Title: Theory-based assessment, treatment, and prevention of sexual aggression
Author(s): Gordon C. Nagayama Hall
Affiliation: Kent State University, Ohio
Citation: Hall, G.C.N., Theory-based assessment, treatment, and prevention of sexual aggression, New York: Oxford University Press, 1996.
The author considers adult sexual attraction to and interaction with children to be a form of sexual aggression, similar to rape, and therefore seeks to understand and treat it in the same way. Several theories have been proposed to explain sexual aggression.
Physiological theories propose that sexual aggression results from deviant arousal; that is, sexual arousal to children, clothing, or violence. This seems to be a more prominent motivational factor for child molesters than for rapists. There are several different theories that attempt to account for this deviant arousal. Some criminologists speculate that it has a biological or neurohormonal cause. Others believe it may result from learning: the individual becomes conditioned to deviant arousal through masturbation. Still others have speculated that it has an evolutionary cause; men copulating with as many women as possible may be an optimal reproductive strategy.
These theories have been called into question by some studies finding that many child molesters have arousal patterns similar to those of normal people in that they are more aroused by “consenting” than “non-consenting” stimuli involving children, and they are more aroused by both of these than by non-sexual violence against children. Even aggressive offenders are more aroused by consenting acts than by rape or non-sexual violence.
Cognitive theories suggest that sexual aggression results from abnormal thinking patterns. For example, an individual’s cognitive distortions about the meaning and impact of sexually aggressive behavior may allow him to justify it. He may believe the victim enjoys or benefits from the act, or at least is not harmed by it.
One cognitive theory proposes that dispositional and situational factors contribute to aggression. Dispositional factors may include aggressive personality, cognitive distortions, sexual experiences, or sexual dissatisfaction. Situational factors may include alcohol or family violence.
Another cognitive theory conceptualizes sexual aggression as an addiction. According to this theory, impulsive and compulsive behavior causes intense immediate pleasure at the expense of long-term consequences. Negative affect leads to fantasy, which in turn leads to the individual making plans to carry out the fantasy. Another theory, known as attachment theory, proposes that insecure family attachment, rejection, fear, and unresolved trauma leads to sexual aggression.
Affective models propose that the individual copes with his negative affect by performing aggressive acts. Anger may lead to rape, while depression may lead to child molesting. One such theory is the Massachusetts Treatment Center (MTC) taxonomy which proposes the existence of 12 types of offenders, based on personality profiles.
Another is Finkelhor’s Four-Factor Model which proposes the following factors as precursors to a potential offender carrying out aggression against children: he must have motivation, he must overcome his internal inhibitions, he must overcome external inhibitions (imposed by society), and he must overcome the child’s resistance.
Developmental theories suggest that sexual aggression results from problems during childhood: negative socialization, parental abuse or neglect, inadequate social skills, academic problems, or early sexual experiences. A small number of studies suggest social skills may be low among child molesters. Poor social skills may prevent them from forming relationships with peers during adolescence, which then prevent them from receiving corrective feedback about inappropriate sexual behavior.
Social learning theory proposes that a boy who is sexually abused by a man will learn to abuse boys himself when he reaches adulthood. However, studies have found that most boys who are sexually abused do not grow up to become sexually abusive. Feminist theory proposes that boys are socialized to believe rape is acceptable, and grow up to become rapists and child molesters. Confluence theory suggests that a convergence of multiple risk variables interact with environmental factors to cause sexual aggression.
All of the above theories tend to be mutually exclusive. Proposed causes are assumed to apply to all offenders, but they are often based on studies of only specific groups of offenders. Many of these studies are case studies; none are controlled scientific studies. They are not replicable and do not allow for alternative causes. Thus, no single theory or set of theories is accepted, and causal explanations are becoming increasingly complex. Furthermore, there is a lack of communication among different researchers and clinicians.
The author proposes that each type of theory has validity—each one describes one type of aggressor. Sexual aggressors against children are typically of the physiological type. Violence and aggression are uncommon in their offenses, they have multiple victims, and their victims are often male.
Proposed theories had led to several different methods of treatment.
Behavioral methods have their goal the reduction of deviant arousal. These methods are easy to implement and assess. The most common is aversion therapy, in which the therapist attempts to condition the patient to associate a deviant stimulus (such as a child) with an aversive stimulus (such as electric shock or an aversive fantasy).
Many studies of behavioral methods have reported success, but they have been single case studies or involved very small numbers of offenders (child molesters, exhibitionists, and sadists), and rarely included comparison groups. In addition, follow-up studies to determine if deviant arousal remained suppressed have been absent or carried out no more than one year later. A meta-analysis of three studies that did use comparison groups found behavioral methods ineffective.
A related method intended to reduce deviant arousal, masturbatory satiation, is conceptually appealing, but is not supported by empirical evidence. Thus it appears that behavioral methods are not effective in reducing deviant arousal. Any effects that do occur may be temporary like those that occur with other addictive behaviors, such as drinking.
Drug treatments are used to reduce sex drive. Earlier drugs suppressed all forms of sexual arousal, leaving no option for a sexual outlet with consenting adult partners. Clinical evidence suggests that cyproterone acetate (CPA) suppresses pedophilic arousal but leaves intact arousal to adults. However, no controlled studies have yet been conducted. Thioridazine (Melleril) may have the same effect, but again no controlled studies have been done.
The use of these drugs is voluntary but invasive (they are administered by intramuscular injection), and must continue over a period lasting two to five years.
Cognitive-behavioral therapy is a comprehensive method which targets deviant arousal, cognitive distortions, social skills deficits, and behavior patterns that lead to offending. It uses relapse prevention methods to help the offender cope with temptations to re-offend.
The most useful varieties are those that account for many motivational variables but are simple enough to be widely applicable. Though not necessarily developed from a theory of sexual aggression, they address most of the motivational precursors of sexually aggressive behavior. Cognitive-behavior therapy usually includes the following components:
These methods have not been found effective in themselves, but several studies show them to reduce offending when used in conjunction with other methods. However, it is not known whether they are a necessary component of effective therapy.
Experiencing deviant fantasies and returning to the source of stimuli associated with the offense patterns are considered lapses and are to be consciously interrupted. Offenders are taught to monitor their thoughts, to recognize when they may lead to offending, and to think of them as deviant, controllable, and stoppable. While the goal is self-control, there is the fear that the offender cannot control himself, so the method usually involves control by others such as the family or probation department.
Unlike with other addictions (such as smoking or drinking) where urges are responses to external cues (such as a cigarette or a bar), the key is to recognize urges and lapses as motivated by internal causes (deviant thoughts) which can be controlled by thinking of aversive consequences or using noxious stimuli such as ammonia. This approach seems most appropriate for those who are motivated by deviant sexual arousal. The use of the plethysmograph and aversion therapy is central to this approach.
Scientific evidence for the effectiveness of the relapse prevention approach is limited. One study found that it greatly reduced re-offense rates over a 7 year period, but the study did not take into account the possibility that the effects were due to motivation rather than treatment. One study that did take this factor into account found a small, statistically insignificant reduction in re-offense rates.
The author writes that the treatment method should be simple. Most methods described here have been successfully implemented by psychologists, graduate students, and masters-level therapists. Especially easy are the cognitive-behavioral methods.
A blanket use of the methods on all offenders is similar to treating all psychiatric patients as if they had schizophrenia. Thus, the author recommends that offenders be classified according to the major motivational precursors of their sexual offense into the four types mentioned earlier: physiological, cognitive, affective, and developmental. Then, each group should receive the treatment method most appropriate for it:
|Offender’s motivational type||Treatment|
|Physiological||Castration, sex-drive reducing medications, and aversion therapy|
|Cognitive||Victim empathy training and relapse prevention|
|Affective||Cognitive therapy for depression, drugs, and cognitive-behavioral anger management|
|Developmental||Cognitive therapy, social skills training, behavior therapy, and prevention during adolescence|
Since child molesters tend to be motivated by physiological factors (deviant arousal), the author advocates castration or sex-drive reducing medications and aversion therapy as the most appropriate treatment.