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The National Victim Center and Crime Victims Research and Treatment Center reported in 1992 that 13 percent of all adult American women have been raped at some time in their lives. The NVC/CVRTC Report estimated that there were 683,000 forcible rapes during 1992, which translates to about 1,871 rapes per day. The American Psychological Association’s Task Force on Male Violence Against Women concluded that between 14 and 25 percent of adult women have experienced rape (Goodman et al.). Although numerous methodological problems clearly preclude any definitive conclusions, a diverse cross-section of studies spanning several decades suggest that approximately 25 percent of adult women have experienced some form of sexual victimization and somewhere between 10 and 15 percent of women have been raped.
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Classification of Rapists
Sexual aggression derives from a complex amalgam of factors and typically reflects a chronic pattern of maladaptive behaviors. Those factors considered to be most importantly related to rape were reviewed by Prentky and Knight. These factors include: (a) impaired heterosexual relationships with peers; (b) relative lack of empathy; (c) poorly controlled and improperly expressed anger; (d) cognitive distortions, particularly around women and sexuality; (e) sexual fantasy that includes thoughts and images of coercion, force, and deviant or paraphilic acts; and (f) a highly impulsive lifestyle that often includes antisocial elements. Although all of these factors may be present in varying degrees, typically several of the factors predominate in a particular offender. When factors are sufficiently robust to differentiate among rapists, they may serve as the basis for classification.
To the best of the present author’s knowledge, the only validated classification model for rapists is MTC:R3 (Knight and Prentky). The principal dimensions that are used for classifying rapists in MTC:R3 are (a) Expressive Aggression (nature, amount, and quality of expressed aggression in all known instances of sexually aggressive behavior); (b) Pervasive Anger (the presence of global, undifferentiated anger in the life of the offender, as reflected by a history of nonsexual assaults, fighting, and verbal aggression directed at men as well as women); (c) Juvenile and Adult Unsocialized Behavior (conductdisordered, delinquent, and impulsive antisocial behavior); (d) Social Competence (as reflected by stability and quality of interpersonal relationships with peers, and stability and level of vocational achievement); (e) Sexualization (as evidenced by high sexual drive, sexual preoccupation, strong and frequent sexual urges, evidence of compulsivity in sexual assaults, evidence of paraphilias); (f) Sadism (evidence that pain, fear, or discomfort increases sexual arousal, preoccupation with sadistic fantasies, ritualization of violence, symbolic expressions of sadistic fantasy); and (g) Offense Planning. In addition to discriminating among rapists, these major dimensions reflect temporally stable behavioral domains that are targeted by most treatment programs.
These seven major MTC:R3 dimensions are used to classify an offender into one of nine subtypes: Type 1 (Opportunistic, High Social Competence), Type 2 (Opportunistic, Low Social Competence), Type 3 (Pervasive Anger), Type 4 (Overt Sadism), Type 5 (Muted Sadism), Type 6 (Sexualized, High Social Competence), Type 7 (Sexualized, Low Social Competence), Type 8 (Vindictive, Low Social Competence), and Type 9 (Vindictive, High Social Competence). The sexual offenses of the two Opportunistic subtypes are impulsive, unplanned, predatory crimes, controlled more by situational factors and immediately antecedent events than by any longstanding, recurrent rape fantasy. The sexual assaults of the Pervasive Anger type are driven by undifferentiated anger. These offenders are, in effect, ‘‘angry at the world.’’ They are as likely to assault men as women. Their anger is not sexualized, and there is no evidence of protracted rape fantasy. The two Sadistic subtypes evidence poor differentiation between sexual and aggressive drives, and long-standing, frequent occurrence of sexually aggressive and violent fantasies. The two Nonsadistic, Sexual types evidence frequent sexual and sexually coercive fantasy that is devoid of the synergistic connection between sex and aggression that characterizes the Sadistic types. The fantasies and offense-related behaviors of these Nonsadistic, Sexual types are hypothesized to reflect an amalgam of sexual preoccupation, distorted attitudes about women and sexuality, and feelings of inadequacy. The Vindictive types harbor focal anger at women. Their attitudes and their behavior reflect this exclusive misogynistic focus. The sexual assaults of these rapists are marked by statements and behaviors that are intended to defile, demean, and humiliate the victims, as well as to physically injure. The MTC:R3 system represents the third version of ongoing programmatic research in this area. MTC:R3 is not a final ‘‘product,’’ and will be revised in accordance with the results of current taxonomic research.
Serial rape is a ‘‘special’’ case that is defined in terms of repetitiveness (e.g., three or more known sexual assaults on adult women). There is no single classification that captures serial rape. Serial rapists may be any one of a number of different subtypes. A fantasy-based drive model for serial sexual homicide (cf. Prentky and Burgess) may be helpful in trying to understand serial rape. Simply stated, once the restraints inhibiting the acting out of internally generated, recurrent rape fantasies are no longer present, the individual is likely to engage in a series of progressively more accurate ‘‘trial runs’’ in an attempt to ‘‘stage’’ the fantasies as they were imagined. Because the trial runs can never precisely match the fantasy, the offender must restage the fantasy with a new victim. Although the number of serial rapists appears to be low, these offenders account for a very large number of victims. In one study of forty-one serial rapists, the collective sample of offenders was responsible for 837 rapes, over 400 attempted rapes, and over 5,000 ‘‘nuisance’’ sex offenses (Hazelwood, Reboussin, and Warren).
The theoretical model referred to above makes a number of implicit assumptions. First, the individual has created an inner world (i.e., a fantasy life) that is intended to satisfy, often in disguised or symbolic fashion, needs that cannot be satisfied in the real world. The inner worlds of serial rapists are dominated by a maelstrom of sexual and aggressive thoughts and feelings. Second, the mechanisms that drive the fantasies and the factors that permit the enactment and reenactment of the fantasies are at least as important as, if not more important than, understanding the specific content of the fantasies. This is critical, since it is commonly accepted that many nonoffenders have sexually deviant and coercive fantasies. Third, the content of the sexual fantasy derives from explicit, protracted sexually pathological experiences first sustained at a young age. Fourth, the parameters governing fantasy life in nonoffenders are different from the equivalent parameters in serial rapists. Rape fantasies in nonoffenders are not typically rehearsed and are not preoccupying. The fantasies are usually associated with an exteroceptive stimulus (e.g., movie) and diminish in intensity, or extinguish entirely, after the withdrawl of the stimulus. The rape fantasies of serial rapists, by contrast, are intrusive (distracting and preoccupying), reiterative (persistent and recurrent), and interoceptive (internally generated).
Although there are, thus far, no unified, theoretical models for rape that are widely accepted, there has been clear progress in the development of such models. There has been a coalescence of ideas emerging from two methodologies: multidimensional linear models and taxonomic models. Both models use a path analytic approach, using multivariate analysis to examine the different life courses or ‘‘paths’’ leading to different outcomes (defined in the former case as the nature, severity, and frequency of sexual offenses, and in the latter case as different subtypes of offenders).
The input for these models are characteristics of familial, childhood, adolescent, and adult development. Childhood variables that are commonly examined include (a) caregiver instability resulting in impaired attachment, incapacity for attachment, empathy deficits, and distorted attitudes about intimacy; (b) developmental history of abuse, specifying the age of onset, duration, severity, and perpetrator relationship for emotional, physical, and sexual abuse; and (c) hypothetical biological factors (e.g., hypothesized biological substrates for psychopathy). These antecedent events from childhood and adolescence influence at least seven relevant adult outcomes: (a) impaired relationships with peers; (b) lack of empathy and callous indifference to others; (c) degree and nature of chronic anger; (d) cognitive distortions around women and sexuality; (e) deviant sexual arousal and high sexual drive; and (f) impulsive, antisocial behavior. These adult outcomes combine in a complex equation to predict the nature, severity, and frequency of criminal outcome (i.e., rape offenses). Since all of these factors throughout the life span interact in complex ways to influence the type of sexual crimes that are committed, the greatest clarity will be achieved by path models in which reliable combinations of events form unique developmental paths that lead to distinct outcomes.
Despite the evident complexity and multidimensionality of rape behavior, there has been noteworthy progress in developing and validating etiologic models using diverse samples of offenders.
There are many risk factors that may be identified when conducting a clinical or forensic evaluation of an individual offender, for example, rape fantasy and urges to act on such fantasy; a long history of polymorphous and paraphilic sexual interests and behavior; multiple instances of coercive sexual behavior; a history of impulsive, antisocial behavior; clear, documented evidence of psychopathy; substance abuse; poor social and interpersonal skills; dominance and control needs; attitudes (e.g., anger toward victims, misogynistic attitudes, global anger, hypermasculine attitudes); denial of problems; poor community adjustment; and failure to comply with parole conditions.
Many of these factors, which may well be noteworthy when evaluating an individual offender, are not supported by empirical research on risk assessment with large samples of rapists. Generally speaking, those risk factors that consistently emerge in empirical research are: (a) impulsive, antisocial behavior; (b) psychopathy; (c) number of prior sexual offenses; (d) sexual drive strength; and (e) history of sexual coercion or documented evidence (using the penile plethysmograph) of arousal to such coercion or to rape fantasy. If we try to be even more reductionistic, we can distill the empirical research down to three basic, fundamental factors: (1) clinical traits associated with psychopathy (e.g., callous indifference to others, lack of empathy, emotional detachment, lack of affect, conning and manipulativeness, glibness, entitlement, and grandiosity); (2) a track record of impulsive, antisocial behavior; and (3) sexual coercion (a willingness to use force or manipulation to satisfy sexual needs). The last factor, referred to as ‘‘sexual coercion,’’ has been variously described and conceptualized by different researchers and at the present time is the focus of considerable study. One element in this complex equation seems to be marked attachment deficits that permit, or increase the likelihood of, ‘‘impersonal’’ sex (i.e., sex in the absence of any emotional attachment). On a hypothetical interpersonal attachment continuum, we find, in addition to impersonal sex, many outlets for anonymous sex (e.g., phone and computer sex, strip clubs). If we put together these three elements, we have emotional detachment, leaving the offender relatively impervious to cues of victim distress and thus unempathic; attachment deficits, increasing the desirability and/or need for impersonal sex; and coercion, the willingness to use force to gratify personal needs.
In a recent meta-analysis of sixty-one followup studies of sexual offenders (N=23,393), the recidivism rate, on average, was low (13.4 percent) (Hanson and Bussiere). It would be impossible to abstract rates of recidivism specific to rapists, since the aggregated studies used highly heterogeneous samples. Hanson and Bussiere did identify, however, subgroups that recidivated at higher rates. These higher base-rate recidivists were those offenders who evidenced clear deviant sexual preferences and those offenders with known prior sex offenses. To a lesser extent, offenders with greater criminal histories had higher recidivism rates. Sex offenders who failed to complete treatment had higher recidivism rates than those who successfully completed treatment. In one of the very few recent studies that examined sexual reoffense rates for rapists separately, the rate of sexual reconviction after an average of fifty-nine months was .20 (Quinsey, Rice, and Harris). Notably, there were only twenty-eight rapists in the Quinsey et al. study. In a subsequent twenty-five-year follow-up of 136 rapists, the failure rates for sexual charges and convictions were .19 and .11 at Year 5, .26 and .16 at Year 10, .31 and .20 at Year 15, .36 and .23 at Year 20, and .39 and .24 at Year 25 (Prentky, Lee, Knight, and Cerce). Can we conclude anything? As critical as recidivism rates are for risk assessment, for evaluating treatment efficacy, for drafting rape laws, and for social policy, we have no reliable estimates. The principal problem is the extraordinary variability of procedures and methods used to calculate recidivism among the extant studies (Prentky et al.). Studies differ considerably with regard to the composition of the samples (e.g., relative proportions of rapists, extrafamiliar child molesters, and exclusive incest offenders), the criminal behavior domains considered (e.g., only sexual offenses, all violent offenses, any new offense, etc.), the legal definition of what constitutes recidivism (e.g., a new arrest, a new conviction, a parole violation, etc.), the sources of outcome data gathered to assess recidivism (e.g., court records, public safety records, parole and probation records, F.B.I. records, etc.), and the length of the follow-up period (i.e., follow-ups range from twelve months to thirty years).
In addition, the most common method of estimating recidivism is to calculate the simple percentage or proportion of individuals who reoffended during the study period. This method will underestimate the rate of recidivism, because some of those individuals who were in the community for a briefer period of time may still reoffend (e.g., not everyone in a thirty-six-month follow-up will have been in the community for thirty-six months at the time the study ends; some individuals may have been in the community only for twelve months). This problem is addressed by using survival analysis.
The rationale for the modification of any unwanted behavior stems from the informed consideration of those factors that are most importantly associated with the emergence and the sustenance of the behavior. In a relatively simple case, such as reactive or acute depression, we attempt to identify the precursors of the depression. Although sexual aggression derives from a substantially more complex amalgam of factors and typically reflects a chronic pattern of maladaptive behaviors, the principles remain the same. That is, before designing strategies for modifying sexually aggressive behavior, we first must identify those factors that are most importantly related to the behavior. The overarching model that is used to treat sex offenders is an adaptation of relapse prevention, with a practical emphasis on cognitive-behavior therapy as the modality of choice. Specific interventions are used to target each of the critical areas of deficit. Given limitations of space, only several of the most important target areas will be discussed.
Lack of Empathy
In all domains of interpersonal violence, a general lack of empathic relatedness for one’s victim can be regarded as a powerful disinhibitor. Alternatively, the presence of empathic concern will serve to inhibit aggression. Although capacity for emotional relatedness and empathic concern have long been a focus of treatment for sex offenders, these issues have, until recently, been included in the larger topic of social skills deficits.
At this point most sex offender treatment programs include a separate component for increasing victim empathy. In addition to the standard exercises and tapes (video and audio) used in victim empathy training, expressive therapy may be used to increase the offender’s emotional or affective response to the distress of the victim. Some programs introduce victim advocates, victim counselors, and occasionally victims to increase further the emotional ante. Moreover, increasing the offender’s affective appreciation of his own childhood experiences of victimization can instill a greater awareness of his victim’s experience of abuse.
The recognition of the importance of anger as a driving force in sexual offenses has resulted in the inclusion of treatment techniques to reduce and contain anger. The most commonly employed of these techniques is anger management training, which uses cognitive-behavioral strategies to increase self-control as well as the timely and appropriate expression of angry feelings. In addition, relapse prevention, which also focuses on increasing self-management skills, and stress management can assist the offender to gain control over chronic and situationally induced anger. Lastly, early life experiences of victimization can fuel lifelong anger that is periodically triggered by real or imagined provocations. A group that focuses on childhood victimization can help the offender to cope more adaptively with these traumatic events.
Cognitive distortions are ‘‘irrational’’ ideas, thoughts, and attitudes that serve to: (a) perpetuate denial around sexually aggressive behavior; (b) foster the minimization and trivialization of the impact of sexually aggressive behavior on victims; and (c) justify and sustain further sexually aggressive behavior. Cognitive distortions are presumed to be learned attitudes that are instilled at an early age by caregivers, reinforced by peers during childhood and adolescence, and further strengthened in adulthood by the prevailing social climate.
The importance of cognitions in moderating sexual arousal has been repeatedly demonstrated. Moreover, clinical observations have suggested that most sexual offenders harbor offense-justifying attitudes and that these attitudes are importantly related to the maintenance of the ‘‘sexual assault cycle.’’ Thus, the modification of irrational attitudes has been a major focus of treatment intervention. Although there are a variety of treatment modalities that may impact these distortions, the most commonly employed technique is cognitive restructuring. For cognitive restructuring to be most effective, it is critical that cognitive and affective components be addressed. That is, it is insufficient merely to confront the ‘‘distorted’’ nature of the attitudes, to discuss the role that such distortions play for the individual, or to provide accurate information about sexual abuse (all cognitive components). It is equally important to create discomfort by focusing on the victim’s response (e.g., fright, pain, humiliation)—the affective component. This latter exercise is also integral to victim empathy training.
In addition to cognitive restructuring, a group that focuses on childhood victimization can also be very helpful. Since the origin of these distorted attitudes is often a primary caregiver who was an influential role model as well as exposure to peer role models, often in institutional settings, a group that focuses on these early life experiences can help to trace the cognitions to their source, thereby challenging their generality and diminishing their sense of ‘‘truth’’ or ‘‘reality.’’
Sexual Fantasy and Deviant Sexual Arousal
The frequent targeting of rape fantasies for therapeutic intervention reflects the widely held belief that deviant fantasies not only lead to and maintain deviant sexual behavior but also impede normal sexual adaptation. Behavioral techniques for modifying sexual arousal patterns are grouped into two categories, those that decrease deviant arousal (e.g., covert sensitization, aversion, masturbatory satiation, biofeedback, shame therapy) and those that increase appropriate arousal (e.g., systematic desensitization, fantasy modification and orgasmic reconditioning, ‘‘fading’’ techniques, exposure to explicit appropriate sexual material). Although over twenty different behavioral techniques have been reported in the literature, the most widely used method has involved some variant of aversive therapy.
In addition to the repertoire of behavioral interventions, organic treatment has become increasingly popular as a complement to psychological treatment. These organic or drug treatments consist primarily of antiandrogens and antidepressants (primarily the selective serotonin reuptake inhibitors such as fluoxetine).
Antisocial Personality/Lifestyle Impulsivity
Clinicians have long recognized the importance of impulsivity for relapse and have introduced self-control and impulsivity management modules into treatment. In addition to groups that focus specifically on impulse control, most treatment programs include components of relapse prevention. Relapse prevention begins by identifying the chain of events and emotions that lead to sexually aggressive behavior. Once this ‘‘assault cycle’’ is described, two interventions are employed: (a) strategies that help the offender avoid high-risk situations; and (b) strategies that minimize the likelihood that high-risk situations, once encountered, will lead to relapse. There is also reasonable evidence in the literature that supports the efficacy of selective serotonin reuptake inhibitors for impulse disorders.
The verdict as to the efficacy of treatment for sexual offenders will inevitably be a complex one that addresses: (a) optimal treatment modalities for specific subtypes of offenders; (b) optimal conditions under which treatment and follow-up should occur; and (c) selection (or exclusion) criteria for treatment candidates. At the present time, the most informed and dispassionate conclusion must be that the jury is still out. The evidence submitted thus far, however, is encouraging. In a meta-analysis that included twelve studies of treatment with mixed samples of sexual offenders (N=1,313), Hall reported an overall effect size of .12 for treatment versus comparison conditions. The overall recidivism rate for treated sex offenders was .19, compared with .27 for untreated sex offenders. As Hall reported, these effect sizes were larger in studies with longer follow-up periods, studies with higher base rates of recidivism, studies that included outpatients, and studies that included cognitive-behavior and/or hormonal treatment. It is thus clear that treatment can work, and it is increasingly clear what factors lead to optimal treatment outcomes.
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