16% and 8%,

respectively), and men
were slightly more likely to have been physically abused.
Nearly one quarter of the
respondents had been physically or emotionally neglected.
Household dysfunction
was also common; 13% had witnessed domestic violence in the
home, 27% experi-
enced parental substance abuse, 19% had a parent who was
depressed, mentally ill, or
attempted suicide, and 23% came from homes in which the
parents were separated or
divorced. Nearly 5% reported that a family member had gone to
prison (CDC, 2013b).
More than two thirds of the participants reported experiencing
at least one adverse
event before they turned 18 years (CDC, 2013b). Multiple forms
of child maltreatment
and household dysfunction were interrelated; the presence of a
single ACE factor more
than doubled the odds of reporting additional ACEs (Dong,
Anda, Dube, Giles, &
Felitti, 2003; Dong et al., 2004). As the number of childhood
adverse experiences
increases, the risk for myriad health, mental health, and

behavioral problems in adult-
hood also grows in a cumulative fashion (Anda et al., 2006;
Dube, Anda, Felitti,
Edwards, & Williamson, 2002; Felitti, 2002; Felitti et al.,
1998). For instance, as ACE
scores increase, so does the likelihood of adulthood substance
abuse, suicide attempts,
depression, smoking, heart and pulmonary diseases, fetal death,
obesity, liver disease,
intimate partner violence, early initiation of sexual activity,
promiscuity, sexually
transmitted diseases, and unintended pregnancies (CDC, 2013a;
342 Sexual Abuse 28(4)
ACE research has clearly and consistently demonstrated the
negative impact of early
trauma on behavioral, medical, and social well-being in
adulthood (Anda et al., 2010;
ACEs and Criminal Offenders

A history of child abuse is common among criminal offenders.
Prevalence rates can
vary depending on how child abuse is defined in an interview or
survey, and male
prisoners in particular may underreport child abuse due to
normalized perceptions of
victimizing behavior or fears of appearing vulnerable. Several
studies have reported
higher rates of physical and sexual abuse in inmates compared
with the general popu-
lation (Courtney & Maschi, 2013; Harlow, 1999; Maschi,
Gibson, Zgoba, & Morgen,
2011; Weeks & Widom, 1998). Household dysfunction is also
common among inmates
and often co-occurs with child maltreatment. Prisoners
frequently report witnessing
violence in childhood and many experienced the death of a
family member, parental
separation or abandonment, or parental substance abuse
(Courtney & Maschi, 2013;
Haugebrook, Zgoba, Maschi, Morgen, & Brown, 2010; Maschi
et al., 2011). Harlow
(1999) found that approximately 40% of prisoners reported out-
of-home foster care

placement in childhood and many had an incarcerated family
member. Abused prison-
ers were more likely than nonabused prisoners to be serving a
sentence for a homicide,
violent offense, or sexual crime (Harlow, 1999).
A study of adverse childhood events among more than 700
California inmates
using a scale very similar to the ACE survey revealed that 28%
were emotionally or
physically neglected and 45% were physically or sexually
abused (Messina, Grella,
Burdon, & Prendergast, 2007). Household dysfunction was also
common, with nearly
half reporting domestic violence in their childhood homes, 43%
reporting parental
separation, 37% having an incarcerated family member, 14%
experiencing placement
in foster care, and half stating that a parent abused substances.
Only 13% of the total
sample reported zero adverse events, while approximately 30%
reported four or more.
There were strong correlations between nearly all categories.
Collectively, research
findings reviewed demonstrate that childhood adversity is

associated with adult crimi-
nality, particularly interpersonal violence, and that greater
exposure to adverse events
significantly increases the likelihood of mental health problems
and serious involve-
ment in drugs and crime (Harlow, 1999; Messina et al., 2007).
ACEs and Sexual Offenders
Although it has been commonly hypothesized that most sexual
offenders are former
victims, studies have varied widely in their findings of the
prevalence of early moles-
tation among sexual perpetrators. An early survey found that
63% of incarcerated sex
offenders reported being sexually abused as children or being
pressured into sexual
activity by an adult (Groth, 1979). A subsequent meta-analysis
of empirical studies
containing a total of 1,717 subjects found that 28% of sex
offenders reported a history
of childhood sexual abuse (Hanson & Slater, 1988). This figure
is substantially greater

Levenson et al. 343
than the 16% to 17% rate of sexual victimization of males in the
general population
(CDC, 2013b; Hunter, 1990). Hindman (1988) offered
surprising findings when she
polygraphed 129 sex offenders in treatment about their reported
sexual histories. The
results showed that although 67% of offenders initially reported
being sexually abused
as children, when polygraphed the number dropped to 29%,
suggesting that some men
may fabricate or exaggerate early childhood trauma in an
attempt to rationalize their
behavior or gain sympathy from therapists (Hindman, 1988;
Hindman & Peters, 2001).
Studies using multiple methodologies have found higher
prevalence rates among sex-
ual offenders, and how a researcher asks relevant questions
(e.g., the use of emotion-
ally laden terms such as abuse) can influence results (Simons,
2007).
In a study administering the ACE questionnaire to child

abusers, domestic violence
offenders, sex offenders, and stalkers (n = 151), it was found
that these offenders as a
group had significantly higher rates of ACEs than men in the
general population
(Reavis et al., 2013). Only 9.3% of the sample reported no
adverse events in child-
hood, compared with 38% of the male sample in the ACE study.
As well, 48% reported
four or more adverse experiences, compared with 9% of the men
in the ACE study.
Sex offenders in particular had significantly higher ACE scores
than the general popu-
lation (Reavis et al., 2013). Weeks and Widom (1998) also
found higher rates of mal-
treatments in male sex offenders, with 26% reporting sexual
abuse in childhood, 18%
reporting neglect, and two thirds revealing childhood physical
abuse.
A meta-analysis of 17 studies compared rates of sexual and
other forms of abuse
reported in a combined sample of 1,037 sex offenders and 1,762
non–sex offenders
(Jespersen et al., 2009). The authors also analyzed the

prevalence of different forms of
abuse in 15 studies that compared sex offenders who assaulted
adults (n = 962) with
those with child victims (n = 1,334). Most of the studies
revealed that sexual abuse,
physical abuse, and neglect were common among sex offenders.
Sex offenders were
more than 3 times more likely to have been sexually abused
than non–sex offenders
but not more likely to have been physically abused. Sex
offenders against children
were more likely to have been sexually abused but those who
assaulted adults were
more likely to have experienced physical abuse in childhood.
The neurodevelopmental pathway from childhood adversity to
adult behavior is an
enormously complex biopsychosocial process. Environmental
stressors stimulate the
overproduction of stress-related hormones associated with fight-
or-flight responses,
inhibiting the growth and connection of neurons and
contributing to lasting effects
such as affective dysregulation, deficits in social attachment,
and cognitive problems

(Anda et al., 2010; Anda et al., 2006; Creeden, 2009). These
social, emotional, and
cognitive impairments often result in adoption of high-risk
behaviors as coping strate-
gies to relieve distress, culminating, for many people, in the
development of illnesses,
disabilities, psychosocial problems, and premature mortality at
rates higher than in the
general population (Felitti et al., 1998).
In summary, early childhood maltreatment and family
dysfunction are common in
the general population. Adverse experiences are associated with
poorer health, mental
health, and behavioral outcomes, and cumulative trauma
dramatically increases the
odds of medical and psychosocial problems as well as
addictions (Anda et al., 2006;
Dong et al., 2003; Dong et al., 2004; Dube et al., 2005; Felitti
et al., 1998). Criminal

populations, including sexual offenders, are even more likely
than the general popula-
tion to have a history of early trauma. Reavis et al. (2013)
opined that given the preva-
lence of early maltreatment in the histories of sex offenders, it
is perhaps unsurprising
that offense-specific models of sex offender treatment have
produced mixed results in
terms of effectiveness. They suggested that treatment programs
should more strongly
emphasize the role of early trauma in self-regulation and
attachment. It is important to
understand the frequency and role of these early experiences in
the development of
sexual offending and to use that knowledge to inform treatment
protocols.
Purpose of the Current Study
The purpose of this study was to explore the prevalence of
ACEs in a large sample of
male sexual offenders and to compare findings with rates of the
same experiences for
males in the general population. It was hypothesized that the
sex offenders would have

higher rates of early adverse experiences than males in the
general population. The
study also sought to explore differences in ACE scores between
different types of
sexual offenders and to examine ACE scores in relation to
recidivism risk. By enhanc-
ing our understanding of the frequency and correlates of child
maltreatment and
household dysfunction, we can better devise clinical
interventions that respond to the
needs of sex offender clients.
Method
Participants
A nonrandom sample of participants was surveyed in civil
commitment (28%) and
outpatient (72%) sex offender treatment programs across the
United States. The pro-
grams were recruited through a solicitation on the professional
listserv of the
Association for the Treatment of Sexual Abusers. Therapists
who responded to the
solicitation agreed to become data collection sites, and they in

turn invited their clients
to participate in the survey. Most outpatient programs serve
clients who have been
ordered to attend treatment by the court as part of their
probation requirements follow-
ing a criminal conviction or as part of their Family Court case
plan following a finding
of sexual abuse in a child protective services investigation.
Participating programs
included sex offenders from New Jersey, Illinois, Texas,
Florida, Georgia, Maryland,
Montana, Washington, and Maine. All clients attending
treatment at the outpatient or
inpatient facilities (n = approximately 970) were invited to
participate in the project,
and a total of 709 clients voluntarily agreed to participate.
Thus, the response rate was
approximately 73%.
The sample for the current study consisted of 679 adult male
sex offenders.
Although females participated in the study, they were excluded
from these analyses
and those data will be reported elsewhere. Sample demographics
are described in

Table 1. The majority of participants were White (67%) and
most (71%) were between
Levenson et al. 345
30 and 60 years of age, with 20% younger than age 30 (7% were
18-25) and 9.6%
older than age 60. Approximately 62% of the sample had
completed high school or
general equivalency diploma (GED), and 19.6% identified
themselves as college grad-
uates. About 59% earned less than $30,000 per year in the last
year they earned income.
Nearly half of the sample had never been married, 16% were
currently married, and
34% were divorced or separated.
Table 2 describes participant, offense, and victim
characteristics. Participants had
been arrested for a variety of sexual crimes; two thirds reported
that their index offense
involved sexual contact with a minor, and 9% reported sexual
assault of an adult.

About 9% said they had been arrested for a child pornography
offense, 7% for Internet
solicitation, 3% for exposure of genitals, and less than 1% for
voyeurism. Participants
were asked a series of questions about victim characteristics,
taking into account their
index offending, any prior offending, and any undetected
offending. Most participants
reported that they had offended against female victims, about
one third reported that
they had victimized strangers, and more than half said they
offended against prepubes-
cent children (percentages do not add up to 100% because some
endorsed multiple
Table 1. Sample Demographics.
Demographic categories % (N = 679)
Race
White 67
Minority 32
Age (years)
18-30 20
31-40 21

41-50 30
51-60 20
Older than 60 9
Marital status
Never married 47
Married 16
Divorced/separated 34
Widowed 3
Education
Not high school graduate 18
High school graduate or GED 63
College graduate or higher 19
Income
Less than $20,000 42
$20,000-$29,999 17
$30,000-$49,999 20
$50,000+ 21
Note. GED = general equivalency diploma.
categories). It should be noted that although most sex offenses

involve perpetrators
and victims who are known to each other (Bureau of Justice
Statistics, 1997, 2010),
28% of this sample was civilly committed and was more likely
to have a stranger vic-
tim. When asked whether they had ever had a stranger victim,
62% of the civilly com-
mitted offenders endorsed “yes” compared with 25% of the
outpatients. Most
participants (69%) reported that they had been arrested once for
a sex crime, 19%
twice, and approximately 12% reported three or more sex crime
arrests. Consistent
with statutory language used to determine whether a person
meets criteria for civil
commitment, civilly committed sex offenders had a higher mean
number of sex crime
arrests (2.3, SD = 1.5) than outpatients (1.2, SD = .79). The
median length of time in
treatment was 30 months (mode = 24, M = 50, SD = 53).
Participants were asked to disclose their total number of victims
(including offenses
they had not been arrested for), and they reported a median
number of two victims

(mode = 1, M = 20, SD = 172). One participant reported more
than 3,000 victims and
2 participants reported more than 1,000 victims, whereas 82%
reported 10 victims or
less and 67% reported 3 or less. Because outliers can skew
measures of central ten-
dency, the 5% trimmed mean number of victims was calculated
(excluding the 5%
highest and lowest values), and was found to be six. It should
be noted that noncontact
Table 2. Offender, Offense, and Victim Characteristics.
Valid n M/%
Female victim 681 77%
Male victim 676 28%
Family victim 677 40%
Unrelated victim 677 48%
Stranger victim 681 35%
Victim younger than 12 years 683 52%
Teen victim 675 56%
Adult victim 673 29%
Total sex crime arrests 684 1.58
Total victims 636 20.32a

Ever used force 682 23%
Ever used weapon 689 9%
Ever caused injury 687 9%
Total non–sex arrests 685 1.50
Months in Tx 645 50.09
On probation 666 61%
Months on probation 400 45.21
Lifetime months in prison 670 85.25
Lifetime months on probation 637 47.31
Note. Percentages may not add up to 100% because some
categories were not mutually exclusive.
aThe average number of victims was skewed due to a few high-
value outliers. Median number of
victims = 2 and mode = 1;Tx=Treatment.
Levenson et al. 347
offenders such as exhibitionists were included in the sample,
perhaps accounting for
some of the outlying cases. Exhibitionism is known to be highly
compulsive and repet-

itive and some men have engaged in the behavior thousands of
times (McGrath, 1991;
Morin & Levenson, 2008).
Instrumentation
A survey was developed by the principal investigator for the
purpose of collecting data
on the prevalence of early trauma. The first section of the
survey consisted of the ACE
scale (CDC, 2013b), a 10-item dichotomous (yes/no) scale in
which participants
endorse certain experiences prior to 18 years of age: abuse
(emotional, physical, and
sexual), neglect (emotional and physical), and household
dysfunction (domestic vio-
lence, unmarried parents, and the presence of a substance-
abusing, mentally ill, or
incarcerated member of the household). One’s ACE score
reflects the total number of
adverse experiences endorsed by that individual. The ACE
categories were developed
using items adapted from earlier studies: the Conflict Tactics
Scale (Straus, Gelles, &
Smith, 1990), the Child Trauma Questionnaire (Bernstein et al.,

1994), and questions
from a survey about sexual abuse (Wyatt, 1985).
The second section of the survey asked questions about offense
history using
forced-choice categorical responses to ensure anonymity.
Questions about the nature
of the sex offenses committed were asked, such as victim age,
gender, and relation-
ship, as well as the number of prior arrests. No information that
could potentially
identify offenders or victims was sought.
Data Collection
Federal guidelines for human subject protection were followed
and the project was
approved by an Institutional Review Board. Clients were invited
to complete the anon-
ymous survey during regularly scheduled group therapy sessions
at participating data
collection sites. Clients were instructed not to write their names
on the survey, and to
place the completed survey in a sealed box with a slot opening.
Informed consent was

provided in writing and explained verbally, however, to protect
anonymity, partici-
pants were not required to sign a consent document. Completion
of the survey was
considered to imply informed consent to participate in the
project.
Analyses
Descriptive statistics are reported for each of the survey items.
Binomial analyses, t
tests, and odds ratios (OR) were used to examine differences
between groups, and
bivariate correlations were used to examine relationships
between variables.
Results
Figure 1 depicts the proportion of participants endorsing “yes”
to each ACE item.
Child maltreatment and household dysfunction were common,
with more than half

of the participants endorsing verbal abuse and parental
separation or divorce (53%
and 54%, respectively), nearly half reporting household
substance abuse (47%),
and greater than one third of participants endorsing childhood
physical abuse
(42%), sexual abuse (38%), and emotional neglect (38%).
Figure 2 shows the dis-
tribution of ACE scores. Slightly less than 16% said that they
experienced no ACEs
and nearly half endorsed four or more. The mean ACE score
was 3.5 (median = 3,
SD = 2.74).
Table 3 shows each ACE item exactly how it was presented to
participants, as well
as the proportion endorsing each item compared with the
prevalence in the original
CDC male sample. In each category, the sex offenders reported
higher prevalence rates
than the general male population, and binomial tests revealed
that all differences were
statistically significant (p < .001).

ORs are used to compare the relative odds of the occurrence of
an event (e.g., child-
hood sexual abuse) in one group with the odds of occurrence of
the same event in
another group (Szumilas, 2010). ORs in the current analysis
were calculated as
described in the following cogent example:
. . . If 25 out of 100 sex offenders have a history of sexual
abuse, their odds of having a
sexual abuse history are 25/75, or 0.33; if 10 of 100 of non-sex
offenders have a similar
history, their odds are 10/90, or 0.11. The OR for this
comparison is thus 0.33/0.11, or 3.0.
An odds ratio of 1.0 represents the absence of a group
difference whereas an odds ratio
0%
10%
20%
30%

40%
50%
60% 53%
42%
38% 38%
16%
54%
24%
47%
26%
23%
Figure 1. Percentage of male sex offenders endorsing ACE
items (N = 679).
Note. ACE = Adverse Childhood Experience; DV = domestic
violence.

Levenson et al. 349
greater than 1.0 means a greater prevalence of abuse in the first
group; an odds ratio
smaller than 1.0 means a lower prevalence of abuse in the first
group. (Jespersen et al.,
2009, p. 182)
In the current analysis, results revealed that sex offenders were
more likely to expe-
rience all ACE items compared with males in the general
population (see Table 3).
As shown in Table 4, correlations between ACE items were all
positive and signifi-
cant, suggesting that child maltreatment occured in household
environments in which
a variety of dysfunctions were often present. The correlation
between verbal abuse and
physical abuse, r = .67, corresponded to a large effect size
(Cohen, 1988). Correlations
demonstrating a medium effect size included domestic violence

and physical child
abuse, r = .41, emotional neglect and verbal abuse, r = .41, and
emotional neglect and
physical abuse, r = .42.
Higher ACE scores were significantly correlated with lower
educational attain-
ment, r = −.26; p < .01, lower income, r = −.25; p < .01, and
more arrests for nonsexual
offenses, r = .29; p < .01. ACE scores had no significant
correlation with the number
of sex crime arrests or the number of total victims. Those with
victims younger than
12 years of age had significantly higher mean ACE scores than
those with older vic-
tims, 4.2 versus 2.9; t = −6.133, p < .001. Higher mean ACE
scores were also found in
the groups of sex offenders who said that they had used force or
violence in the com-
mission of a sex offense, 4.9 versus 3.2; t = −7.043, p < .001,
used a weapon in a sex
crime, 5.3 versus 3.4; t = −4.863, p < .001, or who injured a
victim in a sex crime, 5.4
versus 3.4; t = −5.435, p < .001. Higher mean ACE scores were
found for sex offenders

with contact sex offenses versus noncontact sex offenses, 3.4
versus 2.2; t = 4.069,
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%

0 1 2 3 4+
15.6%
13.7% 12.8% 12.3%
45.7%
Figure 2. Distribution of ACE scores (N = 679).
Note. ACE = Adverse Childhood Experience.
p < .01. No significant differences were found in ACE scores
between those with only
adult victims versus those with at least one minor victim, or for
those with only extra-
familial victims versus those with at least one family victim.
Table 3. ACE Item Comparisons Between Sex Offenders and
Males in CDC Sample.
ACE questions: While you were growing up, in your
first 18 years of life . . .

Sex
offenders
Male CDC
sample
Odds
ratio (N = 679) (n = 7,970)
1. Did a parent or other adult in the household often
or very often swear at you, insult you, put you
down, or humiliate you? Or, act in any way that
made you afraid that you might be physically hurt?
53.3%*** 7.6% 13.88
2. Did a parent or other adult in the household often
or very often push, grab, slap, or throw something
at you? Or, ever hit you so hard that you had marks
or were injured?
42.2%*** 29.9% 1.71
3. Did an adult or person at least 5 years older than

you ever touch or fondle you or have you touch his
or her body in a sexual way? Or, attempt or actually
have oral, anal, or vaginal intercourse with you?
38%*** 16% 3.22
4. Did you often or very often feel that no one in your
family loved you or thought you were important or
special? Or, your family did not look out for each
other, feel close to each other, or support each
other?
37.6%*** 12.4% 4.26
5. Did you often or very often feel that you did not
have enough to eat, had to wear dirty clothes, and
had no one to protect you? Or, your parents were
too drunk or high to take care of you or take you
to the doctor if you needed it?
15.9%*** 10.7% 1.58
6. Were your parents ever separated or divorced? 54.3%***
21.8% 4.26
7. Was your mother or stepmother often or very

often pushed, grabbed, slapped, or had something
thrown at her? Or, sometimes often or very often
kicked, bitten, hit with a fist, or hit with something
hard? Or, ever repeatedly hit at least a few minutes
or threatened with a gun or knife?
24%*** 11.5% 2.43
8. Did you live with anyone who was a problem
drinker or alcoholic or who used street drugs?
46.7%*** 23.8% 2.81
9. Was a household member depressed or mentally ill,
or did a household member attempt suicide?
25.9%*** 14.8% 2.01
10. Did a household member go to prison? 22.6%*** 4.1% 6.83
Note. ACE = Adverse Childhood Experience; CDC = Centers
for Disease Control and Prevention.
***Frequencies endorsed by the sex offenders were compared
with those observed in the CDC male

sample using binomial nonparametric tests and all showed
significant differences between groups
(p < .001). SPSS does not produce coefficients for one-sample
binomial tests.
Levenson et al. 351
Finally, a simulated risk score was devised for each offender by
tabulating the num-
ber of risk factors known to be associated with sexual
recidivism and found in the
Static-99R, the most well-researched and commonly used risk
assessment instrument
in North America (Hanson & Morton-Bourgon, 2005; Hanson &
Thornton, 1999,
2000; Helmus, Thornton, Hanson, & Babchishin, 2012). Age
was coded by the follow-
ing categories: 18 to 25 = 1, 26 to 40 = 0, > 40 = −1 (due to the
way data were col-
lected, categorical breakdowns were similar but did not
precisely correspond to those
in the Static-99R; Helmus et al., 2012). The remaining risk
factors were coded as 1 =

yes and 0 = no: unmarried (never married), …
International Journal of
Offender Therapy and
Comparative Criminology
2016, Vol. 60(4) 371 –396
© The Author(s) 2014
Reprints and permissions:
DOI: 10.1177/0306624X14553227
ijo.sagepub.com
Article
“They Treat Us Like Human
Beings”—Experiencing a
Therapeutic Sex Offenders
Prison: Impact on Prisoners
and Staff and Implications for

Treatment
Nicholas Blagden1, Belinda Winder1,
and Charlie Hames1
Abstract
Research evidence demonstrates that sex offender treatment
programmes (SOTPs)
can reduce the number of sex offenders who are reconvicted.
However, there
has been much less empirical research exploring the experiences
and perspectives
of the prison environment within which treatment takes place.
This is important,
particularly for sexual offenders, as they often face multiple
stigmas in prison. This
study used a mixed-methods approach to explore the
experiences of prisoners and
staff at a therapeutically orientated sexual offenders’ prison to
understand whether
the prison environment was conducive to rehabilitation. The
quantitative strand of
the research sampled prisoners (n = 112) and staff (n = 48) from
a therapeutically
orientated sex offenders prison. This strand highlighted that

both prisoners and staff
had positive attitudes toward offenders and high beliefs that
offenders could change.
Importantly, the climate was rated positively and, in particular,
participants had very
high ratings of “experienced safety.” The qualitative strand of
the research consisted
of semistructured interviews with prisoners (n = 15) and a range
of prison staff (n =
16). The qualitative analysis revealed positive prisoner views
toward staff relationships,
with most participants articulating that the prison and its staff
had contributed to
positive change in prisoners. Crucially, the environment was
perceived as safe and
allowed prisoners “headspace” to work through problems and
contemplate change.
1Nottingham Trent University, UK
Nicholas Blagden, Sexual Offences Crime and Misconduct Unit,
Division of Psychology, Nottingham
Trent University, Chaucer Building, Burton Street, Nottingham
NG1 4BU, UK.

553227 IJOXXX10.1177/0306624X14553227International
Journal of Offender Therapy and Comparative
CriminologyBlagden et al.
research-article2014
mailto:[email protected]
X14553227&domain=pdf&date_stamp=2014-10-09
372 International Journal of Offender Therapy and Comparative
Criminology 60(4)
This research offers some support to the notion that context is
important for sex
offender rehabilitation.
Keywords
sex offender rehabilitation, rehabilitative climate, therapeutic
climate, mixed methods
Introduction
Research has demonstrated that sex offender treatment

programmes (SOTPs) can
reduce the number of sex offenders who are reconvicted
(Hanson et al., 2002; Losel &
Schmucker, 2005). Specifically, programmes that take a risk–
need–responsivity
approach have been found to be the most successful (Hanson,
Morton, Helmus, &
Hodgson, 2009). However, although there is now an established
body of knowledge
regarding sex offender treatment effectiveness, there has yet to
be any significant
attention paid to the environment/context in which treatment
takes place (Ware, Frost,
& Hoy, 2010). Research on the broader environment is limited,
primarily focusing on
“within treatment” climate (see Beech & Hamilton-Giachritsis,
2005; Beech & Scott
Fordham, 1997). For example, findings from Beech and
Hamilton-Giachritsis (2005)
affirmed that a therapeutic climate was related to treatment
outcome, with therapists’
attitudes and goals having an impact on treatment effectiveness.
However, there has been no systematic empirical research
exploring the climate of

the prison where such treatment takes place. Indeed, Woessner
and Schwedler (2014)
asserted that “few researchers have ventured to question
whether therapeutic prisons
actually provide a therapeutic climate” (p. 4). This is surprising,
given the amount of
research that has found that social and therapeutic climate
influences a variety of clini-
cal and organisational outcomes related to staff and patients in
forensic mental health
services (Tonkin et al., 2012; Willets, Mooney, & Blagden,
2014). It is also potentially
important as the broader prison environment could either
facilitate or interfere with
treatment intervention. This is particularly relevant for sexual
offenders as they face
multiple stigmas in prison, occupy the lower rungs of the prison
hierarchy, and experi-
ence hostility and anxiety on a daily basis (Schwaebe, 2005).
For these reasons,
Schwaebe (2005) stressed the need to understand the context of
sexual offenders in
prison and the context of their treatment to understand the
limits of treatment gain in
prison-based programmes. This broader environment is typically

overlooked, despite
research finding that status in prison is a factor in sex offender
treatment refusal
(Mann, Webster, Wakeling, & Keylock, 2013). A prison’s social
environment has been
found to be important for shaping behaviour and is central to
the extent to which treat-
ment gains are sustained and generalised (Ward, Day, Howells,
& Birgden, 2004). If
sexual offenders find themselves in prisons that are
characterised by suspicion, hostil-
ity, and guardedness, this will impair treatment outcome and
may make prisoners less
likely to volunteer for programmes (Ward et al., 2004).
Antitherapeutic prison envi-
ronments have been found to negatively affect on treatment
readiness and programme
outcome (Schalast, Redies, Collins, Stacey, & Howells, 2008;
Ward et al., 2004).
Blagden et al. 373
Thus, the prison climate, whether therapeutic (or not), and the

attitudes of staff (thera-
pists, prison officers, and general staff) within the prison could
play a pivotal role in
the successful treatment and rehabilitation of offenders.
In many jurisdictions, sexual offenders are often isolated for
their own protection
due to the dangers they face. In England and Wales, this often
means segregation onto
“vulnerable prisoner units” (VPUs) or transfer to prisons that
deal predominantly with
sex offenders. However, even in specialised units, sex offenders
still experience threats
and fear from other prisoners and, at times, staff (see, for
example, O’Donnell &
Edgar, 1998). There is a clear international gap in the literature
regarding sex offend-
ers’ experiences of prison climate/environment. This is
important as there are growing
concerns that rehabilitative programmes and practice are being
compromised by inef-
fective correctional environments, staff drift, organisational
resistance, degree to
which therapeutic integrity is maintained, and the quality of
programme implementa-

tion (Day, Casey, Vess, & Huisy, 2012; Smith, Cullen, &
Latessa, 2009).
Evidence from the therapeutic community (TC) literature
highlights the importance
of context and environment for offender rehabilitation. Jensen
and Kane (2012) found
that completing a TC had a significant effect on reducing the
likelihood of rearrest for
prisoners. Marshall (1997) conducted a large-scale evaluation of
the effectiveness of
TCs for sexual offenders. In his 4-year follow-up, he found that
18% of treated offend-
ers (with two or more previous convictions for sexual offences)
were reconvicted
compared with 43% of untreated sexual offenders. Such
environments have been
found to also bolster treatment goals and targets and contribute
to prosocial modelling.
TCs have been found to have a positive effect on self-identity
and enable prisoners to
construct positive identities (Miller, Sees, & Brown, 2006); they
improve quality of
life for prisoners within the institution (Shefer, 2010), effect
personality change, and

prisoners are less likely to receive an adjudication within the
prison (Newton, 1998).
This has led some to argue that TCs, or at least environments
that have an explicit
therapeutic focus, are the ideal environments for “doing” sexual
offender treatment
(Ackerman, 2010; Ware, Frost, & Hoy, 2010).
Prison Climate and Potential Correlates of a Prison Climate
The definition of prison climate is, at times, ambiguous with
some using terms like
“culture” and “climate” interchangeably (Day et al., 2012). A
good prison social cli-
mate can be characterised as being supportive, offering a safe
environment and oppor-
tunities for personal growth and development (van der Helm,
Stamms, & van der
Laan, 2011). Schalast et al. (2008) proposed that a social and
therapeutic climate is the
extent to which the climate is perceived as supportive of
therapy and therapeutic
change. This incorporates whether mutual support is typically
seen as characteristic of
the prison environment and the level of tension, perceived

threat of fear, aggression,
and violence within the prison. We contend that a rehabilitative
climate of a prison can
be understood as the prison’s social climate coupled with the
prison’s culture, philoso-
phy, and fitness for purpose in relation to reducing reoffending.
These critical aspects
of a prison are likely to have a direct impact on the
effectiveness of rehabilitative
Criminology 60(4)
measures, behaviour, and personal change and consequently the
effectiveness of the
prison in reducing reoffending.
The climate of a prison is related to aspects of prison life. A
key component for any
prison climate would appear to be prisoner–staff relationships.
For example, it has
been argued that positive attitudes and beliefs about change in
prison staff and prison-

ers are vital for fostering effective offender rehabilitation and
promoting change in
offending behaviour (see, for example, Hogue, 1993; Kjelsberg
& Loos, 2008; Lea,
Auburn, & Kibblewhite, 1999). This has been found to be
important for sex offenders
as positive attitudes by prison staff toward sex offenders have
been found to facilitate
and motivate offenders onto treatment (Kjelsberg & Loos, 2008;
Lea et al., 1999). In
Lea et al.’s (1999) study, they reported that professional
attitudes were, at times, in
conflict. The conflict stemmed from prison officers feeling
pressured to form a bond
with sex offenders as part of their professional duties, whilst
suffering internal conflict
because of personal “disgust” and “disapproval” of the criminal
activities of these
individuals. This incongruence could lead to more punitive
attitudes and behaviours
from prisoner officers, which can have deleterious impacts on
treatment. Indeed, the
general psychotherapeutic literature stresses the importance of
meaningful relation-
ships between therapist and patient and, in offender behaviour

programmes, emphasis
is placed on the responsivity issue of the therapeutic alliance.
The therapeutic alliance
is pivotal for effective treatment with a constructive
relationship characterised by
warmth, empathy, respect, rewarding behaviour, and
genuineness (see, for example,
Ackerman & Hilsenroth, 2003). Serran and Marshall (2010)
found that therapists who
are warm and empathic with men who sexually offend develop a
more effective thera-
peutic relationship; they reported that this relationship could
account for 20% to 30%
of change in this client group. We argue that constructive
relationships are critical, not
just for therapists, but for all prison staff coming into contact
with prisoners.
Given the potential impact climate and context could have on
rehabilitative pro-
grammes, there is surprisingly little research on the experiences
of sexual offenders in
prison and how they perceive their environment despite this
group making a signifi-
cant proportion of the prison population (Ievins, 2013). The aim

of this research is on
exploring and investigating the therapeutic and rehabilitative
climate of a therapeuti-
cally focused all-male sexual offenders prison from staff and
prisoner perspectives.
The research takes a case study approach, which is most useful
when research wants
to explore the richness of a phenomenon and the extensive
context of that phenome-
non (Yin, 2009). Indeed, deep exploration of even a single case
can be more informa-
tive than knowing a little about 200 or 2,000 cases (Maruna &
Matravers, 2007). The
study will use a mixed-method approach; qualitative interviews
will be implemented
to understand staff and prisoner perspectives and experiences of
the prison environ-
ment, whether participants believe that relationships in the
prison are constructive and
whether the environment allows for growth, change, and
rehabilitation. Cochran,
Mears, Bales, and Stewart (2012) emphasised the importance of
prison experiences for
understanding recidivism. The quantitative phase of the
research will investigate the

therapeutic climate of the prison, attitudes of participants
toward sexual offenders,
participants’ beliefs about change, and prisoners’ readiness for
treatment. The main
Blagden et al. 375
purpose of the research is to understand the context of sex
offender treatment at this
prison through investigating key aspects of the rehabilitative
climate at the prison.
This will be achieved by exploring the perspectives and
experiences of the prison
environment from staff and prisoners. The overarching research
question for this study
is as follows:
Research Question 1: Does this therapeutically informed prison
provide a climate
conducive to personal change and rehabilitation?
Attached to this are a number of research objectives.

1. to explore the rehabilitative and therapeutic climate of a
therapeutically orien-
tated sex offenders prison;
2. to investigate the experiences and perspectives of prisoners
and staff on the
purpose of the prison, its regime, climate, and opportunities for
personal
development;
3. to investigate any differences/divergences, both
quantitatively and qualita-
tively, between staff and prisoners’ perceptions of the prison’s
climate, atti-
tudes toward offenders, and offender change; and
4. to explore theoretically important variables of a rehabilitative
prison climate
and explore associations between the different variables.
Method
Setting and Mixed-Methods Design
This study was conducted at one of Europe’s largest sex

offender treatment prisons.
The site was chosen for this exploratory research due to its
focus on rehabilitative
programmes, its specialisation in sex offender treatment, and
because the prison only
accommodates sexual offenders.
A mixed-methods design was implemented to explore the
climate of the prison. A
positive aspect of such an approach is that it offsets the
weakness of both qualitative
and quantitative methods and can provide rich and detailed data
that would not be pos-
sible through either approach alone (Creswell & Clark, 2007).
Specifically, this
research used a convergent mixed-methods design to gain a
more complete under-
standing of the research topic. The purpose of the convergent
design is “to obtain dif-
ferent but complementary data on the same topic” to best
understand the research
problem (Morse, 1991, p. 122). This design is used when the
researcher wants to tri-
angulate the methods by directly comparing and contrasting
quantitative statistical

results with qualitative findings for corroboration and
validation purposes (Creswell &
Clark, 2007). A convergent mixed-methods design is pragmatic
in the sense that it is
orientated toward exploring and solving problems in the “real
world”; such a position
reiterates that epistemologically and ontologically quantitative
and qualitative research
share many commonalities (Feilzer, 2010). The approach is also
best suited for
Criminology 60(4)
exploring underresearched phenomena, as is the case in this
research. The research
decided against using sequential mixed-methods designs, that is,
qualitative or quanti-
tative phase followed by a quantitative or qualitative phase as
the purpose was not to
test or build on a previous research study. This research also did
not want to privilege
a particular methodological approach and instead wanted to

converge quantitative and
qualitative data to gain well-substantiated and cross-validated
conclusions about the
prison’s climate (Creswell & Clark, 2007). The convergent
design is also efficient and
well suited to research that may be time limited/pressured due
to funding requirements
(as was the case in this research) or other such restrictions
(Creswell & Clark, 2007).
This research was implemented using two research strands,
which were conducted
simultaneously, as is common using the convergent approach.
The two phases are
detailed over the coming sections.
Qualitative Strand
Participants, Recruitment, and Sampling
In the qualitative strand, there was a total of 31 interviews
including prisoner (n = 15
containing untreated n = 6 and treated n = 9 sex offenders) and
staff (n = 16) inter-
views. It should be noted that a final sample of n = 31 is

considered large in qualitative
research (Willig, 2008). Prison staff participants were recruited
through email, research
posters, and presentations within staff briefings and participants
were given contact
details of the lead author if they were interested in taking part.1
The final sample
included senior management (n = 3), psychologist (n = 3),
prison officer (n = 5), group
therapist/trainee psychologist (n = 4), and prison librarian (n =
1). The final sample
purposefully selected participants from varied job positions to
capture the range and
diversity of staff experience at the prison. Similarly, prisoners
were recruited through
posters and contact details left on all wings of the prison and
snowball sampling.
Participant information for prisoners is detailed in Table 1.
Semistructured interviews were conducted in the purpose-built
interview rooms at
the prison following ethical clearance. The interviews focused
on the following areas
and were broadly similar for both staff and prisoners.

•• Purpose of the prison, experience of prison life, relationships
in the prison, and
the regime;
•• Rehabilitative ideals/orientation of the prison; and
•• Opportunities for personal development and access to
constructive outlets for
prisoners.
As this research used in-depth interviews, steps were taken to
minimise researcher
bias. First, questions were open-ended and designed to be
nondirective, allowing par-
ticipants to describe their experience in their own words without
the views of the
researcher imposed on them. In addition, participants’ own
words are used to describe
the phenomena of this investigation (Phillips & Lindsay, 2011).
To try and minimise
Blagden et al. 377

selection bias, the research actively recruited a mix of offenders
and prison staff and
attempted to reach as many prisoners and staff within the prison
as possible.
Qualitative Data Analysis
Data were analysed using thematic analysis, which is a method
for identifying, analyz-
ing, and reporting patterns and themes within the data. It aims
to capture rich detail
and interpret the range and diversity of experience within the
data (Braun & Clarke,
2006). It differs from other qualitative methodological
approaches as it is not tied to an
explicit theoretical assumption or position. The thematic
analysis has been described
as a “contextualist method,” sitting between the two poles of
constructionism and real-
ism. This position thus acknowledges the ways individuals make
meaning of their
experience, and, in turn, the ways the broader social context
impinges on those mean-
ings, thus, the analysis is seen as reflecting “reality” (Braun &
Clarke, 2006). This

epistemological position was seen as important when
triangulating data with the quan-
titative data. The analysis adhered to the principles of
qualitative thematic analysis as
outlined by Miles and Huberman (1994). Data analysis
commenced with detailed
readings of all the transcripts, then initial coding of emergent
themes, through to a
detailed sorting of initial patterns, through to isolating
meaningful patterns, and inter-
preting those patterns (Miles & Huberman, 1994). The data
were organised systemati-
cally and themes were identified and reviewed, with the final
themes being
representative of the participants. A type of interrater reliability
was undertaken, with
the analysis being “audited” (Lincoln & Guba, 1985 by the
coauthors as well as an
independent researcher to ensure the interpretations had
validity.
Table 1. Prisoner Participant Information.
Participant Age Treated/untreated Offence Risk

Prisoner Participant 1 56 Treated Contact—Child High
Prisoner Participant 2 46 Treated Contact—Child Low
Prisoner Participant 3 44 Treated Contact—Adult Low
Prisoner Participant 4 33 Treated Contact—Adult Med
Prisoner Participant 5 47 Untreated Contact—Child Low
Prisoner Participant 6 50 Untreated Contact—Adult Low
Prisoner Participant 7 53 Untreated Noncontact (Internet) Low
Prisoner Participant 9 23 Untreated Contact—Adult High
Prisoner Participant 10 46 Treated Contact—Child Medium
Prisoner Participant 11 55 Treated Contact—Adult High
Prisoner Participant 12 28 Untreated Contact—Adult Medium
Prisoner Participant 14 58 Treated Contact—Child Medium
Prisoner Participant 15 41 Treated Contact—Child Low
Criminology 60(4)
Quantitative Strand
In the quantitative strand of the research, a total of 400
questionnaires were distributed

to prisoners around the different wings of the prison and 112
were returned (28%
response rate). The programme support volunteers (offenders
who have completed an
SOTP) agreed to distribute the questionnaires to prisoner
participants. Questionnaires
were hand delivered to prison staff in all wings of the prison.
Completed question-
naires were anonymously returned to a designated box at the
gate of the prison; this
was decided as the best place to return questionnaires by the
governor of the prison.
The final sample comprised prisoners (n = 112) and prison staff
(n = 48). Prison
staff and prisoners had to have a minimum of 6 months of being
at the prison. The
mean age for prisoners was 48.87 (SD = 14.15, range = 23-80)
and the mean age for
prison staff was 39.77 (SD = 12.02, range = 24-58). All
participants had to have been
at the prison for more than 6 months; the range of years at the
prison was 2 to 18 years.
Table 2 shows a breakdown of prisoner participants by offence
and treatment.

Measures
Essen Climate Evaluation Schema (EssenCES)
This is a measure of social and therapeutic climate in forensic
settings (Schalast et al.,
2008). It consists of 17 items (15 items scored, 2 positively
worded items not scored) and
has been validated in forensic psychiatric and prison settings
(see Day et al., 2012;
Howells et al., 2009; Schalast et al., 2008). Participants indicate
how much they agree
with statements on a 5-point Likert-type scale range from 1 (not
at all) to 5 (very much).
The measure has a reliable three-factor structure, which consists
of the subscales of
Inmates’ Cohesion (e.g., The inmates care for each other),
Experienced Safety (e.g.,
There are some really aggressive inmates in this unit), and Hold
and Support (e.g., Staff
take a personal interest in the progress of inmates). High scores
indicate a positive social
climate. The measure has been found in previous studies to have
moderately strong

internal consistency; Cronbach’s α = .79 to .87 for
patients/prisoners, .73 to .78 for staff,
and .78 to .86 for the total sample (see Day et al., 2012; Tonkin
et al., 2012).
Table 2. Breakdown of Classification of Prisoners by Offence
and Treatment.
Prisoner breakdown %
Adult victim of sexual offence 13.4
Child victim of sexual offence 65.2
Noncontact sexual offender 13.4
Completed sex offender treatment
programme
45.5
Currently undertaking sex offender treatment
programme
11.6
Not participated in sex offender treatment 42.9

Blagden et al. 379
Attitudes Towards Sex Offenders (ATS)
This is a 32-item unidimensional scale (Hogue, 1993) for
assessing attitudes toward
sexual offenders. The scale has been used previously with
community sample, sexual
offenders, young offenders, prison officers, psychologists, and
criminal justice profes-
sionals (Hogue, 1993; Kjelsberg & Loos, 2008). The scale
repeatedly demonstrates
good internal reliability rating, with alphas ranging from .85 to
.95 (see Ferguson &
Ireland, 2006; Nelson, et al., 2002;). Participants indicate how
much they agree with
statements on a 5-point Likert-type scale ranging from 1
(strongly disagree) to 5
(strongly agree). Higher scores on the ATS are indicative of
more positive attitudes
toward sexual offenders.
Individual Theories of Offending Behaviour (Self and Other)

These two measures were designed for this study and are
amended versions of Dweck’s
(2000) domain-specific implicit theories of intelligence and
personality and Gerber
and O’Connell’s (2012) implicit theory of crime and criminality
(self and other). There
were two versions of this scale administered to participants. The
first version was the
“implicit theory of offending behaviour (self),” which was
concerned with prisoners’
beliefs in whether they could change their offending behaviour
and was administered
to prisoners only. The scale is a six-item measure and consists
of items such as “My
offending behaviour is a part of me that I can’t change very
much.” Participants indi-
cated how much they agreed with statements on a 6-point
Likert-type scale from 1
(strongly agree) to 6 (strongly disagree). The internal
consistency of the six items
comprising the measure was computed using Cronbach’s alpha.
The results showed
the measure had good internal consistency (Cronbach’s α =
.893).

The second version of the scale was essentially the same but
amended to the “other”
version so that prisoners and staff could rate the changeability
of offending behaviour
in prisoners generally. This six-item measure consisted of
statements such as “Anybody
can change their offending behaviour.” The internal consistency
of the six items com-
prising the measure was computed using Cronbach’s alpha. The
results showed the
measure had good internal consistency (Cronbach’s α = .858).
Corrections Victoria Treatment Readiness Scale (CVTRS)
This is a 20-item measure designed to assess readiness for
treatment in offenders and
consists of four subscales (Attitudes and Motivation, Emotional
Reactions, Offending
Beliefs, and Efficacy; see Casey, Day, Howells, & Ward, 2007).
Participants indicate
how much they agree with statements on a 5-point Likert-type
scale ranging from 1
(strongly disagree) to 5 (strongly agree). The measure and
subscales have been found

to yield acceptable to good levels of internal reliability ranging
from α = .84 for the
Attitudes and Motivation subscale, α = .79 for the Emotional
Reactions subscale, α =
.73 for the Offending Beliefs subscale, to α = .60 for the
Efficacy subscale (Casey
et al., 2007). The measure has been used previously for
assessing treatment readiness
Criminology 60(4)
in violent and sexual offenders and has also been found to be
positively correlated with
therapeutic engagement (Day et al., 2012).
Results
Qualitative Results
The prisoner and staff interviews were analysed together and
revealed themes associ-
ated with the climate of the prison, experience of the prison,

and relationships between
staff and prisoners.2 Table 3 presents the themes derived from
the qualitative analysis.
The superordinate themes will be discussed below.
Superordinate Theme 1: Purpose and direction. There was
consensus from all partici-
pants, both staff and prisoner, as to the purpose of this prison.
Every participant
believed that the prison was about “rehabilitation” and reducing
reoffending, given the
focus on treatment programmes in the prison. Indeed, the focus
on programmes gave
the prison a clear identity with the prison regime orientated
around that focus. Prisoner
participants articulated that this was a prison you came to
rehabilitate yourself and to
change your way of thinking.
Extract 1: Prisoner Participant 11
It’s about rehabilitation and changing your beliefs erm changing
and looking at your
offending behaviour so when you get out you don’t repeat your
mistakes. Programmes

has taught me a hell of a lot about myself. These were life skills
that I had ignored and
erm I’ve changed now . . .
Extract 2: Prison Staff Participant 16
I feel clear about what our objective is or what our objectives
are and that …
Historical developments in sex offender
treatment
W. L. Marshall1* & Clive Hollin2
1Rockwood Psychological Services, Kingston, ON, Canada &
2Centre for Applied Psychology,
University of Leicester, Leicester, UK
Abstract This paper describes our view of the important
developments in the history of sex offender
treatment with a particular emphasis on aspects of this growth
in the UK. We begin where, in our view,
treatment of sex offenders was first implemented; that is, at the
Institute of Psychiatry in London. After

the move across the Atlantic, we note the beginnings of more
comprehensive programmes in North
America which morphed into the Relapse Prevention model. The
implementation of comprehensive
programmes in Her Majesty’s Prisons led not only to further
refinements but also offered the opportunity
for researchers to explore all manner of possibilities. The more
recent focus on strength-based approaches
is examined, and we then spell out our hopes for the future in
terms of treatment, assessment and theory.
Keywords Sex offender treatment; historical developments;
treatment programs; assessments; Sex
offenders
In the Departments of Psychology and Psychiatry at the
University of London’s Institute of
Psychiatry in the 1950s, the nascent behaviour therapy
movement was beginning to emerge.
Treatments for various disorders, including problematic sexual
behaviours, were being
developed at the institute. Clinicians/researchers like
psychologist Stanley (Jack) Rachman
and psychiatrists Malcolm Gelder, Isaac Marks and John
Bancroft developed treatment

approaches for various types of paraphilic behaviours. These
early approaches, however, were
mostly limited to reducing deviant sexual interests using a
variety of aversive conditioning
procedures (see Laws & Marshall, 2003, for a review of those
early studies). These approaches
were soon exported to North America (e.g., Abel, Levis, &
Clancy, 1970; Bond & Evans,
1967; Marshall, 1971), where they were rapidly expanded into
programmes that incorporated
other targets and other strategies (e.g., Abel, Blanchard, &
Becker, 1978; Marshall &
Williams, 1975). These latter programmes described the first
attempts in North America to
assimilate the emerging cognitive behaviour therapy (CBT)
movement into sex offender
treatment. Subsequently, almost all treatment programmes in
North America have been
described by their authors as CBT with the later addition of
relapse prevention (RP)
components (see Pithers, Marquis, Gibat, & Marlatt, 1983).
Ultimately, CBT/RP approaches
*Corresponding author. E-mail: [email protected]
Like memory, history is a reconstruction and, again like

memory, this reconstruction is always from a personal point
of view. Therefore, we apologise for all those who have made
significant contributions, but who we have omitted to
mention. We have simply tried to identify major threads in the
historical record.
Journal of Sexual Aggression, 2015
Vol. 21, No. 2, 125–135,
http://dx.doi.org/10.1080/13552600.2014.980339
© 2014 National Organisation for the Treatment of Abusers
mailto:[email protected]
http://dx.doi.org/10.1080/13552600.2014.980339
came to dominate North American programmes and influenced
treatment in the UK and
some European countries as well as in Australia and in New
Zealand.
The results of three meta-analytic studies (Hanson, Bourgon,
Helmus, & Hodgson,
2009; Hanson et al., 2002; Lösel & Schmucker, 2005) of
treatment outcome encouraged

optimism that the treatment of sex offenders could produce
reductions in subsequent
reoffending and that CBT appeared to be the most promising
approach. These studies, along
with the development of actuarial risk assessment instruments
(see review by Craig, Browne,
& Beech, 2008), and particularly the identification of
criminogenic factors (see a recent
appraisal by Mann, Hanson, & Thornton, 2010) markedly
advanced the empirical basis of
both assessment and treatment. While the adoption of the
actuarial risk assessment approach
has been widespread, the adaptation of treatment programmes to
incorporate the findings on
criminogenic factors has not been as universal. As surveys of
North American programmes by
the Safer Society (McGrath, Cumming, & Burchard, 2003;
McGrath, Cumming, Burchard,
Zeoli, & Ellerby, 2010) have revealed, many still address
numerous non-criminogenic targets
and at the same time fail to address all criminogenic factors.
Apparently, evidence takes some
time to persuade treatment providers to change what they view
as their tried-and-true
approaches. When Hanson et al. (2009) demonstrated that

Andrews’ (Andrews & Bonta,
2006) Principles of Effective Offender Treatment applied
equally to sex offender treatment, a
basis was provided for the emergence of a rational, empirically
sound treatment approach with
sex offenders. Again, however, the field has been slow to adapt.
The negative emphasis of the RP model seemed to many
treatment providers to fit well
with Salter’s (1988) confrontational approach. In combination,
these two models encouraged
a negative view, not just of the criminal behaviours of sex
offenders, which we all consider to
be repulsive, but of the offenders as human beings, as if they
had no saving graces and as if
they were devoid of any strengths. Therapists following these
models aggressively challenged
clients at the outset and pressured them to agree with every
detail provided in the victim’s
statement and the police reports; not the usual way therapy is
done with other Axis 1 or Axis 2
disorders. Good therapists work initially to establish confidence
in their clients and to develop
a positive and respectful relationship before moving on to more
difficult issues. We might ask

why did so many sex offender treatment providers decide that
years of research in all other
fields of therapy was irrelevant to dealing with sex offenders;
fortunately some did not. For
example, Tony Ward’s (2002) Good Lives Model (GLM) has
spurred at least some treatment
providers to think differently about their clients. What Ward’s
GLM suggested was that the
model advocated by Salter (1988), which had come to dominate
programmes in the USA, was
ill-founded and was more likely than not to reduce the effects of
treatment.
What follows in this paper is our personal view of the important
developments in the sex
offender field. For convenience, we will break this into three
parts: (1) developments in North
America; (2) developments in Britain; and (3) speculations
about the future.
Developments in North America
We will not provide a comprehensive history of sex offender
treatment in North America as
that has already been described in two papers by Laws and

Marshall (Laws & Marshall, 2003;
Marshall & Laws, 2003). We will do our best to summarise the
most important features of this
history.
While there were numerous attempts in the late 1960s and early
1970s in North America
to treat sex offenders, the US psychiatrist, Gene Abel, was the
pioneer in the USA for the
application of CBT to these problematic offenders. After
publications describing early
programmes (Abel et al., 1970; Marshall, 1971, 1973), Abel put
together a series of meetings.
126 W. L. Marshall & C. Hollin
These small conferences were aimed at expanding the scope of
assessments and treatments.
Early treatment descriptions (Abel et al., 1978; Marshall &
Williams, 1975) outlined the first
comprehensive CBT programmes in North America. It was a
long time, however, before any
programmes were evaluated for their long-term benefits. In fact,

the debate about effective-
ness, and how to properly determine effectiveness, continues to
this day (see debates between
Marshall & Marshall, 2007, 2008; and Seto et al., 2008).
Recently, RP has lost some of its appeal as a result of Marquis’
well-designed evaluation
of California’s programme showing no overall effects (Marques,
Weideranders, Day, Nelson
& van Ommeren, 2005). These results led Yates (2007) to call
for the abandonment of RP,
although this appears not to have happened in most
programmes. Yates took the view that RP
should be replaced by either the self-regulation model outlined
by Ward and Hudson (2000)
or Ward’s (2002) GLM, and there is recently emerging evidence
supporting the efficacy of
these two approaches (Bickley & Beech, 2002; Harkins, Flak,
Beech, & Woodhams, 2012;
Kingston, Yates, & Olver, 2013).
While it is always bad science to generalise from one study to
all programmes employing
the same title, there may be good reasons to fault an excessive
adherence to the early RP

model. It is, for example, a decidedly negative approach to
treating people, and there is now
substantial evidence (see Linley & Joseph, 2004; Snyder &
Lopez, 2005 for various reports)
showing that with all human problematic behaviours a more
positive orientation, particularly
one that incorporates features facilitating a therapeutic alliance
and group cohesion (see
Marshall & Burton, 2010; Marshall, Marshall, & Burton, 2013),
is likely to be far more
effective. In any event, there appears to be a move away from
thinking of sex offenders as
simply characterised by a series of deficits. Strength-based
approaches to both assessment
(Craig et al., 2008) and treatment (Marshall, Marshall, Serran,
& O’Brien, 2011) are
emerging and appear to offer a more hopeful agenda.
Developments in the UK
Other than work at the Institution of Psychiatry, much of the
early psychologically informed
treatment of sex offenders in the UK took place in prisons
rather than in the community. The
undoubted reason for this situation was that by far the majority

of psychologists within the
criminal justice system were employed by the Prison Service.
Laycock (1979) noted that at the
time there were 93 psychologists employed in the Prison
Service for England and Wales, with
most being based in penal institutions. Laycock suggested that
most of them were likely to be
involved in the delivery of some type of treatment with
prisoners. While not all of the
treatment was behavioural in orientation, or aimed at sex
offenders, there was a small amount
of treatment specifically targeting sex offenders. Laycock noted
that in the 1970s, the
treatment of sexual deviance was centred at Wormwood Scrubs
and Birmingham Prisons.
Laycock’s description of the Wormwood Scrubs’ treatment
programme indicates that it
was aimed primarily at child molesters and employed traditional
behaviour modification
methods, including aversive conditioning. With a group of 10
sex offenders, the short-term
effects of the intervention were monitored using penile
plethysmography (PPG). Laycock
notes that a follow-up of these 10 men, two years after their

ArticleSex Offender Recidivism Revisited Review ofRecen.docx

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