coercion in the DSM. She notes that rape as a symptom of psychiatric illness has a long history dating back to the early 20th century. Rape and sexual assault were included in the first DSM in 1952 under the ‘vague’ diagnosis of ‘sexual deviance’, which included the subcategory of ‘sexual sadism’, which seems to be a ‘catch-all’ for rape and many other sex offences (Tosh, 2011, p 2). Tosh (2011, pp 3–4) raises concerns about the ‘medicalisation’ of rape. Frances and First (2011, pp 558–9) similarly express concerns about the attempts of the US legal system to use the medicalisation of rape as a justification for the extended incarceration of rapists; they note that ‘the act of being a rapist is almost always an aspect of simple criminality, and that rapists need to receive longer prison sentences not psychiatric hospitalizations’.
Medical treatments are available for sex offenders – primarily in the form of anti-libidinal medication – which are usually combined with some form of ‘talking’ therapy. The evidence for the effectiveness of this treatment is inconclusive, although there are concerns about the long-term side effects of medication (Basdekis-Jozsa et al, 2013). However, medical understandings and responses to sex offending highlight a central issue for (medical) practitioners: ‘as long as paraphilias are regarded as a disorder, sexual offenders with paraphilias have to be seen as patients first and not (only) as perpetrators’ (Basdekis-Jozsa et al, 2013, p 314). The majority of medical theorising and treatments are focused on male offenders; there does not appear to be a significant body of literature that addresses biological perspectives directly relating to female offenders.
Understanding sex offenders
This section concerns how responses to sex offenders are shaped within some academic disciplines. Some approaches consider both the offender and the crime/offending. Theological and biomedical perspectives contain an overview of the nature of the offences and a response to the individual offender, which was briefly explored in the previous section. Sociological theory does not propose responses to the individual offender, but locates individual offenders, inextricably, within their social context (Messerschmidt, 1993, 2012). This section is primarily concerned with psychological understandings of individual sex offenders; while the bulk of the literature considers adult male sex offenders, we also consider female and young sex offenders.
Psychologically informed understandings of sex offenders
Approaches to convicted sex offenders are primarily rooted in the discipline of psychology and are accessed through criminal justice systems. An aspect of early psychological theorising was the development of classification systems for both (convicted) rapists (eg Groth et al, 1977) and men who had sexually harmed children (‘child molesters’) (eg Knight et al, 1989). These systems were based on the study of convicted populations; they focused on offending behaviour and apparent motivations. Initial systems were strongly influenced by psychiatric perspectives. In 1998, Fisher and Mair (1998, abstract) undertook a comprehensive review of these systems and noted: ‘none of the existing classification systems reviewed complied with the requirements of being reliable, efficient, pertinent to a large number of offenders, and simple to administer’. Bickley and Beech (2001, p 65) raise similar concerns about these systems, particularly their inability to discriminate suitable treatments for different groups. They suggested that a way forward would be to develop a wider ‘conceptual model’ for understanding the process of offending. However, interest in developing classification systems continues (Marshall et al, 2015); the main objective appears to be greater precision in identifying offender type and effectively targeting appropriate treatment. Recently, Ward and Beech (2015) have suggested that classification systems need to be much more rigorous in accounting for their intellectual foundations. They suggest using ‘exemplars’ as a way to avoid conflating description (of offenders) and explanation (the development of theory in relation to offending).
Critically examining professional knowledge is of central importance to developing robust theory. Beech and Ward (2004) suggest that risk assessment be rooted in a clear aetiological theory of offending. Aetiological theory is important in accounting for the onset and continuance of sexual offending (Ward and Hudson, 1998). Three types of theory are identified (Ward and Hudson, 1998): single-factor theories focus on one issue to account for the aetiology and continuance of sex offending; multi-factorial theories offer a complex account of the aetiology and continuance of sex offending; and micro-level or offence process theories give particular attention to an aspect of offending behaviour. In the mid-20th century, single-factor theories were common and often in conflict with one another (eg feminist theory and evolutionary perspectives).
A key aspect of multi-factorial theories is that they have been developed from analyses of empirical studies of sex offenders, their personal histories and their offence patterns. Multi-factorial explanations incorporate physiological, psychological and emotional dimensions relating to the offender, along with situational and historical (fixed) matters. Apart from these issues, the models are also mindful of time and change; thus, change in physiological, psychological and emotional states is important. Key contributions to this area of theory include: the confluence model of sexual aggression (Malamuth et al, 1996); integrated theory (Marshall and Barbaree, 1990); the quadripartite model of sexual aggression (Hall and Hirschman, 1991); the four preconditions model (Finkelhor, 1984); the pathways model (Ward and Siegert, 2002); the integrated theory of sexual offending (Ward and Beech, 2006), and a ‘new integrated theory’ of ‘child sexual abuse’ (Smallbone et al, 2008). Summarising the content of (multi-factorial) theories, Hanson and Morton-Bourgon (2005, pp 1154–5) comment:
Contemporary theories posit … that, apart from sexual deviancy and lifestyle instability, there may be three additional characteristics of persistent sexual offenders: (a) negative family background, (b) problems forming affectionate bonds with friends and lovers, and (c) attitudes tolerant of sexual assault.
However, while Hanson and Morton-Bourgon (2005) acknowledge the value of multi-factorial explanations of sex offending, they note that the evidence behind the identification of the factors and how they interrelate with reoffending is weak. They suggest that if the primary therapeutic objective of correctional work with sex offenders is to reduce recidivism (reconviction), then detailed attention must focus on what, statistically, can be shown to be directly related to reoffending. A statistical means of analysing large amounts of quantitative data from many studies is meta-analysis, and it is by using meta-analysis that issues directly related to sex offending have been identified. Table 2.2 outlines the key features of meta-analysis.
Table 2.2: What is meta-analysis?
Although meta-analysis is an efficient and effective way of collating and analysing large amounts of data, and it is clearly very influential, the analysis is susceptible to bias. A good meta-analysis carefully outlines the detail of the data included and excluded, and highlights the limitations of the study.
Karl Hanson and colleagues (eg Hanson and Bussiere, 1998; Harris and Hanson, 2004; Hanson and Morton-Bourgon, 2005) conducted a series of meta-analyses relating to sex offender recidivism. The early study (Hanson and Bussiere, 1998) was of major significance in highlighting the low recidivism rate of sex offenders. Moreover, meta-analyses raise questions about some elements common in treatment programmes that appeared to be unrelated to reoffending (the index offence, the nature of that offence, the denial of responsibility and the motivation for treatment). Hanson and Morton-Bourgon (2005, p 1154) suggest that the key factors linked to recidivism are ‘deviant sexual preferences and anti-social orientation’, while many well-established treatment targets – such as ‘psychological distress, denial of sex crime, victim empathy, stated motivation for treatment’ – ‘had little or no relationship with sexual or violent recidivism’.
The importance of developing a subtle (multi-factorial) understanding of sex offenders is not only to develop treatment programmes, but also
