RYAN, HUNTER & MURRIE Juvenile Sex Offenders OUP. 1e, 2012 (T)

Juvenile Sex Offenders
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A Guide to Evaluation and Treatment for
Mental Health Professionals
E I L E E N P. R YA N
JOHN A. HUNTER
DANIEL C. MURRIE
1
1
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Library of Congress Cataloging-in-Publication Data

Ryan, Eileen P.
Juvenile sex offenders : a guide to evaluation and treatment for mental health
professionals / Eileen P. Ryan, John A. Hunter, Daniel C. Murrie.
p. cm.
Includes bibliographical references and index.
ISBN 9780195393309 (hardcover)
1. Teenage sex offenders. 2. Teenage sex offendersPsychology.
3. Teenage sex offendersEvalulation. 4. Teenage sex offendersRehabilitation.
I. Hunter, John A. II. Murrie, Daniel C., 1974 III. Title.
RJ506.S48R93 2012
364.1530835dc23
2011040353
135798642
Printed in the United States of America

on acid-free paper
To Liam and Ellen, who never fail to forgive me
for working too much and are the lights of
my life. (EPR)
To my wife, Linda, whose unflagging support and

encouragement has inspired and sustained me
throughout my career. (JAH)
CONTENTS
Preface ix
1. Changing Perceptions of Juvenile Sexual Offending in Society

and the Legal System 1
Eileen P. Ryan
2. Placing Sexual Behavior Problems in Context: What Is Normal

Sexual Behavior Among Juveniles? 21
Daniel C. Murrie
3. Patterns of Sexual Offending in Juveniles and Risk Factors 34

John A. Hunter
4. Juvenile Sexual Offending and Psychopathology 54

Eileen P. Ryan
5. Forensic Evaluation Versus Clinical Evaluation: How Do They Differ? 101

Eileen P. Ryan
6. Interviewing, Evaluation, and Risk Assessment of Sexually

Offending Youth 119
Eileen P. Ryan
7. Assessment Instruments for Juveniles Who Sexually Offend 161

Daniel C. Murrie
8. Management and Treatment Methods 175

John A. Hunter
9. Biological and Pharmacologic Treatment of Sexually

Aberrant Behavior 193
Eileen P. Ryan
Index 239
PREFACE
Juveniles are responsible for a significant percentage of sexual abuse in the

United States, and youth who sexually offend are a heterogeneous group. There
is a critical need for a thoughtful, well-informed, and thorough approach to
the evaluation and treatment of sexually abusive youth and juvenile offenders.
The idea for this book arose from a workshop that one of us (EPR) conducted
at the American Academy of Child and Adolescent Psychiatry on clinical and
forensic evaluation strategies with juvenile sex offenders. The overwhelming
response was that psychiatrists and other mental health clinicians working
with youth need practical empirically based guidance on best practices in the
area of evaluation and treatment. There are several excellent books on juvenile
sexual offenders, and they are often referenced in the chapters of this text.
However, we wanted our emphasis to be on practicality and utility, realizing
that skilled clinical practitioners often have limited forensic training and there-
fore may shy away from dealing with a population very much in need of their
clinical child and adolescent expertise. Mental health clinicians who consider
themselves forensic experts and have received the bulk of the mental health
training with adults may feel as though they lack a developmental perspective
and expertise in the evaluation and treatment of children and adolescents. We
anticipate that this book will provide a much-needed sensible and functional
guide to experienced mental health clinicians who are involved in evaluating
and treating sexually abusive youth, including child and general psychiatrists
and psychologists. Because of the greater familiarity of many general forensic
psychiatrists and psychologists with the literature on adult sexual offenders,
we have highlighted the many ways in which the juvenile population differs
from adults.
This book is geared toward psychiatrists, psychologists, and other men-
tal health professionals who are already skilled in the evaluation, diagnosis,
and treatment of children and adolescents but are new to the areas of forensic
x P R E FAC E
evaluation and sexual offending. We also anticipate that experienced forensic

psychiatrists, psychologists, and mental health professionals who evaluate or
work with juvenile sex offenders will also find this book helpful in providing
more targeted and developmentally informed assessment and treatment.
Chapter 1 focuses on changing perceptions and legal trends with respect
to youth crime in general and sex offending specifically, and it provides some
insight into how we deal with youthful offenders has evolved over the last
two decades. In Chapter 2 the question of What is normal? is tackled with
a review of the literature that describes common sexual development and
behaviors in youth. Chapter 3 reviews the major subpopulations of sexually
abusive youth, including prepubescent, female, and adolescent male offend-
ers. Risk factors for the development of sexual offending are also explored. In
Chapter 4, the differences between purely clinical evaluation and forensic eval-
uation are discussed, as well as common dilemmas that may arise clinically
when forensic issues surface. Commonsense advice for working with attorneys
is provided, and case examples are used to illustrate important points. Chapter 5
offers an in-depth discussion of how to conduct a thorough evaluation and
risk assessment of a sexually abusive or offending juvenile. The importance
and specifics of risk assessment in the overall evaluation of such youth within
a developmental context is discussed. Important differences between adults
and youth with respect to risk factors for sexual recidivism are examined in
some detail. Chapter 6 offers an examination of risk assessment instruments
that are in existence for youth, and it includes a discussion of their strengths
and weaknesses when utilized to assess the risk of sexual and nonsexual
reoffending. Chapter 8 examines empirically validated psychotherapeutic
interventions for sexually offending youth. Chapter 9 provides an in-depth
review of pharmacological approaches to sexual offending, noting that most of
the work in this area for practical and ethical reasons has been done with adult
sex offenders. However, it is reasonable to assume that innovations in pharma-
cological therapies may prove useful in the treatment of that subgroup of older
adolescents with paraphilias.
We have made every effort to provide accurate and current information in
accord with accepted standards and practices at the time of this publication.
However, the authors, editors, and publishers cannot guarantee the informa-
tion contained in this book is completely free from error in some part because
clinical practices and standards change rapidly through research and regula-
tion. Therefore, the authors, editors, and publishers disclaim all liability for
damages resulting from the use of medications presented in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any equipment or drugs they use.
Preface xi
We hope that child and adolescent mental health clinicians will feel more
comfortable and confident applying their wealth of clinical knowledge to this
poorly understood and served population. Likewise, we hope that seasoned
forensic evaluators and clinicians who are expanding their horizons to evalu-
ate and work with youth will find this book helpful in their quest to understand
how juvenile sex offenders differ from adult offenders and provide a hopeful
and optimistic framework for working with these youth.
1
Changing Perceptions of Juvenile

Sexual Offending in Society and
the Legal System
OV ERV I E W
This chapter examines the changing perception and responses of society and
the legal system to the problem of juvenile sexual offending. Sexual abuse has
received increasing recognition and attention in recent decades as a significant
problem. Adult sex offenders often begin their sexual offending in their youth
(Abel, Coffey, & Osborn, 2008). It is estimated that one-third to one-half of
adult sex offenders began their sexual offending as adolescents (Prentky, Harris,
Frizzel, & Righthand, 2000). Between 15% and 20% of all sexual offenses and
up to 50% of all child molestations may be committed by individuals under
the age of 18 (Murphy & Page, 2000; Zolendek, Abel, Northey, & Jordan, 2002).
Individuals younger than age 20 account for nearly 50% of all incidents of sex-
ual aggression in the United States (Lowenstein, 2006). A survey of high school
students indicated that 20% of the students had forced sex on another student,
and 60% of the boys thought it acceptable in one or more situations to force sex
on a girl (Davis, Peck, & Storment, 1993). A national survey of 1,600 sexually
abusive youth revealed that they came from all racial, ethnic, economic, and
religious backgrounds, ranging in age from 5 to 21 years, predominantly male
with a modal age of 14 (Ryan, Miyoshi, Metzner, Krugman, & Fryer, 1996).
In California in 2009, adult arrests accounted for 88.4% of forcible rapes, and
2 JU VENILE SEX OFFENDERS
juvenile arrests accounted for 11.6%. Although there was a 2.0% increase in
the rate of juvenile arrests for forcible rape in California between 2008 and
2009, there was a 25.7% decrease in the rate of juvenile arrests from 2004 to
2009 (California Department of Justice, 2010). The problem of juvenile sexual
offending is not one to be ignored or minimized; however, societys responses
to adult sex offenders have had a trickle-down effect on youth accused and
convicted of sexual offenses despite the lack of evidence that such measures are
necessary or effective for most juveniles.
C L A R I F I CAT I O N O F T ER M I N O LO GY U S ED I N T H E F I EL D
Paraphilias are characterized by recurrent, intense sexually arousing fan-

tasies, sexual urges, or behaviors, generally involving 1) nonhuman objects,
2) the suffering or humiliation of oneself or ones partner, or 3) children or
other nonconsenting persons that occur over a period of at least 6 months
(American Psychiatric Association, 2000, p. 566). The individual must be at
least 16 years of age and at least 5 years older than the victim. Although it is
often presumed that a sexual offender evidences at least one or more paraphil-
ias, this is not uniformly true, and it is typically not the case for juvenile sexual
offenders. Sexual aggression involves the use of threats, intimidation, force,
or the exploitation of authority on a nonconsenting individual with the pur-
pose of imposing ones sexual will (Shaw & Antia, 2009). Sexually abusive/
offending behavior is defined (American Psychiatric Association, 1999) as a
purposeful sexual act committed against another person, which may include
physical, verbal, or other forms of coercion or manipulation. The National
Task for Juvenile Offending defines sexually abusive behavior as any sexual
behavior that occurs without consent, without equality, or as a result of coer-
cion (National Task Force on Juvenile Sex Offending, 1993).
Most juveniles who molest children do not develop pedophilia and do not
continue sexual offending into adulthood. For adults who have paraphil-
ias, including pedophilia, the onset of deviant fantasies usually begins in
adolescence, and there is consensus that pedophilic arousal patterns begin
around puberty (Abel et al., 2008). Masturbation to deviant sexual fantasies
may lead to these fantasies becoming entrenched (Marshall & Marshall,
2000). The prevalence of pedophilia in adults is unknown, but it could be
as high as or higher than the prevalence of obsessive-compulsive disorder
(Bradford, 1999). (Recent epidemiological studies estimate a lifetime preva-
lence of obsessive-compulsive disorder of 1% to 3%; Ruscio, Stein, Chiu, &
Kessler, 2010; Weissman et al., 1994.) The considerable research attention
focused on juvenile sex offenders in the past two decades has demonstrated
Changing Perceptions of Juvenile Sexual Offending 3
that this is a heterogeneous population that has far more in common with
non-sexually-offending juvenile delinquents than with adult sexual offenders.
Most (although not all) sexual offending in juveniles is best understood as
embedded within a framework of developmental, emotional, and behavioral
problems, rather than as a harbinger of adult paraphilia. The cognitive and
psychosocial immaturity of youthful offenders suggests that these juveniles
are still experimenting and are not fi xed in their expressions of sexuality.
Hence, there is considerable potential for response to appropriate treatments
and interventions.
The Center of Sex Offender Management in their April 2002 guide states:
Available research does not suggest that the majority of sexually abusive
youth are destined to become adult sex offenders. Further, the emerging wis-
dom among experts who work with these youth is that they are profoundly
different from their adult counterparts. Their experiences suggest that it is
inappropriate to respond to juveniles who commit sex offenses by simply
applying what is known about adult sex offenders (Bumby, Talbot, & Carter,
2002, p. 4).
Wetzel (2008) summarized 85 research studies from 1943 to 2008 (13,034
youth). Methodology varied widely, as did the range of recidivism rates, from
0% to 75%. Wetzel calculated the mean recidivism rate for all studies to be
7.73%.
A low sexual recidivism rate (less than 5%) for juvenile sex offenders was
reported in a 10-year follow-up recidivism study of male juvenile sex offenders
incarcerated in two sex offender treatment programs administered through
the Virginia Department of Juvenile Justice. The more intense program was
a self-contained program that operated in specialized living units that were
separate from the rest of the incarcerated juvenile population. The less intense
program offered sex offender treatment services to juveniles housed within
the general incarcerated juvenile justice population. Arrest and incarcera-
tion data were obtained for 261 male juvenile sex offenders released between
1992 and 2001. For both groups, rearrest was most likely to be for a nonsexual
offense (31% and 47%, respectively) and least likely to be for a sexual offense
(<5%). Interestingly, the self-contained treatment group had the lower rearrest
rate and longer mean time to rearrest for all types of crimes. Furthermore,
juveniles in both groups (the self-contained/higher intensity and lower inten-
sity sex offender treatment programs) with high levels of impulsive/antisocial
behaviors were significantly more likely to recidivate regardless of treatment
type (Waite et al., 2005).
Sexual offender is technically a legal term for an adult or juvenile who
has been found guilty or adjudicated (the terminology for found guilty in
juvenile court) or has been awarded deferred adjudication of a sexually based
crime. It is not until the youth has been found guilty or adjudicated in a court
of law that the term sex offender is technically accurate.
Inappropriate sexual behavior occurs on a continuum. A review of the
professional literature reveals that public policy and programs designed
for youth who sexually offend have typically been based on knowledge and
interventions designed for adults, without adequate attention paid to the
developmental issues and needs of juveniles. As previously noted, extant
research indicates that children and adolescents who commit sexually based
offenses comprise a heterogeneous group, far more similar to generally delin-
quent youth as a whole than to adult sex offenders. In fact, the term juvenile
sex offender may contribute to an erroneous and destructive notion that the
youth is destined to become an adult sex offender, and it may set into motion
interventions that inadvertently contribute to limited opportunities and
increasingly antisocial choices. Language that emphasizes the actual behav-
ior and pathology rather than attempts to characterize the individual may be
helpful to avoid this trap and enable more specific and targeted treatments in
the pediatric population. However, since much of the literature on youth who
engage in sexually abusive behavior (regardless of whether they have been for-
mally adjudicated) utilizes the term juvenile sexual offender, it will be used
in this book to describe this population of youth who engage in sexually abu-
sive behavior. A juvenile sex offender may be described as a youth ranging
from puberty to the age of legal majority who commits any sexual interaction
with a person of any age against the victims will, without consent, or in an
aggressive, exploitative, or threatening manner (Lakey, 1994, p. 755; Scavo &
Buchanan, p. 60). However, prepubescent juvenile offenders as young as age
6 have been identified (Rothchild, 1996).
Consent is defined as agreement or implied agreement in which the person
consenting must possess (1) an understanding of what is proposed, (2) knowl-
edge of the societal standards of what is being proposed, (3) awareness of
potential risks and consequences, (4) knowledge of alternatives, (5) volun-
tariness (the assumption that agreement and disagreement will be equally
respected), and (6) mental competence. Consent is typically equated with the
legal competence to give consent, and therefore if the youth is below the legal
age of consent, the issue of willingness or voluntariness is moot.
There are sometimes ethical and legal dilemmas for the treating clinician
and parents of a youth who has engaged in potentially sexually abusive behav-
ior with a family member or peer and has not come to the attention of legal
authorities. Reporting laws in the United States mandate that clinicians must
report suspected sexual abuse of a child for whom the youth has had any care-
taking responsibilities to whatever the localitys equivalent of the Department
of Social Services or Child Protective Services. This will set in motion a series of
event that often results in charges being pressed against the youth, the youths
removal from the home, and the possibility that treatment will give way to
punishment.
Juveniles who engage in sexually offensive behavior vary according to victim
and offense characteristics; types of sexual offending; histories of neglect
and abuse; social and interpersonal skills; relationships with peers, parents,
and other adults; sexual knowledge and experience; academic and cognitive
functioning; and mental health.
T R EN D S I N J U V EN I L E J U ST I C E A N D T H E C R I M I N A L
M A N AG EM EN T O F YO U T H
Understanding societys response to youthful sexual offenders requires an

appreciation of the evolution of societys response to juvenile offenders gen-
erally. There was a significant increase in juvenile crime and high-lethality
violence among juveniles in the 1980s and 1990s (Ash, 2006; Zimring, 2004),
which mirrored a general increase in crime, fueled in large part by the intro-
duction of crack cocaine to cities. Catchphrases such as If youre old enough
to do the crime, youre old enough to do the time frequently graced political
campaigns and dominated media stories regarding juvenile crime in the 1990s
(Zimring, 1998). In 1993, for African American males aged 1519, homicide
was not only the leading cause of death, but it accounted for more deaths than
all other causes combined (National Center for Health Statistics, 1998). Public
fear and disillusionment with juvenile justice responses to the problem of
youth violence led to a just desserts model of dealing with juvenile offend-
ers, which emphasized punishment over rehabilitation. The concept of a more
retributive system in dealing with juveniles was not a new concept (Rutherford,
1978); however, the increase in juvenile crime combined with growing public
disenchantment, as well as a relative lack of empirically grounded treatment
approaches to the problem of youth violence (Bank, Marlowe, Reid, Patterson,
& Weinrott, 1991), helped fuel the changes in criminal justice policy. In many
ways the mental health community has been playing catch-up ever since.
Ironically, the exciting development of empirically ground treatment modali-
ties for delinquent youth is being introduced within a society that has in many
respects moved away from the parens patriae model of juvenile justice. This
reflects the reality that current juvenile justice policies tend to regard youth in
trouble as offenders first and children second (Goldston, 2000, p. 256).
In response to the increase in violent juvenile crime, states began enacting
legislation aimed at addressing and preventing the coming of the juvenile
super-predator, whose much-anticipated arrival never materialized (Dodge,
2008). The term super-predator has been attributed to John Dilulio, Ph.D.,
a political scientist at the University of Pennsylvania, in an article he authored
and published in the political opinion journal The Weekly Standard (Dilulio,
1995). Other noted criminologists agreed (Fox, 1996), predicting a bloodbath
by the year 2005 or a coming storm of juvenile violence (Council on Crime
in America, 1996). The media latched onto the catchy super-predator label, and
caricatures of adolescent super-predators began to adorn the front covers of
major magazines along with sensationalized articles discussing the prediction
that an explosion of violence was in store for America as a ticking demo-
graphic time bomb came of age (Zuckerman, 2010). These dire predictions
proved to be erroneous. Between 1994 and 2004, arrest totals for homicide
dropped by almost two-thirds, whereas the population of youth in the United
States increased (US Department of Justice, Federal Bureau of Investigation,
19762001). However, in response to the 19851993 period of increased youth
violence, legislators crafted law that greatly changed how juveniles who com-
mitted criminal acts are handled. Since 1992 almost every state has expanded
provisions for transferring juveniles to adult criminal court (Sickmund, 2003).
The number of delinquency cases waived to adult court increased by 71%
between 1985 and 1994 (Szymanski, 1998). The number of delinquency cases
waived to adult court from 1994 to 2005 declined 47%, but this hardly rep-
resents a swing back toward the concept of treating youth as juveniles with
an increased capacity for rehabilitation (Adams & Addie, 2009). Rather, the
decline in juvenile waivers is due to new and expanded nonjudicial waiver
laws, by which cases that might have been subjected to waiver proceedings
in juvenile court in the past are now fi led directly in adult criminal court,
completely bypassing the juvenile court.
There are a variety of ways in which youth may be transferred to adult/
criminal court, and many states have adopted hybrid approaches incorporat-
ing two or more of these variations (Kokrda, 2005). Judicial waiver has been
the traditional method for transferring juveniles to adult court, although it
has decreased in recent years secondary to the ascendance of other meth-
ods of transferring jurisdiction. In juvenile waiver, the youth is entitled to
an evidentiary hearing in juvenile court in which the judge weighs several
statutorily determined factors in making his or her decision. This individual-
ized decision making is in keeping with the rehabilitative design of the juvenile
court. Sweeping changes in the 1990s with respect to how juvenile crime is
handled saw the expansion of mechanisms making it easier to try juveniles in
adult court and take the decision-making process out of the hands of judges.
In legislative waiver, sometimes known as automatic transfer, the states legis-
lature places certain serious offenses (for example, murder and rape) outside
the jurisdiction of the juvenile court, divesting the juvenile court judge of the
ability to retain jurisdiction regardless of the youths specific circumstances

(first offense, amenability to treatment, immaturity or cognitive deficits, etc.).
In prosecutorial waiver, the prosecutor has the discretion to fi le cases in crimi-
nal court for certain offenses if he or she deems it appropriate to do so. Some
states allow wide discretion to prosecutors; others require prosecutors to con-
sider various factors before fi ling the case in adult court. Reverse transfer is a
mechanism by which the adult court may hold a hearing to determine whether
to waive its jurisdiction back to juvenile court; however, it is rarely utilized
(Kokrda, 2005).
Recent Court Decisions
The US Supreme Court in 2005 ruled that imposing the death penalty on
adolescents under the age of 18 was unconstitutional under the Eighth and
Fourteen Amendments, noting that adolescents are less culpable than adult
offenders (Roper v. Simmons, 2005). Most recently in 2010, the Supreme Court
held that juveniles cannot be sentenced to life without parole for crimes short
of homicide (Graham v. Florida, 2010a). This ruling marked the first time the
Supreme Court has categorically banned a punishment other than the death
penalty. Terence Jamar Graham was 16 years old when he committed armed
burglary and another crime. A Florida circuit court sentenced him to proba-
tion and withheld adjudication of guilt. Subsequently, the trial court found
that Graham had violated the terms of his probation by committing addi-
tional crimes. The trial court adjudicated Graham guilty of the earlier charges,
revoked his probation, and sentenced him to life in prison for the burglary.
Because Florida had abolished its parole system, the life sentence left Graham
no possibility of release except executive clemency. The Supreme Court held
that the Eighth Amendments Cruel and Unusual Punishments Clause does
not permit a juvenile offender to be sentenced to life in prison without parole
for a nonhomicide crime. Chief Justice Roberts concurred regarding the
unconstitutionality of Terence Grahams sentence, noting Grahams juvenile
status combined with the nature of his crime and the severity of the punish-
ment imposed. However, he took issue with the categorical banning of a life
sentence, stating, Some crimes are so heinous, and some juvenile offenders so
highly culpable, that a sentence of life without parole may be entirely justified
under the Constitution. He mentioned several sex offenses (one involving the
beating and rape of an 8-year-old by a 17-year-old and another involving the
gang rape of a woman by a group of juveniles) as so heinous as to potentially
constitutionally qualify for life in prison without parole (Graham v. Florida,
2010b).
S E X O FFEN D ER R EG I ST R AT I O N
All 50 states in the United States have some type of sex offender registration
and notification law, and 38 states register juvenile sexual offenders. These
statutes, commonly known as Megans Laws, are typically enacted with
minimal resistance from state legislatures and the public. Their purpose
is to track convicted sex offenders and make their identity, including their
names, addresses, criminal records, and other information, available to the
public. The purpose of Megans Laws is to promote child safety, and they are
named after 7-year-old Megan Kanka, the victim of a sexual homicide com-
mitted in New Jersey by an adult neighbor and convicted child sex offender.
After Megans rape and murder, citizens were outraged to discover that a sex
offender, convicted of multiple past sexual crimes, was living in their neigh-
borhood without their knowledge. Residents believed that they should have
been aware that such an individual was residing among them. In response to
the high-profile and heart-wrenching circumstances of Megan Kankas death
(she was lured into her murderers home with the promise of seeing a new
puppy), states began to pass sex offender registry laws that more closely moni-
tor convicted and incarcerated sex offenders.
In 1994, Congress passed the Jacob Wetterling Crimes Against Children
and Sexually Violent Offenders Registration Act. The Jacob Wetterling Act
imposed financial penalties on states for failure to create sex offender registries
(42 USC 14071 [1994]). By 1996, all 50 states had established sex offender reg-
istries. However, the Jacob Wetterling Act allowed states latitude with respect
to making the sex offender registries public. In response to this perceived
inadequacy, in 1996 Congress passed, and President Clinton signed, a federal
Megans Law, mandating all states to pass legislation making their sex offender
registries public (42 USC 14071 [Supp. IV 1998]). States that did not comply
with these federal Megans Law requirements would lose 10% of the funds that
would have been allocated to them under the Omnibus Crime Control and
Safe Streets Act of 1968 (Geer, 2008).
The most far-reaching sex offender registry law affecting juveniles is the
Adam Walsh Child Protection and Safety Act, bipartisan federal legislation
that was signed into law by President George W. Bush on July 27, 2006. This
legislation organizes sex offenders into three tiers and would include juveniles
as young as age 14. A portion of the act known as the Sex Offender Registration
and Notification Act (SORNA) also mandates the creation of a national sex
offender registry.
In May 2010, the Supreme Court in a 7 to 2 ruling upheld Section 4248 of
the Adam Walsh Child Protection and Safety Act, establishing a civil commit-
ment procedure to keep any inmate deemed by the government to be sexually
dangerous behind bars (with Justices Scalia and Thomas dissenting). However,
also in May 2010, revised rules allowed states to decide whether to include
teen offenders in their registries. The handling of juvenile sex offenders has
been one of the most contentious aspects of the legislation for states trying to
implement the law.
Whether Megans Laws accomplish their purpose with respect to adult sex
offenders is the subject of some controversy. A recent study funded by the
Department of Justice (Zgoba, Witt, Delessandro, & Veysey, 2008) found that
Megans Law had no effect on the time to first rearrest, demonstrated no effect
in reducing sexual reoffenses, had no effect on the type of sexual reoffense
or first-time sexual offense (still largely child molestation/incest), and had no
effect on reducing the number of victims of sexual offenses. However, the costs
associated with the initial implementation as well as ongoing expenditures
continue to expand. Start-up costs totaled $555,565 and costs in 2007 totaled
approximately $3.9 million for the 15 responding counties in New Jersey
according to the study. The study noted that given the lack of demonstrated
effect of Megans Law on sexual offenses, the growing costs might not be jus-
tifiable. Other studies have also concluded that adult sex offender registration
is not associated with lowered sexual recidivism rates (Caldwell & Dickinson,
2009; Zevitz, 2006).
Juveniles and Sex Offender Registries
Despite the bulk of research that indicates that the risk of sexual recidivism in
juvenile sex offenders is relatively low, the issue is far from settled. Hagan and
colleagues make the excellent point that although juvenile sexual recidivism has
not been considered high, the consequent generalization that all juvenile sex-
ual offenders are at relatively low risk to recidivate is not actually true (Hagan,
Anderson, Caldwell, & Kemper, 2010). Their small study, which consisted of 12
juveniles recommended by experts for civil commitment under Wisconsins
sexually violent predator law but who were ultimately not committed, found
a rate of 42% sexual recidivism with a 5-year at-risk period. The authors con-
cluded that the capacity to assess the risk of juvenile sexual reoffending might
be higher than previously estimated. Although actuarial instruments have not
proven particularly effective at assessing the risk of sexual recidivism in juve-
niles, a more comprehensive type of evaluation of these youth may well be
indicated and useful in risk assessment and treatment provision.
Juveniles are increasingly included in sex offender registration laws
under the premise that they represent a group at distinctively high risk for
future sexual violence and that registration may help to mitigate this risk
(Caldwell & Dickinson, 2009). Despite the fact that both the ethics and efficacy
of including juveniles (whether convicted in juvenile or adult court) in these
registries has been called into question (Chaffi n, 2008; Chaffin et al., 2008;
Letourneau, Bandyopadhyay, Sinha, & Armstrong, 2009), there is little empir-
ical research addressing these issues. However, a recent study on sex offender
risk and recidivism risk among juvenile sex offenders (106 registered and 66
unregistered male juvenile sex offenders) did not support the assumption that
registration lowers the risk of sexual recidivism (Caldwell & Dickinson, 2009).
Letourneau and colleagues conducted a study investigating the effects of sex
offender registration policies on juvenile judicial decision making, examining
prosecutor decisions and disposition outcomes over a 15-year period. They
found that prosecutors were significantly less likely to move forward on both
serious sexual and assault offense charges after registration implementation.
Their results suggest that state and national policies requiring long-term
public registration of juveniles might unintentionally decrease the likelihood
of prosecution (Letourneau et al., 2009).
As will be noted repeatedly throughout this text, juveniles who commit
sexual offenses are less likely to recidivate sexually than adult sex offenders.
Therefore, one of the major reasons cited for singling out sexual crimes from
among all other violent crimes (the premise that sex offenders have a far higher
recidivism rate than other criminals) is not supported, especially with respect
to juvenile sex offenders. This premise with respect to adults is also question-
able, at least generally. In the seminal meta-analysis by Hanson and Bussiere
(1998), the examination of results from 61 follow-up studies revealed that, on
average, the sexual offense recidivism rate for adult males was low (13.4%;
n = 23,393). However, subgroups of offenders who recidivated at high rates
were identified. Sexual offense recidivism was best predicted by measures of
sexual deviancy (deviant sexual preferences), prior sexual offenses, and, to a
lesser extent, by general criminological factors (e.g., age, total prior offenses).
Despite the recognition of the diminished culpability of adolescents, the
Court has upheld the constitutionality of sex offender registries in general.
The Supreme Court upheld Alaskas retroactive application of its sex offender
registration law to those convicted of sex crimes prior to the passage of the
law, indicating that it did not violate the ex post facto clause because it was
nonpunitive in nature. The Courts position is that because laws creating sex
offender registries are passed with the intention of protecting the public rather
than further punishing sex offenders they do not violate the ex post facto
clause (Smith v. Doe, 2002).
Some state courts have addressed the legality of applying sex offender
notification laws to juveniles. Although the application of registries and noti-
fication has withstood judicial scrutiny, the courts noted that the placement of
juveniles in the registry should not be automatic. The Massachusetts Supreme

Court upheld that a juvenile may be placed in the sex offender registry only
after a determination has been made as to the risk to the public, indicating
that the juveniles inclusion is not as automatic as an adults and based only
on certain crimes (Roe v. Attorney General, 2001). The Iowa Supreme Court
upheld a statute giving judges broad discretion with respect to whether to
place a juvenile on the states sex offender registry (In re S.M.M., 1997). In re
J.W. (2003a) concerned a 12-year-old boy adjudicated delinquent of aggravated
criminal assault of two 7-year-old boys. As a condition of his probation, J.W.
was required to comply with the Illinois Sex Offender Registration Act and
register as a sex offender for the rest of his life. The US Supreme Court has
yet to hear a case arguing the constitutionality of including juveniles in a sex
offender registry. J.W. argued that the requirement that he register as a sex
offender for the remainder of his natural life was a violation of his substantive
due process rights, and that imposition of a lifetime registration requirement
was at odds with the purpose and policy of the Juvenile Court Act, noting that
juveniles have traditionally been viewed as less culpable than adults and more
amenable to rehabilitation and treatment (In re J.W., 2003a). However, the
Illinois Supreme Court disagreed that the statute infringed on a fundamental
right. The Court instead applied the less stringent rational basis test, requiring
that the statute be upheld if it bore a reasonable relationship to a public inter-
est and the methods implemented are a reasonable method of accomplishing
the desired goal (In re J.W., 2003a). The US Supreme Court denied cert (In
re J.W., 2003b), which means they chose not to hear the case, automatically
allowing the Illinois Supreme Court decision to stand (Hafemiester, 2003; In
re J.W., 2003b).
Sex offenders have been considered the lepers of the criminal justice system
(Greer, 2008, p. 47; Shepherd, 2007, p. 35). When sex offender notification
involves door-to-door notification, listing on a sex offender Web site, or
other forms of public notification, the likelihood that the juvenile offenders
peers and community will discover the offense is very high with the potential
fallout being public ridicule, ostracism, vigilantism, loss of employment, and
eviction (Geer, 2008). Job opportunities are severely limited for these youth.
Jobs in education, health care, and the military are off limits, and even low-
skilled, minimum-wage employment at businesses such as McDonalds and
Target, which perform background checks, is limited as well (Jones, 2007). It
has been argued that sex offender registration and notification in its current
form is unlikely to achieve the goal of enhancing public safety and instead
will divert limited resources from more pressing law enforcement needs to
tracking nonviolent offenders and individuals unlikely to commit future sex
crimes (Appelbaum, 2008). These are especially important considerations with
respect to juveniles who as a group are far less likely to recidivate sexually than
adult sex offenders.
Geer (2008) proposed three changes to how sex offender registries are
applied to juveniles:
1. Careful consideration of the individual juveniles placement in a sex

offender registration, with juveniles neither automatically nor routinely
included in long-term adult sex offender registries. Judicial review
should be required before inclusion, and the judge should be provided
with specific factors and criteria to consider prior to the decision being
made.
2. Creation of separate juvenile sex offender registries.
3. Maintaining confidentiality of names listed in the juvenile sex offender
registry with access limited to officials with a clearly established need
to know this information.
J U V EN I L E S E X O F F EN D ER S A N D T R A N S F ER STAT U T ES
As discussed earlier, in response to the rising juvenile crime rate in the 1980s
and 1990s and media attention to what turned out to be an erroneous, yet
highly sensational, prediction that America was producing a new breed of
juvenile super-predator, states began to enact legislation that reflected a
get tough approach to juvenile crime, which radically altered the juvenile
justice system. Public opinion was not particularly sympathetic to youthful
offenders in the wake of highly publicized violent juvenile offenses, includ-
ing school shootings (Roberts, 2004). Whereas formerly the juvenile justice
system, at least in theory, was geared toward rehabilitation with an acknowl-
edgment that youth were still developing and potentially more capable of
positive change than adult criminals, beginning in the 1980s many states
passed legislation that made it easier to transfer youth from the juvenile
system into the adult system (Redding, 2008). Subsequently the number
of youth convicted of felonies in adult criminal courts and incarcerated in
adult prisons increased, reaching a peak in the mid-1990s and then declin-
ing, commensurate with the decrease in juvenile crime (Redding, 2003,
2008; Snyder & Sickmund, 2006). Several studies, which utilized large sam-
ple sizes, different methodologies, and several measures of recidivism, were
conducted in five states (New York, Florida, Pennsylvania, Minnesota, and
New Jersey) with different types of transfer laws (judicial, prosecutorial, and
legislative/automatic). These large-scale studies all found higher recidivism
rates for youthful offenders transferred to adult criminal court compared to
those retained in juvenile court. This was the case even for offenders who
received only probation in the adult court (Bishop & Frazier, 2000; Bishop,
Frazier, Lanza-Kaduce, & Winner, 1996; Fagan, Kupchik, & Liberman,
2003; Lanza-Kaduce, Lane, Frazier, & Bishop, 2005; Mason & Chang, 2001;
McGowan et al., 2007; Redding, 2008). The picture is even less clear with
respect to the question as to whether transfer laws deter would-be juvenile
offenders (Redding, 2003, 2008).
Adolescents psychosocial immaturity, including their tendency to focus on
immediate and short-term benefits of their choices, may reduce the likelihood
that they will perceive or anticipate the substantial risks posed by being tried
as an adult and facing adult punishments (Cauffman & Steinberg, 2000). Most
youthful offenders do not become adult criminals because their choices to
engage in illegal behavior are shaped by processes and factors peculiar to and
characteristic of adolescence (Scott & Steinberg, 2003). Although the capabili-
ties of individual adolescents can vary significantly, as a group, adolescents
capacities for self-management, perception of risk, autonomous choice, and
calculation of future consequences are deficient when compared with adults.
These deficits can influence risky and impulsive behaviors, including engage-
ment in illegal activities (Steinberg & Cauff man, 1996). Clearly some youth
are in the early stages of developing a criminal identity (what Moffitt and col-
leagues have termed life-course persistent offenders); however, most are not
(Moffitt, 1993; Moffitt, Caspi, Harrington, & Milne, 2002; Odgers et al., 2008)
and desist offending as their judgment and decision-making capacities mature
(Mulvey & LaRosa, 1986). It is clearly a conundrum that in some states juve-
niles that can be held legally blameworthy and charged with sexual offenses
are not considered old enough to consent to sexual activity. In some states a
14-year-old is not legally old enough to consent to sexual activity with a peer,
but he or she is old enough to be tried as an adult and to be subjected to adult
sanctions as a sex offender.
S E X UA L LY V I O L EN T PR EDATO R C O M M I T M EN T L AWS
Adolescents convicted of sex offenses in criminal court may be subjected to

civil commitment under sexually violent predator (SVP) statutes. Twenty
states have passed SVP laws, which permit states or the federal government to
indefinitely confine an individual after his or her sentence has been completed
if the person has a mental abnormality, which includes personality disor-
ders and paraphilias. The first SVP law to be upheld as constitutional by the
US Supreme Court in a 54 decision in 1997 was Kansas v. Hendricks (1997).
Under Kansass SVP Act, any person who due to a mental abnormality or
personality disorder is likely to engage in predatory acts of sexual violence

can be committed indefinitely (Kansas v. Hendricks, 1997).
There are a variety of actuarially derived risk assessment instruments that
are commonly utilized in SVP hearings. Some of the more commonly used
instruments that provide a quantitative estimate of adult males risk to reoffend
sexually include the Rapid Risk Assessment for Sexual Offenses (RRASOR),
Minnesota Sex Offender Screening Tool (MnSOST), the Minnesota Sex
Offender Screening ToolRevised (MnSOST-R), Sex Offender Risk Appraisal
Guide (SORAG), and the STATIC-99 and STATIC-2002 (Barbaree, Langton,
& Peacock, 2006; Epperson et al., 1998; Hanson, 1997; Hanson, Helmus, &
Thornton, 2010; Hanson & Thornton, 1999; Harris et al., 2003). In general,
courts have found these instruments to be admissible in SVP proceedings
(In re Commitment of R.S., 2001). However, some courts have limited the use
of such instruments to a determination of the presence of risk factors rather
than as a prediction of the risk to recidivate based solely on a numerical score
(In re Detention of Daniel Holtz, 2002). One case addressed the admissibility
of testimony derived from the results of actuarial instruments in an action
seeking civil commitment of a sex offender whose only offenses were com-
mitted when he was a juvenile (In re Commitment of J.P., 2001). The appellate
court found that the trial judge erred in admitting testimony concerning the
Static-99 and MnSOST-R at the commitment hearing because the testimony
regarding the reliability of the offenders scores was ambiguous and incomplete
(In re Commitment of J.P., 2001). Specifically, the courts opinion noted that the
prosecution experts testimony regarding the application of these instruments
to juveniles calls their reliability into question (In re Commitment of J.P.,
2001). The Court concluded that the instruments were insufficiently reliable
predictors of sexual recidivism when applied to a sex offender incarcerated
since adolescence.
S U M M A RY
Since the 1970s, sexual abuse has been viewed as a major social problem
that is within the purview of the legal system. In the 1980s, it came to be
viewed as a public health problem, with the thinking that if sex offenders
are incarcerated, the public is protected (Kendall & Cheung, 2004). More
recently the debate has shifted as to questions regarding appropriate inter-
vention strategies. How important is treatment or rehabilitation compared
to deterrence and punishment? Perhaps nowhere is this debate more stark
and the stakes as high as in the area of juvenile sex offending. Even those
citizens who view adult sex offenders as hopeless menaces that should be
incarcerated for life might pause at the thought of lifetime incarceration for
a 14-year-old. At the same time that society is demanding that citizens be
protected from sexual offenders, it is also demanding that juveniles be held
increasingly accountable for criminal behavior. Despite the fact that sexual
crimes vary in their severity, that youthful sexual offenders as a group appear
to be more amenable to treatment than their adult offenders, and that most
juvenile sex offenders do not persist into adulthood with sexual offending,
many jurisdictions express a readiness to waive juvenile sex offenders to adult
court. Additionally, current legislation that indiscriminately treats children
and adolescents who commit sexually related offenses as adults and requires
registration and community notification makes rehabilitation that much
more difficult. Waiving juveniles to the adult system results in youth being
housed with adult criminals, where their risk of being sexually victimized
is increased (Robertson, 2003; Struckman-Johnson & Struckman-Johnson,
2006; Wolff, Blitz, Shi, Bachman, & Siegel, 2006) and lessens the probability
that they will receive appropriate treatment. By publicly shaming juvenile
offenders and their families, forcing them to move (registered sex offend-
ers cannot reside or work near schools, school bus stops, or other facilities
where there are children), and severely limiting their opportunities, the leg-
islation all but condemns most juvenile offenders caught in this net to a life
of significantly limited opportunities in the areas of education, employment,
and social and moral development. Clearly a better approach to this serious
problem is necessaryone that would enhance public safety by providing a
targeted developmentally informed approach to both assessment and treat-
ment of juveniles who sexually offend.
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2
Placing Sexual Behavior

Problems in Context
What Is Normal Sexual Behavior Among Juveniles?
DANIEL C. MURRIE
OV ERV I E W
Working with youth who display sexual behavior problems often evokes a
simple question: What is normal juvenile sexual behavior anyway? Both
courts who refer juveniles for an evaluation and parents seeking a psychiat-
ric consultation for their child often ask about normal behavior. But most
mental health professionals recognize that the question of normal sexual
behavior is far from simple, because it can be interpreted in many different
ways. Normal can refer to behavior that is statistically normative, or com-
monplace, regardless of whether the behavior is healthy or ideal. Thus, abnor-
mal behavior might simply be uncommon, even if it is entirely healthy, and
some behaviors that are statistically normal may nevertheless be harmful.
Many questions about normal behavior are really questions about whether
a behavior is cause for concern. When parents or courts ask about whether a
behavior is normal, they may really be asking whether it reflects pathological
development, that is, whether it suggests a risk of greater problems as the child
grows older. All of these questions become more complicated because culture
plays some role in understanding normalcy. Behaviors that are atypical in
some cultures may be entirely typical in other cultures, so the implications of
certain behaviors vary by the familial, social, and cultural contexts (Heiman,
Leiblum, Esquilin, & Pallitto, 1998). Some clinicians considering juvenile
sexual behaviors err on the side of cultural rigidity, failing to recognize that
cultural context might make some behaviors less worrisome than they initially
appear. Other clinicians err on the side of cultural relativism, too quickly dis-
missing problematic behaviors as attributable solely to cultural differences, in
a well-intentioned effort to be culturally sensitive. In short, clinicians who are
asked about normal juvenile sexual behaviors face a challenge where simple
answers rarely suffice.
So how do clinicians consider questions about normal sexual behavior?
And how do clinicians make sense of behaviors that may seem provocative,
precocious, or problematic? As a starting point, clinicians should be familiar
with the scientific literature that describes common juvenile sexual develop-
ment and behaviors. This literaturecomprised primarily of survey data
documents the frequency of certain sexual behaviors within particular juvenile
populations. Therefore, it helps clinicians gauge the extent to which behaviors
are common versus uncommon, and it provides some context against which
to compare any individual case. Indeed, in the Report of the Task Force on
Children with Sexual Behavior Problems, authorities recommend, In deter-
mining whether sexual behavior is inappropriate, it is important to consider
whether the behavior is common or rare for the childs developmental stage
and culture, before moving on to consider individual, case-specific factors
(Chaffin et al., 2006, p. 3). In this chapter, we provide an overview of the
scientific data regarding typical juvenile sexual behaviors, in order to provide
clinicians a frame of reference for considering sexual behavior in individual
cases.
However, there are many limits to the scientific data on normative sexual
behaviors. First, there is actually less rigorous research data than we might
expect. Of the relatively few studies on childhood sexual behavior, many were
designed to address issues surrounding child sexual abuse, rather than normal
child sexual development (e.g., Rutter, 1971; Sandfort & Rademarkers, 2000).
Furthermore, sexual behavior is usually private and difficult to study, so even
the best-designed surveys are often constrained by the limits of self-report
or observational measures. More broadly, research methods from the social
and medical sciences are more useful for some questions than others. Survey
results are helpful to shed light on which behaviors are more and less common,
which is essential knowledge for clinicians who work with juveniles with sex-
ual behavior problems. But social science data are less helpful when it comes
to complex questions about whether particular behaviors in juveniles forecast
more serious problems in the future. Despite these important limitations,
clinicians cannot approach complicated questions about normal sexual
behavior without a solid grounding in the available data on sexual behavior
in juveniles.
Placing Sexual Behavior Problems in Context 23
W H AT D O W E K N OW A B O U T S E X UA L B EH AV I O R S
I N E A R LY C H I L D H O O D?
Studies suggest that at virtually every stage of childhood, children engage in

some degree of sexual behavior (sometimes labeled genital behavior to avoid
implying motives identical to adult sexuality). For instance, infant boys experi-
ence erections (Korner, 1969). And infants and toddlers, whether boys or girls,
appear to stimulate their genitals (Friedrich, 1993; Rutter, 1971; Ryan, 2000).
Childrens early interest in genital stimulation is unsurprising given that some
of the reinforcing physical sensations that accompany genital stimulation are
present from the youngest ages.
Of course, clinicians are rarely asked to address problematic sexual behav-
iors among infants. The preschool years tend to be the earliest point when
concerns arise, perhaps because children are interacting with other chil-
dren outside the home for the first time. Research on child sexual behaviors
at this stage consists primarily of survey results from parents and day care
staff (e.g., Davies, Glaser, & Kossoff, 2000; Larsson & Svedin, 2002b; Lindblad,
Gustafsson, Larsson, & Lundin, 1995). For example, one survey of preschool
staff revealed that they often observed preschool children expressing curiosity
about genitals, touching their genitals, or attempting to touch womens breasts
(Davies et al., 2000).
But the most comprehensive of studies of common child sexual behaviors
come from Friedrich and colleagues (1991, 1998), who used a structured mea-
sure, the Child Sexual Behavior Inventory (CSBI), to survey parents about a
variety of sex-relevant behaviors their children may have demonstrated. The
survey covered broad categories of behaviors, including touching self, touching
others, sexual play, sexual knowledge, sexual curiosity, and gender awareness.
Results suggest the preschool and kindergarten years are a peak time of sexual
behaviors, or at least observed sexual behaviors, in young children.
In the largest of their studies (Friedrich, Fisher, Broughton, Houston, &
Shafran, 1998), which attempted to exclude children with any history of sexual
abuse, the most commonly observed sexual behaviors among children ages
2 to 5 years included the following: touching sexual (private) parts when at
home, touching sexual (private) parts in public, touches . . . their mothers
or other womens breasts, and tries to look at people when they are nude or
undressing. According to parents, each of these behaviors occurred among
at least 25% of children ages 2 to 5, with some behaviors reported among half
the sample. Other commonly endorsed sexual behaviors, such as stands
too close to people, appear more related to knowledge of social norms or
boundaries than to sexuality per se. In addition to those particularly common
behaviors, a large minority of children ages 2 to 6 appear to engage in more
overtly sexual behaviors. For example, adults observed 23% of boys and 16%
of girls masturbating by hand (Friedrich, Grambsch, Broughton, Kuiper, &
Beilke, 1991). Similar proportions of young children exposed their genitals to
adults (Friedrich et al., 1991).
Of course, although some sex-related behaviors are commonplace among
children, many other forms of sexualized behavior are exceedingly rare. For
example, in broad samples that attempted to exclude children who had been
sexually abused, less than 1% of young children were reported to attempt
intercourse, pretend their toys were having intercourse, make sexual sounds,
place their mouth on genitals, masturbate with objects, or insert objects into
vagina or rectum (Friedrich et al., 1991, 1998; see Davies et al., 2000, for sim-
ilar conclusions based on reports from preschool staff ). Presumably, these
rare and explicitly sexual behaviors suggest that a youth has witnessed adult
sexuality or experienced sexual abuse (Hornor, 2004; Ryan, 2000). Indeed,
age-inappropriate sexual behavior tends to be the most specific marker of
sexual victimization, particularly among young children (Friedrich, 1997;
Friedrich et al., 2001; Kendall-Tackett, Williams, & Finkelhor, 1993).
To summarize, the frequency of child sexual behavior observed by adults
tends to increase steadily until peaking around age 5, but it declines thereafter
(Friedrich et al., 1998). This decline presumably occurs because children learn
that many sexual behaviors are prohibited in public and they adjust their behav-
ior accordingly (Poole & Wolfe, 2009). Yet even during these young ages in which
sexual behaviors are most often observed, behaviors that are explicitly similar to
adult sexuality (e.g., attempting intercourse, penetration) remain rare.
W H AT D O W E K N OW A B O U T S E X UA L B EH AV I O R S I N
M I D D L E C H I L D H O O D?
In the elementary school years, sexual behaviors that were common at younger
ages decrease, or are at least observed less often by adults. Nevertheless,
a significant minority of youth are still observed touching their genitals at
home and even masturbating. The sexual behaviors that increase during the
elementary school years appear to reflect increasing curiosity about adult
sexuality. For example, based on parent report, at least 10% of children ages
6 to 12 show interest in looking at pictures of nude people, attempting to watch
nudity on television, or talking about sexual acts (Friedrich et al., 1998).
Of course, as children grow older they may become better reporters of their
own sexual behavior, including behaviors their parents do not observe. Thus,
the research on middle childhood sexuality relies not only on parent report
but also on retrospective accounts from (grown) children themselves. Not
surprisingly, these retrospective reports tend to describe more sexual behavior

than studies based on parent report. For example, self-report surveys reveal
that most males, and many females, report masturbating prior to adolescence,
even though the surveys based on parent reports suggest far lower rates (see
Poole & Wolfe, 2009). Intimate contact between children is also apparently
more common than surveys of parents suggests. In a survey of over 600 under-
graduates, 59% recalled at least one sexual experience with another child (i.e.,
exposing genitals, fondling genitals, fondling other body parts, or intercourse)
before age 13 (Haugaard, 1996). Of these behaviors, exposing genitals was
the most common, with intercourse the least common. An older US study
(Haugaard & Tilly, 1988) reported that 42% of their undergraduate sample
reported some form of sexual contact with a peer before age 13; the most com-
mon age of contact was age 9. Again, exposing genitals was the most common
behavior, but some respondents reported genital fondling, and even oral sex or
attempted intercourse.
Although middle childhood sexual behaviors may be commonplace, sur-
vey respondents reported that such experiences were not always desired. Most
occurred with a friend of the opposite sex. A minority involved peers of the
same sex or elements of coercion, and study participants characterized these as
more negative experiences (Haugaard & Tilly, 1988). Likewise, nearly a third of
undergraduate women who reported childhood sexual contact or play reported
that the contact was coerced or manipulated (Lamb & Coakley, 1993).
The available studies agree that some degree of sexual exhibition or contact
is fairly common among preadolescent children. But it is important to
emphasize the limits to what these studies can reveal. Self-recollection stud-
ies from undergraduates from a few US universities may not generalize to
children from more diverse socioeconomic groups or children in other con-
texts. For example, a similar study from Sweden found much higher rates of
self-reported sexual contact among peers during preadolescence (Larsson &
Svedin, 2002a). Likewise, surveys of undergraduates conducted a few decades
ago may not generalize to any children in contemporary culture, after rapid
changes in media and technology have prompted rapid changes in social
norms and relationships.
Faced with this limited research base, we can draw a few conservative
conclusions about sexual behaviors prior to adolescence:
a) Compared to preschool children, children of elementary school age

tend to display fewer overt sexual behaviors, and they better respect
social norms related to personal boundaries and modesty. Yet many
still display sexual behaviors at home, and they demonstrate increasing
curiosity about adult sexual behaviors.
b) A substantial portion of elementary and middle school age youth (as

self-reported once they reach adulthood) have some form of sexual
play or sexual contact with peers. Though exposing genitals is most
common, a significant minority engage in behaviors more similar to
adult and adolescent sexuality.
W H AT D O W E K N OW A B O U T S E X UA L B EH AV I O R S I N
A D O L ESC EN C E?
Compared to the limited data on sexual behaviors in childhood, we have

far more (and far more rigorous) scientific research that describes sexual
behaviors in adolescence. Perhaps because of social concerns about teenage
pregnancy and risky sexual behaviors, federal and private sources have funded
several large-scale studies that address adolescent sexuality. For example, the
Youth Risk Behavior Survey (YRBS), conducted every 2 years by the Centers
for Disease Control and Prevention ([CDC], 2010), presents detailed data
gathered from 9th through 12th grade students in public and private schools
in the United States. Thus, it provides one of the best snapshots of typical
teenage sexual behavior. Other large-scale surveys of sexual behaviorsuch
as the National Survey of Family Growth (NSFG; Abma, Martinez, & Copen,
2010; Abma, Martinez, Mosher, & Dawson, 2004), which is also conducted by
the CDC, or the National Survey of Sexual Health and Behavior (Center for
Sexual Health Promotion, Indiana University, 2010)also provide a helpful
overview of teenage sexuality.
Overview of Adolescent Sexual Behaviors
First Intercourse
Despite the frequency of childhood sexual behaviors mentioned earlier, most
youth do not have sexual intercourse before adolescence. Nationwide, only
5.9% of students reported having sexual intercourse before age 13 (CDC,
2010). Rates of first intercourse before age 13 were generally higher among
males (8.4%) than females (3.1%) (CDC, 2010). Overall, age 17 is the average
age of first sexual intercourse. For females, first sexual intercourse tends to
occur with a slightly older male. But for males, first intercourse tends to occur
with a female of the same age or younger.
Adolescents first experiences with sexual intercourse are not always posi-
tive. Among females in the NSFG, 7%9% reported that their first experience
of sexual intercourse was not voluntary, and this rate was higher among girls
who had first intercourse at earlier ages (Abma et al., 2004, 2010). Similarly,
10% of females (compared to 5% of males) reported that they really didnt
want [their first sexual intercourse experience] to happen at the time. An even
higher percentage47% of females and 34% of malesreported that they had
mixed feelings about their first sexual intercourse (Abma et al., 2010).
Adolescent Sexual Activity

As adolescents grow older, sexual intercourse becomes more commonplace.
Thus, the percentage of students who report having ever had sexual inter-
course increases from 9th grade (31.6%) through 10th grade (40.9%), 11th
grade (53.0%), and 12th grade (62.3%) (CDC, 2010). Overall, 34.2% of high
school students are currently sexually active, defined as having reported
sexual intercourse with at least one person during the 3 months preceding
the survey (CDC, 2010). Of course, current sexual activity is more common
among older students than younger students (e.g., a 49.1% rate among 12th
graders compared to a 21.4% rate among 9th graders). By the 12th grade, more
females (53.1%) than males (45.1%) report that they are currently sexually
active (CDC, 2010).
However, other rigorous surveys of adolescents (based on somewhat differ-
ent methodologies) suggest we should be careful not to overestimate adolescent
sexual activity. At any point in time, most US adolescents are not participating
in sexual behavior with a partner. While 40% of 17-year-old males reported
vaginal intercourse in the past year, only 27% reported intercourse in the past
90 days (Center for Sexual Health Promotion, Indiana University, 2010). As one
research team stated, an adolescents sexual experience does not necessarily
indicate ongoing sexual activity (Fortenberry et al., 2010, p. 311). Finally, a
substantial portion of youth have not had sexual intercourse at all. Among
those who abstained from intercourse, the most commonly cited reason was
that it was against [their] religion or morals (Abma et al., 2010).
The National Survey of Sexual Health and Behavior ([NSSHB], Center for
Sexual Health Promotion, Indiana University, 2010) sampled adolescents
by age (14 through 19) rather than grade and examined somewhat different
behaviors than the YRSB (CDC, 2010). Thus, this survey allows for a slightly
different perspective on adolescent sexuality, although results are generally
similar. By age 19, most males (62.5%) and females (64.0%) reported that they
had engaged in vaginal intercourse at least once. Generally, the NSSHB found
that rates of intercourse were slightly higher among girls than boys at every
stage: that is, ages 1415 (12.4% of females versus 9.9% of males), ages 1617
(31.6% of females versus 30.3% of males), an 1819 (64% of females versus
62.5% of males).
Oral sex is prominent among adolescent sexual behaviors, according to

several rigorous studies (e.g., Halpern-Felsher, Cornell, Kropp, & Tschann,
2005). In the NSSHB (2010), most participants reported performing oral sex
by age 19. For example, 60.9% of males had performed oral sex on a female,
and 61.2% of females had performed oral sex on a male. Rates of same-sex oral
sex were lower (10.1% for males and 8.2% for females by age 19) but significant.
In a study of 580 ethnically diverse ninth-grade adolescents (mean age 14.5
years), more youth reported having had oral (19.6%) than vaginal (13.5%) sex
(Halpern-Felsher et al., 2005). Likewise, when asked about the sexual behav-
iors that they anticipated in the next 6 months, slightly more youth reported
that they anticipated oral sex (31.5%) than vaginal sex (26.3%). Generally, these
ninth graders perceived oral sex as more prevalent, acceptable, and safe, com-
pared to vaginal sex (Halpern-Felsher et al., 2005). Indeed, although young
people hold divergent views about what behaviors should be considered hav-
ing sex, most report that they do not consider oral-to-genital contact as hav-
ing sex (Sanders & Reinisch, 1999).
Compared to oral sex, anal sex appears far less common among adolescents,
but it is not rare. By age 19, almost 10% of males and 20% of females had par-
ticipated in anal sex (Center for Sexual Health Promotion, Indiana University,
2010). As with oral sex, many young people do not consider anal penetration
as having sex (Sanders & Reinisch, 1999).
Some adolescents report having sex with multiple partners, but promiscuity
appears to be the exception rather than the rule. Nationally, 13.8% of high
school students reported that they had sexual intercourse with four or more
persons over the course of their life (CDC, 2010). Again, these rates increase
with age, with the percentage of students who report having had four or
more partners increasing from 9th grade (8.8%) through 10th grade (11.7%),
11th grade (15.2%), and 12th grade (20.9%). But these rates always reflect
a minority of students overall.
Finally, much adolescent sexual activity does not involve a partner. Most
males acknowledged masturbation alone (with rates ranging from 67.5% at
age 1415 to 86.1% by age 1819), as did approximately half of females (with
rates ranging from 43.3% at age 1415 to 66.1% by age 1819) in the NSSHB
(Center for Sexual Health Promotion, Indiana University, 2010). Indeed, sol-
itary masturbation (whether past month or past year) was more commonly
reported than most partnered sexual behaviors for boys age 14 through early
adulthood, and for girls ages 14 to 17 (Herbenick et al., 2010).
Regarding sexual orientation, in the NSSHB (Center for Sexual Health
Promotion, Indiana University, 2010) most adolescents identified them-
selves as heterosexual (96.1% of males and 90.5% of females). Whereas very
few females identified themselves as lesbian (0.2%), somewhat more males
identified themselves as gay (1.8%). Conversely, many more females identified

themselves as bisexual (8.4%) compared to males (1.5%).
Adolescent Sexual Behavior Differs by Ethnicity and Locality
Adolescent sexual behavior can vary so much across groups and contexts that
it can be misleading to discuss adolescent sexual behavior in global terms. For
example, regarding early sexual intercourse, recall that only 5.9% of students
reported having sexual intercourse before age 13 (CDC, 2010). But across local
survey sites, these rates ranged from 4.8% to 14.5% (CDC, 2010). Culture and
ethnicity appear to play a part in that variability. Intercourse before age 13 was
more common among black (15.2%) and Hispanic (6.7%) than white (3.4%)
students. Black males reported the highest rates of early intercourse (24.9%)
among all ethnicity/gender groupings.
Regarding sexual behaviors generally, more black (47.7%) and Hispanic
students (34.6%) than white students (32.0%) report they are currently sexu-
ally active, as defi ned by having had intercourse during the 3 months preced-
ing the survey (CDC, 2010). According to the YRBS (CDC, 2010), black male
high school students are the most likely (72.1%) to report that they have ever
had sexual intercourse, followed by black females (58.3%), Hispanic males
(52.8%), Hispanic females (45.4%),white females (44.7%), and white males
(39.6%).
Gender and ethnic differences emerge again when we look specifically at
more risky sexual behaviors. The prevalence of reporting sexual intercourse
with four or more persons over the course of their life was higher among
male (16.2%) than female (11.2%) students. Likewise, reporting four or more
partners was more common among black (28.6%) than Hispanic (14.2%) or
white (10.5%) students (CDC, 2010). The prevalence of condom use, as defined
by having used a condom during last sexual intercourse, appears more com-
mon among white (63.3%) and black (62.4%) students than among Hispanic
(54.9%) students (CDC, 2010).
Of course, describing ethnic differences in adolescent sexual behavior can
be misleading, because most ethnic differences are confounded with variables
related to income and neighborhood context. Even well-designed studies like
the YRBS fail to account for socioeconomic variables in reporting most of their
results, so it is important for clinicians to use caution when considering data
reported by ethnicity alone. Typical sexual behavior for an African American
male in an impoverished urban neighborhood may differ from typical sexual
behavior for an African American male from an affluent family in a small
university town.
Adolescent Sexual Behavior Differs Over Time

and Generation Cohorts
Intuitively, we might assume that rates of teenage sexuality steadily increase

with each passing year, as American social norms toward sexuality become
more open and new technology facilitates romantic and sexual relations among
teens. But the data suggest otherwise. Across most traditional measures of
sexual behavior, there has been a slight decrease in sexual activity since the
early 1990s. For example, the percentage of high school students who reported
they had ever had sexual intercourse decreased from a majority (54.1%) in
1991 to a minority (46.0%) in 2009 (CDC, 2010). Likewise the percentage that
reported sexual intercourse with four or more persons decreased from 18.7%
to 13.8% between 1991 and 2009. In contrast, safer sex practices have tended
to increase over the years: 46.2% reported condom use in 1991, whereas 61.1%
reported condom use in 2009 (CDC, 2010).
Why should clinicians care about cohort effects and shifts in sexual behavior
over time? They should care because normal or common sexual behaviors
may vary slightly over time. Admittedly, these shifts are modest and will prob-
ably not drastically change the perceived normality of most sexual behaviors.
But clinicians in one era should not necessarily assume that the norms they
observed when they were adolescents, or even the norms they learned dur-
ing their professional education, reflect normative adolescent sexuality today.
Reviewing current data can provide a helpful reorientation.
S U M M A RY
Most juveniles engage in a variety of sexual behaviors beginning in early child-

hood and spanning through middle childhood, although as a child ages these
sexual behaviors become less easily observed by adults and more congruent
with social norms. Beginning in adolescence, increasing proportions of youth
engage in intimate sexual contact with others, although the nature and extent
of this contact vary considerably.
Research data like those reviewed earlier are helpful to provide a frame of
reference for a juveniles sexual behavior. The data are important for clinicians
faced with questions like How common is it to have had sexual intercourse
before entering high school? or Is it unusual for a 10th grader to have had five
sexual partners? Research data can help define what is statistically normative,
which may be a starting point for considering whether a particular behavior is
problematic. But we can rarely answer important questions about a particular
sexual behavior, by a particular juvenile, based on normative data alone.
The type of juvenile sexual behavior that comes to the attention of clinicians
usually falls somewhere along a continuum that ranges from typical sexual
behavior to inappropriate sexual behavior to sexually aggressive behavior. To
understand these behaviors, clinicians rely on much more than normative
data. For example, as the ATSA Task Force on Children with Sexual Behavior
Problems (Chaffin et al., 2006) explained:
In determining whether sexual behavior is inappropriate, it is important

to consider whether the behavior is common or rare for the childs
developmental stage and culture; the frequency of the behaviors; the
extent to which sex and sexual behavior has become a preoccupation
for the child; and whether the child responds to normal correction from
adults or continues to occur unabated after normal corrective efforts.
In determining whether the behavior involves potential for harm, it is
important to consider the age/developmental differences of the children
involved; any use of force, intimidation, or coercion; the presence of any
emotional distress in the child(ren) involved; if the behavior appears to be
interfering with the child(ren)s social development; and if the behavior
causes physical injury. (p. 3)
In short, considering whether a behavior is normal is just a first step.

Thereafter, clinicians assess the juvenile and the sexual behavior that has
prompted concern. Whereas this chapter provides a frame of reference by
reviewing common sexual behavior, the remainder of this text details sub-
sequent steps in understanding, assessing, and treating youth with sexual
behavior problems.
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3
Patterns of Sexual Offending in

Juveniles and Risk Factors
JOHN A. HUNTER
OV ERV I E W
Youth who engage in sexual offending behavior represent a heterogeneous clin-

ical population that differs on a number of important dimensions, including
age at onset, sex, personality characteristics, extent of comorbid psychopathol-
ogy, and modus operandi. This chapter reviews three major subpopulations of
sexually abusive youth: (1) prepubescent youth who engage in sexually abusive
behavior, (2) adolescent females who sexually offend, and (3) adolescent male
sex offenders. Within each subpopulation, there is discussion of salient sub-
types of youth, as identified through clinical observation and research. Finally,
this chapter reviews risk factors for the emergence of sexual behavior problems
in youth, and sexual and nonsexual recidivism.
PR EPU B ESC EN T C H I L D R EN W I T H S E X UA L B EH AV I O R
PR O B L EM S
Professional and media attention is generally directed at adolescents who

engage in sexual offending behavior. However, it has been clinically observed
that such behavior may emerge even earlier in the developmental process and
prior to puberty. This includes children who aggress against peers and those
who engage younger children in sexual behavior. One of the most compre-
hensive studies aimed at describing subtypes of these youth was conducted
Patterns of Sexual Offending in Juveniles and Risk Factors 35
by Pithers, Gray, Busconi, and Houchens (1998). They focused on male and
female children between the ages of 6 and 12 years who had exhibited prob-
lematic sexual behaviors. The researchers used theory-driven cluster analysis
to identify five subtypes of these youth: (1) sexually aggressive, (2) nonsymp-
tomatic, (3) highly traumatized, (4) rule breaker, and (5) abuse reactive.
Over 90% of the children in the highly traumatized group were diagnosed
with posttraumatic stress disorder (PTSD). The sexually aggressive subtype
had an overrepresentation of males, the highest percentage of children with
a diagnosed conduct disorder, and the greatest percentage of children who
engaged in highly aggressive sexual misbehavior. Additionally, the sexually
aggressive group manifested the lowest trait anxiety of any child type and
showed the poorest response to sex offenderspecific treatment.
Hall, Mathews, and Pearce (2002) also found differences among prepubes-
cent children with sexual behavior problems based on the extent to which the
behavior was planned and coercive. Like Pithers et al. (1998), they found a
group of youth who engaged in more persistent and intentional sexual act-
ing out. As will be subsequently discussed, a number of these empirically
identified subtypes parallel the authors categorization of adolescent male sex
offenders.
Children with sexual behavior problems appear to respond well to short-
term cognitive-behavioral interventions. Carpentier, Silovsky, and Chaffin
(2006) conducted a 10-year follow-up study on 135 children (ages 512) with
documented sexual behavior problems who were randomly assigned to either
cognitive-behavioral or play therapy. Each therapy was 12 sessions in dura-
tion. The cognitive-behavioral group had significantly fewer cases of sexual
recidivism (2% vs. 10%) and did not significantly differ from a general clinic
comparison group (3%). These results are encouraging and suggest that the
emergence of sexual behavior problems in children need not portend a devel-
opmental continuance of the behavior. Examination of treatment outcomes
across studies suggests that sexually abusive children with trauma histories
have particularly favorable treatment prognoses.
S E X UA L LY A B U S I V E A D O L ESC EN T FEM A L ES
Within the larger population of adolescents who engage in sexually abusive

behavior are teenage girls. However, females account for less than 10% of
the arrests of juveniles for sexual offensessuggesting that the prevalence of
sexual offending in this subpopulation is relatively low. It is noted, however,
that arrest data may reflect reporting biases and that the actual incidence of
juvenile female sexual offending may be higher. Clinical data suggest that
many males do not construe sexual experiences with older females as abusive
and therefore do not report them to authorities.
The role of trauma in the etiology of sexual offending behavior in females is
compelling. Estimates are that over three-quarters of sexually offending ado-
lescent females report a prior history of sexual abuse (Mathews, Hunter, &
Vuz, 1997). Mathews et al. (1997) not only found that adolescent female sex
offenders were more likely to report a history of sexual abuse than their male
counterparts, but that their abuse experiences were more extensive and severe.
Their survey data suggested that seven times more adolescent females than
males had multiple perpetrators, that the females were younger on average at
first sexual victimization, and that they were more often subjected to force.
Adolescent female sex offenders also report high levels of childhood physical
abuse and exposure to domestic violence.
Not surprisingly, PTSD is a frequent comorbid condition in juvenile
females who engage in sexually abusive behaviorparticularly those found
in residential treatment centers. PTSD may directly or indirectly contribute
to sexual preoccupation and arousal issues in these youth, and it lends itself
to mood regulatory and impulse control problems (Hunter, Becker, & Lexier,
2006). Also frequently found, and closely associated with extensive trauma
histories, are mood disturbances, histories of substance abuse, and problems
of conduct (Hickey, McCrory, Farmer, & Vizard, 2008).
As noted by Hunter, Becker, and Lexier (2006), the majority of hands-on
sexual offenses committed by adolescent girls are against younger children.
Sexual aggression directed at peers is much less common. As with younger
children and adolescent boys who engage in sexually abusive behavior, a vari-
ety of offense patterns and levels of sexual disturbance is displayed. Mathews
et al. (1997) describe three clinically observed subgroups of these youth:
(1) nave/experimenters, (2) sexually traumatized, and (3) pervasively
disturbed. The first group (i.e. nave/experimenters) represents girls who
sexually act out with younger children on a limited basis and typically in
the context of babysitting. The motivation for the behavior may be curiosity,
fueled by uncertainty or a lack of self-confidence regarding sexual matters.
These youth do not manifest strong sexual or other psychopathology and
typically respond well to short-term psychoeducational and supportive
therapy. The second group of youth includes those with more extensive
trauma histories. With these youth, there are typically parallels between
their sexual victimization experiences and their sexual perpetrations. In
some cases, their own sexual victimization may temporally overlap with
their perpetrating behavior. Concomitant mood and identity disturbances
are often seen in these youth, and their treatment needs are more intensive
and comprehensive.
The third group of youth represents those with more pervasive and long-
standing sexual and related psychopathology. These youth have typically
offended against more than one child and may have used coercive methods.
In addition, they generally manifest substantial psychiatric comorbidity. The
latter may include PTSD, major mood disturbance (e.g., bipolar I or II), and
conduct disorder. Substance abuse problems are also common in this sub-
group, and many have engaged in suicidal gestures or attempts. Because of
their more severe psychopathology, this latter group of girls requires more
intensive and longer term treatment. In more severe cases, this may include
placement in intensive residential treatment programs.
S E X UA L LY A B U S I V E A D O L ESC EN T M A L ES
Adolescent males account for the preponderance of juvenile arrests for

sexual crimes, including 98% or more of the rapes and over 90% of other
juvenile-perpetrated sexual offenses (OJJDP Statistical Briefing Book, 2009;
Snyder & Sickmund, 2006). As with sexually abusive prepubescent children
and adolescent females, adolescent boys who perpetrate sexual crimes present
with a range of sexual and related psychopathology.
Early efforts to classify sexually abusive adolescent males included the
contrast of those who targeted children and those who offended against peers
or adults. In one comparative study, Hunter, Hazelwood, and Slesinger (2000)
utilized police investigative records to examine offense characteristic dif-
ferences between these two groups. Offenders of peers/adults were found to
more often choose female victims (93.7% vs. 67.7%) and those outside of the
family unit (84.4% vs. 59.7%). They also displayed more gratuitous violence
in the commission of their sexual offenses and greater nonsexual criminality.
Worling (1995) found that offenders of peers/adults were more likely to have
a childhood history of physical abuse. Butler and Seto (2002) established that
adolescent male sex offenders with histories of nonsexual offenses had more
extensive histories of childhood conduct problems and poorer adolescent
psychosocial adjustment than those without concurrent patterns of nonsexual
offending.
More recently, Miner and colleagues (2010) compared sexual offenders of
children to nonsex offending delinquents, and peer/adult sex offenders, on
three personality constructs: (1) attachment style, (2) interpersonal involve-
ment, and (3) hypersexuality. Their results revealed that adolescents with
child victims displayed more pronounced feelings of personal inadequacy,
more oversexualization, and more positive attitudes toward others compared
to peer/adult offenders and nonsex offending delinquents. Thus, a number of
studies have suggested that adolescent males who target peer or adult females
are generally more antisocial and physically aggressive than those who offend
against children. The latter group of youth appears to be more prone to
self-esteem and social competency deficits, and feelings of inadequacy.
Other studies have attempted to classify adolescent male sex offenders
based on their manifest personality characteristics. In one of the first such
studies, Worling (2001) used scores on the California Psychological Inventory
to cluster adolescent male sexual offenders into four groups: (1) antisocial/
impulsive, (2) unusual/isolated, (3) overcontrolled/reserved, and (4)
confident/aggressive. He found that the offenders in the first two groups
were more likely to be charged with a subsequent criminal offense (sexual or
nonsexual).
Hunter, Figueredo, Malamuth, and Becker (2003) studied the following
personality constructs in a sample of 186 adolescent male sex offenders:
hostile masculinity, egotistical-antagonistic masculinity, and psychoso-
cial deficits. Hostile masculinity was defined as a set of negative and pejorative
attitudes toward females, including the belief that females are manipulative
and ultimately rejecting of males. Such attitudes are closely related to rape
mythology. Malamuth et al. (1996) had previously applied the hostile mas-
culinity construct to the study of sexually aggressive adult males. In these
studies, he found that hostile masculinity coupled with sexual promiscu-
ity predicted coercive sexual behavior directed at females.
The studied egotistical-antagonistic construct relates to dominance
characteristics and heightened intrasexual competition between males in
the pursuit of females. Psychosocial deficits is associated with poor social
self-esteem and related feelings of depression and social anxiety. Using
structural equation modeling (SEM), Hunter et al. (2003) found that psycho-
social deficits predicted sexual offending against prepubescent child victims.
Both psychosocial deficits and egotistical-antagonistic masculinity predicted
nonsexual delinquency. Hostile masculinity was predicted by both egotistical-
antagonistic masculinity and psychosocial deficits, but it did not itself predict
victim status (child or peer/adult). Offenders of peer/adult females were found
to be more likely to offend against strangers or acquaintances and to commit
more dangerous offenses (a composite index of level of violence displayed,
weapon utilization, and accompanying nonsexual crime) compared to offend-
ers of prepubescent children.
In a follow-up study of 256 adolescent male sex offenders, Hunter and
colleagues (Hunter, 2008, 2009; Hunter, Figueredo, & Malamuth, 2010)
expanded the studied personality constructs to include pedophilic interests
and lifestyle delinquency. The former construct was defined as self-reported
sexual interest in children. Lifestyle delinquency represents psychopathic
personality traits and behavioral impulsivity. Hierarchical cluster analysis was

used to form five subtypes of sexually abusive adolescent males: (1) socially
impaired, anxious, and depressed; (2) life-course persistent; (3) pedophilic
interest (without antisocial traits); (4) pedophilic interests/antisocial; and
(5) adolescent-onset experimenters.
The life-course persistent youth scored high on three of the grouping
constructs: lifestyle delinquency, egotistical-antagonistic masculinity, and
hostile masculinity. The adolescent-onset experimenter group did not score
high on any of the grouping constructs. Comparison of these groups suggested
that the life-course persistent youth had relatively high levels of childhood
exposure to violence and were most likely to have a history of drug abuse.
They had engaged in the highest level of general nonsexual delinquency and
(along with the adolescent-onset experimenters) had the highest percentage of
sexual abuse victims who were adolescent or adult females. The pedophilic
interests/antisocial youth also were exposed to relatively high levels of vio-
lence as children and had the highest average number of sexual abuse victims.
These youth also had the highest index of childhood physical abuse and the
highest index of sexual victimization by a male perpetrator. They also had
relatively high levels of substance use. The adolescent-onset experimenters
had the lowest index of childhood maltreatment and the lowest number of
sexual abuse victims.
R I S K FACTO R S
In this section of the chapter, both endogenous and exogenous risk factors
for sexual offending and recidivism are reviewed. For discussion purposes,
endogenous risk factors will be defined as those relating to the youths per-
sonality characteristics and his sexual attitudes and interests. Exogenous
risk factors will refer to developmental experiences and events in the life of
the youth that may help shape or influence his personality and behavior, and
environmental influences. For purposes of brevity, this review will be limited
to discussion of certain better researched and clinically understood endog-
enous and exogenous risk factors. However, a general caveat is in order: The
study of risk and risk factors in juvenile sex offenders is in its relative infancy
compared to the study of the same in adult sex offenders and other clinical
populations of youth. What research has been conducted has almost exclu-
sively focused on adolescent male sex offenders. Furthermore, the extent to
which various endogenous risk factors are static versus dynamic in juveniles
is not entirely clear. For example, sexual interests and psychopathic attitudes
may be far less fi xed or static in juvenile sex offenders than adult sex offenders
(Hunter & Becker, 1994). Risk is a focus of intense research interest in the field,
and it is expected that knowledge on this subject will rapidly expand in the
next decade.
Endogenous Risk Factors
Three personality constructs that have received particular attention in the

study of risk of sexual and nonsexual recidivism in adolescent male youth
are reviewed: (1) psychopathy, (2) deviant (or paraphilic) sexual interests, and
(3) distorted sexual cognitions/attitudes.
Psychopathy and Antisocial Orientation

Psychopathy is a multidimensional construct that typically encompasses
interpersonal (e.g., grandiose, manipulative), affective (e.g. callous, shallow),
lifestyle (stimulation seeking, impulsive), and antisocial features (criminal
orientation) (Hare & Neumann, 2006). Th is four-factor model has been found
to fit for both adult and adolescent populations (Neumann, Kosson, Forth,
& Hare, 2006). Frick (2009) argues that the affective dimension of callous-
unemotional traits is the best predictor of negative treatment outcomes and
enhanced risk for aggressive and antisocial behavior in youth. Frick opines that
callous-unemotional (CU) traits are often first manifested in early childhood
and are overrepresented in a distinct and more pathognomic subtype of youth
with childhood-onset conduct problems. Frick and White (2008) reviewed
studies showing that youth who are high in CU can be differentiated from
other conduct disordered youth on the basis of social, cognitive, emotional,
and personality characteristics. Detected differences include the following:
greater deficits in processing negative emotional stimuli (i.e., underrespond
to signs of fear and distress in others), less relationship between dysfunctional
parenting practices and conduct problems, less sensitivity to punishment cues,
and more fearlessness and thrill-seeking behavior. Behavioral genetic research
suggests that CU traits are highly heritable and thus relatively stable over time
(Frick, Kimonis, Dandreaux, & Farell, 2003; Neumann et al., 2006; Viding,
Blair, Moffitt, & Plomin, 2005; Viding, Jones, Frick, Moffit, & Plomin, 2008).
While the callousness trait appears linked to genetic factors, there is research
suggesting that certain behavioral aspects of psychopathy (i.e., reactive aggres-
sion) may be linked to trauma experiences (Blair, Peschardt, Budhani, Mitchell,
& Pine, 2006; Knight & Sims-Knight, 2003; Neumann et al., 2006).
The poorer treatment response of youth with CU traits may be in some part
a function of therapeutic approach. Studies suggest that these youth respond
better to interventions that involve positive reinforcement than those that are
based on punishment paradigms (Frick, 2009). This may be due to neurological

deficits in the processing of punishment information. Blair and colleagues have
found that youth who score high on psychopathy have deficits in processing
stimulus-punishment associations and have difficulty with reversal learning
(i.e., they perseverate in response patterns after reinforcement paradigms shift)
(Blair et al., 2006). These researchers argue that these deficits, and those seen
in emotional processing (particularly fear and sadness), are linked to dysfunc-
tion in the amygdala and orbital and ventromedial prefrontal cortex.
As reviewed by Hare (1999), there is long-standing research indicating that
psychopathy is a robust predictor of general and violent crime in adults. Adult
criminals who score high on measures of psychopathy are three to four times
more likely to reoffend than their lower scoring counterparts. Meta-analytic
studies show that psychopathy reliably predicts sexual recidivism in adult sex
offenders (Hanson & Morton-Bourgon, 2005). Psychopathy has been dem-
onstrated to predict both general and sexual recidivism in adolescent males
(Gretton, McBride, Hare, OShaughnessy, & Kumba, 2001; Parks & Bard,
2006). It is less clear that psychopathy is a reliable predictor of recidivism for
juvenile females (Vincent, Odgers, McCormick, & Corrado, 2008).
Research suggests that unique dimensions of psychopathy may differentially
predict nonsexual and sexual recidivism. For example, Parks and Bard (2006)
found that the interpersonal factor of the Psychopathy Checklist for Youth
(PCL:YV) predicted sexual recidivism, whereas the behavioral factor (e.g.,
impulsivity) predicted nonsexual recidivism. These investigators found that
the antisocial factor of this scale predicted both types of recidivism.
Antisocial orientation is closely related to psychopathy. The principal dif-
ference is that antisocial orientation is typically more broadly defi ned and
encompasses both antisocial personality and behavioral traits (Hanson &
Morton-Bourgon, 2005). The latter includes impulsivity, substance abuse, job
instability, and a history of rule violation. Antisocial orientation has been found
to be a reliable predictor of sexual and general recidivism in both adolescent
and adult sex offenders. As previously discussed, antisocial orientation has
been found to be more prevalent in the samples of rapists than child molesters.
This has been found in both adolescent and adult sex offender populations.
Deviant Sexual Interests

Deviant sexual interests are typically clinically defined (see Hunter & Becker,
1994) as those that are age inappropriate, and if acted upon, would constitute
a legally definable sexual offense. Such interests are essentially synonymous
with paraphilias, as defined by DSM-IV-R. Thus, deviant sexual interests would
encompass the following: (1) the persistent sexual interest of an older adoles-
cent in prepubescent youth (i.e., pedophilia) (note: must be at least a 5-year
age difference per DSM-IV-R criteria and of at least 6 months duration); (2)
a sexual interest in coercive and/or nonconsensual sexual behavior, including
rape and sexual sadism; and (3) a sexual interest in exposure of ones genitals
to nonconsenting individuals (i.e., exhibitionism).
It must be emphasized that while deviant sexual interest is potentially
quite important in understanding risk of sexual recidivism in juveniles, only
modest research has been conducted on this subject matter. Furthermore, vir-
tually all of the extant research is limited to the study of adolescent males who
have perpetrated sexual crimes. Thus, there are little to no systematically col-
lected research data on the sexual interests and arousal patterns of nonsexual
offending adolescent males or that of sexual and nonsexual offending ado-
lescent females. The absence of sexual interest data in nonsexual offending
males is largely the result of the impracticality (i.e., ethical and consent issues)
of conducting such research using more invasive psychophysiologic measures
(e.g., plethysmograph). Both ethical concerns and technological complica-
tions make psychophysiological measurement of sexual interests in adolescent
females impractical. While less invasive methodologies for gathering sexual
interest data in juveniles exists (e.g., viewing time and self-report measures),
they are generally regarded as less reliable and of more uncertain validity.
Deviant sexual interests have been firmly established as a reliable predictor
of sexual recidivism in adult sex offenders (Hanson & Morton-Bourgon, 2005).
There is also empirical support for its importance in predicting sexual recidi-
vism in juveniles (Hanson & Morton-Bourgon, 2005). Regarding the former,
Hanson commented in his review of recidivism risk factors that the single
strongest predictor of sex-offense recidivism was sexual interest in children,
assessed phallometically (Hanson, 2000, p. 106). In their meta-analysis of 82
recidivism studies, Hanson and Morton-Bourgon (2005) separately analyzed
data on adolescent sex offenders and concluded that sexual deviance predicted
sexual recidivism as well for juveniles as it did for adult sex offenders. Deviant
sexual interest is typically not a good predictor of nonsexual recidivism.
Available studies suggest that deviant sexual interest in juveniles is
associated with having a male victim. This association was found in juvenile
samples by Hunter, Goodwin, and Becker (1994) and Seto, Lalumiere, and
Blanchard (2000). It is less clear that deviant sexual interest is a reliable predic-
tor of sexual offending against young females in adolescent perpetrators. Data
pointing to the greater salience of deviant sexual interest in offending against
young boys than girls in adolescent offenders are consistent with retrospec-
tive studies of adult sex offenders. Marshall, Barbaree, and Eccles (1991) found
that the earliest age of developmental onset for sexual offending within adult
child molesters was for those with male victims. Furthermore, this subgroup
of adult child molesters has been found to have the highest ratio of deviant
to nondeviant sexual arousal upon phallometric assessment, and the highest

average number of victims over the course of a lifetime of sexual offending
(Marshall et al., 1991). Hence, available data suggest that deviant sexual inter-
est plays a prominent role in juvenile and adult sexual offending against male
children, and that same-gender pedophilia may have a juvenile onset.
There is generally less empirical support for the prominence of deviant sexual
arousal in the commission of rape of peer/adult females (Looman, 2007). A
number of studies have failed to distinguish rapists from nonrapists based on
phallometrically measured sexual response to rape cues (Baxter, Barbaree, &
Marshall, 1986; Murphy, Krisak, Stalgatis, & Anderson, 1984). However, there
is research support for the assumption that rapists represent a heterogeneous
population and that there are subtypes of rapists who are motivated by deviant
arousal (Barbaree & Marshall, 1991; Looman, 2007). For example, there are
rapists who show evidence of direct arousal to cues of violence and/or victim
distress (i.e., sadists). However, there appear to be others who rape opportu-
nistically, and those who lack empathy and for whom cues of victim distress
do not perform their normal inhibitory role in sexual arousal (Barbaree &
Marshall, 1991). Research suggests that deviant arousal is not found in the
majority of exhibitionists (Marshall, Payne, Barbaree, & Eccles, 1991).
Distorted Sexual Cognitions

It has been long assumed that both adult and juvenile sex offenders frequently
display distorted beliefs regarding sexual behavior and the intentions of their
victims. The presence of distorted sexual cognitions is a risk factor on the
J-SOAP-II, a popular instrument for assessing risk of sexual recidivism in
juvenile sex offenders. It is believed that the presence of distorted sexual cogni-
tions may increase the risk of sexual offending by lowering the offenders inhi-
bition to engaging in such behavior. This may occur through minimization of
the significance or harmfulness of the behavior to the victim or by reducing
the perpetrators culpability. The latter includes beliefs that help justify the
offenders behavior (e.g., the victim dressed provocatively).
Within this category of risk factors are misogynistic beliefs and those
involving a general resentment of females or hostile masculinity (Malamuth et
al., 1996). Within Malamuths confluence model, hostile masculinity syner-
gistically interacts with promiscuous-impersonal sex to predict mens sexual
aggression toward women. The confluence model has received empirical sup-
port in a number of studied ethnic groups and cultures (Abbey, Parkhill,
BeShears, Clinton-Sherrod, & Zawacki, 2006; Hall, Teten, DeGama, Stanley,
& Stephens, 2005). Hunter et al. (2010) have examined such attitudes in juve-
nile sex offenders in relationship to both etiological variables and offense
characteristics. They found that hostile masculinity was strongly predicted by
psychopathic and antagonistic attitudes, and associated to a lesser extent with

psychosocial deficits. In their study, hostile masculinity made a modest contri-
bution to the prediction of pedophilic interests in juveniles.
Distorted sexual beliefs have been shown to predict sexual recidivism. In
the previously referenced meta-analysis conducted by Hanson and Morton-
Bourgon (2005), sexual attitudes was a predictor of sexual recidivism, though
a weaker predictor than either sexual deviancy or antisocial orientation. In the
cited Hanson study, it was a more robust predictor of any general recidivism
(i.e., pooled sexual, violent nonsexual, and violent offenses) than sexual recidi-
vism. Allan, Grace, Rutherford, and Hudson (2007) found that pro-offending
attitudes (cognitive distortions and rape myths) was a reliable predictor of
sexual and general recidivism in adult child molesters.
Exogenous Risk Factors
Four exogenous developmental variables are briefly reviewed in relation-

ship to the onset of sexual behavior problems in juveniles and recidivism:
(1) a history of sexual victimization, (2) childhood exposure to violence,
(3) childhood exposure to pornography, and (4) negative peer influences.
Childhood Sexual Victimization

The previously cited high incidence rates of sexual abuse in studied juvenile
sex offender samples have spurred considerable theoretical discussion of its
role in the etiology of sexual offending behavior in juveniles. The author will
summarize research findings that relate to the role of this variable in the risk
of developing sexual behavior problems and sexual recidivism. The reader is
referred to the work of Finkelhor and Browne (1985); Veneziano, Veneziano,
and LeGrand (2000); and Burton (2003) for discussion of theoretical issues.
A number of studies have established a higher rate of sexual victimization
in juvenile sex offenders relative to various comparison groups of juvenile
offenders (Burton, 2008; Spaccarelli, Bowden, Coatsworth, & Kim, 1997).
Researchers have investigated sexual trauma variables that potentially con-
tribute to subsequent sexual offending behavior. Hunter and Figueredo (2000)
identified four such variables in their comparison of 55 adolescents with
a history of sexual victimization and no known subsequent sexual perpetration
to 28 adolescents with a history of both sexual victimization and subsequent
sexual perpetration. In comparison to youth who did not subsequently sexu-
ally offend, juvenile sex offenders with histories of prior sexual victimization
were on average (1) younger at the time of initial sexual victimization experi-
ence, (2) sexually victimized a greater number of times, (3) waited a longer
period of time between the experienced victimization and first report of the
same, and (4) perceived their families as being less supportive of them upon
revelation of the victimization. Fleming, Burton, and Lampros (2001) found
that adolescent sex offenders were more likely to have been sexually abused by
a male, were abused over a longer period of time, and experienced more coer-
cive and invasive sexual abuse than nonsexual offending delinquents with a
sexual victimization history. Both of these studies point to trauma severity as
a relevant variable in understanding sexual victimization outcomes and asso-
ciated risk of subsequent perpetration.
It has been suggested that sexual victimization experiences may under
certain circumstances contribute to the emergence of deviant sexual arousal to
younger males (Becker, Hunter, Stein, & Kaplan, 1989). This potential associa-
tion has been discussed from both classical conditioning and social learning
theory paradigms. There is at least indirect empirical support for both models.
Becker et al. (1989) found that a history of sexual victimization predicted phal-
lometrically measured sexual interest in adolescents who had molested young
boys. Hunter et al. (2010) found that a history of sexual victimization by a male
positively contributed to self-reported pedophilic interests in adolescent male
sex offenders. A number of researchers have found parallels between the ado-
lescent sex offenders victimization experience(s) and his subsequent offending
behavior (Burton, 2008; Veneziano et al., 2000). For example, Burton (2003)
found that a youth who was sexually abused by a male was approximately six
times more likely to have a male victim than a youth who was not sexually
abused by a male. Hunter et al. (2003) similarly found in their studied sample
of adolescent male sex offenders that a history of childhood sexual victimiza-
tion by a male perpetrator was predictive of the youth later sexually offending
against a male child.
While childhood sexual victimization, especially when severe and
perpetrated by a male, appears to increase the risk of juvenile sexually
offending, it is less clear that it contributes to an increased risk for sexual
recidivism. In the previously referenced meta-analysis conducted by Hanson
and Morton-Bourgon (2005), a history of sexual victimization was only
weakly associated with sexual recidivism. Hence, childhood sexual victimiza-
tion may be more relevant to understanding the emergence (i.e., etiology) of
sexual behavior problems in some youth than to predicting sexual recidivism
in known juvenile and adult sex offenders.
Exposure to Violence
There is no hard evidence that childhood exposure to violence directly con-
tributes to risk of sexual perpetration or recidivism in juveniles. Hunter et al.
(2010) did find that exposure to violence both directly, and indirectly through
psychopathic and antagonistic attitudes, contributed to the prediction

of nonsexual delinquency in adolescent male sex offenders. However, the
observed association between exposure to violence and psychopathic and
antagonistic attitudes suggests that the former may indirectly contribute to
the prediction of sexual recidivism. As previously reviewed, psychopathy and
antisocial attitudes have been shown to predict sexual recidivism in both juve-
nile and adult sex offenders.
Exposure to Pornography
It is the authors clinical impression that exposure to hard-core pornography
has dramatically increased in adolescent male sex offenders, commensurate
with growth in public access to computers and the Internet. Many youth-
ful offenders report that they began viewing pornography prior to their first
sexual offense. In some cases, this began prior to puberty. While most youth
report that their exposure to pornography exclusively involved the viewing
of images of adults presumably engaging in consensual sexual activity, a few
youth clinically report the viewing of images of prepubescent children and/or
sexually coercive behavior.
The aforementioned clinical impression is supported by survey data
indicating the widespread exposure of youth in the general population to
pornography. Wolak, Mitchell, and Finkelhor (2007) found that 42% of
a national sample of youth ages 1017 was exposed to pornography over the
Internet in the prior year. Sixty-six percent (66%) of these youth reported
that their exposure to pornography was unwanted and primarily the result
of using fi le-sharing soft ware. College students report even higher rates of
exposure to pornography during adolescence. Sabina, Wolak, and Finkelhor
(2008) found that 93% of boys and 62% of girls reportedly being exposed to
pornography (via the Internet) during adolescence. The effects of exposure to
pornography on youth are not well understood in spite of considerable public
and professional interest in this subject matter. There are limited data suggest-
ing that young adult females generally express more concern about the poten-
tially harmful effects of pornography exposure than their male counterparts,
and they report more unwanted exposure to pornography (Hald & Malamuth,
2008; Rasanen & Wilska, 2007; Wolak et al., 2007).
While many nonclinical population males and females perceive pornog-
raphy exposure to have had more positive than negative effects on their lives
(Hald & Malamuth, 2008), there are data which suggest that pornography
can have a negative influence on high-risk individuals and those with
documented histories of sexual offending. For example, Vega and Malamuth
(2007) found that high-risk college males who were heavy users of pornog-
raphy had nearly twice as high sexual aggression indices as high-risk males
who were not frequent users of pornography. This relationship was not found
for low- and moderate-risk men. In their extensive review of the importance
of individual differences in pornography use, Kingston, Malamuth, Federoff,
and Marshall (2009) concluded that pornography consumption . . . may facil-
itate the likelihood of future sexual aggression . . . among individuals with a
predisposition for sexual offending (p. 227). Cited mechanisms of action
included the alteration of cognitive schemas related to sexual attitudes. These
researchers stress the importance of examining moderating variables when
predicting the impact of pornography on behavior. These include the indi-
viduals premorbid personality adjustment and his cultural, family, and peer
environment.
The content of the viewed pornography must also be taken into consider-
ation when studying the effects of pornography exposure on youth and its
clinical significance. Interest in child pornography, for example, is generally
considered more pathognomic than interest in stimuli depicting pubescent
individuals. Similarly, an interest in the viewing of images of coercive sexual
activity is considered more clinically significant than an interest in stimuli
depicting consensual sexual activity. There is empirical support for making
clinical distinctions based on the content of the pornography. For exam-
ple, Seto, Cantor, and Blanchard (2007) found that 60% of a sample of men
convicted for possession of child pornography showed clinically significant
sexual arousal to children upon phallometric assessment. In a more direct
assessment of pornography content relevance, Kingston, Fedoroff, Firestone,
Curry, and Bradford (2008) found adult sex offenders who viewed deviant
pornography (defined as that involving children or violence) were at higher
risk to recidivate than their nondeviant viewing counterparts. This effect was
present regardless of the offenders level of risk (i.e., no interaction effects).
There is relatively little research on the effect of pornography on juveniles
with sexual behavior problems. In one of the first and few studies conducted,
Ford and Linney (1995) found that juveniles with histories of sexual offenses
reported greater childhood exposure to pornography than status offenders
and nonsexual violent offenders. Hunter et al. (2010) found that exposure to
pornography predicted both psychosocial deficits and psychopathic and
antagonistic attitudes in adolescent male sex offenders. It is expected that the
empirical literature on the influence of pornography on high-risk youth and
those with known sexual behavior problems will rapidly expand over the next
few years.
Negative Peer Influences

Affiliation and/or exposure to negative peers has long been theorized to
increase the risk of future delinquency in youth (Coie, 2004; Kim, 2006). Data
are generally supportive of this assumption (Dodge, Dishion, Lansford, &

Putallaz, 2006). However, extant research suggests that there may be modera-
tors of this variable and that not all youth are equally vulnerable to its influence.
For example, Mrug and Windle (2009) found that peer deviancy predicted
externalizing problems in adolescent boys and girls only when combined with
negative parenting and in youth who engaged in higher levels of delinquent
behavior. Similarly, Matjasko, Needham, Grunden, and Farb (2010) found that
negative peers differentiated between violent victimization and perpetration,
and that its influence was strongest in young adolescents. Other research sug-
gests that the influence of negative peers on adolescents may be attenuated
by attachment to positive siblings (e.g., nondelinquent older brother) and/or
fathers (Clark-Miller, Fisher, & Clark-Miller, 2005; Fishbein & Perez, 2000).
While association with negative peers appears to increase the risk of
engagement in future delinquent behavior in juveniles, there are no known
studies that directly link it to an increased risk of sexual recidivism in identi-
fied juvenile sex offenders. There are data that support the association between
negative/criminal companions and sexual recidivism in adult sex offenders,
although the strength of the association is only moderate (Hanson, 2009). In
spite of the limited research that supports the association between exposure
to negative peers and sexual recidivism in juveniles, it is generally considered
to be of clinical relevance and is an item that is included in formal risk
assessment (e.g., J-SOAP-II). It is also a major focus on ecologically oriented
interventions for juvenile sex offenders, such as multisystemic therapy (MST;
Borduin, Schaeffer, & Heiblum, 2009).
S U M M A RY
Juvenile sex offenders are a heterogeneous clinical population. Most basically,

they can be distinguished on age (prepubescent vs. pubescent) and sex (male
vs. female). There also appear to be distinct subtypes of youth within each
of these categories based on identifying personality characteristics, sexual
attitudes/interests, and offending patterns. In particular, there appear to be
youth who are generally more antisocial and aggressive. Such youth tend to
have peer or older victims and to use more coercive methods. While there
are undoubtedly aversive environmental events that impact the developmental
trajectories of these youth, there may be genetic influences as well. Also seem-
ingly present are subgroups of youth who manifest more persistent deviant
sexual interests and those where the behavior seems mostly exploratory and
based on curiosity. Finally, across major age and sex categories, there appear
to be youth who have deficits in social competency and show concomitant
affective disturbances (i.e., anxiety and depression). The sexual offending of

these youth may be largely compensatory in nature, and preceding trauma
experiences may loom large in the clinical presentation.
A number of risk factors for the emergence of sexual behavior problems in
youth, and sexual and nonsexual recidivism, were reviewed. The study of risk
factors largely mirrors discussion of observed phenotypic subtypes of offend-
ing youth; namely, there appear to be multiple developmental trajectories
leading to sexually abusive behavior in juveniles and differential vulnerability
across youth to the effects of certain risk factors. It is believed that an improved
understanding of risk will emerge from future research that examines the
environmental context in which the risk factor occurs, as well as endogenous
and exogenous protective or moderating influences.
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4
Juvenile Sexual Offending and

Psychopathology
CAS E 1
Tom is a 16-year-old boy charged with three felony counts of indecent exposure
and sexual assault and battery on a child under 14 (a 10-year-old niece
on three separate occasions). He admits to episodic urges to have sex with
children. Tom compulsively views pornography, including child pornography,
despite his parents efforts to limit and supervise computer access. When they
removed his computer, he began to attempt to access pornography sites at the
public library. He was diagnosed with attention-deficit/hyperactivity disorder
(ADHD) at age 6, and 3 years ago he was diagnosed with bipolar disorder,
not otherwise specified (NOS) and obsessive-compulsive disorder (OCD). His
medications include a stimulant, an antipsychotic, and a selective serotonin
reuptake inhibitor. He reports daily use of marijuana and intermittent
alcohol use. Tom claims that during a summer vacation 2 years ago with
relatives, he was heavily exposed to Internet pornography on a daily basis
by an older male cousin, who also fondled him, and that his difficulties with
pornography, including child pornography, began then. He is overweight
and socially awkward and isolated, and he has been the target of bullying at
school. Toms parents and attorney believe that he committed his offenses in a
manic phase, and they are hoping for a recommendation from a psychiatrist
that he be court-ordered into a psychiatric hospital or residential treatment
center.
Juvenile Sexual Offending and Psychopathology 55
CAS E 2
Bruce is a 12-year-old boy diagnosed at age 7 years with Aspergers disorder and
ADHD. He has a full-scale IQ of 124. Bruce has been charged with five felony
counts of indecent exposure and assault and battery of a child under 14 (several
boys, ages 2 to 5 years) at his mothers home day care and two counts of rape
(two boys ages 3 and 4 years). He initially denied the offenses but now admits to
them. A year ago, he was court-ordered into therapy for fondling a 5-year-old
boy, a charge he denied, and which was eventually downgraded to a nonsexual
assault charge. He has a long history of being teased and bullied at school, and
last year he began to be homeschooled after an incident in which he claimed to
have been sexually abused and humiliated (stripped naked and fondled by a
group of same-aged peers in the boys bathroom at school). All the boys accused
denied the allegations during a school investigation, and no further legal action
was taken. Subsequent to this incident, Bruce was diagnosed by a child psy-
chiatrist with major depression, ADHD, and posttraumatic stress disorder
(PTSD) and prescribed an antidepressant. Several stimulant trials in the past
have been terminated secondary to significant side effects and questionable effi-
cacy. Bruces father is serving prison time for statutory rape and has done time
in the past on drug-related charges. Bruces mother suffers from an unspecified
mood disorder herself and is a recovering alcoholic. She has expressed a desire to
transfer custody of Bruce to her father with whom Bruce has always been close.
The maternal grandfathers medical status is somewhat precarious, however, as
he has been hospitalized several times this year for unstable diabetes. Bruces
mother has expressed a willingness to relinquish custody to Social Services in
the event that her own father is not approved as Bruces custodian in order for
Bruce to get the help he needs.
CAS E 3
Gerald is a 17-year-old boy treated for a major depressive episode (severe with
psychotic features) several months ago with antidepressant and low-dose antip-
sychotic medication. Family history is notable for two cousins diagnosed with
bipolar disorder and a maternal aunt diagnosed with schizophrenia. The mater-
nal great-grandfather committed suicide at age 33 after a losing his job. Three
weeks after initiation of the antidepressant Gerald announced that he was start-
ing his own church. Where as previously he had been hypersomnic, spending
most of the day in bed, his mother described Gerald more recently as bursting
with enthusiasm and energy. Within a week of that change, he was no longer
bathing, claiming that he was too busy doing the Lords work. He slept only
an hour or two a night, and his speech was pressured and at times difficult to
follow. His parents subsequently found a note indicating that Gerald had left
home to begin his ministry. A few days later, they received a call from a police
station several hundred miles away indicating that Gerald had been picked up
and charged with public exposure and lewdness. He was also charged with statu-
tory rape, as he was traveling with a 13-year-old runaway whose parents pressed
the charges.
CAS E 4
Elisha is a 16-year-old girl diagnosed with bipolar disorder when she was in a
residential treatment facility for a year at age 13. She is charged with rape of a
13-year-old mildly retarded boy for whom she was babysitting after school until
his parents arrived home from work. She is currently prescribed an antidepres-
sant and an antipsychotic, with which she is often noncompliant. A thorough
review of systems reveals evidence of chronic depression and significant anger
control problems. However, she denies any history of symptoms compatible with
mania or hypomania, and records available from other treatment providers
(including the discharge summary from the residential program) do not describe
symptoms that substantiate the bipolar diagnosis. Elisha was removed from her
biological mother when she was 7 years old for neglect and abuse. The sexual
abuse came to light when it was discovered that her mother and her boyfriends
were making videos of Elisha being sexually abused by adult males from the
time she was a toddler. Further investigation revealed that she spent long periods
locked in her room, where she was forced to urinate and defecate and was then
beaten and burned as punishment. Upon removal from the home and placed in
therapeutic foster care, Elisha made significant gains. She has been in weekly
individual therapy for years with a variety of therapists. She is an A-B student
and a cheerleader, and she is active in her youth church group. Elisha admits to
engaging in sexual activity with the 13-year-old but claims that the boy initiated
it and she went along because she felt sorry for him. Two months after these
charges surfaced, another family for whom Elisha did child care came forward,
claiming that their 5-year-old daughter told them that Elisha licked her pri-
vates and made [her] do bad things.
CAS E 5
Billy is a 17-year-old, mildly mentally retarded boy charged with multiple counts
of rape over a 4-month period, of a 12-year-old girl, Allison, who was residing in
the same foster home as Billy. He has also been diagnosed on various occasions
with ADHD; depressive disorder, NOS; mood disorder, NOS; and bipolar dis-
order. He admits to intermittent alcohol and cannabis abuse. He is currently
prescribed a stimulant medication and an antipsychotic. Billy was removed
from his biological mother at 6 years of age secondary to severe neglect, although
he first came to the attention of Social Services at age 4, secondary to repeated
bruising noted and reported by his teacher. His mothers live-in paramour was
incarcerated at the time of his removal for sexually abusing a 4-year-old sister.
Sexual abuse of Billy was suspected, but never proven, and Billy has consistently
denied that he was sexually abused prior to his removal from his biological
mother. Since age 6, Billy has had numerous foster and group home placements.
A founded case of physical and sexual abuse of Billy in one of his foster place-
ments by an 18-year-old foster child when he was age 10, which had gone on for
over a year, was documented. Apparently, Billy experienced the onset of depres-
sive symptoms, including suicidal ideation as well as oppositional behavior,
after his abuser was removed from the home. Billy claims that Allison is his
girlfriend and they plan to get married when he is 18. He denies ever using
physical force or coercion, and he claims that Alison is the only girl he has ever
been sexually active with. Billy has been removed from the foster home and is
in the juvenile detention center, awaiting transfer to jail as he is being tried as
an adult.
OV ERV I E W
What are the implications of psychiatric comorbidity in sexually offending

youth? After all, with few exceptions (e.g., sometimes mania and psychosis),
psychopathology is not causative of sexual offending. However, comorbid
mental illness, including substance abuse disorders, can be contributory to
sexually abusive behavior. Ignoring psychiatric comorbidity may doom or
compromise the efficacy of structured sex offender treatment. Mental illness
must be treated in this population, but treatment can be provided simultane-
ously with other forms of sex offender treatment, unless of course the offender
is psychotic, manic, or so severely depressed as to be unable to participate
in the program, in which case treatment of the acute episode in an inpatient
setting may be necessary.
Whether untreated psychiatric comorbidity raises the risk of sexual offend-
ing or recidivism in juveniles already adjudicated for a sex offense is unknown,
but for the clinician, commonsense application of knowledge of the morbidity
and mortality of untreated mental illness in the general and delinquent popu-
lations should guide intervention. There is remarkably little research on the
comorbidity of psychiatric disorders in adult sex offenders, and even less on

psychiatric comorbidity with sexual offending in youth. Given the paucity of
research on psychopathology in sexually offending juveniles, as well as the
fact that as a group they more closely resemble general delinquents rather
than adult sex offenders, this chapter includes a discussion of psychopathol-
ogy and mental illness among general juvenile offenders as well as juvenile sex
offenders. It should be emphasized that our knowledge base regarding juvenile
sex offenders is growing. While noting the similarities between nonsexually
offending juvenile delinquents and juvenile sex offenders, common sense leads
to the conclusion that there must be some differences. Seto and Lalumire
conducted a meta-analysis of 59 independent studies comparing 3,855 male
adolescent sex offenders with 13,393 male adolescent non-sex offenders. Their
results did not support the idea that adolescent male sex offending is just a
simple outgrowth of antisocial tendencies. Rather adolescent sex offenders
had less extensive criminal histories, less antisocial peers, and fewer substance
abuse problems than their counterparts who had not sexually offended. When
ranked for effect size, the largest difference between the groups was found for
atypical sexual interests. The next largest difference was found in sexual abuse
history. Other differences noted in the sexual offenders were exposure to sex-
ual violence, early exposure to sex and pornography, other forms of abuse or
neglect, social isolation, and low self esteem (Seto & Lalumire, 2010).
S O W H Y R E V I E W T H E R ES E A RC H O N A D U LT S E X
O FFEN D ERS?
Why are studies of adult sex offenders included in this book on juvenile sex
offenders? There are several reasons. First, most of the research in the area
of sexual offending has been done with adults, and any expert in this area
needs to be familiar with it. Second, as is often the case (for example, in the
area of psychopharmacology), research fi ndings in adults are often extrapo-
lated to youth, sometimes with unforeseen, erroneous, and even dangerous
results. Clinicians who evaluate and treat this population need to be aware of
the limitations of current research, especially with respect to youthful offend-
ers. Third, an unfortunate consequence of increased attention to the problem
of juvenile sexual offending and increased involvement of the criminal justice
system is the involvement of experts who may or may not have expertise in
the area of adult sex offending and psychopathology but who are inexperienced
and unknowledgeable regarding children and adolescents. It is important for
clinicians and forensic experts who work with youth to be knowledgeable
about the profound impact of developmental issues as well as the many ways
in which kids and adults are different.1 It is this authors opinion that the com-
bination of a firm foundation in child and adolescent development and psy-
chopathology enables the evaluator to place what we know about adult sex
offenders in the proper perspective when it comes to evaluating the juvenile
population, as well as to recognize and respond to flawed opinions and recom-
mendations based on erroneous information.
T H E O R I ES R EG A R D I N G T H E D E V ELO PM EN T
O F S E X UA L O FFEN D I N G
The term sexual offender technically relates to an individual who has been
convicted of a sexual crime and should not be assumed to be synonymous with
any specific mental disorder(s), including paraphilias. This is particularly true
for juvenile sexual offenders, a heterogeneous group, most of whom will not
continue sexually offending into adulthood. While adolescents who commit
sexual offenses as a group are more similar to juvenile delinquents who do not
sexually offend than to adult sex offenders, the limited number of studies of
comorbidity in adolescent sex offenders indicates a high incidence of diverse
psychiatric pathology. Additionally, a history of nonsexual offending has
been found in 28% to 50% of adolescent sex offenders (Becker, Cunningham-
Rathier, & Kaplan, 1986; Fehrenbach, Smith, Monastersky, & Deisher, 1986).
OShaughnessey (2002) notes that descriptive studies of youths who sexually
offend can be categorized into three groups: (1) underlying sexual deviation;
(2) general antisocial orientation; and (3) traits that indicate more general psy-
chopathology. Although such a framework is undoubtedly simplistic, it can
be useful to organize assessment and treatment as we await more definitive
research in this area.
Despite major advances in developing better methods for determining risk
of recidivism for adult sexual offenders, scholars and researchers in the area
of sexual abuse have yet to put forward a comprehensive theoretical frame-
work regarding the cause of sexual offending and subsequent treatment of
sex offenders. The lack of such a theoretical framework for sexually offending
youth is even more glaring. There is no empirically derived and validated clas-
sification system describing the heterogeneity that characterizes juveniles who
engage in sexually abusive/offensive behavior (Becker & Hicks, 2003).
1. As a forensic evaluator, I have been appalled at the blithe assumptions of some experts that
the research findings regarding adults can be applied to juveniles. The damage done from
both a public safety perspective and clinical/rehabilitative approach can be enormous.
A variety of theories have been proposed regarding the etiology of sex

offending in adults (Lanyon, 1997; Prins, 1991; Stinson, Becker, & Sales,
2008; Whitaker et al., 2008). While there is no generally accepted theory
regarding the cause of sex offending in youth, several factors have received
empirical and clinical interest, including a history of maltreatment, exposure
to pornography, substance abuse, and exposure to aggressive role models
(Becker & Hunter, 1997). Several theoretical models have been presented in
the sex offender literature that attempt to describe the development of sexu-
ally abusive behavior (OReilly & Carr, 2004). While most of the models were
advanced to explain adult sexual offending, the focus on developmental fac-
tors that promote criminal behavior generally, and sexual offending specifi-
cally, offers useful perspectives for the evaluation and treatment of youthful
sex offenders. Ryan and colleagues model of the cycle of sexual offending
begins with a negative self-image, which increases the probability of develop-
ing maladaptive coping strategies when confronted with negative responses
(Ryan, Lane, Davis, & Isaac, 1987). In this model, vulnerable youths develop
a habit of predicting negative responses from others, and in a protective
manner become withdrawn and socially isolated, retreating into fantasies to
compensate for powerlessness and helplessness. The sexual offending occurs,
which further increases negative emotions and self-image and thoughts of
rejection, with a negative repetitive cycle established. Deviant sexual arousal
in adult male sex offenders was noted long before such research into juvenile
sex offenders was undertaken. In the past, many clinicians dismissed sexu-
ally assaultive youth as engaging in sexual experimentation. While some
adolescents and children are sexually reactive and engage in sexually offen-
sive behavior with peers and younger children as part of a phase related to
inappropriate sexual exploration, this should not be automatically assumed.
Some adolescents do have deviant sexual arousal patterns and acknowledge
them to evaluators. Some have had prior victims and are beginning a pat-
tern of behavior that is similar to that of adult paraphilic sexual offenders
(Becker, Hunter, Stein, & Kaplan, 1989; Becker & Kaplan, 1992; Fehrenbach
et al., 1986).
The Marshall and Barbaree model traces the origins of sexual offending to
critical experiences in early childhood (Barbaree & Langton, 2006; Barbaree,
Marshall, & McCormick, 1998; Marshall & Barbaree, 1990; Marshall &
Marshall, 2000; OReilly & Carr, 2004). Marshall and Barbaree propose that
the developmental pathway that can lead to sexual offending begins with dis-
turbed and poor-quality relationships with early attachment figures (typically
parents). While the caretakers may be physically present, they are often emo-
tionally unavailable secondary to substance abuse or other problems. These
children learn that they are more successful at engaging their caretakers
attention through disruptive behavior, which in turn typically leads parents
to adopt an aggressive, coercive, and manipulative parenting style, which lim-
its the childs experience of prosocial, nurturing interactions. When the child
enters school, he is less likely to successfully manage his impulses and negotiate
positive, healthy relationships with peers or teachers. The failure at developing
healthy, prosocial, and satisfying relationships leads to a negative self-image
and lack of confidence. From there, what the authors call a syndrome of social
disability develops, with the emergence and consolidation of sexually abusive
behavior as part of a larger framework of antisocial or delinquent behavior.
This theoretical model suggests that understanding and tackling those aspects
of the family that promote criminal behavior is critical in the development of
a treatment plan.
Another model, also not empirically validated, postulates that the fi rst
sex offense results from a combination of individual characteristics, includ-
ing a lack of social skills, a history of nonsexual deviance, family variables,
and social-environmental variables, such as social isolation and antiso-
cial behavior (Becker & Hicks, 2003; Becker, Kaplan, & Kavoussi, 1988).
Following the fi rst sex offenses, the youth may pursue three possible paths:
(1) a dead-end, in which there are no further crimes; (2) a delinquency
path, in which the juvenile engages in continued sexual offending and in
general nonsexual offenses and deviant behaviors; and (3) a sexual interest
path, in which the juvenile continues to commit sexual offenses and devel-
ops a paraphilia.
Shaw identified four types of juvenile offenders: (1) offenders with true
paraphilias; (2) offenders with strong antisocial personality traits; (3) offenders
compromised by a neurological disorder (such as mental retardation, autistic
spectrum disorder, etc.); and (4) youth with impaired social skills who turn to
younger children for sexual gratification (Shaw & Antia, 2009).
Hunter, Figueredo, Malamuth, and Becker (2003) studied male juvenile
sex offenders in an effort to identify developmental pathways and ultimately
a typology for juvenile male offenders. Adolescent males who offended against
prepubescent children were contrasted with those who offended against pubes-
cent and postpubescent females. Those boys who offended against prepubes-
cent children had greater deficits in psychosocial functioning, engaged in less
aggression during the offense, and were more likely to offend against relatives.
Physical abuse by a father or stepfather and exposure to violence against
females were found to be associated with higher levels of comorbid anxiety
and depression. Noncoercive childhood sexual abuse by a male nonrelative
was found to be associated with sexual offending against a male child.
Table 4.1 Paraphilias

Pedophilia: Individuals, over a period of at least 6 months, experience recurrent,
intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual
activity with a prepubescent child or children. The adolescent should be at least
16 years of age and at least 5 years older than the child or children being victim-
ized. The person has acted on these sexual urges, or the sexual urges have caused
marked distress or interpersonal dysfunction.
Exhibitionism: Individuals display or attract attention to their genitals.
Frotteurism: Individuals bump, touch, or rub against others for sexual satisfac-
tion without the victims knowledge or consent.
Sexual masochism: Individuals derive sexual satisfaction from being humili-

ated, beaten, or otherwise made to suffer.
Sexual sadism: Individuals are sexually aroused by the psychological or physical

suffering they cause their victims.
Voyeurism: Individuals are sexually aroused by observing another person who is

nude, undressing, or engaging in sexual activity without that persons knowledge
or consent.
Transvestic fetishism: Male individuals who cross-dress and may or may not
have persistent discomfort with their gender role or identity.
source: Adapted from The Diagnostic and Statistical Manual of Mental Disorders (4th ed.,
text revision; American Psychiatric Association, 2000).
PA R A PH I L I A S A N D D E V I A N T S E X UA L A R O U S A L
Paraphilias are characterized by the sexual acts involved and by defi nition
require intense sexually arousing urges, fantasies, or behaviors that involve one
or more of the following: (a) nonhuman objects, (b) suffering or humiliation of
oneself or others, or (c) children or other nonconsenting persons. To qualify
for the diagnosis of a paraphilia, these behaviors must have occurred for at
least 6 months and have caused distress or impairment that impedes social,
occupational, or other important areas of functioning (American Psychiatric
Association, 2000). Specific paraphilias are briefly described in Table 4.1.
Evaluating the presence of paraphilias is critical in the evaluation of adult
sex offenders and in the development of treatment planning. Research indicates
that adults with paraphilias are at increased risk for sexual reoffending (Abracen
et al., 2004; Hanson & Bussiere, 1998; Prentky, Knight, & Lee, 1997; Prentky,
Lee, Knight, & Cerce, 1997). Most juveniles who engage in sexually offensive
behavior will not go onto develop a paraphilia, but some will. One of the more
vexing problems in this area involves attempting to identify those adolescents
at risk for developing paraphilias in order to initiate, and even mandate, specific
treatments, as well as monitoring and periodic reevaluation of progress.
Again, adults and adolescents are not the same. For example, while devi-
ant sexual arousal as measured by penile plethysmography has been noted to
be the most predictive factor for sexual reoffending among adult sex offend-
ers (Hanson & Bussiere, 1998), in adolescents the results are at best mixed.
In a study of an outpatient sample of 220 male juvenile offenders, Gretton
and colleagues reported no association between deviant sexual arousal in
juvenile sex offenders as measured by phallometric assessment with repeated
sexual offending (Gretton, McBride, Hare, OShaughnessy, & Kumka, 2001).
However, juveniles with both elevated psychopathy and deviant sexual arousal
were at increased risk for general recidivism. A more recent study by Clift and
colleagues considered the discriminative and predictive validity of the penile
plethysmograph (PPG) in a sample of 132 male adolescent sex offenders who
were admitted to a sex offender treatment program. The subjects were assessed
pretreatment and posttreatment, under an arouse condition (subjects allowed
themselves to become aroused) and a suppress condition (subjects attempted
to suppress or control their arousal). Posttreatment arousal to male and female
children was significantly related to sexual offense recidivism. Posttreatment
inability to suppress deviant arousal to male and female children was also sig-
nificantly related to sexual offense recidivism over the 6-year follow-up period
(Clift, Rajlic, & Gretton, 2009).
Abel and Rouleau summarized the results of two studies of 561 adult male
sex offenders and found that most of the offenders had developed deviant sex-
ual interests in their adolescence, with 50% of nonincest offenders with male
victims acquiring their deviant sexual interests before age 16, and 40% of those
with female interests before age 18. Abel and colleagues reported that 42% of
adults diagnosed with paraphilias reported deviant sexual arousal at 15 years
of age, and 57% by age 19 (Abel et al., 2004; Abel, Coffey, & Osborn, 2008).
They describe an evolutionary pattern paraphilia development as follows:
Stage I: Deviant sexual fantasies are first experienced around the time of
puberty.
Stage II: Deviant sexual behaviors are enacted after 23 years.
Stage III: Patterns of sexually deviant behaviors are not established until
early adulthood.
In an online survey of 563 college students, 93% of males and 62% of females
indicated that they had been exposed to online pornography during adoles-
cence, with boys more likely to be exposed at an earlier age. Boys were also more
likely to be exposed to extreme images, including rape and child pornography

(Sabina, Wolak, & Finkelhor, 2008). Exposure to child pornography during
adolescence would seem to present a risk factor for sexual offending against
children during adolescence, especially if masturbation is associated with the
viewing. A newly recognized area of forensic interest involves individuals iden-
tified through the Internet and arrested for possessing child pornography and/
or attempting to meet children via the Internet. There is no research on ado-
lescents arrested for this activity, but some recent work on adult male Internet
offenders reveals a high incidence of sexual pathology and psychopathology.
Data obtained from a chart review of evaluations conducted on 60 adult
males referred for a psychosexual evaluation following an arrest for possession
of child pornography and/or attempting to meet children through the Internet
revealed that 40% had at least one paraphilia (31% pedophilia and 18% pedo-
philia, NOS, and 33% diagnosed with a sexual disorder, NOS characterized
by hypersexuality). Seventy percent of the total sample had an Axis I disorder
that antedated and was judged to be contributory to the behavior leading to
their arrest (Krueger, Kaplan, & First, 2009). In another study, a sample of 505
Internet adult sex offenders and a sample of 526 adult contact sex offenders were
compared on a range of psychological measures relating to offense-supportive
beliefs, empathic concern, interpersonal functioning, and emotional man-
agement (Elliott, Beech, Mandeville-Norden, & Hayes, 2009). The authors
found that Internet offenders could be successfully discriminated from con-
tact offenders on 7 out of 15 measures. Contact offenders were found to have
significantly more victim empathy distortions and cognitive distortions than
Internet offenders. Internet offenders were found to have significantly higher
identification with fictional characters than contact offenders. Further analysis
indicated that an increase in scores on scales of fantasy, underassertiveness,
and motor impulsivity were predictive of an Internet offense type. An increase
in scores of scales of locus of control, perspective taking, empathic concern,
overassertiveness, victim empathy distortions, cognitive distortions, and
cognitive impulsivity were found to be predictive of a contact offense type
(Elliott et al., 2009). Again, it is reiterated that this research was conducted
on adult male sexual offenders, and so findings regarding adult Internet sex
offenders are not necessarily applicable to adolescents, and research specifi-
cally on the adolescent population is necessary.
Studies of Psychopathology in Adult Sex Offenders
Several studies of adult sex offenders with paraphilic and nonparaphilic deviant
behavior have indicated relatively high rates of comorbid psychiatric disorders
(Allnutt, Bradford, Greenberg, & Curry, 1996; DelBello et al., 1999; Dunsieth
et al., 2004; Fedoroff, Peyser, Franz, & Folstein, 1994; Kafka & Hennen, 2002;
McElroy et al., 1999; Raymond, Coleman, & Miner, 2003; Raymond, Coleman,
Ohlerking, Christenson, & Miner, 1999).
Raymond and colleagues noted the paucity of research on comorbidity in
the adult population. In their study of 45 adult males with pedophilia par-
ticipating in outpatient or residential sex offender programs and interviewed
using the patient version of the Structured Clinical for DSM-IV Disorders
(SCID-P) (First, Spitzer, Gibbon, & Williams, 1995), 93% of subjects met cri-
teria for an Axis I disorder other than pedophilia, with 64% meeting criteria
for an anxiety disorder, 60% for a substance use disorder, 53% for another
paraphilia diagnosis, and 24% for a sexual dysfunction diagnosis (Raymond
et al., 1999). The lifetime prevalence of mood disorder was 67%. Criteria for an
Axis II disorder was met in 60% of the 40 subjects who completed the SCID-P
interview for Axis II disorders (Raymond et al., 1999).
McElroy and colleagues studied 36 adult male sex offenders consecutively
admitted from jail, prison, or probation to a residential treatment facility, using
structured clinical structured interviews for DSM-IV Axis I and Axis II dis-
orders (McElroy et al., 1999). Subjects displayed high rates of lifetime DSM-IV
Axis I disorders: 83% had a substance abuse disorder; 58% a paraphilia; 61% a
mood disorder (36% with bipolar disorder); 39% an impulse control disorder;
36% an anxiety disorder; and 17% an eating disorder. Personality disorders
were also prevalent, with 72% meeting DSM criteria for antisocial personal-
ity disorder. Compared with participants without paraphilias, subjects with
paraphilias displayed statistically significant rates of mood, anxiety, and eat-
ing disorders, as well as significantly higher rates of reported sexual abuse
(McElroy et al., 1999). Dunsieth and colleagues later expanded on that work,
assessing the psychiatric pathology of 113 adult male sex offenders consecu-
tively administered from jail, prison, or probation to a residential treatment
facility, with similar findings (Dunsieth et al., 2004). Using structured clini-
cal interviews, they found that 85% had a substance abuse disorder; 74% a
paraphilia; 35% a mood disorder; 38% an impulse control disorder; 23% an
anxiety disorder; 9% an eating disorder; and 56% antisocial personality dis-
order. The presence of a paraphilia correlated positively with the presence of
a mood disorder, an anxiety disorder, impulse control disorder, and avoidant
personality disorder.
Clinicians who work with juveniles who have sexually offended should be
aware of these findings in the adult population, limited though they may be.
However, a strict downward application of such findings to the adolescent
population is not useful for a variety of reasons. Perhaps most important is the
following often reiterated caveats: (1) most juveniles who commit sex offenders
do not go on to become sex offenders in adulthood; (2) most juvenile sex

offenders do not go on to develop paraphilias; and (3) adolescent sex offenders
are a far more heterogeneous group than are adult sex offenders.
Personality Pathology in Adult Sex Offenders

Personality disorders predispose adult male offenders to recidivate sexually,
but personality style and traits seem to have different effects depending on
the type of sex offense and age of the victim (Andrade, Vincent, & Saleh,
2006). Among adult male rapists, antisocial personality and lifetime impul-
sivity (identified in this study as a personality disorder trait) were the most
consistent discriminating traits, whereas among child molesters, discriminat-
ing characteristics were personality traits related to social incompetence such
as poor social skills, social isolation, and low self-esteem (Prentky & Knight,
1991; Prentky et al., 1997). Antisocial personality disorder and behaviors are
strong predictors for sexual reoffending among adult males, regardless of the
type of offense (Prentky et al., 1997).
Psychopathy is a personality disorder characterized by a cluster of interper-
sonal, affective, and lifestyle traits and behaviors, including arrogance, shallow
emotions, lack of empathy or remorse, callousness, a deceitful interpersonal
style, irresponsibility, impulsivity, and violation of social norms (Hare &
Neumann, 2009). It has received increasing attention in the area of adult sex
offender risk assessment because of its association with an increased risk for
violent and criminal reoffending (Hanson, Helmus, & Thornton, 2009; Hare,
1999, 2006; Hare & Neumann, 2009; Olver & Wong, 2006; Parks & Bard,
2006). Psychopathy is not synonymous with antisocial personality disorder as
defined in the DSM-IV, as psychopathy is less narrowly focused on behavior-
ally based criteria and includes interpersonal and affective traits (Hare, Hart,
& Harpur, 1991). Psychopathy is a more malignant personality style than is
antisocial personality disorder. Research indicates that between 50% and 80%
of prisoners meet criteria for antisocial personality disorder, while only 15%
are psychopathic as assessed by the PCL-R (Ogloff, 2006). The Psychopathy
ChecklistRevised (PCL-R), developed by Robert Hare, is an instrument that
has empirical validation and reliability in the assessment of psychopathy
(Hare, Clark, Grann, & Thornton, 2000). While the biological basis of psy-
chopathy has not yet been elucidated, a variety of biological brain abnormal-
ities have been observed in psychopaths, including amygdala abnormalities,
reduction in prefrontal gray matter volume, gray matter loss in the right supe-
rior temporal gyrus, decreased posterior hippocampal volume, exaggerated
hippocampal asymmetry, and corpus collosum abnormalities (Weber, Habel,
Amunts, & Schneider, 2008). Causal conclusions cannot be drawn from cur-
rent research, but psychopathy is increasingly being viewed as a multifactorial
process involving genetic, neurobiological, and sociobiographical factors. In

the adult sex offender research, significantly higher rates of psychopathy have
been found among rapists than among child molesters (Brown & Forth, 1997;
Firestone, Bradford, Greenberg, & Serran, 2000; Porter et al., 2000). Adults
who offend against both adults and children have the highest psychopathy
rates, with 64% of those offenders meeting criteria for psychopathy (Porter
et al., 2000).
Mentally Handicapped and Developmentally Disabled

Adult Offenders
Among adults, sex offenses were consistently found to be overrepresented

in studies of criminal offending in the mentally retarded population (Day,
1994), but data regarding characteristics of the offenders and the offenses were
limited. A retrospective chart analysis of 47 mentally retarded patients in
England referred for antisocial sexual behavior indicated that 55.6% of the
sexual offenses were heterosexual offenses, 24% involved indecent exposure,
12.4% involved homosexual assaults, 13.6% were deemed serious, and 3.6%
involved physical assault. The average age of the offenders was 23.9 years, with
a mean IQ of 59.5, and a high prevalence of family psychopathology, psychi-
atric illness, physical disabilities, sexual navet, impaired relationship skills,
poor impulse control, and sexual recidivism (Day, 1994).
Walker and McCabe studied 90% of 960 patients committed to a psychiat-
ric hospital under the mental health law in England. Of the men detained,
about one-third had intellectual disabilities and two-thirds had mental illnesses
and personality disorders. Of the sex crimes committed by the entire cohort,
two-thirds of the crimes were committed by the one-third that was intellectually
disabled (Walker & McCabe, 1973). Walker and McCabes data do not indicate
that individuals with cognitive disabilities are more prone to commit sex crimes.
Also, there is little to indicate that adolescents with cognitive and developmental
disabilities who engage in sexually reactive and abusive behavior are similar to
mentally handicapped and developmentally delayed adult sex offenders. Studies
of sex offender offenders (including adults and adolescents) have indicated that
mentally retarded offenders are more likely than nonmentally retarded offend-
ers to offend against both males and females and offend against same age and
older victims; are less likely to know their victims; are less likely to be violent; and
are less likely to engage in penile penetration of their victims vaginally (Gilby,
Wolf, & Goldberg, 1989; Murrey, Briggs, & Davis, 1992).
Another study investigated the reported association of pedophilia with
lower intelligence. Blanchard and colleagues (2007) studied 832 adult male
patients referred to a clinic for evaluation of their sexual behavior. The subjects
preferences for prepubescent, pubescent, or adult partners were assessed with
phallometric testing. Full-scale IQ was estimated using six subtests from the
WAIS-R. The results showed that the relationships among pedophilia and
lower IQ, lesser education, and increased rates of non-right-handedness were
the same in a homogeneous group referred by lawyers or parole and proba-
tion officers as they were in a heterogeneous group referred by a variety of
other sources. Their results supported the conclusion that the relationship
between pedophilia and cognitive function is genuine and not an artifact.
The findings, which included left-handedness, were interpreted as evidence
for the hypothesis that neurodevelopmental disruptions increase the risk of
pedophilia in males.
M EN TA L D I SO R D ER S A M O N G D EL I N Q U EN T YO U T H
Given the paucity of research on mental illness among youth charged with or
admitting to a sexual offense as well as the fact that juvenile sexual offenders
as a group seem to be more like their delinquent peers who have not offended
sexually, the literature on mental illness among incarcerated youth (not
specifically sex offenders) is reviewed next.
McManus and colleagues studied 40 incarcerated seriously delinquent
males using the SADS (Schedule of Affective Disorders and Schizophrenia)
(Endicott & Spitzer, 1978; Spitzer & Endicott, 1978), six of whom had com-
mitted sexual assaults (McManus, Alessi, Grapentine, & Brickman, 1984).
All of the boys in this cohort had multiple psychiatric diagnoses, and there
was a high prevalence of psychiatric disorders, especially conduct disorder,
substance abuse, alcoholism, affective disorders, and personality pathol-
ogy (especially borderline). In another study, 71 serious juvenile offenders
(40 male, 31 female) were interviewed using the Schedule for Affective
Disorders and Schizophrenia (SADS) (Endicott & Spitzer, 1978; Spitzer &
Endicott, 1978), as well as a series of rating scales and diagnosed according to
Research Diagnostic Criteria (Endicott & Spitzer, 1979; Spitzer, Endicott, &
Robins, 1975; Spitzer, Endicott, & Williams, 1979). Eleven (15%) subjects were
diagnosed as having an active major depressive disorder, six (8%) subjects
were diagnosed as having a major depressive disorder in remission, and nine
(13%) as having a minor depressive disorder (Alessi, McManus, Grapentine,
& Brickman, 1984).
A meta-analysis of the research literature on the prevalence of mental
disorders in adolescents in juvenile detention centers and correctional facili-
ties was conducted, in which 25 surveys involving 13,778 boys and 2,972 girls
(mean age 15.6, range 1019 years) were analyzed (Fazel, Doll, & Langstrom,
2008). Among boys, 3.3% were diagnosed with psychotic illness, 10.6% with
major depression, 11.7% with ADHD, and 52.8% with conduct disorder.
Among girls, 2.7% were diagnosed with psychotic illness, 29.2% with major
depression, 18.5% with ADHD, and 52.8% with conduct disorder. The study
concluded that adolescents in correctional facilities were 10 times more likely
to suffer from psychosis than the general adolescent population, and that girls
were diagnosed with major depression more often than boys. Although the
numbers of girls who sexually offend remain small compared to boys, and it
is not clear that sexually offending girls are as similar to generally delinquent
girls as are sexually offending boys to generally delinquent boys, this finding
has important implications in designing treatment programs. The prevalence
of major depression (29%) in the delinquent adolescent female population is
considerably higher than the 12% of women adult prisoners diagnosed in a
previous systematic review (Fazel & Danesh, 2002). Also, major depression
is about four to five times more common in girls and twice as common in
detained boys as compared with the general adolescent population (Costello,
Mustillo, Erkanli, Keeler, & Angold, 2003).
Using version 2.3 of the Diagnostic Interview Schedule for Children
(Shaffer et al., 1996), evaluators assessed a randomly selected, stratified sample
of 1,829 African American, non-Hispanic white, and Hispanic youth (1,172
males, 657 females, ages 1018 years) detained in a juvenile detention center
(Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). Looking at 6-month
prevalence rates, Teplin and colleagues found that nearly two-thirds of males
and nearly three-quarters of females met diagnostic criteria for one or more
psychiatric disorders. When conduct disorder was excluded, nearly 60%
of males and more than two-thirds of females met diagnostic criteria with
diagnosis-specific impairment for one or more psychiatric disorders. Half of
males and almost half of females had a substance use disorder. Mood disor-
ders were also prevalent with more than 20% of females meeting criteria for
a major affective disorder (Teplin et al., 2002). Significant psychiatric comor-
bidity was found in the same cohort, specifically that 57% of females versus
46% of males met criteria for two or more of the following disorders: major
depression, dysthymic disorder, mania, psychosis, panic, separation anxiety,
overanxious disorder, generalized anxiety, obsessive-compulsive disorder,
ADHD, conduct and oppositional defiant disorders, and alcohol, marijuana,
and other substance use disorders (Abram, Teplin, McClelland, & Dulcan,
2003). Only 17% of females and 20% of males had only one disorder. Nearly
14% of females and 11% of males met criteria for both a major mental illness
(psychosis, mania, or major depression) and a substance use disorder. Nearly
30% of females and more than 20% of males with substance use disorders
had major mental disorders (Abram et al., 2003). Investigators also found
that for this cohort official records seriously underestimated the prevalence of
maltreatment. The authors called for reviewing multiple collateral sources of
information in order to document the true prevalence of abuse. In their cohort
of 1,829 detained youth, only 17% of those who reported any maltreatment,
and 25% who reported requiring medical treatment as a result of abuse, had a
court record of documented abuse (Swahn et al., 2006).
Domalanta, Risser, Roberts, and Risser (2003) studied 1,024 incarcerated
youths over a 6-month period, during which time the youths completed the
Beck Depression Inventory (BDI) (Beck & Beamesderfer, 1974; Teri, 1982) and
the Patient Health Questionnaire (PHQ) (Spitzer, Kroenke, & Williams, 1999),
which is linked to the DSM-IV and assesses depression; drug and alcohol use;
and somatoform, panic, and anxiety disorders. From the BDI, 25% had moder-
ate depression and 22% had severe depression. From the PHQ, 10% had major
depressive disorder, 41% drug abuse, 27% alcohol abuse, and 29% one of the
other disorders.
Among adolescents ages 13 to 18 years, 11,717 of which were processed
in juvenile court and 275 in adult criminal court, Washburn and colleagues
found that boys, African Americans, Hispanics, and older youths had greater
odds for being tried as adults than girls, non-Hispanic whites, and younger
youths, even after analyses controlled for felony-level violent crimes. Among
youths tried as adults, 68% had at least one psychiatric disorder and 43% had
two or more psychiatric disorders (Washburn et al., 2008).
Mood Disorders
In the study of 1,024 incarcerated juveniles by Domalanta and colleagues

described earlier, 60% had one or more psychiatric disorders, and comorbid-
ity was particularly common between depression and anxiety and drug and
alcohol abuse. Of those youths who were depressed, only 20% had been previ-
ously diagnosed and treated, and only 10% with other disorders (Domalanta
et al., 2003).
A smaller study in which the Diagnostic Interview Schedule for Children
(Chambers et al., 1985; Kovacs, 1985) was administered at an urban detention
center to 50 youths, ages 11 to 17 years old, found an even higher rate of
affective disorder (42%), with 20% meeting criteria for mania, 20% meet-
ing criteria for major depressive disorder, and one child meeting criteria
for bipolar disorder, mixed type. High rates of alcohol and substance abuse
disorders were found, and 60% of subjects met criteria for conduct disorder
(Pliszka, Sherman, Barrow, & Irick, 2000).
Substance Abuse
McClelland and colleagues studied a randomly selected sample of 1,172 male

and 657 female detainees over a 6-month period and found that nearly half the
detainees had substance use disorders as assessed by the Diagnostic Interview
Schedule for Children, version 2.3 (Shaffer et al., 1996); they also found that
among detainees with a substance use disorder, multiple substance use disor-
ders were the rule, rather than the exception (McClelland, Elkington, Teplin,
& Abram, 2004). More than 21% had two or more substance use disorders. Of
those detainees with any drug use disorder, about 50% also had an alcohol use
disorder.
Personality Development and Pathology
The development of antisocial personality disorder (APD) in detained youths

was examined in a stratified random sample of 1,112 detained youth at a 3-year
follow-up interview (Washburn et al., 2007). Nearly 20% of male juvenile
detainees had developed APD in adulthood, with about 25% of male juvenile
detainees diagnosed with conduct disorder (CD) later developing APD.
Significantly more males than females developed APD, with no differences
found with respect to race or ethnicity. While some disorders were strong pre-
dictors of APD (having had five or more symptoms of CD, dysthymia, alcohol
use disorder, or generalized anxiety disorder), none were adequate markers to
identify which youths would go on to develop APD (Washburn et al., 2007).
Posttraumatic Stress Disorder
The prevalence of PTSD and comorbid psychiatric disorders among detained

youth (Abram et al., 2004, 2007) was examined in 898 youths ages 10 to 18
years. Investigators found that trauma and PTSD were more prevalent than in
community samples, with 83% of males and 84% of females reporting at least
one traumatic experience, and 11% of the sample meeting criteria for PTSD
within the past year (Abram et al., 2004; Costello et al., 1996; Costello et al.,
2003). Among youth with PTSD, 93% had at least one comorbid psychiatric
disorder; among those without PTSD, 64% had at least one comorbid psy-
chiatric disorder. Of those youths with PTSD, 54% had two or more types
of comorbid disorders (affective, anxiety, behavioral, or substance abuse
disorders), and 11% had all four types of comorbid disorders. Among girls,
alcohol use disorder and having both alcohol and substance use disorders
significantly increased the odds of having PTSD. The prevalence of any

comorbid psychiatric disorder was significantly greater for boys with PTSD
than for girls (Abram et al., 2007).
Among 100 incarcerated female juvenile offenders ages 13.5 to 19 years in
Australia assessed using semistructured interviews, 37% of offenders reported
PTSD, with sexual abuse the precipitant in 70% of cases. Offenders with PTSD
had significantly more comorbidity than those without, and 73% of comorbid
diagnoses appeared concurrently with or after PTSD onset (Dixon, Howie, &
Starling, 2005). In their sample of 96 incarcerated female offenders, utilizing sem-
istructured interviews and self-report questionnaires, Cauffman and colleagues
also found a high rate of PTSD in female offenders; 65% had met criteria for
PTSD at some point in their lives (9.5% had met partial PTSD criteria); and 49%
were experiencing PTSD (12% partial PTSD criteria) at the time the study was
conducted (Cauffman, Feldman, Waterman, & Steiner, 1998). Among 85 boys
with mostly violent offenses incarcerated in California, 32% fulfilled full PTSD
criteria, and 20% fulfilled partial criteria (Steiner, Garcia, & Matthews, 1997).
Suicidality
Abram and colleagues found that among 1,829 newly detained juveniles ages
1018 years, more than one-third of detainees and nearly half of the girls had
felt hopeless and thought about death in the 6 months prior to detention, with
10% considering suicide in the past 6 months, and 10% having made a suicide
attempt. Recent suicide attempts were more prevalent in girls and youths with
major depression and generalized anxiety disorder (Abram et al., 2008).
PSYC H O PAT H O LO GY I N J U V EN I L E S E X UA L O FFEN D ER S
Identifying psychiatric disorders in sexual offenders is critical for a variety

of reasons. First, the morbidity caused by mental illness in this population
is no less real or compelling than in the general population. Also, all factors
potentially pertaining to an individuals behavior should be delineated and
addressed in considering the root causes and contributors to the behavior and
developing a treatment plan (Anderson & Smith, 2005). Despite the impor-
tance of this area of study, little research on the prevalence of mental illness in
the juvenile sex offender population exists (Andrade et al., 2006). The sparse
literature available reflects significant variation from sample to sample.
Fagan and Wexler identified 34 juvenile sex offenders among a sample of
242 chronic violent offenders (14.1% of the sample). The sample was not broken
down by victim age or sex, but subjects had felony convictions for forcible
rape or sodomy, statutory rape, attempted rape, sexual assault, or sexual
misconduct (Fagan & Wexler, 1988). The investigators found few character-
istics typically associated with conduct disorder. Their sample of juvenile sex
offenders had fewer drug and alcohol problems, more often lived with birth
parents, and were less frequently involved in gangs. They resembled normal
youth on measures of official and self-reported crimes, attitudes toward the
law, family composition, attachment to work and school, and work experience.
Yet the juvenile sex offenders more often came from families with spousal
violence, child abuse, and sexual molestation, according to both official and
self-reports. They appeared to be more socially and sexually isolated; less
often had girlfriends; and less frequently reported sexual activity, interest, or
experience. They had stronger beliefs in the law but less internal controls on
their behavior.
Family Instability
Like general juvenile delinquents, juvenile sexual offenders have high rates of
family instability and psychopathology with frequent separations from their
families of origin (Becker et al., 1986; OShaughnessy, 2002).
A study investigated the adult outcome of a group of 19 sexually assault-
ive male juveniles and a comparison group of 58 violent (nonsexual) juveniles
over an 8-year period through criminal records and clinical interviews
(Rubinstein, Yeager, Goodstein, & Lewis, 1993). Although the two groups were
similarly violent and delinquent through adolescence, on follow-up the sexu-
ally assaultive adolescents were significantly more likely to commit adult sex
offenses (37%), and more violent nonsexual offenses (89%), such as murder,
kidnapping, robbery, and assault. Among the violent (nonsexual) comparison
group, 10% had a record of sexual assaults, and 69% were arrested for violent
offenses as adults. In the sexually assaultive group, 41% admitted to a history
of sexual abuse versus 22% in the 44 interviewed subjects in the comparison
group. Of all the sexually abused subjects in both groups, 75% were victimized
by females. Although the diagnosis of mental illness was not a focus of this
study, the authors raised the issue of dissociation as a mechanism by which
victims keep emotionally overwhelming experiences of physical and sexual
abuse out of awareness. They noted impaired recollections of documented
sexual abuse in some subjects, suggesting that the actual proportion of sexual
abuse was higher than admitted.
OHalloran and colleagues (2002) compared 27 Irish adolescents who
had sexually abused others with a group of 20 adolescents with behavioral
problems but no history of sexual offending and a group of 29 normal

adolescents without significant psychological problems. The psychological
adjustment of adolescents with a history of sexually abusing others was more
pathological than that of normal controls, but it was less problematic than that
of adolescents with a history of significant behavioral problems but no sexual
offending. Childhood physical abuse by a father or stepfather and exposure to
violence against females has been found to be associated with higher levels of
comorbid anxiety and depression (Hunter et al., 2003).
Psychopathology
Kavoussi, Kaplan, and Becker (1988) studied psychiatric pathology in 58 male

sex offenders, ages 13 to 18 (mean age 15.3 years), using structured instru-
ments. They used the SCID (Structured Clinical Interview for DSM-III; Spitzer
& Williams, 1984) to assess for diagnoses of affective, psychotic, anxiety, and
substance abuse disorders. The KSADS-E (Kiddie Schedule for Affective
Disorders and Schizophrenia, epidemiologic version) was used to assess for
diagnoses of conduct disorder and attention-deficit disorder (Puig-Antich &
Chambers, 1978). Subjects had been referred to an outpatient evaluation and
treatment program from the justice system and Social Services. All of those
admitted were found guilty of a sexual crime. White males comprised 11%,
black males 61%, and Hispanic males 28% of the cohort. Of the 58 subjects, 23
had offended against girls younger than age 11 (10 with female relatives), and 14
of the 58 had offended against boys under age 11 (three with siblings). No prior
sexual offense histories were noted in 52 of the 58; three offenders had been
arrested once before for a sexual offense, and one subject had been arrested
more than once on a sexual charge. With respect to nonsexual crimes, 44 of
the 58 had no previous history of charges for nonsexual crimes. Eight of the
58 had one previous charge; three of the 58 had two previous arrests, and one
boy had five previous arrests for nonsexual crimes (robbery, burglary, petty
theft, trespassing, and drug charges). Conduct disorder was the most preva-
lent diagnosis, with 48% of the cohort meeting full DSM-III criteria for con-
duct disorder; 8.3% meeting criteria for alcohol abuse (10.3% for both alcohol
and cannabis abuse); 8.6% for adjustment disorder with depressed mood; 6.9%
ADHD; and 5.2% social phobia. No diagnosis was found in 19.2% (Kavoussi
et al., 1988). The authors hypothesized that perhaps one of the reasons for the
lack of severe psychopathology was that sexually offending youth with less
severe disorders were referred to either hospital or residential programs.
Galli et al. (1999) studied 22 males ages 13 to 17 who had molested at least
one child. In structured clinical interviews for DSM-III-R Axis I disorders,
all met DSM-III-R criteria for pedophilia (with exception for the age require-
ment). In addition:
95% were diagnosed with two or more paraphilias.

64% were diagnosed with three or more paraphilias.
14% were diagnosed with seven paraphilias.
94% were diagnosed with conduct disorder.
71% were diagnosed with ADHD.
82% were diagnosed with a mood disorder (55% with bipolar
disorder).
55% were diagnosed with an anxiety disorder.
55% were diagnosed with impulse control disorder.
50% were diagnosed with a substance use disorder.
Bipolar disorder was more commonly diagnosed in this cohort than were
unipolar depressive disorders. Some subjects reported a relationship between
increased sexual behaviors and impulses and the experience of depressive and
mixed affective symptoms (Galli et al., 1999).
Neuropsychiatric Pathology
Lewis, Shankok, and Pincus (1979) compared the neuropsychiatric status of
17 sexually assaultive male juveniles with a group of 61 delinquent incarcer-
ated male adolescents who had not committed sexually assaultive acts. The
sexually assaultive adolescents were similar to the nonsexually assaultive vio-
lent adolescents. Similar proportions exhibited psychotic and subpsychotic
symptomatology (73% of the sexually assaulted versus 83% of the nonsexually
assaultive exhibited paranoid ideation; 47% versus 41% endorsed auditory hal-
lucinations). Also, 24% of the sexually assaultive subjects and 31% of those
who were not sexually assaultive manifested neurological signs, abnormal
electroencephalograms (EEGs), and/or seizures. Both groups had scores on
intelligence tests in the low average range. A similar proportion of sexual
abuse (76%) was noted in both groups, with a similar proportion abused by
both mothers (46% versus 43%) and fathers (58%). A cohort of 73 male juve-
nile violent, nonviolent, and sex offenders, mean age 15.3 years, were referred
for outpatient treatment by the juvenile court and compared across a broad
array of intellectual, neuropsychological, and psychoeducational measures; 43
of the subjects were Caucasian; 30 were African American (Tarter, Hegedus,
Alterman, & Katz-Garris, 1983). None exhibited EEG abnormalities, and there
were no signs of neurological abnormalities when examined by a pediatric
neurologist. No systematic group differences were noted, and cognitive status
was not related to the severity of violent behavior. These findings cast doubt
on the generalizability of investigations implicating cerebral dysfunction in

juvenile delinquents (Lewis et al., 1979).
Mood and Anxiety Disorders

In a cohort of 246 male juvenile sex offenders, Becker, Kaplan, Tenke, and
Tartaglini (1991) found elevated Beck Depression Inventory (BDI) (Beck &
Beamesderfer, 1974; Teri, 1982) scores in all the youths studied. While most
of the youths scores placed them in the mildly depressed range, 42% had
scores that placed them in at least the moderately depressed range, with ado-
lescents with a history of having been sexually abused themselves demonstrat-
ing greater depression. Of the study participants, 147 were African American,
62 were Hispanic, and 34 were Caucasian, with 3 adolescents electing not
to reveal their race. Subjects were divided according to their self-reports of
having been sexually or physically abused. The mean BDI score across all sub-
jects was 14.3, a value markedly higher than published norms and indicative
of mild depression. Forty-two percent of subjects attained scores indicative
of appreciable depressive symptomatology. A history of sexual or physical
abuse was significantly related to high BDI scores; abused subjects had a mean
BDI score of 16.4, as contrasted to 12.3 for nonabused subjects. Th is relation-
ship was apparent across all racial groups. While Hispanic subjects tended to
have higher BDI scores and Caucasians lower scores, racial differences were
not statistically significant (Becker et al., 1991). Results indicate that juvenile
sex offenders have a higher level of depressive symptomatology than would
be expected in a random sample of juveniles where only 8.6% of subjects had
BDI scores indicative of moderate or severe depression (Kaplan, Hong, &
Weinhold, 1984). Forty-two percent of Beckers subjects scored in this range
(Becker et al., 1991).
Personality Pathology in Sexually Offending Youth

Carpenter and colleagues compared the personality characteristics of 36
adolescent sexual offenders (16 peer offenders and 20 child offenders)
committed to Virginias Department of Juvenile Justice with the Millon
Clinical Multiaxial Inventory (MCMI) (Millon, 1977) and compared the
two groups on six of its subscales. The results suggested that adolescent child
offenders were more schizoid, dependent, and avoidant than adolescent peer
offenders (Carpenter, Peed, & Eastman, 1995). Preliminary work in which 70
incarcerated male adolescents ages 13 to 18 years of age (23 sex offenders, 17
violent offenders, and 30 noncontact offenders) were evaluated indicated that
witnessing severe domestic violence against women was related to both sex
offending and violent offending in general (Caputo, Frick, & Brodsky, 1999).
There were no differences found among groups with respect to poor impulse
control or sexist attitudes toward women. Sex offenders were found to have
more callous and unemotional traits than other offenders.
Butler and Seto studied 32 sex offenders, 48 criminally versatile offenders,
and 34 nonaggressive offenders referred by juvenile courts for mental
health assessments in Canada between 1994 and 1997, comparing them on
measures of childhood conduct problems, current behavioral adjustment,
antisocial attitudes and beliefs, and risk for future delinquency. Sex offenders
were further divided into those without (sex-only) and those with (sex-plus)
nonsexual offenses in their criminal histories. Sex offenders were similar to
nonsex offenders in their childhood conduct problems, current behavioral
adjustment, and antisocial attitudes and beliefs, but they had a lower risk
for future delinquency. Sex-only offenders had significantly fewer childhood
conduct problems, better current adjustment, more prosocial attitudes, and
a lower risk for future delinquency than did the nonsex offender groups,
whereas sex-plus offenders resembled criminally versatile offenders (Butler &
Seto, 2002). Juveniles who commit only sex crimes (without other types of
offending) have been identified as having schizoid and socially isolative char-
acter styles (Henderson & Kalichman, 1990; Losada-Paisey, 1998; Myers &
Blashfield, 1997). However, it should be noted that research findings have been
contradictory (van Wijk, Loeber, et al., 2005; van Wijk, van Horn, Bullens,
Bijleveld, & Doreleijers, 2005; van Wijk et al., 2006) and again highlight the
heterogeneous nature of this population.
The construct of psychopathy has been extended to adolescents with the
development of the Psychopathy Checklist: Youth Version (PCL:YV) (Forth,
Kosson, & Hare, 2003). However, controversy exists regarding the stability of
psychopathic traits into adulthood and potential misuse of the diagnosis to
divert adolescents who receive it to correctional facilities rather than to treat-
ment. (Edens, Skeem, Cruise, & Cauffman, 2001; Vincent, 2006). Also, the
PCL:YV appears to have limited utility in girls (Vincent, Odgers, McCormick,
& Corrado, 2008). A study of the utility of the PCL:YV in risk assessment
for criminal recidivism in adulthood with 201 male juvenile offenders and
55 female juvenile offenders over a 4.5-year-follow-up period revealed that
while the PCL:YV was predictive of male recidivism, the PCL:YV was not a
significant predictor of nonviolent or violent recidivism for girls (Vincent et
al., 2008). This study did not lend support for the use of the PCL:YV as a risk
factor for girl offenders. The construct of psychopathy has been studied in ado-
lescent sex offenders and has been identified in some adolescent offenders on a
continuum from mild to severe.
Gretton and colleagues (2001) used the PCL:YV as part of their assessment
and 55-month follow-up of 220 adolescents using criminal record reviews.
Almost 70% of the adolescents had a history of a prior sex assault, and 22% had
a previous history of violent assaults before their index offenses. At follow-up,

15% had committed a sex offense; 13% had committed a nonsexual violent
offense; and 51% had committed a nonviolent nonsexual offense. The designa-
tion of low, medium, or high psychopathy was based on PCL:YV scores. Those
with high PCL:YV scores were significantly more likely to commit sexual
assaults, violent offenses, and general offenses than youth with medium or low
scores, and they were rated significantly higher in escape attempts and breach
of probation. The combination of high psychopathy and deviant sexual arousal
as measured by phallometry formed a subgroup that showed even higher rates
of violence and sex offending (Gretton et al., 2001).
The relationship between psychopathy as measured by the PCL-R and
violent reoffending was studied in 98 young (range 1520 years) violent and sex
offenders forensically evaluated in Sweden between 1988 and 1995 and followed
during detainment and for 24 months to first recidivism for a violent offense.
While a modest but significant association between PCL-R scores and violent
recidivism was found, the association was almost exclusively accounted for by
behavioral criteria, specifically conduct disorder before age 15 and a young
age at first conviction, which eliminated the relationship between psychopathy
and violent recidivism. The authors concluded that psychopathy may be a less
valid predictor for violent criminal recidivism among severe youthful offend-
ers than among adult offenders (Langstrom & Grann, 2002).
Another study investigated differences in recidivism risk factors and traits
associated with psychopathy among three groups of male adolescent sex-
ual offenders (N = 156): offenders against children, offenders against peers
or adults, and mixed-type offenders (Parks & Bard, 2006). The same vari-
ables were also examined for their association with sexual and nonsexual
recidivism, and the three groups were compared for differences in rates of
recidivism. Based upon both juvenile and adult recidivism data, 6.4% of the
sample reoffended sexually and 30.1% reoffended nonsexually. Retrospective
risk assessments were completed using the Juvenile Sex Offender Assessment
Protocol-II (JSOAP-II) and the Psychopathy Checklist: Youth Version
(PCL:YV). Results suggested significant differences among the three offender
groups on multiple scales of the JSOAP-II and PCL:YV, with mixed-type
offenders consistently producing higher risk scores as compared to those who
exclusively offend against children or peers/adults. The Impulsive/Antisocial
Behavior scale of the JSOAP-II and the Interpersonal and Antisocial fac-
tors of the PCL:YV were significant predictors of sexual recidivism. The
Behavioral and Antisocial factors of the PCL:YV were significant predic-
tors of nonsexual recidivism. Results supported previous research indicating
that most adolescents who sexually offend do not continue offending into
adulthood. The authors suggested that such results can lead to improved
treatment by targeting specific risk factors for intervention and better use
of risk management resources in the community, while preserving the most
restrictive treatment options for the highest risk offenders. Edens and col-
leagues note that due to the major developmental changes that occur dur-
ing young adulthood and the lack of longitudinal research on the stability
of the construct of psychopathy in adolescence as well as its association with
adult violence, it is inappropriate and contraindicated to use the construct to
make long-term placement decisions. However, given the fact that existing
evidence indicates a moderate association between measures of psychopathy
and various forms of aggression, the construct of juvenile psychopathy may
be relevant for purposes of short-term risk appraisal and management among
juveniles (Edens et al., 2001).
Attention-Deficit/Hyperactivity Disorder
ADHD has been found in up to 22% of juvenile sex offenders with more than
one-third of offenders showing some traits of ADHD without meeting full
criteria (Becker, 1994; Becker et al., 1986; Kavoussi et al., 1988).
Alcohol and Substance Abuse

Alcohol abuse has been found in up to 10% of juvenile sex offenders and in
20% to 33% of their parents (Awad & Saunders, 1991; Fehrenbach et al., 1986;
Kavoussi et al., 1988). Becker and Stein (1991) found that 61% of a sample
of 160 male juvenile sex offenders seen at an outpatient treatment program
abused alcohol, with only 11% reporting that it increased their sexual arousal,
while 39% reported abuse of drugs, with 23% reporting that use increased
their sexual arousal. There was some indication that juveniles who reported
increased arousal with alcohol or substances had more victims than those who
said alcohol had no effect on their arousal. There were no statistically signifi-
cant differences between subjects in terms of drug use and number of victims
(Becker & Stein, 1991).
Conduct Disorder
While conduct disorder and substance abuse are frequently diagnosed in
juvenile sex offenders, the incidence rates do not appear to differ significantly
from rates found in the general delinquent population (Kavoussi et al., 1988;
Lewis et al., 1979; Lightfoot & Barbaree, 1993). Conduct disorder was the most
common diagnosis (48%) among 58 male juvenile sex offenders referred to an
outpatient evaluation and treatment program from Social Services or juvenile
justice and studied using structured instruments (Kavoussi et al., 1988). The
researchers investigated the prevalence of conduct disorder in offenders who
raped adult women versus those involved in other sexually deviant behavior.
A much higher percentage of adolescents who raped or attempted to rape adult

women (75%) met conduct disorder criteria versus only 38% of other boys in
the sample who met criteria for conduct disorder.
A B U S E H I STO R I ES A M O N G J U V EN I L E S E X O F F EN D ER S
The role that a history of childhood sexual abuse plays in sexual offending
remains controversial and is complex. What can be defi nitively stated is that
having been sexually abused as a child does not de facto place one at risk
for sexually abusing others. Most sexually abused children do not offend
against others (Salter et al., 2003; Widom & Ames, 1994), and so individual
differences must play an important role in any association between sexual
offending and having been sexually abused. A number of risk assessment
instruments include a history of sexual victimization among purported risk
factors; however, the role of sexual victimization and sexual offending is
likely to be far more complicated and contextually determined. Greenberg
and colleagues studied 135 pedophiles and 43 hebephiles (individuals with
a sexual interest in pubescent children, generally ages 11 to 14, although
the age of puberty may vary) who admitted their offenses. Sexual victim-
ization during their own childhoods was reported in 42% of pedophiles
and 44% of hebephiles, with pedophiles reporting abuse at a younger age
than hebephiles. Both groups appear to choose their age-specific victims
in accordance with the age of their own experience of sexual victimization
(Greenberg, Bradford, & Curry, 1993). However, many sex offenders do not
have a history of sexual abuse. A sexual abuse history is neither a sufficient
nor a necessary condition for adult sexual offending (Seto & Lalumire,
2010).
As most male victims of child sexual abuse do not become pedophiles, it
may be that particular experiences and patterns of childhood behavior are
associated with an increased risk of victims becoming abusers in later life
(Salter et al., 2003). Salter and colleagues conducted a longitudinal study of 224
former male victims of childhood sexual abuse (mean age of time of referral
was 11.0 years of age) followed for 7 to 19 years. Risk factors contemporane-
ous with the abuse and putative and protective influences were identified from
Social Services and clinical records. A nationwide search of official records
was performed to obtain evidence of later criminal acts. Of the 224 victims of
childhood sexual abuse studied, 12 subsequently committed sex offenses, in
almost all cases with children, mainly outside their families. Risk factors dur-
ing childhood for later offending included material neglect and sexual abuse by
a female. Victims who became abusers had more frequently witnessed serious
intrafamilial violence. Six (29%) of 21 victim-abusers on whom relevant data

were available had been cruel to animals (Salter et al., 2003).
Widom studied 908 individuals who had been subjected as children to abuse
(physical or sexual) or neglect, and whose cases were processed through the
courts between 1967 and 1971 (Widom, 1995; Widom & Ames, 1994). All were
11 years of age or younger at the time of the abuse. Arrest records revealed
that, compared to children who had not been victimized, those who had been
victimized were more likely to be arrested for sex crimes. Thus, experienc-
ing any type of abuse/neglect in childhood increased the risk for sex crimes.
Children who were sexually abused were about as likely as neglect victims to
be arrested for any sex crime and less likely than victims of physical abuse.
Studies have found that children who were the victims of sexual abuse did not
have a higher risk for arrest as adults than the victims of other forms of abuse
and neglect, except for the offense of prostitution (Widom & Kuhns, 1996;
Wilson & Widom, 2010).
Burton and colleagues examined 216 sexually victimized adolescent sexual
offenders and 93 sexually victimized nonsexual offending adolescents and
found that sexually abused males were much more likely to have committed
sexual offenses if they had been abused by both men and women, the perpe-
trator was related, the perpetrator used violence, the abuse took place over
several years, and the sexual abuse included penetration (Burton, Miller, &
Shill, 2002). Hunter and colleagues found that childhood physical abuse by
a father or stepfather and exposure to violence against women was associ-
ated with higher levels of anxiety and depression among male sex offenders.
Noncoercive sexual victimization by a male relative was associated with sexual
offending against a male child (Hunter et al., 2003).
Kendall-Thacket and colleagues reviewed 45 studies, demonstrating that
sexually abused children had more symptoms than nonabused children, with
abuse accounting for 15% to 45% of the variance (Kendall-Tackett, Williams,
& Finkelhor, 1993). Fears, PTSD, behavior problems, sexualized behaviors,
and poor self-esteem occurred most frequently, but no one symptom charac-
terized a majority of sexually abused children. Some symptoms were specific
to certain ages, and approximately one-third of victims had no symptoms.
Penetration, the duration and frequency of the abuse, force, the relationship
of the perpetrator to the child, and maternal support affected the severity of
symptomatology. About two-thirds of the victimized children showed recov-
ery during the first 12 to 18 months. Their findings suggested the absence of
any specific syndrome in children who have been sexually abused and no sin-
gle traumatizing process.
Data from case histories of 118 female juvenile sex offenders revealed that
female juvenile sex offenders are a heterogeneous group (Roe-Sepowitz &
Krysik, 2008). Female juvenile sex offenders with a history of childhood abuse
were more likely to have a mental health diagnosis and experience clinical
levels of anger and anxiety than those without a history of child maltreatment.
A history of sexual abuse for juvenile female sex offenders was associated
with higher levels of coercion toward their victims (Roe-Sepowitz & Krysik,
2008).
A recent meta-analysis examining 17 studies and comparing the sexual
abuse histories of 1,037 adult sexual offenders versus 1,767 nonsexual offend-
ers provided support for the sexually abusedsexual abuser hypothesis, in that
sex offenders were more likely to have been sexually abused than nonsexual
offenders, but not more likely to have been physically abused. The prevalence
of different forms of abuse in 15 studies was examined and compared adult sex
offenders against adults (n = 962) and against children (n = 1,334) in an effort
to determine if the sexually abusedsexual abuser association is more specific
to individuals who sexually offend against children (Jespersen, Lalumire, &
Seto, 2009). The results indicated higher prevalence of sexual abuse history
among adult sex offenders than among nonsexual offenders. The two groups
did not significantly differ with regard to physical abuse history. There was
a significantly lower prevalence of sexual abuse history among sex offend-
ers against adults compared to sex offenders against children, whereas the
opposite was found for physical abuse. The authors noted that more research
is necessary to assist in understanding the relationship between a history of
sexual abuse and later sexual offending. If additional research demonstrates
a true causal relationship between abuse and later offending, sexual abuse
prevention programs could provide the dual benefits of both decreasing the
incidence of sexual abuse and decreasing the prevalence of sex offenders as
victims grow up. However, the authors pointed out that because a history of
sexual abuse does not appear to be a risk factor for sexual recidivism, pre-
vention and treatment programs may have an impact on the onset of sexual
offending, but not persistence of sexual offending (Hanson & Bussiere, 1998;
Jespersen et al., 2009). Therefore, treatment and prevention programs are
particularly important for sexually abused youth as the research shows that
most juvenile sexual offenders do not persist in sexual offending into adult-
hood or become pedophiles; however, sexual offending by juveniles is a sig-
nificant problem.
Mentally Handicapped and Developmentally Disabled Offenders
There is a scarcity of research on youth with significant cognitive impair-

ments who offend sexually. However, children and adolescents with mental
retardation and developmental disabilities do engage in sexually reactive and

offensive behaviors (Adams, McClellan, Douglass, McCurry, & Storck, 1995;
Gilby et al., 1989; Greydanus, Rimsza, & Newhouse, 2002; Lindsay, Law, Quinn,
Smart, & Smith, 2001), and it has been suggested that cognitively impaired
and developmentally disabled youth are overrepresented among juvenile sex
offenders (Shaw, 1999).
A retrospective review of 200 youth with sexually inappropriate behaviors
(hypersexuality, exposing, and victimizing) and cognitive impairment and
serious mental illness revealed that lower IQ was associated with increased
sexual acting out. For more serious victimizing sexual behaviors, only Verbal
IQ differences reached statistical significance. Overall, sexual misbehavior was
strongly associated with a history of sexual abuse, but a history of sexual abuse
was significantly associated only with lower Performance IQ. The association
between low Verbal IQ and sexual victimizing behavior was independent from
the effects of sexual abuse. The authors noted that their results highlighted the
importance of verbal cognitive abilities, regardless of overall cognitive level, in
the development and treatment of sexual behaviors, especially among youth
who do not have a history of sexual abuse (McCurry et al., 1998).
In a Dutch sample of 175 juvenile male sex offenders, compared with a
healthy male control group (N = 500) and 114 males with DSM-IV autistic
spectrum disorders (ASD), followed for 3 years, significantly higher levels of
ASD symptoms were found in juvenile sex offenders than in healthy controls,
while levels were lower than in the ASD group. Solo peer offenders and child
molesters scored higher on several subscales as well as on core autistic symp-
toms than did group offenders (t Hart-Kerkhoffs et al., 2009).
S U M M A RY A N D CAS E D I S C U S S I O N
Juveniles with sexually reactive behaviors, including juveniles charged with

sexual offenses,, are a heterogeneous group, and lumping all juveniles who
commit sex offenses into one group does little to decrease risk and improve
public safety (Chaffin, 2008; Chaffin et al., 2008). Risk assessment should
include a thoughtful and thorough evaluation of the presence of mental illness,
including substance abuse disorders, possible incipient character pathology
(maladaptive personality traits), as well as deviant sexual arousal. The cases at
the beginning of this chapter were chosen expressly because they raise difficult
questions without easy answers and tap into many evaluators natural inclina-
tion to declare certain aspects of the histories as indicative of high risk. We
will briefly touch on some of the issues in a question format that hopefully will
serve to highlight their complexity.
Case 1
1. Toms mental illnesses (bipolar disorder, ADHD, and OCD) are asso-
ciated with both impulsivity (bipolar and ADHD) and compulsivity.
Is it appropriate to conclude that adequate treatment of his mental
illnesses will diminish his risk to recidivate?
Answer: Adequate treatment of Toms Axis I psychiatric disorders is

critical to the success of treatment of his sexually abusive behavior, but most
likely it is not sufficient to address the complexity of his behaviors. Toms
case brings up a number of important concepts, some of which are reviewed
in other chapters of this book. Evaluators, perhaps especially those with
considerably more expertise in the area of diagnosing and treating mental
illness than sexual reactivity or offending, may intuitively but erroneously
conclude that treating Toms mental disorders will have a dramatic effect on
his sexual behavior. Th is is not necessarily the case. Of course, mental ill-
ness must be treated appropriately and aggressively, and it is not uncom-
mon for the mental health needs of general delinquents as well as sexual
offenders to be overlooked or minimized. We have often heard statements
such as Youd be depressed too if you were looking at 10 years in prison or,
regarding adolescents who engage in suicidal behavior in correctional facili-
ties, Hes manipulating to try to get to a hospital where hell have more free-
dom. The list goes on. However, it is a good rule of thumb to regard most
adolescent sex offenders with psychopathology as having mental illnesses
which may exacerbate their sexual acting out and compromise their engage-
ment in and completion of treatment. The nature of Toms sexual offenses,
as well as the evolution of his sexual interests and behaviors, is not compat-
ible with a manic episode, especially if careful, nonsuggestive interviewing
indicates that he did not experience other symptoms of mania (decreased
need for sleep, pressured speech, increased motor and goal-directed activ-
ity, grandiosity, or other grossly disinhibited or impulsive behaviors) around
the time of the alleged offenses. Additionally complicating the hope that
treatment of the psychiatric disorders will eliminate his sexually offensive
behavior is the reality that comorbid bipolar disorder, ADHD, and OCD can
be quite difficult to treat, and even if his offending was partly driven by an
acute exacerbation of his mental illness(es), pharmacological treatment will
be difficult and is clearly not a panacea. For those adolescents determined to
have a major mental illness, aggressive treatment of the underlying psychi-
atric disorder should be undertaken, along with other appropriate therapies
focusing on those vulnerabilities that led to or contributed to the offending
(case management, family therapy, reassessment of appropriateness of edu-

cational placement, substance abuse treatment, etc.). Reassessment of mental
health in the context of the sexual offending (including cognitions, emotions,
and behaviors) and compliance with treatment should be assessed at regular
intervals, regardless of response to psychotropic medication.
2. Is Toms risk for adult sex offending increased by the fact that he is a
loner?
Answer: No. First of all, we have no validated or accepted way of predicting

which adolescent sex offenders will continue sexually offending into adulthood.
The extant research indicates that as a group most adolescent sex offenders
will not continue their sexual offending into adulthood. Second, while some
characteristics may have greater predictive factors than others (deviant sex-
ual arousal, for example, which we cannot automatically extrapolate from
the age and sex of the victim alone), no single factor should be used to pre-
dict increased risk to sexually recidivate, even in the short term. A pattern of
behavior that indicates deviant sexual arousal is cause for concern, however,
and warrants more intensive intervention. The fact that Tom is alleged to have
molested a single 10-year-old girl on three occasions does not constitute a pat-
tern. However, molesting three different 10-year-old girls would suggest a pat-
tern. Third, we do not know that Tom is a loner. This term is poorly defined
and may mean different things to different people. The motivation for social
withdrawal of an adolescent who wants friendships but who is avoidant of peers
secondary to being teased or bullied is different from the motivation for social
isolation in a schizoid adolescent. While peer relationships are important to
consider in the evaluation of sexual offending youth, especially with respect
to understanding criminogenic factors that contribute to general offending
and addressing vulnerabilities underlying sexual offending, no single factor
independently (except perhaps deviant sexual arousal, which is often difficult
to determine from sexual behavior alone) appears to increase a youths risk for
adult reoffending.
3. Is it appropriate for Toms outpatient psychiatrist or therapist to write

a letter or report to the Court opining that Tom is at low risk for sexual
reoffending?
Answer: No. Blurring the boundaries between the clinical and forensic role is
inappropriate and has potential negative consequences for Tom and the public.
While Toms psychiatrist and therapist may have well-informed opinions
regarding Toms psychopathology and treatment needs, they are not privy to
the kind of information necessary to perform a thorough forensic evaluation.
Treating clinicians do not receive documents related to police investigations,
witness statements, prior juvenile charges and findings, all prior treatment
records, and reports from multiple sources of information, nor would it be
appropriate for them to do so. A treating clinician cannot perform a thor-
ough forensic evaluation without irrevocably rupturing the doctorpatient or
therapistclient relationship. While the clinicians role is to help and advocate
for the patient or client, a forensic examiners role is to provide a fair, thorough,
and objective assessment, regardless of the effect it may have on the evaluees
well-being (for example, prison versus a hospital in the case of an evaluation of
insanity at the time of the offense).
Case 2
1. Is Bruce at higher risk for sexual reoffending by virtue of Aspergers

disorder and ADHD?
Answer: The actual diagnoses of Aspergers and ADHD do not alone con-
fer increased risk for reoffending. However, the fact that Bruce has sexually
abused significantly younger boys on several occasions and continued to do
so after being caught and incurred legal consequences (court-ordered therapy)
is concerning and confers higher risk of continued sexual offending during
adolescence. As noted in the previous case, there is not sufficient empirically
validated research evidence to predict adult recidivism, however. Given his
young age, sexual arousal patterns are not yet fi xed. One would want to know
much more information that might help inform the examiner as to how Bruce
became so sexually reactive at such a young agefor example, has he been
exposed prematurely to sexual activity or abuse? Is he frequently engaged in
viewing Internet pornography, for example, and then presented with easy
access to children when he is sexually aroused? Are his offenses opportunistic
in that his mothers day care center affords access to victims that are easy to
coax into sexual activity; or has he developed, or is he on his way to devel-
oping, preferential deviant sexual arousal to young children? The answers to
these questions may be complicated, but they are critical to understanding
Bruce and the etiology of his offending, as well as for developing a treatment
plan. Addressing vulnerabilities conferred by Aspergers disorder (social isola-
tion and poor social skills) and ADHD (impulsivity and poor frustration toler-
ance) are important in the development of Bruces treatment and should not
be neglected; however, treatment should be incorporated into a comprehensive

treatment plan addressing his sexually abusive behavior.
2. What problems can you foresee with respect to Bruces mothers

decision to relinquish custody? How do these problems impact on his
treatment?
Answer: Family dysfunction, including psychopathology and alcohol and

substance abuse, can significantly impact on the development and resolution
of many crises in the lives of children and adolescents. Bruces mother may not
be a competent parent in the best of situations, and she may be unwilling and/
or unable to provide the necessary level of supervision for her son; however, the
appropriateness of the grandfather as a full-time caretaker must be thoroughly
investigated. Bruces mothers continued contact with him and involvement in
his therapy may help mitigate his fear of being permanently rejected and aban-
doned. Clearly, if Bruce remains in his mothers custody, she will need to close
her day care business, which may be a major factor in her desire to relinquish cus-
tody. Regardless of where Bruce lives, his mother should be part of his treatment
and participate in family therapy. If Bruce does live with his grandfather, his
grandfather should also be willing and able to participate in Bruces treatment.
3. What are some possible risk factors and potential protective factors in
Bruces case?
Answer: Possible risk factors include a pattern of sexual offending against

very young prepubescent males, even after having suffered legal consequences
for such behavior. While the research does not support sexual abuse as being
a risk factor for adult sexual offending or recidivism, the relationship between
sexual abuse and sexual reactivity is a complex one, and the contemporaneous
nature of the onset of his first sexual offense charge and his own sexual abuse
should be neither dismissed as irrelevant nor casually considered the root
cause of his sexual offending. Aspergers disorder makes it more difficult for
Bruce to take anothers point of view; however, it should be noted that lack of
empathy has not been shown to be a risk factor for recidivism for sexual offend-
ing in either adults or youth. Impulsivity as a risk factor certainly makes sense
intuitively, but there is no evidence that impulsivity alone is a risk factor for sex-
ual offending; indeed, it has not been adequately studied in this population. The
fact that Bruces father is an incarcerated sex offender does not increase his risk
to sexually reoffend. However, as in all thorough forensic evaluations of youth,
it is important to explore the meaning of seminal life events, including the
meaning to Bruce of his fathers incarceration and designation as a sex offender.

Has Bruce been compared favorably (or more likely unfavorably) to his father
growing up, and if so, how does Bruce perceive this more recent similarity?
Possible protective factors include intelligence, and possibly a competent and
involved grandfather who may still be invested in caring for Bruce when the
extent of his treatment and the necessity of his involvement, as well as moth-
ers involvement, are explained. The grandfathers capacity should be evalu-
ated and whether he possesses the resources and health to facilitate Bruces
treatment plan. Presumably at some point Bruce will either be returned to his
mother, or she will need to be responsible for him during visitation home. She
will need to be willing to invest time in his treatment on a regular and ongoing
basis, regardless of the demands of her employment.
Case 3
1. Gerald appears to have suffered an episode of mania, perhaps triggered

by initiation of an antidepressant medication. What questions might
assist in determining a possible nexus between the manic episode and
the sexual behavior?
Answer: There is sometimes an automatic response on the part of men-

tal health professionals to identify inappropriate sexual behavior as a direct
result of mental illness in an individual clearly diagnosed with a major psy-
chiatric disorder. However, mental illness does not confer immunity against
the multitude of other factors and vulnerabilities that go into sexual offend-
ing in the nonmentally ill population. Forensic evaluators should consider
a variety of questions and data in determining the extent of the role of an
acute exacerbation of a mental illness in a sexual offense. Some examples
follow:
Is the sexually inappropriate behavior clearly defined to the period of

mania?
Are there other clear signs and symptoms of mania coinciding with
the sexual behavior, such as marked decrease in sleep, a decreased
need for sleep, pressured speech, increased energy and impulsivity,
and an increased overindulgence in other pleasurable activities?
Do other collateral sources (for example, teachers, coaches, etc.) cor-
roborate that the youths behavior was altered in a manner consistent
with mania, and did the sexual behavior in question take place during
this period?
Case 4
1. Is there any way to predict Elishas propensity for continued sex offend-
ing over the short term, as well as her risk for continuing to sexually
offend into adulthood?
Answer: Remember that risk assessment is in some ways like weather

prediction. A thorough forensic evaluation may be useful to predict short-term
delinquency and violence, but the ability to make longer term predictions
remains poor. When it comes to sex offending in females, there is an even
greater paucity of research regarding the etiology and risk than in males.
What can be said is that Elisha has a variety of risk factors that would be
expected to compromise treatment of her emotional problems as well any
interventions aimed specifically at sex offending. The chronic and severe
abuse (and probably neglect) that Elisha sustained during early childhood, as
well as multiple placements and caregivers, has probably damaged her abil-
ity to trust; modulate her impulses and emotions, including anger; and form
healthy attachments. Her vulnerabilities can be expected to create challenges
with respect to addressing her sex offending in treatment. It is noted that she
is frequently noncompliant with medications. Therefore, development of a
treatment plan must take into consideration potential resistance and noncom-
pliance and develop contingencies.
2. What role, if any, might mental illness play in Elishas sexual

offending?
Answer: The role of a major mental illness (bipolar disorder) is unclear.

It should be noted that the diagnosis was made 3 years ago in a residen-
tial facility, and records should be obtained to assist in determining what
specific symptoms (if any) were elicited or observed that would actually
merit the diagnosis. Her excellent functioning as well as her pharmaco-
logical regimen do not really support the diagnosis, but while they raise
legitimate questions regarding the accuracy of the diagnosis, more thor-
ough psychiatric assessment is warranted. It is possible that the behavioral
disinhibition, impulsivity, and impaired judgment accompanying a manic
or mixed manic episode contributed to Elishas sexual offending in a signifi-
cant way, but one would expect to fi nd evidence of impairment across other
domains, not just with respect to sexually abusing her babysitting charges.
Elishas history of chronic sexual victimization in combination with long-
standing neglect and abuse is more likely related to her sexual reactivity and
abusive behaviors than is mania or hypomania. However, the convergence
of mood instability related to developmental and personality pathology

(Axis II) with a superimposed major mood disorder (Axis I) along with
potential environmental stressors yet to be identified in a thorough evalua-
tion should be considered. Sexually reactive and abusive behaviors in youth
are typically complex and multidetermined. Understanding and treating
them requires expertise in the areas of normal and abnormal child devel-
opment, the diagnosis and treatment of mental illness, and an up-to-date
awareness of recent advances in the fields of juvenile sex offender evaluation
and treatment.
Case 5
1. What role might Billys bipolar disorder, ADHD, and substance and
alcohol abuse play in his sexual offending?
Answer: As in the previous cases, Billys psychopathology should be thoroughly

evaluated and treated with appropriate pharmacologic and psychotherapeutic
modalities. While it is appropriate to consider the contribution of psychiatric
symptomatology to his offending, one must be cautious about overinterpreta-
tion of the role of mood instability and impulsivity in understanding and treat-
ing sexually reactive and abusive behaviors. Disinhibition caused by substances
and/or alcohol abuse deserves careful and methodical scrutiny, particularly as
to whether sexually inappropriate behavior escalates (or is only observed, which
is more atypical) when Billy is under the influence of drugs or alcohol.
2. Is Billys lack of remorse a risk factor for sexual offending into

adulthood? Does it indicate a callous interpersonal style and likely
psychopathy?
Answer: No. First, remorse is a difficult state to measure and can have differ-
ent meanings to different people. Unfortunately, the phrase lack of remorse
may conjure up a variety of impressions (often erroneous) in the minds of
others, including judges and juries, which have little probative or predictive
value. Second, remorse has not been shown to be a useful predictor of sexual
recidivism in either adults or juveniles. This case also illustrates some of the
risks associated with generalizations based on inadequate knowledge of the
construct of juvenile psychopathy, its real limitations with respect to predict-
ing adult psychopathy, and the lack of research evidence that it is a risk factor
in sexual offending continuing into adulthood.
3. What role, if any, might Billys mental retardation play in his offense?
Answer: It may play a very significant role, but the nexus between his
cognitive deficits, psychosocial immaturity and deficits, and the offense must
be thoroughly assessed, and not just assumed. There are clues from the case
that Billy may not understand that a 12-year-old is not an appropriate sexual
partner; it is likely that he is uninformed about issues such as capacity for
consent.
4. What role, if any, does Billys sexual abuse play in his offending?
Answer: Its hard to tell from the brief information provided, but this area
should be explored in depth with Billy. There is some indication that perhaps
Billy was attached to his abuser, in that he became depressed and suicidal
when his abuser was removed from the home. This is not unusual and serves
to highlight the complexities of attachment and victimization. If Billy was not
physically abused or threatened as part of his own sexual abuse, he may not
understand that sexual abuse does not need to include those components in
order to satisfy the definition of abuse.
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5
Forensic Evaluation Versus

Clinical Evaluation
How Do They Differ?
CAS E E X A M PL E
You are the only child psychiatrist in a small city. Hannah is a 16-year-old girl
charged with several felony counts of aggravated sexual battery of a child under
age 13 for allegedly performing fellatio on two boys, ages 5 and 7, and direct-
ing another girl, age 6, to perform sexual acts on her. The three children are
unrelated and the alleged molestations occurred while Hannah was babysitting
the children in their homes. Hannah is being charged as an adult and is out
on bond and can have no unsupervised contact with children. She is receiving
homebound instruction. Her trial is not scheduled for several months. Hannahs
parents explain that Hannahs attorney would like for Hannah to receive a psy-
chiatric evaluation and treatment for what they believe is her bipolar disorder.
Hannah denies any involvement in the alleged assaults, but she does endorse a
long-standing history of mood lability, impulsivity, problems with anger, some
superficial cutting, and episodic binging and purging. She endorses episodes of
increased energy accompanied by pressured speech, racing thoughts, increased
impulsivity, and elevated mood that last from several minutes to hours, and once
or twice may have lasted for a couple of days. There is no evidence or history of
psychosis. Currently, Hannah does endorse symptoms that meet full criteria for
a major depression, with the onset about a year ago after the death of her grand-
mother with whom she was very close. Two months after her grandmothers
death, her boyfriend broke up with her, and when she learned that her best
friend was sleeping with him, she overdosed with unspecified medications that
she found in the house. She states that she fully intended to die and hoped to not
wake up. When she did awaken, she told no one about the attempt. Hannah
continues to experience intermittent passive death wishes, but she is not suicidal
and has no plan to harm herself. However, she does say that she will kill herself
if she is sentenced to prison.
In early childhood, Hannah was briefly prescribed methylphenidate for
attention-deficit/hyperactivity disorder (ADHD), which was ineffective and pro-
duced gastrointestinal distress. She was molested by a 19-year-old uncle between
the ages of 4 and 8. The abuse came to light when she was diagnosed with a
sexually transmitted disease, chlamydia. Family history is positive for depres-
sion, anxiety, and alcoholism. Her mother experienced a severe postpartum
depression after Hannahs birth and was treated successfully with antidepres-
sant medication and psychotherapy. The maternal grandfather had a history of
alcoholism and committed suicide by hanging at age 65 after being diagnosed
with prostate cancer. One cousin convicted of drug trafficking is in prison.
You provisionally diagnose Hannah with major depressive disorder, single
episode, moderate, with rule outs of bipolar disorder, posttraumatic stress disor-
der (PTSD), and Cluster B traits. You see her weekly in individual psychotherapy
with a cognitive behavioral focus targeting her depressive symptoms, and start
her on an antidepressant, which she tolerates well. Her depressive symptoms
improve significantly. Two months prior to trial, you receive a call from Hannahs
attorney who informs you that you will be receiving a subpoena to testify at her
trial. He would like you to provide testimony that her profile does not fit the
typical profile of a sex offender and that she is at low risk for sexual offending
if released into the community, especially now that her psychiatric disorder is
being treated.
OV ERV I E W
This is a case scenario with aspects that are familiar to many clinicians who
work with youth. Hannahs clinical presentation is not uncommon. As a child
psychiatrist, you feel well prepared to evaluate Hannah, make provisional
diagnoses that may change over time as you get to know and understand her
better, and provide psychotherapeutic and pharmacologic treatment. You are
nonjudgmental regarding the charges and stressors that brought her into treat-
ment, and you are determined to provide the same quality of psychiatric care
to Hannah as all of your other patients. You wonder how you got sucked into
this legal vortex and how you should handle the situation.
Forensic Evaluation Versus Clinical Evaluation 103
After reading this chapter, clinicians will understand the difference between
a clinical evaluation and a forensic evaluation. There are several ways to con-
ceptualize the differences, and there are clear similarities between the two
types of evaluation.
C L A R I F Y I N G YO U R R O L E
It is not unusual for a parent or an attorney to request a psychiatric or psy-

chological evaluation of a youth who has been charged with an offense and to
request the clinician to provide treatment recommendations. Almost as an
afterthought, the clinician is sometimes asked to provide an opinion on the
patients future risk for violence. The concerns may include whether it is safe
for the adolescent to be treated in the community and whether treatment is
expected to decrease his or her risk of reoffending. Concerns on the part of
school officials regarding violence on school grounds and the fear of miss-
ing another Columbine may generate ultimatums that a child or adolescent
may not return to school until he or she has been cleared by a mental health
professional. Unfortunately, often the issues are not immediately addressed
this directly or clearly, but frequently these are the underlying questions. The
unsuspecting clinician may discover that what he or she thought was a clinical
evaluation has morphed into a situation in which an opinion regarding risk
and future dangerousness is sought.
Sometimes the first clue that the clinician may become involved in a legal
issue is receipt of a release-of-information form signed by the youth and/or his
parent to provide copies of records to an attorney. Discussion of this with the
adolescent may yield little information, and parents are also sometimes genu-
inely vague about the attorneys plans. Experienced and/or better-prepared
attorneys may call and clarify why you were (or are about to be) subpoenaed
to testify. This is the time to clarify (1) your objection to testifying at all given
the likelihood that testifying would alter (usually negatively) your relation-
ship with the patient and/or family; (2) the fact that you have not performed a
forensic evaluation and will therefore be unable to testify about risk, custody,
or whatever the legal issue might be; and (3) that if you must testify, you are by
necessity restricting any testimony to that of a fact witness, rather than as
an expert witness.
Expert witnesses are called upon to assist the trier of fact (typically a judge
or jury) because they have specialized knowledge or skill beyond that of the
layperson. There is sometimes confusion and disagreement regarding use of
the term expert. Physicians and psychologists have put forth considerable
time, expense, and energy in developing expertise in their chosen fields and
areas of concentration, and therefore they possess considerable expertise in

these areas. However, in the forensic arena, expert witness is typically used
to connote a professional who has conducted a forensic evaluation (face-to-face
and/or record review) of the facts of the case, to which he or she has entered
as an objective or neutral source.1 Expert witnesses may offer opinion testi-
mony. Physicians and clinicians testifying as fact witnesses provide testimony
regarding what they have actually observed during evaluation and treatment.
They do not provide opinions. Examples of fact witness testimony during a
custody case might include the childs diagnosis, the treatment prescribed,
the parent who brings the child for treatment, compliance with treatment,
whether the clinician has made attempts to contact the noncustodial par-
ent, and the level of involvement of the noncustodial parent in the treatment.
Testimony does not include the clinician (fact witness) rendering an opin-
ion on which parent is the more nurturing, supportive, or competent parent.
Likewise a clinician treating a child in individual psychotherapy, even if it is
intensive therapy over a substantial period of time, does not offer opinions
regarding the risk to offend sexually. The reasons are obvious. As clinicians
treating the child or adolescent, we typically are not privy to the wide array
of information available from police records, victim statements, prior legal
history, and collateral informants. We rely primarily on the information pro-
vided by the patient (with some collateral information, typically from a parent
or guardian). The forensic examiner utilizes his or her clinical skill to sort
through information obtained through multiple interviews and evaluations,
with multiple informants, as well as records from numerous sources often
spanning years, in an attempt to fully understand the person being evaluated
and the nature of the persons problems in the service of assisting with a legal
question or issue.
Lets take the example of a custody hearing. In custody litigation attorneys
may attempt to draft clinicians into providing opinions based on their clinical
work with patients. Imagine that you are the therapist for a little girl whose
mother is attempting to obtain sole custody. If the mothers attorney calls you
to testify, you may need to reveal statements made by the child that reflect
poorly on the mother and well on the father. Rather than telling the attorney
1. The issue of whether a forensic evaluator can ever be truly objective and neutral has been
debated. Some consider impartiality and objectivity to be impossible (Diamond, 1959),
noting that even if the evaluator begins an assessment with impartiality and objectivity, at
some point the need to defend ones opinion turns the evaluator into a biased advocate. The
American Academy of Psychiatry and the Law ethical guidelines (American Academy of
Psychiatry and the Law, adopted May 2005) accepts the premise that complete impartial-
ity may be impossible, but it states that the forensic evaluator must be honest and strive for
objectivity.
that you do not want to testify because it will damage the doctorpatient
relationship, it may be more useful to inform the attorney that your testimony
under cross-examination may actually be damaging to his clients case (if that
is so). Attorneys are often more interested in winning the case and may care
little about the doctorpatient relationship.
Many experienced clinicians who evaluate and treat youth who have engaged
in or have been suspected of engaging in sexually abusive behavior have not
received formal forensic training in the form of a forensic psychiatry fellow-
ship or postdoctoral training. Therefore, it is helpful to highlight that there
are important differences between forensic and clinical evaluation. While
clinical skills are critical to performing a forensic evaluation, clinicians do not
perform forensic evaluations of their patients or clients. Forensic evaluations
are requested in order to assist the court in making a legal disposition. While
judges may request recommendations regarding treatment, the forensic evalu-
ator is really a consultant to the court or to the party requesting the evaluation
(the defense attorney, prosecutor, judge, Social Services, etc.). Th is can be a dif-
ficult situation for clinicians entering the forensic arena to get used to initially,
and patience and diligence are required for clinicians to adapt their style to
forensic work.
The mental health professional asked to perform a forensic evaluation of
a youth charged with sexual offending must understand the relevant legal
standard (competency to stand trial, insanity, commitment as a sexually vio-
lent predator, etc.) and be able to evaluate the youth against that standard.
The forensic evaluator must also be able to effectively communicate his
or her fi ndings in the context of the legal system (Grisso, 1988). Forensic
evaluators must understand the specific statutes of their states and how they
apply to the legal issue in any case in which they are requested to participate
forensically.
H OW D O ES F O R EN S I C E VA LUAT I O N D I F F ER F R O M
C L I N I CA L E VA LUAT I O N A N D T H ER A PEU T I C PR ACT I C E?
There Is No DoctorPatient Relationship in Forensic Evaluation
The well-known dictum in medicine Primum non nocere (First do no

harm) is not applicable in forensic evaluation. The forensic examiner is
a skeptic and an investigator whose search for the truth may lead him or her to
conclusions that help inform decisions that may be harmful to the individual
being evaluated (incarceration, for example). There should be no expectation
of developing a therapeutic alliance and obtaining help from the evaluator
on the part of the defendant. Despite the forensic evaluators understanding

of these limitations, defendants, especially youthful evaluees, may dismiss,
misinterpret, or forget them over the course of an evaluation. The maxim of
patientdoctor confidentiality is sacrosanct in medicine. People are used to
trusting physicians and therapists to be their advocates and keep their secrets
safe. Even the most sophisticated and/or cynical adolescent may still retain a
sense that adults are in charge and that nice adults are helpful. Children and
adolescents certainly understand the power differential, which may play out in
a variety of ways over the course of an evaluation and ultimately compromise a
youthful defendants rights. Youth and their families need to be well informed
of the limits on confidentiality in a forensic evaluation, and the evaluator
should ask the youth to repeat back his or her understanding of these limits in
order to ensure adequate appreciation.
Forensic Evaluation Has a More Limited Purpose

Than Clinical Evaluation
The purpose of clinical evaluation is to better understand the problems,

symptoms, and concerns related to a patient or client in order to recom-
mend (and often administer) a treatment that will hopefully relieve suffering.
Accurate diagnosis is important, because appropriate treatments depend in
large part on what it is that one is treating, as with any other disorder or dis-
ease. One purpose of a forensic evaluation is to provide clinical expertise to
help the criminal justice system more accurately resolve a legal question that
has a mental health component. It is not to help the person being evaluated.
It is not to provide treatment (although treatment recommendations may be
solicited). Novice forensic evaluators often struggle at first with the urge to call
evaluees and defendants patients, reflecting how difficult it can be to shift
from the role of empathic healer to neutral evaluator.
The forensic evaluator may be called to testify as an expert witness. As
previously noted, an expert witness possesses specialized knowledge and
may render an opinion about facts relevant to his or her area of knowledge
or expertise and assist the trier of fact (jury or judge) to understand the
evidence or to determine a fact in issue (Federal Rules of Evidence, 2006).
Clinicians providing treatment to a patient may testify as fact witnesses. As
a fact witness, the clinician testifies only about matters directly observed
and is treated in the same manner as other witnesses. For example, a treat-
ing psychiatrist testifying as a fact witness may testify that her patient has
bipolar disorder and has responded well to lithium, but he or she should be
very wary of testifying that the patients sexual offense was related to a manic
episode.
Although Forensic Evaluation Is More Limited in Scope, It Often

Takes Longer to Complete Than a Clinical Evaluation
In the forensic realm, referral questions are typically drawn more narrowly
and tied to legal questions (for example, whether a defendant is competent
to stand trial, meets the threshold for legal insanity, or meets the states legal
definition of a sexually violent predator). Understanding the development
of the behavior in question and answering the legal question often require
a thorough and sometimes exhausting examination of the evaluees family,
developmental history, mental status, and other biopsychosocial influences.
Forensic evaluation requires more than diagnosis, and yet forensic evaluators
must resist the temptation to venture beyond the referral question. A clini-
cian would be remiss in performing a clinical psychiatric evaluation based
on referral concerns regarding depression and not report on findings per-
taining to substance abuse, psychosis, and anxiety. However, for a forensic
evaluator to plough ahead and discuss issues pertaining to legal insanity in
a competency report is grossly inappropriate and may seriously compromise
the defendants defense. When in doubt with respect to the scope of a forensic
evaluation, it may be helpful to discuss the issue with both the attorney and
an experienced forensic colleague.
Forensic Evaluation Has Limited Condentiality/Privilege
Results of a forensic evaluation are always shared with someone else. Even for
evaluations that are not ordered by the Court, the results of the evaluation will
be shared with the evaluees attorney at the very least. As previously explained,
it is critical to notify defendants/evaluees regarding the limits of confidenti-
ality. In clinical work, confidentiality is the obligation of the clinician, and
privacy is the right of the patient. The clinician has an obligation to his or her
patient/client only, except in the case of a direct threat to an identifiable source,
in which case the clinician also has an obligation to protect the potential vic-
tim (Tarasoff v. Regents of University of California, 1976).2 Clinicians may not
2. The clinicians duty to protect was established in the second Tarasoff case (1976). The
California Supreme Court ruled: When a therapist determines, or pursuant to the standards
of his profession should determine, that his patient presents a serious danger of violence
to another, he incurs an obligation to use reasonable care to protect the intended victim
against such danger. A duty is present by the therapist to take some action to prevent fore-
seeable harm to a third party injured by the client. Most states that have dealt with a Tarasoff
interpretation now require the third party be defined as an identifiable victim, before the
therapist can be said to have a duty to this victim. This is not the case in all states; some states
continue to hold that foreseeable harm to any third party creates a duty for the therapist.
reveal any information to a third party without the patients consent, and even
then a clinician must be mindful of his or her role as the patients advocate.
This of course does not mean that clinicians lie to help their patients; however,
clinicians should be cognizant of how clinical information can be misused if
it gets into the wrong hands. This is one reason why we provide a minimum
of information to insurance companies and even are careful with respect to
information recorded in the medical record.
The fact that there is no patientdoctor or therapistclient privilege or
confidentiality must be clearly explained to the child/adolescent and family.
It is often useful to have the youth repeat this position back to the forensic
examiner, as it is alien to their typical experience of a therapist or doctor. The
examiner is not an advocate for the individual being examined, and this must
be explained to the youth being evaluated. The information obtained may be
helpful to the youths defense attorney; however, there is some potential that
the prosecutor may use it. If a report must also be sent to the prosecutor and/or
the judge (in some court-ordered sex offender evaluations, for example), the
evaluee must be informed of this possibility.
Forensic Evaluation Is Objective
The forensic evaluator must remain nonbiased and clinically objective

regardless of the referral source. The forensic evaluators primary allegiance is
to a third party, not to the evaluee. This is not to imply that it is ever ethical to
shape ones opinion or testimony to comport with the desires of the retaining
or requesting party, as the forensic evaluator has a greater allegiance to the
truth. Regardless of whether an evaluator is retained by the defense or pros-
ecution, the evaluators goal is accuracy. After a forensic evaluator who has
approached an evaluation objectively and neutrally and completes a thorough
evaluation and forms his or her opinion, it is acceptable to advocate for that
opinion. This is different from being an advocate for the attorney or the defen-
dant or plaintiff.
The Forensic Evaluator Is an Investigator
Skepticism, without veering into cynicism, is a crucial mindset for the forensic
examiner to maintain during a forensic evaluation. However, skepticism is not
critical, and it may actually act as a barrier, to empathic clinical assessment.
For example, when a patient presents to his or her primary care doctor com-
plaining of chest pain, the physician does not doubt the presence of the pain.
The questioning on the part of the physician is aimed at developing a differen-

tial diagnosis, which will guide further assessment and ultimately treatment.
When a child and adolescent psychiatrist performing a clinical evaluation
encounters an adolescent who reports experiencing pervasive sadness, loss of
energy, and suicidal thoughts, the truthfulness of the patient is seldom ques-
tioned. For the most part, people (including, or perhaps especially, children
and adolescents) do not show up complaining of bogus emotional problems.
However, forensic evaluators must consider the possibility that psychological
signs and symptoms are being feigned or exaggerated. Reasons may include
the potential for monetary gain (damages awards, etc.) as well as to avoid or
minimize criminal responsibility.
The Forensic Evaluator Must Be Aware of the

Potential for Malingering
Given the high stakes and context of forensic evaluations, evaluators must be
aware of the possibility of malingering and consider the possibility in every
forensic evaluation. As noted earlier, this level of skepticism is not encour-
aged in clinical evaluation. The evaluation of malingering requires specialized
knowledge, and it may be enhanced by a variety of techniques, including
testing.
The Forensic Evaluator Is Communicating His or Her

Findings With Nonclinicians
The results of a forensic evaluation are conveyed to nonclinicians. In

a privately retained case, your impressions and conclusions are often first
conveyed verbally to the retaining attorney who may have the option of
requesting (or not requesting) a report. If your opinions are not in sync with
what the retaining attorney had hoped, you may be fi nished with that case
and provide neither a report nor testimony. In court-ordered evaluations,
a report is usually required. Opinions and conclusions may also need to be
conveyed through testimony. Forensic report writing and testimony require
the development of special skills in order to convey ones opinions and the
basis for ones opinion in a compelling and easily understandable way. For
example, while terms such as affect, elopement, delusions, and even
psychotic are well understood among mental health professionals, these
terms should be avoided or their defi nitions and meanings well clarified
when used in reports or testimony.
The Stakes Are High for Most Forensic Evaluations, and

the Results of a Forensic Evaluation May Impact Dramatically
on the Life of the Defendant
Forensic evaluators do well to keep in mind that the conclusions drawn

from their forensic evaluations can have a significant impact on the lives of
many individuals. This is undoubtedly the case in sex offender evaluations of
juveniles. In clinical work, it is common for clinicians to significantly revise
a diagnosis or modify a treatment regimen as new information and history
become available over the course of the patients management, but this is a
luxury that is typically unavailable to the forensic evaluator. Therefore, it is
critical that forensic evaluators are clear with referral sources as to what infor-
mation (records, collateral sources) they will require in order to complete a
thorough evaluation, as well as the time that they estimate they will need to
complete the evaluation. The quality and thoroughness of a forensic evalua-
tion should be the same regardless of the hourly rate or fee involved. If you are
unwilling or unable to put in 40 to 100 hours on a low-fee case, then do not
accept the case. There is nothing wrong with only accepting cases in which
your full hourly rate is paid, as long as that does not influence your opinion.
It is unethical to do shoddy work because youre not being fairly compensated
for your time.
Forensic Work Is Stressful in Some Ways That

Therapeutic Work Is Not
The fact that the forensic evaluators conclusions and opinions can so
dramatically alter the trajectory of an individuals life should be stressful.
Forensic work exposes evaluators to unusual circumstances that may stimulate
voyeuristic interest on the part of the evaluator and others, with the potential
and sometimes the temptation to compromise professionalism (for example,
the evaluation of a defendant in a high-profi le criminal case). Forensic work
may lead to media coverage and recognition. Also, certain types of cases
may stimulate strong reactions and can create significant personal stress. For
mental health clinicians who regularly evaluate and treat victims of sexual
trauma, the evaluation of juveniles charged with sexual offenses may be par-
ticularly difficult. Evaluators must be able to acknowledge biases that could
compromise their objectivity and/or performance and refuse cases in which
they perceive potential problems remaining objective. More mundane sources
of stress are related to difficulty controlling the pace of forensic work, which is
typically dictated by attorneys and the Court. Continuances (delays) in hear-

ings and trials are common and may result in several cases that the clinician
is involved in coming to trial (and/or reports coming due) uncomfortably
close to one another. Deadlines for reports, delays in obtaining records, and
difficulty contacting crucial collateral sources of information contribute to the
stress of forensic work.
The Process of Reimbursement in Forensic Work

Differs From Therapeutic Work
The issue of how the evaluation is paid for should be determined in advance
of beginning an evaluation, and it should include the anticipation of pos-
sible report writing and testimony. Forensic evaluation is not covered by
insurance, Medicaid, or Medicare, which is for clinical (diagnostic and
treatment) purposes. Some attorneys do not realize this, confusing the dif-
ference between a clinical and forensic mental health evaluation. The hourly
rate for forensic work is typically higher than that for clinical work. Th is
stems in part form the stress inherent in forensic work, as well as the fact
that payment for legal work is not constrained by government and insurance
regulations and capping. If the evaluation is not court ordered, many foren-
sic evaluators request a retainer from the attorney requesting the evaluation
against which they work (refunding any balance not used). A retainer is a
sum of money paid in advance by the attorney requesting (retaining) the
psychiatrist or psychologist to perform a forensic evaluation. The retainer
presupposes nothing regarding the evaluators opinion. It should also be
clarified at the outset of the evaluation with the retaining attorney how
billing will progress if the retainer is exceeded. Will the evaluator present
the law fi rm with a monthly bill or request another retainer against which
the evaluator will continue to work? Court-ordered evaluations in criminal
cases often have a flat fee that is determined by statute, regardless of the time
expended in the evaluation.
Forensic Evaluation Is a Multifaceted Process
Referral/Court Order
Referrals for court-ordered evaluations come from the court, typically at the
request of one of the attorneys. Court orders ensure reimbursement at the fee
specified within the states legal code. For example, competency to stand trial,
insanity, and sexually violent predator evaluations are often reimbursed at set
fees that vary from state to state. However, sometimes attorneys will request
an evaluation that is not court ordered and will not be reimbursed according
to the states (typically low) fee schedule. Regardless of whether the evaluation
is court ordered, the attorney requesting you as an evaluator should contact
you ahead of time to ensure your availability, the time frame in which you can
complete the evaluation, including the report, and your availability to testify
(if a trial date has been set).
Attorney Consultation
The initial call from the attorney will often involve providing you with a
thumbnail sketch of the case as well as the type of evaluation requested. If
you decide to accept the evaluation, you should let the attorney know your fee
and send out a fee agreement (if not reimbursed at a state-mandated fee) and
a copy of your curriculum vitae. You should ask specific questions germane
to the type of evaluation sought, such as why the attorney is requesting an
evaluation. What are the specific behaviors on the part of the defendant that
had led the attorney to see a particular evaluation? How does the attorney
anticipate that an evaluation may be able to assist in his or her representation
of the client? Are the attorneys hopes realistic? Sometimes attorneys utilize
court-ordered evaluations for purposes other than those for which they are
specifically meant. Sometimes this makes sense from a legal advocacy per-
spective, but it is important for the forensic evaluator to know this up front.
For example, is an evaluation of mental state at the time of the offense (typi-
cally called an insanity evaluation) actually about the question of whether the
defendant met the legal threshold for insanity at the time of the alleged crime,
or is the attorney actually hoping that mitigating information will be obtained
that can be used in sentencing?
Attorney consultation may be useful at various points throughout the
evaluation. The attorney should provide the evaluator with all available
records prior to the interview with the defendant. This maximizes the efficient
use of the evaluators time, and it reduces the likelihood that the defendant
will need to return for an additional interview merely to clarify discrepan-
cies between information provided by the evaluee and information in the
records. As the evaluation unfolds, attorney discussion may be useful in order
to explain the details and significance of your findings, discuss the findings/
opinions of other experts involved in the case, and suggest further evaluations
(e.g., neuropsychological testing, neuroimaging, etc.) if indicated. Awareness
of the importance of being able to translate complex clinical concepts to a lay
audience is critical for the forensic evaluator and expert witness. The forensic
evaluator should be able and willing to prepare the attorney to make the most
effective use of his or her expertise. Conversely, the most successful attorneys
are able and willing to prepare their experts for what to expect during direct
examination and cross-examination.
Obtaining and Reviewing Background Information

It can be said that if a forensic evaluator has to choose between only review-
ing all the records on a defendant and doing only a face-to-face interview
with that defendant, the records win hands down. This is a false choice used
for illustration, as both are often necessary to perform a thorough and com-
petent forensic evaluation, especially in criminal forensic work. However, it
does highlight the role of skepticism in forensic evaluation, the importance
of not accepting anything at face value, and the need to obtain corroboration
of critical information. The importance of obtaining all available records
cannot be overemphasized, and it goes to the heart of the difference between
clinical and forensic evaluation. Because of the dramatic impact that these
evaluations may have on an individuals life, there is the distinct possibility
that evaluees will not be forthcoming or truthful with respect to details of
the alleged offense or past history. Additionally, relevant information may
emerge from a thorough record review that the evaluee and his or her fam-
ily did not realize was useful or pertinent. Evaluators need to obtain and
carefully review records from a variety of sources, including psychiatric
and other medical records, therapy records, Department of Social Services
records if available (the retaining attorney may need to have a subpoena
issued for these, as they are usually very difficult to obtain even with a nota-
rized release), and school/educational records. Also it is necessary to review
all information available regarding the alleged offense (police reports, wit-
ness statements, etc.), some of which will come from the attorney in the form
of Discovery.3
Interviews of the Defendant

Defendants may be interviewed more than once, and this is often valuable in
complex cases, especially involving youth. With respect to interviewing sexual
offending youth for a risk assessment evaluation, multiple interviews spread
out over the period of time during which interviews with collateral sources
and additional records are obtained may be preferable. The nature and utility
of the interview are determined in part by how well focused it is. A thorough
review of records and documentation pertaining to the alleged offense assists
in that focus. The focus is also informed by the evaluators knowledge of recent
3. Discovery is information regarding the crime that the prosecutor or commonwealths

attorney is legally and/or ethically bound to produce to the defense.
developments in the area of juvenile sex offender risk assessment if one is doing
such an evaluation.
Interviews of Collateral Sources

Corroboration is crucial in forensic evaluation. If an adolescent with a major
depression withholds information or outright lies about his prior shoplifting
record during a clinical evaluation, the psychologist or psychiatrist evaluating
the youths lack of interest and energy, pervasive sadness, increased irritability,
and sleep and appetite disturbance will still be able to accurately diagnose and
treat the clinical problem that the adolescent presented with (depression).
However, if a youth charged with a sex offense does not mention or denies
that he was previously charged with a sex offense that was pled down to a non-
sexual offense such as assault and battery, acceptance of that omission without
corroboration will seriously compromise the forensic evaluation.
Forensic evaluators should interview sources with potentially useful
information, including family, friends, teachers, employers, witnesses, and vic-
tims. While defendants and their legal guardians can consent to interviewing
family members, friends, neighbors, teachers, employers, and so on, alleged
victims of the defendant should not be contacted without first discussing the
necessity of this with attorneys, including the prosecutor if charges are pend-
ing. Victim interviews are typically unnecessary and not allowed; however,
transcripts of victim interviews can serve as invaluable sources of informa-
tion. It is important to keep an open mind throughout the evaluation and not
to reach conclusions too quickly.
Report Writing
Many forensic clinicians consider report writing to be one of the most stressful
aspects of forensic work and one of the most difficult areas in which to transi-
tion from clinical to forensic work. As previously noted, one must be aware that
the report is not written for other mental health clinicians or physicians, but
for attorneys and judges. Therefore, the use of mental health jargon should be
curtailed. Reports should be useful to the court and cannot be helpful if they
are not easily understood. The forensic evaluator must document what he or
she did, what was discovered, his or her opinion, and why the evaluator holds
that opinion. It is important to explain your reasoning and the basis for your
opinions. Another perspective is that the language of the report tells a story
that is persuasive to the legal audience (Griffith, Stankovic, & Baranoski, 2010).
There are a number of accepted formats for written forensic reports. Silva,
Weinstock, and Leong (2003) suggest the following sections:
1. Introduction (including identification of the examinee, person

requesting the evaluation, and purpose of the evaluation)
2. Sources of information (records and documents reviewed, persons

interviewed in person and by telephone)
3. Notice of confidentiality. Document what was explained to the
examinee and an assessment of the evaluees comprehension of the
communication
4. Data surrounding the events in question (events and information lead-
ing up to the events in question, as well as data provided by others and
records reviewed)
5. Relevant past history (background information, including family,
developmental, medical and psychiatric, and legal histories)
6. Mental status examination and interview results
7. Summary of special studies (laboratory evaluation, neuroimaging,
psychological or neuropsychological testing results)
8. Diagnostic and forensic formulation (to include consideration of
malingering) linked to the legal questions that the evaluator set out
to clarify and answer at the outset of the evaluation. The evaluators
opinions should be clearly buttressed and supported by data contained
within the body of the report.
Novice forensic evaluators frequently write reports that are not much (if
at all) different from their clinical evaluation reports, dutifully delineating
clinical impressions, Axis I through V DSM diagnoses, and treatment
recommendations. However, this information may not be particularly mean-
ingful to the court. For example, in a competency-to-stand-trial evaluation,
the legal question is whether the defendant has the present ability to consult
with his lawyer with a reasonable degree of rational understanding and
whether he has a rational and factual understanding of the proceedings
against him (Dusky v. United States, 1960) and whether the defendant is able
to consult with his or her attorney and assist in preparing a defense (Drope
v. Missouri, 1975). There are components of a psychiatric and psychological
evaluation that are not particularly relevant to the issue of competency
social history, for example. While substance abuse history may be relevant
(for example, if heavy inhalant abuse is considered to be a factor in the
defendants memory deficits), a detailed cataloging of the defendants past
may not only be irrelevant to the question of competency, it may go beyond
the scope of the evaluation. Likewise, information provided regarding what
transpired during the alleged offense is never included in a competency
report, which goes to the judge, prosecutor, and defense attorney. The issue
in a competency evaluation is the here-and-now issue of whether the defen-
dant is competent to stand trial, not what may or may not have happened at
the time of the offense. Again, be aware of the legal question and issue and
do not overstep.
Testimony
Obsessive preparation is the rule for effective testimony, whether it is in the
courtroom or for a deposition.4 Never underestimate the value of prepara-
tion in being an effective expert witness. The job of the forensic evaluator is to
translate clinical concepts that underlie an opinion for a lay audience. As pre-
viously mentioned, the forensic evaluator/expert should avoid using technical
jargon, such as affect, psychomotor retardation, and so on. Even terms
such as hallucinations and delusions may need to be clearly explained,
and not assumed to be understood as the evaluator understands them. Cross-
examination by opposing counsel is typically the aspect of testifying that
experts find the most anxiety provoking. The purpose of cross-examination
is to discredit or impeach the witness and decrease the impact of the witnesss
testimony. Some guiding principles for the expert during cross-examination
(Kambam & Benedek, 2010) include the following:
Be honest. Mental health professions have an ethical obligation to

truthfulness but also take a sworn oath in the courtroom.
Acknowledge the limitations of your opinion (when asked) and admit
when you either dont know something, or do not have information or
did not have it at the time of your report or when you formulated your
opinion.
Be thoughtful and take time to pause and answer questions.
Do not talk too much but attempt to give full answers. Be straight-
forward and avoid jargon. The expert can easily lose the interest of
the judge or jury if he or she offers rambling, ponderous, or obtuse
explanations and discussions.
Do not speculate on the opinions of other experts, and do not
criticize other experts. Neither is looked upon favorably by the
Court.
4. A deposition is the sworn testimony of a witness taken before trial. It is part of pre-
trial discovery (fact finding) and is commonly employed in civil (noncriminal) cases.
Depositions in criminal cases cannot be taken without the consent of the defendant. A
deposition is held out of court with no judge present. The witness is placed under oath, and
lawyers for each party may ask questions. The questions and answers are recorded. When
a person is unavailable to testify at trial, the deposition of that person may be used, but it
may also be used to impeach an expert whose testimony at trial deviates from deposition
testimony. Preparing for deposition testimony should be as thorough as preparation for
trial testimony.
Hannahs case provides an example of the uncomfortable and untenable

position that a treating psychiatrist may be faced with. The duty of a clinical
psychiatrist is to his or her patient, and this makes it difficult to refuse to do
something (testify) that could potentially help the patient. Expert witnesses have
obligations also, and in order to testify as an expert on the issue of Hannahs
legal charges, an evaluator must be privy to far more information that would
be necessary to treat Hannahs psychiatric disorders. Also, because a forensic
evaluator is by definition not bound by patientdoctor confidentiality, wearing
the hat of both treating psychiatrist and forensic evaluator is a conflict of inter-
est. With respect to whether Hannahs mood disorder may fall on the bipolar
spectrum, it is quite possible that the disorder had nothing to do with her
state of mind at the time of the alleged offenses. The nexus between an acute
exacerbation of an underlying mood disorder and sexual offending is difficult
to establish and requires an assessment by an objective evaluator which will
include data obtained form collateral sources. The forensic evaluator will need
to be aware of the possibility that the defendant as well as family members may
be highly invested in the idea of bipolar disorder as an excuse for the sexu-
ally abusive behavior, and will need to sort through all the data and come to
an opinion. In addition to the treating clinical psychiatrist having insufficient
data on which to form an expert opinion on the legal issue, it is a conflict for
the treating clinician to do anything that could potentially be harmful to his
or her patient, and offering testimony that could enter into the delivery of a
harsh sentence is definitely not in keeping with the credo, First do no harm.
The psychiatrist in this case should refuse to offer any opinions regarding the
alleged offense or Hannahs risk. The psychiatrist can offer testimony as a fact
expert, testifying as to Hannahs diagnosis, her compliance with treatment,
and the prognosis with respect to her mental illness with and without treat-
ment, but he or she must assiduously avoid attempts on the part of the defense
attorney to link the alleged offenses with her psychiatric diagnosis and treat-
ment. That is the role of a forensic evaluator with access to far more informa-
tion than the clinician has. As will be discussed in subsequent chapters, there
is no profile of a juvenile sex offender, and only a thorough evaluation will
more clearly elucidate Hannahs risk. Clearly, Hannah is a troubled girl with
numerous risk factors for a major mood disorder as well as personality pathol-
ogy; however, her attorney needs to be told clearly and definitively why the
psychiatrist is unable to function in a forensic role. If it is the expectation of
Hannah and her parents that you will testify regarding the role of bipolar dis-
order in her offense, they must also be informed of the confl ict.
A forensic evaluation of Hannah would be undertaken by a mental health

clinician who has not developed a doctorpatient relationship with Hannah
and who approaches the evaluation with an open mind and no predetermined
biases. A thorough evaluation of Hannahs educational records, medical and
mental health records, and documents pertaining to the offenses, including
witness statements, would be accomplished prior to a face-to-face evaluation,
and the limits of confidentiality would be fully explained to Hannah and her
parents. Collateral sources of information, favorable and unfavorable, would
be sought. The forensic examiners opinions would be based on a multitude
of sources and not be shaped consciously or unconsciously by forces that are
critical to the patientdoctor relationship, including acting in Hannahs best
interests, which can inadvertently lead to a minimization of risk in an effort to
effect a less punitive result.
R EFER EN C ES
American Academy of Psychiatry and the Law. (2005, May). Ethical guidelines for the
practice of forensic psychiatry. Retrieved October 2011, from http://www.aapl.org/
ethics.htm
Diamond, B. L. (1959). The fallacy of the impartial expert. Archives of Criminal
Psychodynamics, 3, 221236.
Drope v. Missouri, 420 US 162 (1975).
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evaluation of juveniles (pp. 135). Sarasota, FL: Professional Resources.
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6
Interviewing, Evaluation, and

Risk Assessment of Sexually
Offending Youth
OV ERV I E W
Evaluating youth who are suspected of or have been charged with sexual
offending requires an in-depth understanding of normal child and adolescent
development as well as knowledge and expertise in evaluating child and ado-
lescent psychopathology. A major purpose of comprehensive assessment is to
understand the youth thoroughly in order to make treatment-planning deci-
sions or assist the court in dispositional and treatment decisions. This chapter
focuses on critical components of evaluation and risk assessment of children
and adolescents who have engaged in sexually abusive behavior. The scope
of the interview and evaluation is often dictated by the nature of the referral
questions. Readers should not interpret this chapter as a rigid roadmap for
conducting evaluations, but rather as a guide that can be utilized flexibly given
the needs of the assessment.
G EN ER A L G U I D EL I N ES F O R T H E E VA LUAT I O N O F
S E X UA L LY A B U S I V E YO U T H
The Academy of Child and Adolescent Psychiatry (AACAP) in their prac-

tice parameters for the assessment of sexually abusive youth note that
assessment should be comprehensive and not narrowly focused on sexual

behavior (Shaw, 1999). An exclusive focus on risk in these evaluations leads to
a constricted and narrow view of youth and a missed opportunity to under-
stand their behaviors within a developmental and familial framework. This
may seem like a contradiction of an earlier assertion that forensic evaluation
is narrower in scope than clinical evaluation, but it is not. As clinicians, we
realize that sexual behavior in humans is complex and determined by the con-
vergence of numerous biopsychosocial factors that need to be explored.
The AACAP parameters recommend that comprehensive evaluation of a
sexually abusive youth should accomplish the following (Shaw, 1999):
Describe and understand the type, development, evolution, and

trajectory of sexually abusive behavior in the youth being assessed.
Delineate and define any major mental illnesses present, as well as
subthreshold mental disorders.
Consider the risk for repeat sexual offending, including the potential
impact of risk and protective factors.
Explore the youths psychosocial history, appreciating those aspects
that may have shaped current thinking and behavior, especially
around sexual issues.
Assess the youths capacity and motivation for treatment.
Develop a biopsychosocial formulation and thorough risk assessment
that drives recommendations regarding treatment and continued
assessment of treatment results.
Develop a treatment plan designed to mitigate risks for reoffending
identified in the evaluation (for example, inpatient versus outpatient
treatment, recommendations for treatment with a therapist with
expertise in the treatment of juvenile sex offenders and youth with
sexually abusive behaviors, substance abuse treatment, pharmacologic
and psychotherapeutic treatments directed at identified psychiatric
disorders, only supervised access to young children, etc.).
Some essential characteristics of an assessment of youth who have been

charged or convicted of a sexual offense as adapted from OReilly and Carr
(2004) include the following:
The evaluator possesses good interviewing skills and characteristics

associated with positive engagement.
The evaluation aims to build a holistic understanding of the youths
life, which distinguishes between the young persons sexually abusive
behaviors and his or her underlying personality.
Interviewing, Evaluation, and Risk Assessment of Sexually Offending Youth 121
There is awareness on the part of the evaluator that the youth and
his or her family may be at various points along a continuum from
denial to acknowledgment of sexually abusive behavior. The evalu-
ator assumes that most youth who have engaged in sexually abusive
behavior will not be motivated to disclose full details of the behavior
during the assessment.
The evaluator possesses effective strategies for detecting the possibil-
ity of deception and managing conflicting information in a manner
that is neither disengaging nor apologetic.
The evaluation incorporates approaches to motivate the youths
engagement and participation in the evaluation.
It is conveyed to the youth and family undergoing evaluation that the
evaluator understands the problems and difficulties they face.
The evaluator makes use of records from varied sources, including
school, victim statements, court records, police records, medical
records, and prior mental health records, as well as information from
collateral sources that may shed light not only on the youths sexual
development and behavior but also on his or her functioning outside
of the sexual realm.
The issue of the risk of continued sexual offending in the youth
being evaluated is addressed and an opinion is formulated based on
research findings and clear empirically based theoretical models.
The assessment appraises the strengths and vulnerabilities of the
youth and family undergoing evaluation and formulates a plan for
how strengths can be mobilized in a treatment plan to mitigate risk
for future offending, and how weaknesses or vulnerabilities need to
be addressed to increase the treatment plans chances for success.
We know that aspects of the environment interact with each other over
time in shaping individual development and adaptation. There is also evidence
that children and their environments mutually influence each other over
time (Lynch & Cicchetti, 1998). Cicchetti and Toth (1997) described the use
of an ecological-transactional framework for understanding the emergence
of maladaption and psychopathology as it relates to broad ecological forces
such as abuse, divorce, community violence, persistent poverty, substance
abuse, and parental pathology. A major goal of comprehensive assessment of
sexually reactive or abusive youth is to understand and evaluate the risk for
sexual reoffending in the context of the emotional, cognitive, behavioral, and
ecological-transactional systems in which it has developed. Comprehensive
forensic evaluation of sexually abusive youth attempts to understand the child
or adolescent and his or her behavior in the context of his or whole life.
G EN ER A L A PPR OAC H ES TO R I S K A S S ES S M EN T
In the past 40 to 50 years there have been two fundamental changes in the
conceptualization of how risk assessment evaluation is performed (Borum,
2000; Heilbrun, 1997). The first change has been a shift from a violence pre-
diction model to a risk assessment and management model. In the older
prediction model, dangerousness is a dispositional and dichotomous vari-
able that either does or does not exist within an individual. In addition to being
neither realistic nor clinically relevant, in this model the degree of risk is seen as
static and not subject to change. In the more contemporary view of risk assess-
ment, the risk of violence is seen as contextual (highly dependent on a variety of
circumstances), dynamic (subject to change), and continuous (varying along a
continuum of probability). Whereas in the previous model the forensic examiner
was expected to determine whether an individual was a dangerous or violent
person, now the evaluator is tasked with determining the nature and degree
of risk posed by a specific individual for certain kinds of behaviors depending
on anticipated conditions, contexts, and circumstances (Borum, 2000). Also
the examiner is often asked to posit interventions expected to mitigate risk
in the person evaluated. The more specific and individualized the proposed
interventions, the more useful the evaluation is to the referral source.
The second change in the conceptualization of risk assessment has been
a major difference in the manner, procedures, and practices for conducting
violence (including sexual violence) risk assessments. Early first-generation
studies on predictive accuracy of violence risk yielded the disappointing con-
clusion that clinicians predictions of violent behavior were highly inaccurate
(Monahan, 1984). However, the studies were plagued by methodological short-
comings and weak criterion measures of violence (resulting in false positives)
(Monahan, 1996; Monahan et al., 2006). Second-generation studies of violence
risk prediction are more promising, indicating that accuracy rates are now
higher and that clinicians can distinguish violent from nonviolent mentally ill
patients with a modest, better-than-chance level of accuracy (Borum, 1996;
Mossman, 1994, p. 790).
Although risk assessment is often thought of as splitting into the two broad
approaches, actuarial and clinical, there are actually several risk assessment
models (Doren, 2002, 2004; Hanson & Bussiere, 1998).
Unstructured Clinical Judgment
The evaluator reviews evaluation data/information without any significant

theory that prioritizes the relative importance of the information. Decision
making is often described as informal, impressionistic, and subjective, and

it has poor reliability (consistency and replicability) because several evalua-
tors could reach different conclusions about the same evaluee. This model is
not considered to be an appropriate method of risk assessment (Bengtson &
Langstrom, 2007).
Guided Clinical Judgment
The evaluator starts out with a set of ideas regarding what is important with
respect to recidivism, but they are based on the evaluators experience, not
on research. This model is not considered to be an appropriate model of risk
assessment (Hanson & Bussiere, 1998).
Clinical Judgment Based on a Historical Approach

(Anamestic Assessment)
The evaluator reviews the subjects life history to identify historical factors
that contribute to risk and then determines which factors still exist (Heilbrun,
2003). The evaluation of risk of recidivism is guided by history, but not research.
This model in its pure form is not considered to be an appropriate model of risk
assessment (Hanson & Bussiere, 1998); however, the practice of identifying
risk factors from an individuals past offending and incorporating them into
an evaluation of risk is incorporated into other recommended approaches to
risk assessment.
Empirically Guided (Structured) Clinical Judgment
This is the most accepted and widely employed form of evaluation and risk
assessment among sex offenders, including juveniles. The evaluator considers
a wide array of empirically validated risk factors and then forms an overall
opinion regarding the offenders risk of reoffending. This assessment of risk
requires research-based information that can be supported across multiple
evaluations. This approach has the advantage of being evidence based and
individualized, although the quality of the assessment is determined by the
quality and thoroughness of the literature review, the evidence base (there may
be a paucity of research on a particular group of offenders, for example, adoles-
cent female sex offenders), the experience and thoroughness of the evaluator,
and the evaluators skill at interpreting the research and applying the evidence
base to the individual or situation in question. A number of instruments have

been developed for use in empirically guided or structured clinical risk assess-
ment in youth, but none has demonstrated any predictive validity for sexual
offending specifically. Controversies abound regarding what are the most
accurate, valid, and reliable methods of assessment. A recent meta-analysis
showed that diagnoses generated from clinical evaluations frequently disagree
with the results of structured or semi-structured interviews (Rettew, Lynch,
Achenbach, Dumenci, & Ivanova, 2009). Rather than implying that one of the
other (clinical evaluations or structured diagnostic interviews) is inferior or
inadequate, the authors indicated that characteristics of both techniques may
limit agreement and generalizability from diagnoses obtained from structured
instruments to clinical practice.
Pure Actuarial Assessment
There are no actuarial instruments that have been validated in the juve-
nile sexual offender population. Actuarial assessment has its origin in the
insurance industry. For car insurance, statistics are closely monitored and
evaluated to price polices such that those individuals at more risk for an
accident pay more. In forensic risk assessment, the examiner evaluates the
offender on a limited set of predictors and then combines these variables
using a predetermined numerical weighing system. Since most actuarial
instruments are based almost entirely on static risk factors, this approach
places little weight on dynamic risk factors. Completion of an actuarial instru-
ment involves scoring the answers to each question, and a total score (and
sometimes subtotals) is calculated. Actuarial instruments are formal, algo-
rithmic, and objective. They tend to be more reliable than clinical judgment,
because in theory if several different evaluators use the same instrument
on the same offender, they should all reach the same conclusion. However,
in reality, actuarial assessments are often conducted poorly. Instruments
may be utilized in populations for which they are not intended. Inaccurate
record information may be used, and scoring may be faulty. However, when
conducted properly and by evaluators who have had appropriate training in
the use and scoring of specific instruments, they should produce the same
results for the same offender regardless of who conducts the assessment.
Actuarial assessments are also quicker than assessments that utilize clinical
judgment. However, it is important to note that actuarial tests developed
in one setting or in a specific population may not be predictive in other
settings. Unfortunately, it is not uncommon to fi nd actuarial instruments
used in populations (women and youth, for example) that differ from the
population on which the instrument was developed and in populations on
which the instrument has not been tested. It is especially important to be
aware of the potential inappropriate use of actuarials in youth convicted of
sex offenses in adult court. There are no empirical measures, tests, or instru-
ments that can identify, diagnose, or classify the risk of sexual recidivism in
juvenile sexual offenders.
A weakness of actuarial instruments (which is also their strength) is that
the research on which they are based is conducted on groups. Actuarial risk
assessment eliminates the individual from risk assessment. This is a critical
point to understand about actuarial assessments. Lets examine an example
based on car insurance statistics and look at an individual 17-year-old male
driver. Lets say that the statistics indicate that 40% of young male drivers have
an accident as compared with 25% for other groups. It does not mean that this
particular 17-year-old has a 40% risk of having an accident; it means that this
particular 17-year-old boy is similar to a group of young drivers, where 40 of
100 had accidents. Identifying who in this group of 100 individuals are the
ones who will have the accidents is impossible based on the tool used to make
the assessment. Actuarial tests in forensic risk assessments are more useful for
the extremes. For example, if an actuarial instrument reveals that the defen-
dants score is similar to a group of people with a 95% recidivism rate, then one
could state more confidently that the defendant is likely to reoffend (although
since 5% of that group did not reoffend, it is possible that the defendant could
be one of those). Judgments using actuarial instruments become more difficult
as one moves into the middle ranges.
Clinically Adjusted Actuarial Judgment
Here, the evaluator uses one or more actuarial instruments followed by poten-
tial adjustments to the actuarial results based on clinically derived consid-
erations (Doren, 2002). Adjustments can be based on research findings. This
remains a controversial area. Harris and Rice (2003) have argued that adjust-
ments to actuarial instrument scores should not be performed, because they
make the final decision regarding the risk of recidivism less accurate. In real-
ity, this appears to be a common practice forensically. The fact that in sex
offender civil commitment proceedings, evaluations are ordered based on and
after actuarial instrument cutoff scores have been made, indicates that clini-
cally relevant and individualized information at least in theory is considered
important in decision making.
G OA LS O F R I S K A S S ES S M EN T
Most violence risk assessments (including sex offender risk assessments) have
a few primary objectives (Conroy & Murrie, 2007):
Clarification of the specific risk assessment question. The specific risk

assessment question is often clarified in statute, although situations
may arise that prompt attorneys, judges, agencies, or even parents to
request evaluations pertaining to sexual offense risk. Understanding
the referral question is critical to understanding your role as an
evaluator, the nature and scope of the evaluation, appropriate risk
communication strategies (including who gets the information), and
whether a risk management plan is indicated. If the referral question
is not clearly defined by law or statute, then the evaluator can assist
the referral source in articulating a precise referral question.
Identification of a base estimate of risk using research-derived base
rates (group data, often available using actuarial risk measures). This
is a problem in assessment of juvenile offenders, since there are no
adequate actuarial risk measures. It is clearly accepted within the
field of risk assessment that knowledge of the appropriate base rate
data is critical to accurate risk assessment and violence prediction
(Monahan, 2003). Violence base rate is the proportion of a particu-
lar population (for example, released sex offenders) who commit
violence within a specified time period. For adults, sex offender risk
assessments are usually (though not always) requested for individu-
als who have already committed sex offenses, and so it is important
to consider base rates of sexual reoffense, or recidivism. This is far
more difficult with juveniles, in part secondary to a lower base rate
of sexual recidivism relative to adults. Even in adults, base rates of
sexual reoffending are difficult to identify with precision. Base rates
of sexual offense vary by method of detection and how the sexual
offenses are defined.
Consideration of research-supported risk and protective factors
manifested by the individual being assessed. There is less research
validation for risk and protective factors for sexual reoffending in
juveniles than adults. This does not mean that there is no research to
guide evaluators, but rather that they must have an appreciation for
the limitations in this area.
Cautious modification of risk estimate using information specific
to the individual being assessed. As previously noted, modifying
risk estimate based on individual factors assessed clinically is

controversial, because some researchers and experts in the field
believe that clinical assessment only contaminates information
arrived at through reliable, validated actuarial tools. However,
given the fact that there are no reliable or valid instruments that
have been developed to predict sexual recidivism risk in juveniles,
individualized clinical evaluation is critical to risk assessment in
this population.
While the process of adult sex offender risk assessment continues to be

debated (how much factors specific to the individual should modify risk
assessment, for example), significant progress has been made with respect to
the development of instruments and actuarial risk measures for adults. There
remains some controversy as to how much weight actuarial instruments
should carry in adult sex offender evaluations, but few would debate their util-
ity. Their use has become so accepted that it would be considered remiss to not
utilize them in the assessment of sexual recidivism risk in adult sex offenders.
The same cannot be said for the assessment of juvenile sex offenders. One of
the most important pitfalls for evaluators of juveniles to avoid is inappropri-
ately extrapolating adult data on risk to juveniles and/or using instruments
in juvenile sex offender evaluations that have been developed and normed on
adults.
Nevertheless, clinicians who perform forensic evaluations on youthful sex
offenders, as well as those who treat these youth, should be familiar with the
research on sexual offense recidivism risk in adults.
As noted in Chapter 4, it is understandable to wonder why juvenile eval-
uators should be familiar with the research findings on adult sex offenders.
Most of the research on sexual offenders has been conducted on adults.
Because of the shortage of clinicians with training and expertise with both
youth and forensic assessment, many of these evaluations are by necessity
done by evaluators well versed in the adult literature who may erroneously
conclude that adolescents are just younger versions of adult sex offenders
who have been caught earlier. This is particularly true for adolescents tried
in adult court, where attorney and judges are far more experienced with
adults than youth. Evaluators and clinicians who work with these youth
should be knowledgeable about adult risk factors for recidivism and real-
istically expect that they will be confronted with predictions and recom-
mendations that do not necessarily apply to children or adolescents who
sexually offend. Evaluators and clinicians can counter inaccuracies by
having a solid familiarity with both the adult and juvenile research.
R I S K FACTO R S F O R S E X UA L R EO F F EN D I N G I N A D U LTS
Static risk factors are those that are historical and cannot be changed by treat-
ment or intervention. In adults, static factors are typically considered using
well-designed actuarial instruments, such as the Static-99 and Static-2002
(Hanson & Thornton, 1999; Hanson, Helmus, & Thornton, 2009; Sreenivasan
et al., 2007). Static factors are the easiest to operationalize and study. In
adults there is substantial research evidence linking them to recidivism risk.
Important static risk factors in adults include the following:
Age. The highest risk for sexual reoffending is in young adulthood

(ages 1830), with the age/reoffense relationship stronger for rapists
than child molesters (Hanson et al., 2002). The rate of recidivism
among adult child molesters declines more slowly over time.
Prior sex offenses. In adults, a prior history of sex offending is one
of the strongest correlates with sex offense recidivism (Hanson &
Bussiere, 1998; Prentky, Knight, & Lee, 1997). It has been argued by
Quincy and colleagues that in adult sex offenders, general violent
offenses are also accurate predictors of sexual recidivism (Quinsey,
Jones, Book, & Barr, 2006).
Victim gender. Adult sex offenders who choose male victims are more
likely to reoffend (Hanson & Bussiere, 1998).
Stranger offense. Relationship to victim in adults is also related to
recidivism. Adults who offend against strangers seem to be at higher
risk (Hanson & Bussiere, 1998).
Adult sexual partner. Offenders who have never been married or
maintained a stable long-term sexual relationship with an adult
partner are also at higher risk (Hanson & Bussiere, 1998).
Treatment failure. Treatment or intervention failure is also
associated with recidivism in adult sexual offenders. Th is is not to
say that treatment is always effective. Rather, it appears that offend-
ers who fail to cooperate with treatment or law enforcement limits
(failure of conditional release, for example) are at increased risk for
recidivism (Hanson & Bussiere, 1998; Hanson, Morton, & Harris,
2003).
Dynamic risk factors are those that can change, at least theoretically.
Dynamic factors can be further divided into stable dynamic factors and
acute dynamic factors. Stable dynamic factors are expected to change very
little and very slowly (such as psychopathy and intimacy deficits), although
acute dynamic factors (such as intoxication and anger) can be expected to
change rapidly. Obviously, a problem with juvenile offenders is that many fac-
tors (intimacy deficits, for example) and even constructs such as psychopa-
thy may not persist into adulthood, and they may represent entirely different
entities in adolescence than in adulthood. Dynamic factors associated with
sexual reoffending among adult sex offenders include the following (Hanson
& Morton-Bourgon, 2005):
General self-regulation problems (impulsivity and lifestyle instability)

Any deviant sexual interest
Sexual preoccupation
High score on the Psychopathy ChecklistRevised (PCL-R)
Employment instability
Antisocial personality disorder
Hostility
There are several factors that are sometimes erroneously alleged in reports
and court testimony to increase the risk of sexual reoffending in adults. These
factors lack research evidence for an association with sexual offense recidivism
and include the following:
Failure to verbally accept responsibility for the offense

Failure to express empathy for the victim(s)
Failure to express motivation for treatment
Force/violence in past sexual offense
Childhood abuse/neglect
Childhood sexual abuse
Poor self-esteem
Denial of the offense
Although intuitively, it would seem that the aforementioned factors are

related to sexual recidivism risk, research has repeatedly failed to find a connec-
tion (Hanson & Bussiere, 1998; Hanson & Morton-Bourgon, 2005; Marques,
Wiederanders, Day, Nelson, & van Ommeren, 2005).
C O N S I D ER AT I O N S PR I O R TO AS S ES S M EN T
Assessment should be considered ongoing, because adolescents have aptly

been described as a moving target (Rich, 2009b). Although clinical inter-
viewing alone is insufficient for a thorough forensic evaluation (and psychiatric
diagnosis barely scratches the surface of what is required in these assessments),
it is the cornerstone of evaluation of sexually abusive youth. A thorough

familiarity with the research on risk factors as they pertain to juveniles is
critical. As previously noted, applying empirically validated risk factors in
adults to juveniles and making predictions regarding the risk for future sexual
offending based on adult risk factors are faulty practices, yielding erroneous
conclusions regarding risk in these high-stakes evaluations.
It is almost always easier, and often preferable, to conduct what is commonly
called a sex offender evaluation after the youth has been adjudicated, given
most offenders tendency to minimize and deny sexual wrongdoing. Many
studies of adolescent sex offenders have noted the presence of minimization
and denial (Becker, 1988; Hunter & Figueredo, 1999). In a national survey of
1,600 youth who had committed a sexual offense, Ryan and colleagues found
that 19.4% accepted full responsibility for their offense at the time of the evalu-
ation, with 33% accepting little or no responsibility (Ryan, Miyoshi, Metzner,
Krugman, & Fryer, 1996). Denials are often in the form of claims of innocence
and that they are victims of false accusations, and/or attempts to discount
the victims credibility. It is also not uncommon for offenders to claim that
the sexual acts were consensual (Shaw, 1999). Minimization of denial is an
important treatment goal, because accepting responsibility for ones actions
increases motivation for change; however, it is critical to keep in mind that
denial is not related to the risk to reoffend. The finding that reoffending is not
related to denial of responsibility has been noted in both the adolescent and
adult populations (Hanson & Bussiere, 1998; Kahn & Chambers, 1991). The
fact that some of the denials and rationalizations are compelling, as well as the
reality that some youth are falsely accused and convicted of sexual offenses,
can be frustrating and anxiety provoking. However, evaluators will do well to
remember that the determination of guilt or innocence is not the role of the
clinician or forensic evaluator. In a forensic evaluation, the ultimate determi-
nation of guilt is the role of the judge or (in the case of a juvenile transferred to
adult court) the jury. The evaluators focus is on (1) understanding the youth
and the alleged offense(s); (2) assessing amenability to treatment; (3) determin-
ing treatment goals and objectives and the most likely treatment plan to attain
those objectives; (4) determining levels of care required; (5) assessing individ-
ualized risk factors for reoffending; and (6) making specific recommendations
for decreasing risk (Hunter & Lexier, 1998).
T H E A S S ES S M EN T O F T H E YO U T H A N D FA M I LY
Rich breaks down the components of the evaluation of sexually abusive

juveniles into three phases with clear tasks(1) Preassessment, (2) Active
Assessment, and (3) Concluding the Assessment (Rich, 2009b). During

what Rich terms the Preassessment Phase, the evaluator prepares for the
interview by becoming familiar with the basics of the case by reviewing
all records available, talking with the attorney(s), identifying possible use-
ful collateral informants, and requesting the attorney to obtain additional
records if indicated. Examiners will develop their own routines, depend-
ing on their personal styles and experience. Typically a thorough review
of all available records before meeting with the patient or defendant is
recommended. Preparation during this phase, including record review,
maximizes efficiency of time and makes it less likely that another interview
will have to be scheduled solely for the purpose of addressing inconsisten-
cies discovered after records have been obtained. On a pragmatic note, for
evaluators who accept low-fee court-appointed cases, the less amount of
time spent on administrative tasks that can and should be completed by
others, the better. Consents to perform the evaluation, to record the evalu-
ation (if that is the examiners usual practice), and to obtain records can
be prepared in advance and signatures obtained to save time during the
actual interview. The attorney should be tasked with obtaining and supply-
ing information regarding the offense, discovery materials (such as witness
statements, police reports, transcripts of interrogations/interviews), and
educational and medical records. Court orders typically specify the day
on which the report is due (which should be cleared by you in discussion
with the attorney before accepting the case). Therefore, it is crucial to fac-
tor in the time it will take to obtain and review the records. Your assess-
ment and opinion may be important in informing the Courts decision on
disposition and treatment. Do not allow yourself or your evaluation to be
compromised by unrealistic expectations on the part of attorneys or the
Court. Explain the importance of reviewing records from multiple sources
and that a multisource/multidimensional evaluation (which is standard in
the field of forensic assessment) will form the basis of your opinion and be
discussed in the report.
During Richs Assessment Phase (Rich, 2009b), the evaluator interviews
the child or adolescent and conducts interviews (in person or by phone)
with individuals who may provide relevant information or perspective on
the youth being evaluated. As previously mentioned, the interview should
begin with a discussion of the purpose of the evaluation, who is requesting
the evaluation, and how the evaluator came to be asked or chosen to do the
evaluation. For example, if the prosecutor has requested that the clinician
evaluate the youth and provide a second opinion regarding risk (potentially
rebutting an expert chosen by the defense), then this should certainly be
disclosed to the youth. Never assume that the youths attorney or parents
have adequately explained the nature and purpose of the evaluation to him
or her.1 The evaluator must ensure that release-of-information forms are
signed by the legal guardian and juvenile, if necessary. Th is is a critical step,
since these forms will inevitably be returned or ignored if they lack the nec-
essary signatures, wasting valuable time.
Collateral informants should also be informed of the limits of confidential-
ity. Many evaluators initially find it difficult to approach collaterals with the
expectation that they will provide no information, while expecting a free flow
of sensitive data from informants. When appropriate, it is often helpful to sug-
gest that the evaluee or his or her parent inform potential collateral sources
about the fact that an evaluator may be calling to interview them. Regardless
of whether this happens, an evaluator must be careful to provide the absolute
minimum information necessary to the informant. You may identifying your-
self (as a psychiatrist, psychologist, or other mental health professional) and
explain that you have been requested or ordered to do a forensic mental health
evaluation, and that you will be talking to those who know the youth and may
be able to shed some light on his or her character and behavior. Inform them
that you are not authorized to otherwise discuss the evaluation and that their
cooperation is voluntary. The collateral informants should also be informed
who has retained the expert for the evaluation, if not court ordered, and that
a report will be prepared.
Concluding the Assessment (Rich, 2009b) involves what many consider the
most burdensome and difficult aspect of forensic work: writing the report. The
report is a synthesis of pertinent information gathered from record review,
interviews with the juvenile, and information obtained from collateral sources.
It is not merely a regurgitation of all the data obtained but is rather a document
that assists in understanding that particular youths sexual offending and pro-
vides individually based recommendations for treatment and risk reduction.
The report should accomplish the following:
Present historical and current information in a manner that assists in

clarifying the reason for referral and in understanding the evolution
of the youths difficulties in multiple spheres, not just related to sexual
1. Frequently, evaluations of individuals (juveniles and adults) charged or convicted of sex

offenses are ordered by the court; however, frequently one side or the other (defense or pros-
ecution) has approached the forensic expert, offered some information regarding the case,
and asked whether the evaluator is willing to do the evaluation. If the examiner agrees, the
attorney will offer the experts name to the court, and if acceptable to the court, the expert
will be appointed (court ordered to do the evaluation). You should come to the same con-
clusions regardless of who retained you or requested that you do the evaluation.
offending specifically (e.g., developmental delays that have impacted

on social interactions, abuse history, parental psychopathology,
substance abuse, etc.).
Formulate a hypothesis supported by data obtained from the
interview with the youth, the records reviewed, and interviews
with collateral sources, in addition to extant research, regarding
the development and evolution of the sexually abusive
behavior.
Formulate a psychological profile of the youth that is developmentally
informed and includes a description of the youths psychopathology,
including mental illness, incipient character pathology (if appropriate
and clear supporting data exists), and substance abuse disorders, and
specifically how the psychopathology has influenced the development
and maintenance of sexual offending.
Formulate a description of the environment that shaped the youths
emotions, cognitions, and behaviors and opine on how environmental
influences may be manipulated to both increase and decrease risk.
(For example, you might consider eliminating unsupervised contact
with younger children, substance abuse treatment with regular urine
drug screens, psychopharmacological treatment of psychiatric disor-
ders with significant impulsivity, court-ordered compliance with sex
offender treatment, etc.).
Discuss the youths risk for nonsexual and sexual reoffending and
how risk can be mitigated. Assigning arbitrary designations, such
as high, low, and moderate risk, is typically not meaningful or
useful without extensive explanation based on data obtained over the
course of the evaluation.
Propose treatment needs and identify treatment goals. Make the
recommendations specific and be clear about factors identified
during the evaluation that may be limitations to successful
implementation.
T H E A S S ES S M EN T O F T H E YO U T H A N D FA M I LY
The following recommendations for areas and topics to be covered in the

assessment are meant to function as guidelines for areas to consider explor-
ing, rather than a strict template for the order in which the interview is
conducted.
Clarify the Assessment Questions and Goals With

the Referral Source
The previous chapter, Forensic Evaluation Versus Clinical Evaluation pro-

vides a more detailed discussion of forensic evaluation in general and the
importance of clarifying a variety of issues prior to beginning an assessment.
What party is requesting the evaluation?

What is the time frame for completion of the evaluation?
Will a report be expected, and if so when is that due?
Is testimony anticipated, and if so is the hearing or trial date
scheduled?
Who or what party bears responsibility for your fee?
How long does a forensic evaluation of a youth accused of a sexual offense

take? The answer to that question depends in part on the type of evaluation
requested. A competency to stand trial (CST) evaluation may only take sev-
eral hours (including record review and interviews) given the narrow scope
of the question and hence evaluation. The amount of time necessary to con-
duct and complete the evaluation will also depend on how much informa-
tion is already available, the clinical complexity of the case, the availability
and necessity of obtaining collateral information and the ease with which it is
obtained, and the youths level of cooperation and participation in the process
(Medoff & Kinscheriff, 2006). A comprehensive forensic risk assessment/men-
tal health evaluation of a sexually reactive or abusive youth can be expected
to take much longer than a few hours. In addition to the face-to-face inter-
views with the child or adolescent, one must also factor in the time it takes to
obtain signed releases, obtain and review the necessary records, interview the
parent(s), contact and interview collateral sources of information, and com-
plete testing that may need to be administered outside of the interview if indi-
cated (personality, educational, or neuropsychological testing, for example). It
is imperative that the evaluator be aware of the constraints in his or her sched-
ule and limitations on conducting and completing the assessment (including
producing a report) early on in the process. The attorney may wish to ask the
court for a continuance (delay in the proceedings) in order for the evaluator
to be able to conduct and complete a thorough assessment. Regardless of the
time constraints imposed by the court or the youths attorney, it is imperative
that forensic evaluators not overextend themselves and perform inadequate,
rushed evaluations, especially given the high stakes.
As previously noted, forensic evaluation is not covered by insurance,
Medicaid, or Medicare, which are designated for clinical (diagnostic and
treatment) purposes. For privately retained evaluations, the issue of how the
evaluation is paid for should be determined in advance of beginning an eval-
uation, and it should include the anticipation of possible report writing and
testimony.
Perform a Record Review Prior to the Interview(s)

With the Youth and Family
A thorough record review prior to the interview enables the evaluator to direct
the interview and deal with the evaluees customary inclination to minimize
and deny. Records may include the following:
Victim statements
Transcripts of police interviews/interrogations of the youth
Investigative police reports of the alleged offense
Probation reports
Presentencing reports
Department of Social Services records
Child Protective Services (CPS) reports. Records of CPS investiga-
tions often can only be obtained by subpoena, and even then with
great difficulty. If you believe that such information is important to
your evaluation, let the attorney know early on, so that he or she can
be preparing a subpoena or motion the court to obtain the records.
Medical records, including records from the youths primary care
physician (which may document concerns or even physical findings
compatible with abuse)
Mental health records, including inpatient and outpatient records,
should be obtained. Request full records if possible (including notes,
not just discharge summaries).
Educational records and reports, including report cards, individual
educational plans (IEPs), psychological evaluations, standardized
testing results, behavioral incident reports, records documenting
suspensions and expulsions, and attendance records
Consider the Timing and Location of the Interviews With the Youth
With respect to how to structure and time interviews with the youth, some-
times logistical issues take precedent, such as in those cases where a juvenile
is transported directly from a juvenile detention center or jail for an evaluation.

In such cases, to maximize the time spent individually with the youth, and
minimize the number of transports that must be ordered by the Court and
arranged by the jail or detention center, the evaluator may wish to spend the
entire day (with breaks of course) interviewing and assessing the juvenile.
Some evaluators make it their practice to travel to the jail and detention center
where the youth is held, particularly in those jurisdictions where the parents
are billed for transport-related costs. Evaluators should be aware, however, that
facilities vary in their ability and willingness to accommodate lengthy evalu-
ations. Evaluators performing evaluations in detention centers, jails, or other
correctional facilities should determine beforehand whether suitable arrange-
ments can be made. In prisons and some juvenile correctional facilities, for
example, lengthy interruptions in the evaluation may be necessary in order
to comply with inmate counts, during which time the evaluee/inmate must
return to his or her cell. Some facilities will accommodate the evaluation by
allowing the inmate to eat lunch during the evaluation. The ability and will-
ingness of a correctional facility to provide a private place for the evaluation
should also be determined beforehand. Evaluators should enlist the assistance
of the attorney requesting the assessment to assist in paving the way for the
evaluations to proceed smoothly.
Interviewing the Youth
There is no gold standard for interviewing and evaluating children and ado-
lescents (McConaughy, 2005); however, skillful interviewing is crucial to a
thorough assessment. Rich states that interviewing the youth lies at the heart
of the assessment, rightly noting that it is the only opportunity for the evalu-
ator to get to know the child or adolescent in a way that cannot be obtained
from records or collateral sources (Rich, 2009a, p. 349). Typically children
and adolescents do not spontaneously request psychiatric or mental health
evaluation or treatment, and they are instead referred by concerned adults;
this is even truer for youth who are referred for evaluation and treatment
of sexually abusive behaviors. When their behaviors are discovered, youth
accused of sexual misbehaviors may refuse to candidly engage in the process
of evaluation out of shame and fear of the consequences. Stonewalling and
blanket denials are often encountered early in the process, particularly before
the youth is aware that the evaluator is privy to a wide assortment of informa-
tion and data. Some youth will only cooperate insofar as they believe necessary
to avoid further discovery and consequences. Such maneuvers should not
be interpreted at the outset by the evaluator as evidence that the youth is
in denial or is planning to reoffend. Children and adolescents often genu-

inely plan to never engage in such behavior again, and they may avoid being
open and honest primarily to avoid the emotional pain from embarrassment
and exposure, and the consequences.
Evaluators should approach the interview with the youth in a warm, support-
ive, nonjudgmental, empathic manner, while also being directive. Although
gentle confrontation may be required in the face of inconsistencies in the
youths narrative, conflicting information from the records, and so on, this is
best left until the latter part of the face-to-face assessment. From a practical
perspective, confrontation regarding inconsistencies and conflicting reports is
more likely to yield useful information if the evaluator has firmly engaged with
the youth and is perceived as genuinely interested in understanding his or her
side. Harshly confrontative styles are seldom effective with this population
and are actually counterproductive (Longo & Prescott, 2006).
Lambie and McCarthy (2004) highlight the importance of the evaluator and
interview climate created, stressing that evaluators should do the following:
Be able to engage the evaluee and be skilled at establishing rapport.

Be respectful and show concern.
Create an environment where both the evaluator and evaluee can be
open and honest with one another.
Provide information when appropriate.
Establish credibility and control of the interview.
Anticipate embarrassment.
Ask open-ended questions.
Predict and challenge cognitive distortions where appropriate.
Expect denial and minimization.
Allow face-saving maneuvers.
Use reframing statements.
Allow the youth to tell his or her story.
Refrain from expressing personal feelings, such as shock or disgust.
Parental Interview
It is imperative that the parent(s) be interviewed as well as the youth. Parents

should be interviewed separately from their child. The style and organization
of the evaluator will in part dictate whether parents are interviewed prior to
the youths interview or afterward. The evaluator should be sensitive to a vari-
ety of issues that may be in play. First, there is the natural and appropriate
instinct of parents to protect the child. Indeed, parents who are overtly hostile
and rejecting of the child should trigger considerations of parental and family
pathology that may be contributing to the youths behavior. Of course, par-
ents are often overwhelmed by the legal, fi nancial, and social realities of
having a child charged with or adjudicated of a sexual offense, and their ini-
tial coping strategies will often mimic their responses to other major crises
in their lives (anger, panic, denial, minimization, blaming, etc.). However, the
parental response to the youth as an individual and to the crisis is typically
informative. The fact that a sexually abusive youth may have victimized a sib-
ling, stepsibling, or other family members may have further compromised
family relationships. A stepparent who may never have had an affectionate
relationship with the offender may be the biological parent of the victim. Such
dynamics should be considered as the evaluator interviews the parents, with
respect to the attitude of each parent, as well as which parent may be the
more dominant in the couple and therefore the louder voice with respect to
feelings and beliefs regarding the youth.
After adjudication, when evaluators (who have not performed the forensic
evaluation) are likely to be assuming a clinical/therapeutic role, rather than a
forensic evaluator role, the importance of developing a collaborative relation-
ship with the parents cannot be overstated (Duane & Morrison, 2004). Here
again, we see a major difference in the treatment approach between adult and
juvenile sex offenders, with family influences and patterns being critical to
understanding and treating the overall environment in which a youths sexu-
ally abusive behavior has evolved. Parents presenting for evaluation, whether
in the context of a forensic evaluation or treatment planning, often are already
feeling ashamed, guilty, and responsible. Negative assumptions that they
caused the behavior should be avoided. Such attitudes not only disengage the
family, and therefore compromise the quality of the information obtained in
the evaluation, they also are likely to influence treatment success and outcome.
As with the youth, it is important to establish rapport and comfort within
the interview with the parents prior to directly delving into sensitive and
uncomfortable areas. Remaining nonjudgmental can be difficult, particularly
in those situations where parental criminality and neglect or abuse appear to
have influenced the youths pathology; however, the advantages of engage-
ment, both with respect to obtaining important information in the evaluation
phase, as well as in treatment planning, cannot be overestimated.
Prejudices regarding families of delinquent youth as well as the fact that
treatments for youthful sex offenders have developed from adult programs
have contributed to the lack of family involvement in all stages of the process
from evaluation to treatment implementation. While the importance of peer
influences on delinquent behavior is undeniable, the role of families and the
influence of parents on delinquency have been underestimated (Farrington

& Loeber, 2000; Kandel, 1996). Failure to engage parents at all stages of the
process undervalues the degree to which attachment issues, loss, and parental
supervision and connection are involved in the development of sexual prob-
lems in youth, and it also undermines the possibility of a positive treatment
outcome (Duane & Morrison, 2004).
Explain the Nature of the Evaluation and the Limits of

Condentiality for a Forensic Mental Health Evaluation
Explain to the youth and his or her parents your role in the evaluation process.
Clarify that patientdoctor confidentiality does not apply and explain what
this actually means, contrasting the limits on confidentiality with therapeutic
relationships they may have had in the past. Be direct about who requested
that you do the evaluationwhether defense counsel, prosecution, or the
court (judge).
Obtain a Comprehensive Developmental History
Developmental issues are critically important in the evaluation of the sexual

behaviors of children and adolescents and in risk assessment. The purpose of
obtaining a thorough developmental history is to gain an understanding of the
developmental trajectory of the youth to assist in constructing a formulation
of the potential predisposing, precipitating, and maintaining factors that pro-
vide a context to the youths sexual offending (OReilly & Carr, 2004).
Like all areas of development, sexual behavior develops over time, and
so at least to some extent the roots of sexual development and adult sexual
behavior can be found in childhood. Chapter 2 provides a more comprehen-
sive review of sexual behavior from childhood through adolescence. There is
some lack of agreement as to what constitutes normal versus abnormal behav-
ior in children and adolescents, although we do know that sexual behavior in
children is not well tolerated by adults (Cantwell, 1995). The sexual behaviors
of children vary and are influenced by a variety of factors, including chance
encounters and opportunistic experiences, the degree of sexual stimula-
tion, the childs sexual curiosity, and the childs previous sexual experiences
(Johnson, 1999). We know that young children require guidance and super-
vision from adults in order to learn the rules of social behavior, the effect
of their behaviors on others, and to develop a moral code. Their capacity to
spontaneously generate and understand these concepts is too immature.
The sexual life of children begins shortly after birth and becomes patterned
upon the basis of early sensitizing experiences (Shaw, 1999). Most children
engage in some genital self-stimulation during the first year of life, and by age
3 to 4 years they may engage in sex play with other children. The nature of
their early environments, including their access to other children, as well as
the environments and sensitizing experiences of peers, influences the trajec-
tory of sexual behavior. A large-scale, community-based survey on a sample
of 880 children, ages 2 through 12 years old, screened to exclude those with
a history of sexual abuse, were rated by their mothers using several ques-
tionnaire measures. The frequency of different behaviors varied widely, with
more aggressive sexual behaviors and behaviors imitative of adults being rare.
Older children (both boys and girls) were less sexual than younger children
(Friedrich, Grambsch, Broughton, Kuiper, & Beilke, 1991). A subsequent study
of 1,114 children, aged 2 to 12 years, screened for the absence of sexual abuse,
was conducted in which sexual behavior was rated by primary female care-
givers. Sexual behavior was found to be related to the childs age, maternal
education, family sexuality, family stress, family violence, and hours/week
in day care. The authors concluded that a broad range of sexual behaviors is
exhibited by children in whom there is no reason to believe have been sexually
abused (Friedrich, Fisher, Broughton, Houston, & Shafran, 1998).
Given the increased exposure of children and adolescents to sexualized
material and messages through the general media as well as the Internet, it
is no surprise that childrens interest in sexual information and material, and
their knowledge of sexual behavior, is greater than it was a couple of decades
earlier (Rich, 2009b). Questions regarding consent and coercion may become
more complicated when the perpetrator is a child or adolescent, especially
given youthful immaturity in the areas of reasoning, judgment, decision mak-
ing, moral understanding, and the effects of social pressures. Parents are the
prime nurturers of morality and empathy, and deficits in moral development
and the beginnings of antisocial leanings are often related to failures in par-
enting (Carlo, McGinley, Hayes, Batenhorst, & Wilkinson, 2007; Hyde, Shaw,
& Moilanen, 2010). However, societal pressures and issues also play a major
role (Perry & McIntire, 1995; Shen, 1982), especially when the influence of
the family wanes during adolescence, and in younger children when there
is inadequate support, nurturance, and guidance. Societies, communities,
and families, with confused or ambivalent moral messages tend to produce
children with a confused, ambivalent, or inconsistent morality (Shrewder,
Mahapatra, & Miller, 1987).
Preadolescent children may engage in sexually abusive behavior toward other
children (Gray, Pithers, Busconi, & Houchens, 1999; Johnson, 1998, 1999, 2002).
It is necessary to distinguish between exploratory sexual behavior and sexually
abusive behavior. More developmentally appropriate sexual exploration occurs

between children of the same age and size and is not coercive. The term sex-
ually reactive has been (Moore, Crumpton, Franey, & Geffner, 2004) used
to describe victims of sexual abuse who act out sexually, especially children.
Sexually reactive children often engage in behaviors that represent repetition
and compulsion related to prior overstimulating sexual exposure and/or abuse.
The decision as to whether a behavior qualifies as abusive among preadoles-
cents is less clear. Sexually abusive preadolescents may engage in and attempt
to coerce others into a wide variety of adult sexual behaviors, including oral
sex. They may be more coercive and focused in their sexual behaviors than
sexually reactive children (Araji, 2004). It appears that younger children who
sexually abuse are more often reacting to their own sexual victimization than
adolescent sexual offenders (Johnson, 1989, 2002). The sexually abusive behav-
iors may increase over time and be associated with other behavioral disorders.
A study of 127 six- to twelve-year-olds who had engaged in sexually reactive,
developmentally inappropriate behaviors indicated that more than half had
been sexually victimized by more than two different perpetrators (one-third
of their abusers were juveniles themselves) (Gray et al., 1999). Other charac-
teristics indicative of family and parental distress were identified, including a
history of sexual abuse within the extended family, domestic violence, parental
arrests, poor attachment between parent and child, physical abuse, and pov-
erty (Gray, Busconi, Houchens, & Pithers, 1997).
Parental History
Areas to inquire about and consider include the parents courtship and mar-
riage; the status of the marriage and how this may impact on the youth;
domestic abuse within the marriage, past and present; and whether there is
a history of either parent being sexually or physically abused and how it was
handled within the parents family of origin.
Prenatal and Perinatal History

Inquiries regarding prenatal and perinatal history may yield important
information regarding maternal malnutrition; fetal exposure to alcohol and
other substances; and fetal distress and hypoxia at birth. Prenatal and peri-
natal insults may be related to current disorders such as attention-deficit/
hyperactivity disorders and other disorders associated with disinhibition,
impulsivity, and cognitive deficits.
Early Infancy and Childhood

A thorough developmental history requires an understanding of the
parentalchild fit and whether a temperamental mismatch may have
contributed to the youths current difficulties. We know that infants who

have experienced complications associated with prematurity have better
outcomes in supportive nurturing environments (Sameroff & Fiese, 2005).
Infants with the biologically based risk factor of a difficult temperament
present special challenges for parents, especially for parents struggling with
emotional issues and/or other types of adversity. Difficult temperaments
in infants and toddlers can be moderated by consistent, nurturing, and
supportive caretaking during these critical developmental periods (van den
Boom, 1994).
Specific queries around the level of supervision provided to the youth may
be necessary, especially if there is a history of behavior that points to impul-
sivity such as early fire setting and aggression. Of course, specifics regarding
discipline should be sought, including the types of discipline used, frequency,
efficacy, and consistency. Caregivers rarely tell evaluators about harsh or
abusive disciplinary practices spontaneously, but empathic, nonjudgmental
questioning may ferret out this history.
Other Caretakers
Sexual abuse may occur in babysitting or caretaking situations, and such
history should be sought directly. Despite the fact that nonfamilial babysit-
ters have created anxiety since they became a fi xture in the postWorld War
II childrearing environment (Kourany, Gwinn, & Martin, 1980; Kourany,
Martin, & Armstrong, 1979), there has been little in the literature on the
sexual offenses of babysitters. The Federal Bureau of Investigations National
Incident-Based Reporting System (NIBRS) designated babysitters as a new
category of offender, and it has some data on serious babysitter offenses.
According to Finkelhor and Ormrod (2001), the NIBRS data (from 17 states
from 1995 through 1998) indicate that babysitters were responsible for 4.2%
of all offenses for children under age 6, less than the percentage accounted for
by family members or strangers. Among the reported offenses that babysit-
ters commit, sex crimes (843 offenses) outnumbered physical assaults (425
assaults) nearly two to one. Almost half (48%) of the babysitter sex offenders
were juveniles. Children most at risk of physical assaults by babysitters are
younger (ages 13) than those at risk of sex crimes (ages 35). Males constituted
the majority of sex-offending babysitters reported to the police (77%); females
made up the majority of physical assaulters (64%). Juvenile offenders were
responsible for nearly half the babysitter sex crimes known to police (48%)
but only 15% of the physical assaults. It must be noted that crime reports on
babysitters may only reflect crimes considered serious enough to report to the
police.
Youth can and should forthrightly be asked about sexual activity with
babysitters or other caretakers. Interestingly, boys tend to minimize the
abusive nature of sexual activity initiated by female babysitters, but careful

interviewing will often reveal that at the outset of the abuse, the child found it
deeply disturbing and confusing. Specifics regarding caretaker abuse should
include who the abuser was and where the abuse took place. Was there abuse
in a caretakers home by noncaretakers (e.g., relatives of a day care provider)?
Developmental Milestones
Specific information regarding developmental milestones such as language
acquisition and toilet training are especially important for those youth in
whom there are questions of developmental delay. What was the response of
parents to developmental delays? Developmentally delayed offenders are over-
represented among juvenile sex offenders (Gilby, Wolf, & Goldberg, 1989;
McCurry et al., 1998).
Social Development
Inquire about the youths relationships with peers, parents or caretakers, and
other adults, including teachers, coaches, and employers. Impaired social and
interpersonal skills have been found in adolescent sex offenders (Fehrenbach
& Monastersky, 1988). It has been postulated that some sexually abusive ado-
lescents turn to younger children for the sexual and relationship gratification
that they are unable to find among same-age peers (Awad & Saunders, 1989,
1991). Awad reported that 46% of the adolescent sex offenders in his cohort
were loners (Awad, Levene, & Saunders, 1984). In another study of adolescent
sex offenders, 65% were found to be socially isolated and 32% did not have a
friend (Fehrenbach, Smith, Monastersky, & Deisher, 1986a).
Family
Studies indicate that most juvenile sex offenders are living at home at the time
of the offense (Kahn & Chambers, 1991; Ryan et al., 1996). Family dynamics
and characteristics are similar to those in the families of delinquent youth
who do not commit sexual offenses and include harsh and inconsistent par-
enting, physical abuse and neglect, exposure to violence, family dysfunction
and instability, and low adaptability and cohesion (Awad et al., 1984; Becker &
Hunter, 1993; Deisher, Wenet, Paperny, Clark, & Fehrenbach, 1982; Fehrenbach
et al., 1986a; Lewis, Shankok, & Pincus, 1979; Shaw et al., 1993). However, it
has been postulated that families that are more likely to produce sexually
abusive behavior are characterized by (1) instability and lack of resources;
(2) failure to promote and establish strong emotional ties between parent and
child; (3) early exposure to sexual material and behavior; (4) an environment
in which the child is vulnerable to sexual abuse or exploitation; and (5) a lack
of resources to deal adequately with sexual abuse after it has been disclosed
(Barbaree, Langton, & Peacock, 2006).
As in a thorough purely clinical evaluation, the following areas should be

explored:
Familial sexual abuse.

Family psychiatric history.
Siblings.
Family secrets, such as a history of incest, criminality, and mental
illness. Whereas these areas may likely be explored elsewhere dur-
ing the evaluation, be aware that because of the shame and guilt
associated with secrets, often the information is not volunteered. For
example, parents may deny knowledge of a history of sexual abuse
of their child (the evaluee) and neglect to volunteer their own sexual
abuse by a parent or relative who may well have had contact or even
caretaking responsibilities for the youth being evaluated. Hence, it is
important to ask specific queries regarding sexual abuse within the
extended family.
How are love, affection, and tenderness expressed within the family?
What about aggression, competition, and sexuality? How available
and competent is the family to be motivated as a treatment resource?
How do religious or cultural mores influence the familys response to
sexual behavior, both developmentally appropriate and inappropriate,
as well as abusive sexual behaviors?
How was sexuality discussed with the youth? Was it discussed at all?
How much awareness does the family have of their childs sexuality
and sexual behavior?
When did the parents first become aware of sexually inappropriate or
abusive behavior?
What are the familys attitudes toward modesty and exposure to sexual
behavior? What are the sleeping arrangements within the family?
What exposure to sexual behavior has the youth had within the family?
What role does the extended family play with the youth? What is the
level of involvement and support provided? What is their potential for
supporting or undermining treatment?
Explore the psychiatric history of the family and pertinent medical
history.
Obtain an Educational History
Juveniles who commit sexual offenses often have a history poor academic
functioning and school behavior problems (Awad et al., 1984; Awad &
Saunders, 1989; Fehrenbach et al., 1986a; Fehrenbach & Monastersky, 1988;

Ryan et al., 1996; Shaw et al., 1993). Studies have indicated that 40% to 80%
of juvenile sex offenders have demonstrated learning disabilities and school
behavior problems (Awad & Saunders, 1989; Ryan et al., 1996; Shaw et al.,
1993). (See Chapter 4 for a discussion of learning disorders and cognitive defi-
cits in this population.)
Obtain a Psychiatric/Medical History
The importance of accurate psychiatric diagnosis in the forensic evaluation

of sexually reactive and abusive youth, as well as how management of men-
tal illness is incorporated into the overall assessment, recommendations, and
actual treatment planning, cannot be overestimated. The forensic evaluator is
in the unique position of being able to review prior inpatient and outpatient
treatment records as well as integrating information regarding psychiatric
symptomatology from numerous collateral sources over a relatively short
period of time. This is a luxury that few child psychiatrists or other mental
health practitioners in clinical practice can afford.
Psychiatric History
The evaluator should review the onset of each psychiatric disturbance
and evolution of symptomatology.
Review treatments received by the youth and family and obtain
specifics in order to determine how appropriate they were and how
likely they are to be efficacious.
Review hospitalizations and symptoms and behaviors noted in the
records.
Were the inpatient and outpatient therapies appropriate to the disorders
targeted? If psychotherapy was employed in the treatment of a youth
with conduct disorder, was it a therapy with some empirically based
validation of efficacy (multisystemic therapy, for example)? If a youth
has already received treatment for a sexually abusive behavior, how
intensive was the therapy? Was a probation officer actively involved in
monitoring compliance of the youth and family? Was the treatment
provider trained in the provision of therapy to youthful sex offenders?
Such questions are important in understanding the youths amenabil-
ity to treatment as well as the youths response to past treatment. It is
hardly fair for a youth to be considered resistant to treatment, if inap-
propriate and poorly executed treatments have been employed.
The dosage and duration of each medication used should be obtained.
It is not uncommon for children and adolescents to remain on
inappropriate doses of medication and/or not be given adequate trials

of medication for various psychiatric disorders. The appropriateness
of psychiatric diagnosis and pharmacologic treatments should be
reevaluated as part of a comprehensive assessment.
Psychopathology in sexually abusive youth is discussed in detail in
Chapter 4. Studies focusing on psychiatric disorders among juvenile
sex offenders have found psychiatric comorbidity in 60%90% of
this population, with the most prevalent disorders being conduct
disorder (45%80%); mood disorders (35%50%); anxiety disorders
(30%50%); substance abuse (20%30%); and attention-deficit/
hyperactivity disorder (10%20%) (Becker, Cunningham-Rathier, &
Kaplan, 1986; Becker, Kaplan, Tenke, & Tartaglini, 1991; Kavoussi,
Kaplan, & Becker, 1988; Shaw et al., 1993; Shaw, 1999). Shaw found
that the younger a child was when he committed his first sexual
offense, the higher the number of coexisting psychiatric diagnoses
(Shaw, Applegate, & Rothe, 1996).
Medical History
Medical history should be obtained, including any history of sexually
transmitted diseases, HIV testing, and known HIV exposure, hospitaliza-
tions, and surgeries. Specifically question the youth and parents regarding any
urogenital abnormalities and surgeries or other treatments.
A careful medication history should be obtained, including present and
past medications that may have produced uncomfortable side effects, includ-
ing sexual side effects (decreased libido, disinhibition, delayed ejaculation,
anorgasmia).
Obtain a Legal History
Is there a prior history of arrests, convictions, and incarcerations? Have

prior sexual assault charges been pled down to nonsexual assault and bat-
tery adjudications or convictions? A history of prior sexual charges does not
automatically mean that the youth has established a pattern of sexual offend-
ing; however, these data must be explored and factored into ones opinion
regarding the youth and his or her risk for reoffending.
Obtaining a history of antisocial activities (sexually motivated as well as
nonsexual antisocial behavior) for which the youth has not been caught or
charged provides a richer understanding of risk. Caretakers and the youth
should be questioned individually and specifically about these behaviors
(fire setting, assault, bullying, cruelty to animals, stealing, lying, vandalism,
coercive sexual behavior, use of weapons, etc.) and details regarding the actual
frequency of behaviors (suggesting a pattern rather than an isolated act) and
severity. Does the youth have deviant nonsexual interests, such as killing
animals? Impulsively and infrequently kicking a dog, although disturbing,
is not qualitatively similar to sadistically torturing or killing animals, and
evaluators should be careful about stretching to fulfill criteria.
Obtain a Thorough Sexual History
The evaluator should obtain a thorough sexual history by assessing the

juveniles sexual knowledge and education, sexual development, and sexual
experiences (Shaw, 1999). This is best accomplished after rapport has been
established, because delving into sensitive issues too early in the evaluation,
especially if not initiated by the youth, can be disengaging. The youths level
of sexual knowledge should be explored. Does the youth have a developmen-
tally appropriate and accurate knowledge base? What is the level of his or her
anatomical and functional knowledge? How was sexual information acquired?
What is the youths understanding, knowledge, and experience of sexual activ-
ities, such as kissing, dating, and petting? Has he or she engaged in oral sex,
intercourse, or homosexual experiences?
Masturbation History
Marshall and Marshall (2000) propose that the origins of sexual offending
lie in the offenders experience of poor parenting during childhood, which
in turn leads to an increased risk of being sexually abused, which feeds into
sexual fantasies during adolescence. They note that the juvenile sexual history
of adult sexual offenders involves high rates of masturbation, which becomes
a preferred method of relieving stress. High rates of masturbation, combined
with a lack of self-confidence in relationships, increase the likelihood that
sexual fantasies incorporating elements of power and control become more
deviant over time. They propose that these factors combine to create a dispo-
sition to offend that is realized only when the offenders social constraints are
disinhibited and he has opportunity to offend. Inquire about fantasies during
masturbation; age at which masturbation began and how fantasies may have
evolved over time; frequency of masturbation; and presence of deviant auto-
erotic practices, such as autoerotic asphyxia.
First Exposure and Evolution of Exposure to Sexual Activity

The evaluator should inquire about sexual activity between parents
and between parents and paramours. What is the role of sexual
coercion within the youths family?
Has the youth been exposed to the sexual activity of other adults, and
if so, what were the circumstances?
Has the youth been exposed to Internet, video, or print pornography?
What was his or her reaction to the initial exposure? How accessible
is pornography, and what is the frequency of use? How distressed is
the youth by his or her use of pornography? Has the youth tried to
stop accessing pornography, and if so what were the results? Are other
obsessive-compulsive symptoms present not pertaining to the use of
pornography?
Although research suggests that involvement with pornography during

adolescence has negative effects, the relationship between pornography and
sexual offending in youth remains unclear. Some surveys of students from ages
12 through college age indicate that exposure to pornography correlates with
increased acceptance of aggression toward women in sexual and nonsexual
interactions, as well as the potential for the development of sexual callousness
(Malamuth, 1993; Malamuth, Addison, & Koss, 2000; Malamuth & Huppin,
2005; Ybarra & Mitchell, 2005). Adolescents with high risk for aggression
(such as hostility toward women, impulsivity, and promiscuity) appear to have
a greater likelihood for sexual aggression when there is frequent use of por-
nography (Malamuth et al., 2000).
Ford and Linney found that 42% of their sample of juvenile sexual offenders
had used or been exposed to pornography as compared to 29% of violent
nonsexual offenders, and that sexual offenders were exposed at an earlier
age, typically between the ages of 5 and 8 years (Ford & Linney, 1995). Becker
and Stein found that 35% of their sample of juvenile sex offenders reported
using sexually explicit magazines, and 26% sexually explicit videotapes, but
9% reported not using pornographic materials. No relationship was found
between the use of pornography and number of victims (Becker & Stein, 1991).
Other researchers have reported an association between sexual offending and
the use of pornography in males (Seto & Lalumire, 2010; Zigourides, Monto,
& Harris, 1997).
Obtain a Sexual Abuse History
Explore in detail the youths prior history of abusewho, what, where, and
when:
When and how was the abuse reported?

What was the response of caretakers?
Where are the abuser(s) now? Were the abusers prosecuted, and if
not, why?
Does the youth believe that he or she has been affected by the abuse,
and if so, how?
Although research does not bear out a correlation between a history

of sexual abuse and sexual offending, early childhood neglect and abuse is
associated with an increased risk for delinquent behavior, adult antisocial
behavior, and violence, and a variety of mental illnesses (Hunter & Becker,
1999; Kendall-Tackett, Williams, & Finkelhor, 1993; Widom, 1989a, 1989b).
Lindsay and colleagues note the intuitive attraction (Lindsay et al., 2004)
of the cycle of abuse to explain sexual offending. In a meta-analysis of the
literature on child molesters who were sexually abused as children, Hanson
and Slater concluded that 28% of 1,717 offenders reported a history of abuse in
childhood. They note the potential confounds including appropriate control
groups as well as the potential for offenders to report abuse in an effort to
mitigate, excuse, or otherwise explain their own offending. Although Widom
and Ames (1994) found that sexually abused children were significantly more
likely than children who were not sexually abused to be arrested for prostitu-
tion, they found no significant difference between the two groups in relation to
their arrest in adulthood for sex crimes. In their study of 46 adult male sexual
offenders with intellectual disabilities who were compared to 48 male nonsex-
ual offenders with intellectual disabilities (IQs ranging from 4079), Lindsay
and colleagues found that 38% of the sexual offenders and 13% of the nonsexual
offenders had experienced sexual abuse, while 13% of the sexual offenders and
33% of the nonsexual offenders had experienced physical abuse (Lindsay, Law,
Quinn, Smart, & Smith, 2001). The authors concluded that the cycle of abuse
is inadequate as an explanation for sexual offending. Of interest is a retrospec-
tive chart review of 843 subjects at a specialized forensic psychotherapy center
in Great Britain, in which they concluded that the data supported the notion
of a victim-to-victimizer cycle in a minority of male offenders but not among
female victims of sexual abuse, with having been abused by a female a possible
risk factor for offending in males sexually abused in childhood (Glasser et al.,
2001). Sexual victimization appears to be more prevalent among female juve-
nile sex offenders than male juvenile sex offenders, with 50 to 95 of girls who
had committed a sexual offense reporting a history of sexual victimization
(Green & Kaplan, 1994; Kaplan & Green, 1995).
Despite the limitations of the cycle of abuse explanation, it is clear that
deviant patterns of eroticization may at least in part be established by early
sexual experiences, particularly if these early experiences are associated with
sexual arousal or excitement. Children who have been sexually victimized
may experience their first sexual arousal during their abuse. Sexual arousal
may coincidentally be paired with aggressive and coercive sexuality, enemas,
abusive corporal punishment, and other experiences. Although a history of
sexual abuse alone does not appear to be a risk factor for sexual offending
recidivism or adult sexual offending, it is known to be a precipitant in the
inappropriate sexual behavior of very young children (Holmes & Slap, 1998).
It appears that the younger the child at the time of his first sexual offense,
the more likely it is that the child has been sexually abused (Holmes & Slap,
1998; Johnson, 1988, 1989, 1999; McClellan et al., 1996). Johnsons study of 47
boys in a program designed for child perpetrators between the ages of 4 and
13 years who had molested children younger than themselves found that 49%
had been sexually abused and 19% physically abused, all by people they knew
(Johnson, 1988). In this group, 72% of abusers under 6 years of age had been
sexually victimized, 42% ages 7 to 10 years, and 35% of those 11 to 12 years old.
All of the perpetrators knew the children they molested. In 47% of the cases
the sexual abuse was of a sibling.
Explore the Nature and Evolution of the Sexually Aggressive

Behavior That Prompted the Evaluation, and the History of
Other Sexually Abusive Behavior
Sexually abusive/offending behavior is defined (American Psychiatric Association,

1999) as a purposeful sexual act committed against another person that may
include physical, verbal, or other forms of coercion or manipulation. The last
criterion can present problems in the evaluation of sexually offending behav-
ior in youth because many victims of sexual abuse may be compliant and even
willing participants but lack the capacity to consent. Sexually inappropriate and
abusive behavior can have a variety of etiologies. Psychodynamic factors, disor-
ganized attachments, character pathology, substance use, affective dysregulation,
psychosis, traumatic brain injury, mental retardation and developmental disor-
ders, traumatic reenactments, and paraphilias may all play a role.
It is often difficult to obtain the details of sexually aggressive behavior from
the evaluee. There are a variety of reasons for this. Lying, especially to avoid
punishment, is fairly normative for children and adolescents. There is also
much at stake in forensic evaluations because there are often stiff legal penalties
for conviction of sexual offenses, even in juvenile court. Additionally, guilt
and shame may hinder disclosure. However, the evaluator must still attempt
to answer a number of questions regarding the offense or behavior that
prompted referral. Some of the information will have already been obtained
from the youth, and especially given the sensitivity of this area, as well as its
complexity, evaluators should not approach these questions in a rote or check-

list manner. Again, not all of the desired information will be provided solely
by the youth but will be discovered through other means, including record
review and collateral sources. Questions may include the following:
What was the relationship to the victim, the age difference between
the aggressor and victim, and the precipitants to the sexually aggres-
sive behavior?
Was the sexual aggression planned or impulsive? Were weapons
involved?
How did the youth choose the victim?
What is the youths understanding of the wrongfulness of his or her
behavior? Confront inconsistencies, such as statements that the youth
did not realize the behavior was wrong, yet asked the victim not to
reveal it, or even threatened the victim if revealed.
What was the intensity of sexual arousal around the time of the
offense? How and when did arousal begin, and when did it peak?
Were their sadistic elements to the sexually abusive behavior?
What was the nature of the sexual aggression? Include when it began,
frequency, and specific characteristics of the behavior. For example,
did it start out as fondling and progress over time? Specifically how
and when did the behavior progress and evolve?
How did the youth attempt to evade detection? Was the victim threat-
ened, and if so, how and with what?
Were there any obsessive or ritualistic aspects to the sexually abusive
behavior?
What is the youths understanding of the meaning of his or her
behavior and the effect it has had or may have had on the victim?
Although juvenile sexual offenders are less likely than adults to physically
harm their victims or use a weapon, they usually use coercion in the form
of bribes and threats (Fehrenbach, Smith, Monastersky, & Deisher, 1986b).
However, victims report higher levels of coercion and threats than do the
offenders (Davis & Leitenberg, 1987). In their study of 305 juvenile sexual
offenders, Fehrenbach and colleagues reported that 22% of offenders persisted
in their sexually aggressive acts even when their victims expressed hurt or fear
(Fehrenbach et al., 1986b). Questioning should cover the following areas:
Types of deviant sexual behavior

Reported deviant sexual fantasies and interests
Emergence of sexually aggressive behavior over time
Frequency and variety of deviant sexual behaviors

When behaviors began
With whom and for how long
Victim profile, if applicable
Evolution of deviant behaviors over time
Force or coercion involved
Internal and external triggers for sexual abuse
Whether grooming of the victim was involved2
Specific factors that place evaluee at risk for offending
Efforts to refrain from deviant behaviors
Ability to control deviant sexual interests, arousal, and behaviors
Whether aggression was a part of the abusive behavior
If aggression is a part of the offense, specifics are important to obtain and

relate in the report. For example, did the offender use verbal threats to obtain
cooperation and submission, and if so, what were they? Did the offender use
physical force, and if so, what was done, and was a weapon used? Did the
offender use just enough force to obtain submission, or was the aggression
excessive and/or sadistic? Did the aggression enhance the sexual arousal of
the offender?
Mental Status Examination
A mental status exam is completed to evaluate the presence of psychopathol-

ogy, including major mental illness, personality pathology, substance abuse
disorders, and other medical disorders with psychiatric manifestations.
Signs within the evaluation of possible incipient character pathology should
be viewed cautiously and evaluated within the context of historical infor-
mation regarding the youths relationships within and outside of the family,
as adolescence is a time of change and fluctuation. Flippant, inappropriate
diagnosis of narcissistic, antisocial, borderline, or psychopathic personality
disorders is always problematic and may be unethical, given how pejorative
2. Professionals have yet to agree on a definition of grooming, but it typically refers to

actions deliberately undertaken with the aim of befriending and establishing an emotional
connection with a child, in order to lower the childs inhibitions in preparation for abuse. It
is a term frequently used in the literature on sex offending and should be used with caution
in this population. Juvenile sex offenders may engage in grooming behaviors, but evalua-
tors should avoid terminology that may be misunderstood by others and would do well to
describe the behavior in some detail.
these diagnoses are, especially to the public (including attorneys, judges, and
juries). Many juveniles charged with sexual offenses demonstrate mental sta-
tus examinations within the expected and normal range. However, suicidality
should always be thoroughly assessed because the shame and guilt associated
with these offenses, as well as the specter of punishment (including incarcera-
tion) and exposure, increase risk.
Psychological Testing
As previously noted, there is no test or instrument that is capable of iden-

tifying or diagnosing an adolescent sexual offender. However, psychological
testing can be very useful as part of a comprehensive evaluation to under-
stand the personality, motivations, defensive structure, coping strategies,
intelligence, and sexual knowledge and behaviors of the youthful offender.
Neuropsychological assessment may be necessary if there is a history that
leads to suspicion of neurological dysfunction and/or learning disabilities.
Follow Up With Additional Collateral Sources of Information
During the interview, the youth and/or parents may identify individuals
who may be able to shed additional light on aspects of the youths character,
functioning, or mental health. Obtain permission to contact them if doing so
may contribute to a better understanding of the youth, your opinions, and/or
formulation of recommendations.
Communication of Findings
The nature of the evaluation, if court ordered, will often determine who a
report goes to and at what point. If retained by the defense attorney and not
court ordered, your evaluation findings and opinion will be protected under
attorney-client privilege. Make sure that a report is desired and/or wanted
before producing one. If a defense attorney has privately retained you, and
your opinion is not favorable to the attorneys client (the evaluee), then the
attorney may not want a report or call you to testify. Whether your opinion
is favorable to the youth whose attorney has retained you is unrelated to pay-
ment. You are being paid for your time and expertise, not for your opinion.
If court ordered, statute will typically delineate what questions need to be
addressed in the report.
S U M M A RY
Thorough assessment of sexually abusive youth requires evaluators to approach

the assessment with an appreciation of child and adolescent development and
be able to evaluate the risk for sexual reoffending in the context of the emo-
tional, cognitive, behavioral, and family and community systems in which it
has developed. Comprehensive forensic evaluation of sexually abusive youth
attempts to understand the child or adolescent and his or her behavior in the
context of his or her whole life. Knowledge of risk factors for sexual reoffend-
ing in adults is necessary but insufficient for evaluators of juvenile offenders,
and an application of the findings regarding risk for adults to youth is not sup-
ported by research and can have significant negative ramifications for youth
and society.
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7
Assessment Instruments for

Juveniles Who Sexually Offend
DANIEL C. MURRIE
OV ERV I E W
A thorough evaluation of youth with sexual behavior problems requires far

more than psychological assessment instruments. Administering instru-
mentseven well-designed onesis only a component of an evaluation or a
risk assessment; an instrument should never comprise the entire assessment
(Conroy & Murrie, 2007). Indeed, as detailed in Chapter 6, a thorough evalu-
ation is based upon a review of collateral data sources and a comprehensive
clinical assessment of the juvenile. We discuss assessment instruments in this
chapter, separate from the Chapter 6 guidance on interview and evaluation, to
underscore that administering an instrument is not the same as conducting
an evaluation.
But given strong clinical and legal pressures to identify youth who are likely
to reoffend sexually, the field has been understandably motivated to develop
risk instruments specific to juvenile sexual offenders. Furthermore, the prom-
inent role of formal risk measures in adult sex offender risk assessment (see,
e.g., Hanson & Morton-Bourgon, 2009), and in violence risk assessment more
generally (see, e.g., Otto & Douglas, 2009), certainly makes risk instruments
for juvenile sexual offending seem like a reasonable goal. In this chapter,
we review the three measures most commonly used for risk assessments of
juvenile sexual offenders: the Juvenile Sex Offender Assessment ProtocolII
(J-SOAP-II; Prentky & Righthand, 2003), the Estimate of Risk of Adolescent
Sex Offender Recidivism (ERASOR; Worling & Curwen, 2001), and the Hare
Psychopathy Checklist: Youth Version (PCL:YV; Forth, Kosson, & Hare, 2003).
The J-SOAP-II and ERASOR were developed specifically for assessing risk of
reoffense among juvenile sexual offenders, whereas the PCL:YV was devel-
oped to assess psychopathic personality traits among juveniles, which may
be related to risk for reoffense. As underscored throughout this chapter, the
instrumentsthough widely used in practiceremain in the early stages of
development. Research suggests scores from these measures cannot predict
sexual reoffending as accurately as we might assume. Although evaluators
may be tempted to substitute instruments for a comprehensive evaluation, the
available research suggests these measures have considerable limitations.
M E A S U R ES D ES I G N ED TO A S S ES S R I S K O F
S E X UA L O F F E N D I N G
There are countless psychological tests, designed to measure a variety of

psychological or cognitive constructs, and any one (or more) of them might
be relevant to a particular juvenile who has committed a sexual offense.
For example, IQ testing may be informative when intellectual impairment
appears to play a role in a juveniles sexual behavior problems, and neuro-
psychological testing may be helpful to better identify the causes of some
impulsive behaviors. But a comprehensive review of all possible psycholog-
ical testing is well beyond the scope of this chapter, and readers can consult
other excellent resources for reviews of the instruments most often used with
young offenders (see, e.g., Grisso, Vincent, & Seagrave, 2005). Instead, we
focus on the few measures that have been developed specifically to assess risk
for sexual offending among youth who have demonstrated sexual behavior
problems, and one measure (i.e., the PCL:YV) that is increasingly employed
in risk assessments of young sexual offenders.
Actuarial Measures
In the field of adult sex offender risk assessment, most evaluations rely heavily
on actuarial measures. Actuarial risk assessment involves explicit research-
supported rules that specify which risk factors are examined, how those
risk factors are scored, and how those scores are mathematically combined
to yield an objective estimate of risk (Monahan, 2006). Generally, actuarial
approaches tend to yield more accurate estimates than unstructured clinical
judgments (Grove & Meehl, 1996; Grove, Zald, Lebow, Snitz, & Nelson, 2000).
Regarding sex offender risk assessment, the most recent and comprehensive
Assessment Instruments for Juveniles Who Sexually Offend 163
meta-analysis of the subject (Hanson & Morton-Bourgon, 2009) revealed that

actuarials designed to predict sexual reoffense (d = .67) clearly outperformed
unstructured professional judgment (d = .42). One actuarial risk instrument
in particular, the Static-99 (Hanson & Thornton, 1999; 2000) is well supported
by more than 60 validity studies. Static-99 scores are moderate predictors
of sexual recidivism, with the most recent Static-99 meta-analysis reporting
a median Cohens d effect size of .67 (Hanson & Morton-Bourgon, 2009).
Thus, evaluators familiar with sex offender risk assessment procedures for
adults, which are based primarily on actuarial risk instruments such as the
Static-99, are quick to ask, Is there something like a Static-99 for juveniles?
In other words, is there a well-validated actuarial instrument that can offer an
initial risk estimate for juveniles? The short answer is no.
Actuarial measures have a long history in juvenile justice (e.g., Baird, 1984),
and manyif not mostjuvenile justice agencies use some form of screening
measure for classification. But developing measures to predict the common
outcome of general criminal recidivism is much easier than developing mea-
sures to predict the uncommon outcome of sexual recidivism among youth.
Any actuarial measures designed to predict recidivism must be based on
normative samples large enough to include many recidivists. But even large
samples of juvenile offenders rarely have enough sexual recidivists to allow
researchers to develop and validate actuarial measures to predict sexual recid-
ivism. Even when one jurisdiction develops a promising approach, research
often demonstrates that actuarial measures developed in one jurisdiction do
not work as well in other jurisdictions (e.g., Boccaccini, Murrie, Caperton, &
Hawes, 2009; Howell, 1995) and the predictive validity of actuarial-like instru-
ments is often hampered by gender or ethnic bias (Schwalbe, Fraser, Day, &
Cooley, 2006). With regard to assessing sexual reoffense risk among juveniles
who have sexually offended, a few states (e.g., Wisconsin, Texas, and New
Jersey) have attempted to develop actuarial-type instruments for local use. But
the available research suggests these have little or no predictive value in other
jurisdictions (Caldwell, Ziemke, & Vitacco, 2008). Indeed, given that state sys-
tems rarely conduct rigorous research on their procedures, we usually know
too little about how instruments operate even in the jurisdiction for which
they were designed, let alone in other jurisdictions. Thus, at present, there
appear to be no actuarial sexual recidivism risk measures for juveniles that are
appropriate for wide-scale use.
Structured Professional Judgment Measures
However, the actuarial approach is not the only approach to risk assessment.
Many violence risk assessment instruments follow the Structured Professional
Judgment (SPJ) approach. In SPJ models, evaluators review the available

clinical data to determine the presence of specific risk factors. These risk fac-
tors have been identified, defined, and operationalized in an instrument man-
ual based on their association with violence (or sexual violence, or recidivism)
in the scientific literature. After reviewing the risk factors applicable to a given
case, in this structured manner, evaluators form an overall judgment of risk
(see, e.g., Douglas, Ogloff, & Hart, 2003). This method has appeared promising
when applied to juvenile sexual offenders, for whom the research has iden-
tified some well-supported risk factors for reoffense. So scholars have devel-
oped two well-known juvenile sex offender risk assessment instruments based
on the SPJ model: The most widely used instrument for evaluating juvenile
sex offenders is the Juvenile Sex Offender Assessment ProtocolII (J-SOAP-II;
Prentky & Righthand, 2003). The second most commonly used instrument
is the Estimate of Risk of Adolescent Sex Offender Recidivism (ERASOR;
Worling & Curwen, 2001).
The Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II)
The J-SOAP-II (Prentky & Righthand, 2003) is a structured guide created to help
clinicians review the risk factors associated with sexual and criminal offend-
ing in boys ages 12 to 18. The instrument includes static risk factors, which
do not change with time, and also dynamic risk factors, which may change
with time or intervention. These risk factors are arranged according to four
separate scales: Impulsive/Antisocial Behavior, Sexual Drive/Preoccupation,
Intervention, and Community Stability. Prentky and Righthand (2003) selected
the items based on their association in the research literature with both sexual
recidivism and general recidivism.
Early research with the J-SOAP-II (and its predecessor, the J-SOAP) sug-
gested some potential for identifying youth at high risk for reoffense. In the
original study, Prentky and colleagues (Prentky, Harris, Frizzell, & Righthand,
2000) explored the utility of the J-SOAP in predicting reoffense among 75
adolescents who had committed sexual offenses. After a 12-month follow-up,
researchers compared nonrecidivists to recidivists and observed that recidi-
vists scored an average of 7 points higher on the J-SOAP. However, because
there were only three recidivists, the researchers were appropriately cautious in
drawing conclusions (Prentky et al., 2000). In another early study, Righthand
and colleagues (2005) compared youth in residential facilities to youth in the
community. They observed higher J-SOAP scores among youth in residential
facilities, who presumably were at higher risk. But, of course, these descriptive
results tell us little about the predictive utility of the J-SOAP. The initial results
from these two exploratory studies were apparently sufficient to prompt other
researchers to begin studying the J-SOAP and to prompt clinicians to begin
using the measure in practice. But the instruments authors remained cau-
tious about applied use, in the sense that they did not propose specific cutoff
scores for a juvenile to be considered high versus low risk, because there was no
research to justify doing so.
Some more recent research better explored the predictive validity of the
J-SOAP and concluded that the instruments scale scores may be more mean-
ingful measures of risk than the total scores. For example, Waite and colleagues
(2005) examined J-SOAP scores in light of reoffense data for 253 juvenile sex
offenders in Virginia. Youth who scored high on the Impulsivity/Antisocial
Behavior scale were three times more likely to sexually reoffend, though total
scores were not useful for predictive purposes. Similarly, Parks and Bard
(2006) completed the J-SOAP-II (based on fi le review alone) for 156 juvenile
sex offenders. They too found that the Impulsivity/Antisocial Behavior scale
was the best predictor of sexual recidivism, as well as general recidivism, but
again, the total score appeared unrelated to sexual reoffense.
More recent research with the J-SOAP-II does not appear any more
supportive. For example, in their study of sexual reoffense among serious
juvenile offenders in an intensive treatment program, Caldwell and col-
leagues (2008) scored 91 juvenile sexual offenders on the J-SOAP-II but
found that the J-SOAP-II total score did not predict sexual reoffending over
the follow-up period (mean length = 71 months) after the juveniles left the
treatment program. Likewise, none of the J-SOAP-II scale scores predicted
sexual reoffending or general reoffending. Again, the only predictive value
appeared to lie in the Impulsivity/Antisocial Behavior scale, which predicted
new charges for nonsexual violent offending (Caldwell et al., 2008). Thus,
several studies suggested that the only predictive validity from the J-SOAP-II
lies in a scale more relevant to general impulsivity and delinquency, rather
than a scale more specific to sexual behavior.
In contrast to most other research, two studies found fairly strong predictive
validity for the J-SOAP-II. Researchers examined a sample of 60 urban, eth-
nic-minority males (ages 12 to 18) admitted to a community-based adolescent
sex offender treatment program (Martinez, Flores, & Rosenfeld, 2007). They
reported that after scoring the J-SOAP-II retrospectively, the J-SOAP-II total
score was significantly correlated with general reoffense, sexual reoffense, and
treatment compliance. Predictive values for general reoffending (area under
the curve [AUC] = .76) and sexual reoffending (AUC = .78) appeared stron-
ger than in any prior published study. It is difficult to reconcile these much
stronger and more encouraging findings with the weak results in other stud-
ies. The authors suggest that one explanation might be that treating clinicians
scored the J-SOAP-II, which allowed them to base scores on more personal
knowledge of the youth (as opposed to many instrument raters in research
studies, who rely solely on records). They also acknowledged that in this study,
J-SOAP-II ratings were not completed until many months or years after the
initial intake evaluation. Thus, despite efforts to score J-SOAP-II items solely
on information available at intake, it is possible that information regarding
reoffense contaminated clinician ratings (Martinez et al., 2007, p. 1293). In
short, J-SOAP-II raters in this study had more knowledge of participants than
may be typical in some research studiesand perhaps this bodes well for use
of the J-SOAP-II by treating clinicians in the fieldbut some of this knowl-
edge may have compromised the internal validity of the study in ways that
could have inflated the apparent predictive validity of the J-SOAP-II.
Why does the J-SOAP-II appear unrelated to sexual reoffense in most stud-
ies but relevant in another (i.e., Martinez et al., 2007)? One innovative study
suggests the reason for discrepant research findings may relate to heterogeneity
among young sexual offenders. Rajlic and Gretton (2010) recently examined a
sample of 286 male juvenile sexual offenders in Canada. Rather than simply
examining J-SOAP-II predictive validity for the group as a whole, they divided
the sample into youth who committed sexual offenses only versus youth who
committed sexual offenses and other delinquency. They reported that for the
group who committed sexual offenses only, J-SOAP-II total scores predicted
sexual recidivism (with effect sizes in the large range). However, for the group
who committed other delinquency beyond sexual offenses, the J-SOAP-II
scores did not predict sexual recidivism beyond chance levels. In other words,
offender type had a moderating effect on predictive validity, such that the
J-SOAP-II scores were related to sexual recidivism, but only among those
youth who had a history of solely sexual (not generally delinquent) offenses.
These recent results suggest more potential for the J-SOAP-II than most previ-
ous research has suggested, but it will require additional research to identify
the exact contexts and populations for whom the J-SOAP-II works best. These
recent results alone (Rajlic & Gretton, 2010) are probably not sufficient to give
clinicians a clear basis to routinely use the J-SOAP-II.
Estimate of Risk of Adolescent Sex Offender Recidivism (ERASOR)
Like the J-SOAP-II, the ERASOR (Worling & Curwen, 2001) is an assessment
guide created to assess risk among youth with a history of sexual offending.
But unlike the J-SOAP-II, the ERASOR was designed solely to predict sex-
ual recidivism, rather than sexual and general recidivism. To construct the
measure, the authors selected a total of 25 perceived risk factorsincluding
both static and dynamic risk factorsdrawn from research with adolescent
sex offenders, research with adult sex offenders, and other risk assessment
guides. These 25 factors were arranged according to five separate scales: Sexual
Interest, Attitudes, and Behaviors; Historical Sexual Assaults; Psychosocial
Functioning; Family/Environment Functioning; and Treatment. The ERASOR
was created specifically to assess short-term recidivism risk, and Worling
(2004) emphasized that the measure should not be used to draw inferences
about risk for more than 1 year beyond the assessment.
Worlings (2004) initial research on the ERASOR did not strictly examine
predictive utility of the measure but instead compared scores across groups
in ways that appeared intuitively related to prediction. Specifically, he com-
pared the ERASOR scores for 56 adolescents described as repeaters (i.e., youth
convicted of multiple offenses) versus nonrepeaters (youth convicted of only
an initial offense) and concluded that the ERASOR distinguished first-time
offenders from those who had previously been sanctioned for sexual offending.
But, of course, this was not a test of whether the measure predicted recidivism.
Worling also evaluated the change in scores from the time of treatment intake
to the time of treatment completion. Although scores during intake were
significantly higher than scores upon treatment completion, it was unclear
whether these score changes were attributable to treatment-related variables.
Although these early studies were useful to introduce the field to the
ERASORand have apparently made the measure familiar enough that some
clinicians use it in practicethey have not prompted much further validity
research. As Vitacco and colleagues (2009) concluded, While extant research
on the J-SOAP-II has been inconsistent, research on the predictive ability of
the ERASOR is largely absent (p. 933). One unpublished doctoral disserta-
tion that did examine the ERASOR found it did not predict general or sexual
recidivism among a sample of juvenile sexual offenders (McCoy, 2007).
However, one recent study revealed more promising results. When Rajlic
and Gretton (2010) examined a sample of 286 male juvenile sexual offend-
ers in Canada, they administered the ERASOR as well as the J-SOAP-II (as
discussed previously). But rather than collapsing all participants into one
group, they divided the sample into youth who committed sexual offenses
only versus youth who committed sexual offenses and other delinquency.
Similar to their results with the J-SOAP-II, they reported that for the group
who committed sexual offenses only, ERASOR total scores predicted sexual
recidivism (with effect sizes in the large range). However, for the group who
committed other delinquency beyond sexual offenses, the ERASOR scores
did not predict sexual recidivism above chance levels. In short, ERASOR
scores were related to sexual recidivism, but only among those youth
with a history of only sexual (not generally delinquent) offending. These
results suggest the ERASOR may eventually play a role in certain assessments
after all. But, as with the J-SOAP-II, much more research is necessary before
clinicians can use the ERASOR to inform important decisions in clinical or
forensic contexts.
M E ASU R ES D ESIG N ED TO AS SES S PSYC H O PAT H Y
Clinicians who work in the adult justice system may be tempted to assess psy-
chopathic personality features among young sex offenders, because psychopa-
thy assessment is such a common component of forensic evaluations of adults
who have committed sexual offenses (e.g., Lally, 2003; Otto & Heilbrun, 2002).
Indeed, forensic evaluators assessing sexual reoffense risk among adult offenders
typically include an assessment of psychopathy using Hares (2003) Psychopathy
ChecklistRevised (PCL-R; Jackson & Hess, 2007; Lally, 2003). PCL-R scores
are moderate predictors of sexual recidivism (median d = .29 in the largest
meta-analysis of sex offender recidivism risk; Hanson & Morton-Bourgon,
2005). Furthermore, the combination of high PCL-R scores and sexual devi-
ance is widely considered a potent combination that enhances sexual recidi-
vism risk (see Olver & Wong, 2006; Quinsey, Rice, & Harris, 1995).
But can psychopathy be reliably assessed in youth? Given the well-
documented relationship between psychopathy scores and measures of
violence and recidivism (Leistico, Salekin, DeCoster, & Rogers, 2008),
researchers have devoted considerable attention to identifying psychopathic
features among youth (for reviews, see Salekin & Lynam, 2010). Research has
also generated a series of juvenile psychopathy assessment measures, two of
which are commercially available for clinical use: the Psychopathy Checklist:
Youth Version (Forth et al., 2003) and the Antisocial Process Screening
Device (Frick & Hare, 2001). A substantial body of literature has examined
these juvenile psychopathy measures and generally supported their validity
(Salekin & Lynam, 2010). Just as adult psychopathy is considered a more
narrow and pathological condition than the broader diagnosis of antisocial
personality disorder, a subgroup of youth high in psychopathy-like features
appear to be distinguishable from the more heterogeneous group of youth
who qualify for diagnoses of conduct disorder (Frick & Marsee, 2006).
Indeed, psychopathy-like personality traits tend to correspond with a more
stable and severe pattern of offending (Frick & White, 2008).
Because psychopathy is a well-established risk factor for sexual reoffense
among adults, and because psychopathic traits can be meaningfully assessed
in youth, it seems reasonable to expect that psychopathy scores will relate to
sexual reoffense in samples of juvenile sexual offenders. But the results from
studies that have explored PCL:YV scores and juvenile sexual recidivism fail to
support this expectation. For example, meta-analytic reviews of the PCL:YV
tend to find a negligible relationship between PCL:YV scores and sexual recid-
ivism (Edens, Campbell, & Weir, 2007).
Regarding individual studies, an early study (Forth, 1995) found that juvenile
males with higher psychopathy scores were more likely to have demonstrated
aggressive sexual behavior. But a subsequent study of adult sexual offenders
found no relationship between psychopathy scores and prior (juvenile) sexual
offenses (Brown & Forth, 1997). In one of the largest relevant studies, research-
ers (Gretton, McBride, Hare, OShaughnessy, & Kumka, 2001) examined
PCL:YV scores, sexual deviance, and recidivism in a sample of 220 juvenile sex
offenders. Grouping participants on the basis of their PCL:YV total scores (i.e.,
high, medium, or low) revealed that juveniles in the high-PCL:YV group did
indeed demonstrate higher rates of general, violent, and sexual offenses than
the low-PCL:YV group. But subsequent analyses revealed that PCL:YV scores
did not appear to predict sexual offending beyond the youths offense histories
and age at offense, once these variables were entered into the prediction model.
In a later study of 157 male juvenile offenders, researchers (Gretton, Hare, &
Catchpole, 2004) again grouped participants based on PCL:YV scores and
found that risk for violence over a 10-year follow-up was greater among those
with high PCL:YV scores, even after controlling for other relevant variables.
However, there were no significant group differences for sexual offenses over a
10-year follow-up. In other words, PCL:YV scores appeared relevant to general
recidivism risk, but not to sexual offense risk. Similarly, the PCL:YV related to
violent reoffending, but not sexual reoffending, in a sample of 193 adolescents
who were followed for an average of 7.24 years after discharge from a residen-
tial sex offender treatment program (Viljoen, Elkovitch, Scalora, & Ullman,
2009).
Other studies have found some support for certain PCL:YV factor scores,
but not PCL:YV total scores. One component of PCL:YV scoresthe factor
measuring interpersonal behaviors, rather than the factor measuring anti-
social behaviorsdid appear related to sexual recidivism in a sample of 156
juvenile sexual offenders (Parks & Bard, 2006). However, neither the antisocial
factor nor the PCL:YV total score was related to sexual recidivism. In addition,
the antisocial factor predicted general reoffending, but not sexual reoffending,
in this sample (Parks & Bard, 2006).
The data that appear most supportive of the PCL:YVs relationship with
sexual reoffense risk come from a study of 265 juvenile males (including 91
convicted of felony sexual offenses and 174 convicted of nonsexual offenses)
in a correctional treatment program (Caldwell et al., 2008). PCL:YV scores
predicted violent reoffense, as expected, but also significantly predicted sexual
recidivism, in contrast to PCL:YV results from other studies and even in

contrast to results from the J-SOAP-II as examined in this same study. In other
words, the PCL:YV was related to sexual reoffense even though sex-offense-
specific risk instruments were not, and even though the PCL:YV appears only
negligibly related to sexual reoffense in other studies. The authors speculated
that they may have found more supportive results for the PCL:YV in predicting
sexual offenses because their sample was unusually criminogenic and high in
psychopathy (the mean PCL:YV score for the sample was 31, which is unusu-
ally high). Indeed, all of the juveniles who committed sexual offenses during
follow-up were exceptionally high in psychopathy (i.e., PCL:YV scores 34).
This study might shed some light on the contradictory findings across other
PCL:YV studies of juvenile sexual offenders; perhaps the PCL:YV is more rel-
evant in contexts with unusually high rates of psychopathy and reoffense. But
the authors emphasized that their results did not support using the PCL:YV
to assess sexual reoffense risk in the field: Use of PCL:YV scores to predict
juvenile sexual recidivism is clearly not warranted on the basis of the existing
research (Caldwell et al., 2008, p. 109).
Thus, overall, current research suggests that at least some psychopathy traits
may bear some relationship to sexual reoffense risk, at least in some samples.
But the link between psychopathy and sexual reoffense appears too weak and
inconsistent across studies to justify incorporating the PCL:YV as a component
of routine risk assessments for sexual reoffense. The PCL:YV may have a role
to play in short-term risk assessments for general violence (Vitacco & Vincent,
2006), but at this point there is no clear role for the PCL:YV (or any measure
designed to assess psychopathy among juveniles) in risk assessments for sexual
violence. Using the PCL:YV, or other measures designed for the assessment of
general violence risk, appears particularly likely to generate false-positive
errors, in which clinicians overestimate the risk of sexual reoffense (Vitacco
et al., 2009).
Summary
Given the pressing needs for reliable and consistent methods of assessing risk
among juvenile sex offenders, there has been an understandable enthusiasm for
developing and adopting structured assessments of risk for sexual reoffense.
However, as the previous review demonstrates, enthusiasm has not translated
into success. Although the J-SOAP-II appears to be the best-researched and
most widely used measure for assessing sexual recidivism risk among juve-
niles, the results of J-SOAP-II studies appear equivocal. Most studies have
found weak results, and the two more recent and promising studies will
require further replication and clarification. Regarding the ERASOR, even less
supportive data are available, although it is certainly possible that more will
emerge. Finally, there are ample data regarding the PCL:YV, but none are suf-
ficient to support incorporating the PCL:YV as a routine part of assessments
for juvenile sexual recidivism risk. Although PCL:YV scores do tend to corre-
spond with risk for general recidivism and short-term violence, there are few
data to indicate PCL:YV scores can consistently, accurately inform questions
about sexual recidivism risk.
The weak utility of these measures is less surprising when we remember two
themes stressed throughout this text. First, the base rate of sexual recidivism
is low; most juveniles who come into contact with the juvenile justice system
for a sexual offense never again come to the attention of law enforcement for
further sexual offenses. Second, many juvenile sex offenders are similar
to other delinquent youth and are more likely to reoffend with a nonsexual
offense than a sexual offense. Thus, from a statistical perspective, the deck is
stacked against any measure that aims to predict the highly unusual outcome
of sexual recidivism.
All this leaves clinicians in a predicament. Clinical and legal contexts
often demand that clinicians offer an opinion on sexual recidivism risk. But
the measures that have been developed specifically for this purpose have not
yet demonstrated the ability to predict sexual reoffense. The J-SOAP-II and
ERASOR may have some value, in the sense that they might help evaluators
explore certain factors that research suggests are related to sexual reoffense
risk. But the measures also have some potential for harm or confusion. Based
on the available data, evaluators certainly cannot claim that scores on these
instruments necessarily predict sexual recidivism. In legal contexts, in partic-
ular, clinicians must be careful not to overstate the value of these instruments.
Nevertheless, instruments have much potential to improve accuracy beyond
unaided clinical judgment (Hanson & Morton-Bourgon, 2009), so clinicians
certainly have a duty to stay abreast of the latest research as these instruments
develop. But in the meantime, instruments cannot provide simple solutions,
and clinicians are left with the task of conducting comprehensive evaluations
rooted in scientific research and strong clinical knowledge of the developmen-
tal and contextual factors that influence risk (see, e.g., Caldwell et al., 2008;
Vitacco et al., 2009), as described elsewhere in this text.
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8
Management and
Treatment Methods
JOHN A. HUNTER
OV ERV I E W
As emphasized in Chapter 3, sexually abusive youth represent a heterogeneous

clinical population. As such, it must be stressed that one size doesnt fit all
when it comes to treatment planning. This chapter will focus on the treat-
ment and management of adolescent males who perpetrate sexual offenses,
because they represent the preponderance of referrals for intervention by the
courts. Intervention for these youth will be discussed from the perspective of
a continuum of care, driven by risk and needs assessment. Comment will be
made as to both core components of treatment and individualization of care
based on consideration of salient psychiatric comorbidity. In discussion of the
latter, potentially useful adjunctive treatments for common comorbid condi-
tions will be identified. This chapter also summarizes treatment outcomes for
sexually abusive youth.
C R I T ER I A F O R D E T ER M I N I N G A PPR O PR I AT E
L E V EL O F CA R E
It is recommended that level-of-care decision making be driven by formal risk

and needs assessment. It is advised that the former take into consideration
both risk for sexual and nonsexual (i.e., general delinquency) recidivism, given
that posttreatment rates of general delinquency are at least double that of new
sexual offenses (Waite et al., 2005). The guiding principle in treatment plan-
ning is that clinical service intensity, and concomitant environmental supports
(i.e., supervision level and treatment setting), should reflect the youths mani-
fest level of psychosexual pathology and his or her assessed risk of reoffending.
As formal risk and needs assessment instrumentation (e.g., J-SOAP-II) is
reviewed in other chapters of this book, it will not be discussed here. However,
general guidance is offered in applying clinical criteria to level-of-care deci-
sion making, and there is brief discussion of the role of psychophysiological
assessment of sexual interests/arousal in risk assessment.
Clinical Guidelines
The author developed guidelines for making level-of-care decisions on juve-

nile sex offenders for the Virginia Department of Juvenile Justice (VA-DJJ) in
2003. These guidelines were those that could be used by clinicians and proba-
tion officers tasked with evaluating and managing these youth. It is noted that
the guidelines were intended to complement, and not replace, formal risk and
needs assessment. The developed guidelines were later posted on the Center for
Sex Offender Management (CSOM) Web site. Consistent with VA-DJJs adher-
ence to a balanced approach in the community-based management of juvenile
sex offenders, the guidelines placed equal emphasis on three intervention prin-
ciples: (1) the need to maintain public safety, (2) the need to hold offenders
accountable, and (3) the need to present offending youth with the opportunity
to receive specialized treatment designed to reduce their risk of reoffending.
Clinical profiles were developed for youth at low, moderate, and high
levels of risk for reoffending. These profiles took into consideration the fol-
lowing: the reference sexual offense and offenders criminal history, his or her
psychosexual characteristics, his or her peer affiliations and family character-
istics, and (where applicable) his or her past response to treatment. In brief,
low-risk youth were those who had engaged in time-limited (i.e., 13 inci-
dents) sexual misbehavior of a relatively noninvasive and noncoercive nature
(e.g., fondling). The sexual behavior of these youth was generally exploratory
and opportunistic in nature. In this group of youth, there was no evidence of
paraphilic sexual interests or major character pathology (i.e., antisocial per-
sonality tendencies). Low-risk youth took responsibility for their actions and
appeared remorseful. They appeared to be amenable to less intensive commu-
nity-based services and probationary supervision.
Moderate-risk youth were those who had engaged in more extensive
sexual offending and who demonstrated more pervasive psychopathology
Management and Treatment Methods 177
and/or family/peer dysfunction. However, their sexual offenses were generally

nonviolent and the youth generally had age-appropriate sexual interests.
Moderate-risk youth were seen as in need of more intensive, wraparound
community-based treatment and court supervision.
High-risk youth were those who tended to have multiple victims, and
those who engaged in more invasive sexual offending behavior. Typically, their
offending behavior had occurred over a longer period of time and may have
involved force or threat of the same. This category of youth included those with
paraphilic interests (e.g., pedophilia) and those who displayed more pervasive
antisocial behavior. Many of these youth had histories of substance abuse his-
tories and/or treatment failure. They often either denied their reference sexual
offense or minimized its significance. These youth were difficult to engage in
treatment and generally required intensive residential treatment services (i.e.,
24-hour supervision and care).
Psychophysiologic Assessment Methods
Psychophysiologic methods have also been employed in the assessment of ado-

lescent male sex offenders. These include phallometric assessment and use of
visual reaction time. The premise of these methodologies is that deviant or
age-inappropriate sexual interest (e.g., sexual interest in prepubescent children)
is an important predictor of sexual offending behavior. There is empirical sup-
port for this belief, especially as it relates to the prediction of sexual recidivism
in adult offenders. For example, Hanson and Morton-Bourgon (2005) found
that sexual deviancy and antisocial orientation were the major predictors of
sexual recidivism for both adolescent and adult sex offenders. Sexual deviancy,
as expected, has not been found to be predictive of nonsexual recidivism.
Phallometric assessment involves measurement of penile tumescence in
response to auditory or visual stimuli. There are a number of studies sug-
gesting that the methodology can produce reliable and valid findings in older
adolescent male sex offenders, especially in the identification of youth with
a sexual interest in prepubescent males (Hunter, Goodwin, & Becker, 1994;
Seto, Lalumiere, & Blanchard, 2000). The major problem with phallometric
assessment is that it is relatively invasive and expensive. In addition, there is no
evidence that the majority of adolescent males who perpetrate sexual crimes
are motivated by deviant sexual interests. Thus, the practitioner who utilizes
this methodology is advised to be selective in its application. To expose the
majority of youth, especially first-time offenders, to deviant stimuli and the
psychological discomfort associated with the procedure does not seem to be
warranted. It is suggested that if phallometric assessment is used, it be limited
to older adolescent males with longer histories of sexual offending, and those
with acknowledged deviant sexual interests. Furthermore, it should also only
be used with the full informed consent of the adolescent and his or her par-
ent guardian (Hunter & Lexier, 1998). The plethysmograph may be useful for
diagnostic and treatment-planning purposes when employed in this manner.
It can also be used in the assessment of treatment effectiveness (i.e., pre and
post evaluation) in youth who receive cognitive-behavioral or pharmaco-
logic intervention for established deviant sexual interests.
Visual reaction time measures of sexual interest were developed to avert
the referenced problems associated with phallometic assessment. They do not
require invasive methods or exposure of the youth to explicit sexual stimuli.
They can also be conducted with less time and expense than phallometric
assessment. Probably the best known of these methods is the Abel Screen.
The primary controversy associated with the Abel Screen (and similar mea-
sures) is whether its validity has been firmly established. As pointed out by
Sachsenmaier and Gress (2009) in their review of the Abel Assessment for
Sexual Interests2, it is a commercial measure with a proprietary scoring algo-
rithm that has not been made available for independent empirical evaluation.
However, there is some empirical evidence that the Abel Screen has conver-
gent validity with the plethysmograph in identifying adult offenders against
young boys (Letourneau, 2002). This researcher also found the instrument to
have adequate internal consistency. Thus, this instrument can potentially be of
use to clinicians who are tasked with evaluating and treating sexually abusive
adolescent males.
Level-of-Care Decision Making
It is important for clinicians and juvenile justice professionals tasked with for-
mulating disposition recommendations to be cognizant of the implications
of either under or overprescribing interventions for juvenile sex offenders.
Placement of high-risk youth in community-based programs with few exter-
nal controls obviously raises the risk of the youth perpetrating new sexual
and/or nonsexual offenses. These offenses not only bring harm to their victims
but also lead to new, and perhaps more dire, legal and social consequences
for the youthful offender. They also invite negative attention to the treat-
ment program or provider and perhaps contribute to public perception that
community-based treatment for sex offenders is not viable. Conversely, plac-
ing low-risk youth in correctional or residential settings with youth who are
more antisocial or sexually deviant can result in iatrogenic treatment effects
(Poulin, Dishion, & Burraston, 2001). Such effects may negatively alter the
youths developmental trajectory. Overprescription of services can also lead

to depletion of limited public dollars for intervention and ultimately deprive
deserving youth of the opportunity to receive needed professional help.
Given the gravity of disposition decision making with juvenile sex offend-
ers, empirically guided assessment of risk and needs is advised. This may
include consideration of clinical criteria (i.e., profi le characteristics) in addition
to formal risk and needs assessment. It may also include the judicious use of
methodologies for assessing deviant sexual interests. However, the evaluator
is encouraged to not rely on any single method or source of information in
making risk and needs assessments. As in all clinical and forensic assessment,
recommendations have firmer empirical grounding when there is a convergence
of data supporting the evaluators conclusions.
C O M M U N I T Y- BAS ED T R E AT M EN T
It is the authors belief that the majority of sexually abusive adolescent males
can be safely and effectively treated in the community with proper clinical
programming and the establishment of necessary legal safeguards. The latter
includes the careful integration of court supervisory and clinical services for
adjudicated youth. Community treatment offers a number of potential advan-
tages over residential care. In particular, it is far less disruptive to the youths
life. The youth usually can be maintained in his or her regular school. Where
appropriate, he may still see friends and engage in sports and other healthy
after-school activities. Most important, he remains close to supportive family
members. It is also far less expensive and permits limited public dollars to be
spread over a larger number of youth in need of services.
One of the biggest challenges of residential treatment of sexually abusive
youth is achieving optimal involvement of the family in the treatment process.
Often the immediate and extended family reside a considerable distance from
the residential facility, and visitation can only occur every several weeks or on
a monthly basis. This obviously can hinder family therapy work, and it may
intensify the youths depression and sense of social alienation. Community-
based treatment affords families the opportunity to be closely involved in
the treatment of the youth, even in cases where the youth requires placement
outside the home (e.g., placement with relatives or in a group home). The fam-
ilys proximity not only provides important emotional support to the youth in
addressing his or her problems but also affords the therapist the opportunity
to work intensively with parents and caretakers in the enhancement of their
child management and supervisory skills. It also permits the address of perti-
nent family system issues that have bearing on risk management.
Integration of Clinical and Legal Management Services
Critical to the success of community treatment is careful integration of clinical

and legal supervisory services. This includes working closely with the youths
probation officer and/or Social Services worker, and his or her parents/caretakers,
to ensure that he is adequately supervised during times that he is not in the
treatment setting. Almost all sexually abusive youth benefit from the careful
structuring of their daily schedules and the imposing of curfews. Attention
must be given to both avoidance of high-risk activities and environments,
and ensuring healthy peer involvement. Neither association with delinquent
or behaviorally disordered youth nor social isolation is desirable. The latter is
sometimes overlooked as a risk factor. As explored in Chapter 3, a number of
these youth engage in compensatory sexual acting out with children because of
poor social self-esteem and social skills. They tend to be socially avoidant and
spend an excessive amount of time in solitary pursuits. Many of these youth
require placement in community programs that actively foster social engage-
ment and the development of age-appropriate relationships (e.g., Boys Club).
Parents and caretakers need guidance (and sometimes formal training) in
how to effectively monitor and manage the youth in the home environment.
Even in the absence of a victim or potential victim in the home, unsuper-
vised youth can gravitate toward unhealthy behaviors (e.g., isolation, access of
pornography, etc.). More delinquent or antisocial youth may require terms of
probation that prohibit involvement with negative peers, or the frequenting of
environs which invite engagement in such behavior. Some youth also require
supplementary substance abuse programming and periodic drug testing.
Higher risk youth may benefit from electronic monitoring or the imposing of
specific restrictions on their movement outside of the home environment. As
previously discussed, the level/intensity of supervision and monitoring efforts
should be driven by risk and needs assessment. The treating clinician should
remain cognizant of the importance of interagency cooperation and collabora-
tion in the community management of sexually abusive youthespecially as
it relates to respecting the courts authority on such matters with adjudicated
youth. Typically, the closer the working relationship between the therapist
and probation officer, the more successful is the community management of
sexually abusive youth.
Model Programming
The author details model community-based treatment programming for

sexually abusive adolescent males in two publications: Hunter, Gilbertson,
Vedros, and Morton (2004), and Hunter (2011a). The former describes two
model community-based treatment programs for sexually abusive adoles-
cent malesWraparound Milwaukee and the Norfolk (VA) Juvenile Court
Services Unit. The design of each program was influenced by social-ecological
theory, as applied to delinquency. Social-ecological models characterize delin-
quent behavior as the product of multiple, interactive systemic influences,
including those associated with the youths personality, his or her family,
his or her peer affi liations, and his or her community and culture (Borduin,
1999; Bronfenbrenner, 1977). Working within this theoretical framework, the
youths treatment plan is based on an understanding of the underlying deter-
minants of his or her behavior and developed strategy for effecting positive
and enduring system change. Both programs permit intensification of pro-
gramming based on ongoing needs and risk assessment.
In the Norfolk program, clinicians work alongside trained probation officers
in assessing and treating youth. Acceptance into the program includes con-
sideration of parent and youth acknowledgment of the presence of a sexual
behavior problem, and their mutual willingness to participate in treatment.
Therapists and probation officers conduct joint in-home assessments to evalu-
ate the level of motivation and to identify family system and ecological risk
factors. This program accepts youth who are at moderate risk to reoffend.
Higher risk youth are provided with intensive (e.g., 24 face-to-face contacts
per week) supervision by specially trained probation officers with reduced
caseloads. Youth remain on supervision throughout the course of their treat-
ment and aftercare, and they are randomly checked in their homes, schools,
places of employment, and treatment settings. A system of graduated sanctions
is used to address behavioral noncompliance. All youth receive intensive, sex
offenderspecific group and family therapies. Individual therapy and adjunc-
tive psychiatric care are provided on an individualized basis.
The Wraparound Milwaukee program conducts ongoing holistic assess-
ments of youth and family strengths, needs, and risks and attempts to match
interventions to the same (Hunter et al., 2004). The program works in close
cooperation with the Milwaukee juvenile courts with adjudicated youth.
The development of their comprehensive array of programming resulted in
an approximate 20% drop in adjudicated sex offenders being committed to
correctional facilities. The Wraparound Milwaukee continuum provides for
residential treatment for youth when needed; however, their program outcome
data reflect a reduced utilization of residential stay with the advent of compre-
hensive community services. Program evaluation data suggest that both the
Norfolk Court Services and Wraparound Milwaukee programs enjoy strong
support from stakeholders and have relatively low rates of participant rearrest
for sexual offending (Hunter et al., 2004).
Alternative Placement Options
To remain viable, and serve more than a minimal number of low-risk youth, a
continuum of community-based care for sexually abusive youth must include
alternative living placements. This includes specialized group and/or fos-
ter homes for youth with sexual behavior problems. A large number of such
youth require temporary (or permanent) placement outside of their home of
origin due to risk and supervision issues. The primary reason for alternative
placement is the presence of a victim in the home, as in the case of sibling
incest. Leaving the offending youth in the home with the victim increases the
risk of a reoffense. Even in cases where adequate parental supervision can be
maintained, the mere presence of the offending sibling in the home can pro-
duce unnecessary psychological stress for the victim. As it relates to the latter,
it must be remembered that young children who have been sexually abused
by their older siblings are seldom able to advocate for themselves. Many of
these children harbor guilt and blame for the sexual abuse and the social and
legal consequences the offending sibling incurred. In a number of cases, they
experience subtle or direct pressure from parents and/or other family mem-
bers to forgive and forget. Hence, they often minimize in conversation with
their parents or authority figures the extent of fear they have of the offending
sibling. Such fears and worries of reoffense or future harm are often not ver-
balized until they have established a trusting relationship with a therapist or
helping professional.
In other cases, the offending youth requires placement outside of his or her
home of origin because of family dysfunction and/or difficulty the parent has
in supervising and behaviorally managing him. In some cases, the youth is
exposed to domestic violence or subjected to physical and emotional abuse. A
number of the parents of these youth have serious substance abuse problems
or suffer from a major mental illness. Under these circumstances, and with the
support of court and Social Services professionals, the treating clinician must
assess the feasibility of leaving the offending youth in the home. Where there
is cause for substantial doubt about his or her safety, or parental willingness to
support supervision and intervention efforts, consideration should be given to
his or her alternative placement.
Alternative placements for sexually abusive youth should not be limited to
generic group or foster homes. Many such placements do not accept youth
who have a history of sexually abusive behavior, or they are not properly
equipped to manage them. The latter can result in sexual acting out within
the group or foster home placement and further victimization of others. There
is also the risk of younger adolescents with sexual behavior problems being
taken advantage of sexually by older antisocial youth who are aware of their
histories. Therefore, it is strongly recommended that communities invest in

the development of specialized group and foster homes for sexually abusive
youth. The clinical success of these ventures largely hinges on three factors:
(1) specialized training of supervisory staff and foster parents in understand-
ing the behavior management and treatment needs of this population; (2) the
establishment of sound supervision and behavior monitoring strategies; and
(3) the careful integration of clinical services with supervision and behavior
management efforts.
It requires well-trained and motivated staff to successfully behaviorally
manage youth with sexual behavior problems. Paraprofessionals who are
accustomed to working with more delinquent and aggressive youth may not
believe that there are any particular problems if the youth is being quiet and
respectful. As many sexually abusive youth are not otherwise conduct disor-
dered, they may fall off the radar screen and go relatively unnoticed in group
or foster home settings. Unfortunately, this may provide opportunity for the
youth to engage in covert sexual activity, including viewing pornography. Lax
supervision may also give rise to surreptitious sexual acting out. Staff must
understand that many sexually abusive youth suffer from social anxiety and
low self-esteem, and they require the active structuring of positive socializa-
tion experiences. Boredom is a trigger for sexual activity for a large number of
sexually abusive youth, and thus it is important that the youth develop healthy
leisure time pursuits. Supervision of this population, therefore, must be an
active and not passive process.
The success of group and foster home placements for sexually abusive youth
also hinges on the extent to which therapists working with the youth com-
municate and provide guidance to behavior management staff. The closer and
more collaborative the relationship, the more effective are both treatment and
behavior management efforts. Consistent with a social-ecological model of
intervention, therapists need not always be the direct deliverer of the service.
Instead they can exert their influence indirectly by educating and empowering
the youths primary caretakers. For example, they can teach a foster parent or
group home staff member how to more effectively engage the youth in positive
social activities or redirect his or her negative behavior.
Where a youths return to his or her family of origin is possible, the therapist
should seize the opportunity to work with his or her parent(s) while he or
she is in alternative placement. This work can include the address of parental
relationship dysfunction and parenting skill deficits. Parents can be educated
about the nature of the youths sexual behavior problems, warning signs of
impending sexual acting out, and risk factors. When there has been sibling
incest, the therapist of the offending youth should also maintain a close work-
ing relationship with the therapist of the victim. Decisions about reintegration
of offending youth back into the home must take into consideration progress
in each affected realm (i.e., offender treatment, victim treatment, and the
strengthening of parenting skills/family functioning).
S PEC I A L I ZED R ES I D EN T I A L T R E AT M EN T
Placement in intensive residential care (i.e., 24-hour) should be reserved for

youth at higher risk of sexual offending and those with more extensive psy-
chiatric comorbidity. The clinical programming should be developed for
youth with sexual behavior problems, and thus specialized in content. As in
the placement of sexually abusive youth in generic group and/or foster homes,
their placement in nonspecialized residential programs with nonsexual offend-
ing youth is fraught with clinical and behavior management problems. Even
in specialized programs, attention must be given to separating youth based
on age and nature of psychopathology. The placement of older and younger
adolescents, and more and less antisocial youth, in the same milieu should be
avoided whenever possible. Likewise, attention must be given to the youths
manifest level of sexual deviance and impulse control. Because residential pro-
grams serve higher risk youth, extra security and monitoring protocols must
be developed and faithfully implemented. These youth require continuous,
around-the-clock supervision. Staff must be well trained and vigilant. To sup-
port staff supervision efforts, many programs employ electronic monitoring
devices (e.g., motion detectors and cameras).
Residential programming for sexually abusive youth should be compre-
hensive and holistic. The incidence of psychiatric comorbidity, especially
attention-deficit/hyperactivity disorder (ADHD), affective disorders, and
substance abuse is very high. Because of the high incidence of childhood
maltreatment and exposure to violence in sexually abusive youth, posttrau-
matic stress disorder (PTSD) is also a common comorbid condition. Successful
treatment of the sexual behavior problem is contingent on proper therapeutic
address of all of the relevant disorders the youth manifests. This includes the
application of evidence-based psychotherapies for identified comorbid con-
ditions and judicious use of psychotropic medications. It is optimal for the
residential treatment program to have a multidisciplinary professional staff
who work in a coordinated and collaborative fashion in delivering individual-
ized interventions.
As with community-based programming, it is important that the
residential care program interface with external agency professionals during
the course of the youths treatment. This includes probation and parole offi-
cers, judges, and Social Services workers. It is recommended that probation
and parole officers be invited to case conferences and fully apprised of the
youths treatment progress. It is also recommended that progress reports to
the court be prepared on a regular basis, and that court reviews be requested
when adjudicated youth repeatedly fail to comply with program expectations.
Often a court review will spur a youth (and family) to reinvest in the treatment
process. It is also advised that residential programs make an effort to interface
with mental health professionals in the youths community who have perhaps
treated him in the past and/or who will be providing aftercare services. In
some cases community-based mental health professionals can provide helpful
adjunctive services to the youths family while he is in residential placement.
This can include marital therapy and parenting classes for those families who
have problems or deficits in those areas.
Youth should be stepped down to community care as soon as clinically
feasible. Such decisions should be made on the basis of observed treatment
progress and formal assessment of risk and need. Transitional services need
to be effected prior to the youths discharge. Continuity of service in service
delivery is critical to successful community reintegration efforts and minimi-
zation of the risk of relapse. This is why the discharge planning process should
be a collaborative process that involves the youth, his or her family, the refer-
ring agency, the residential treatment provider, and community professionals
who will be assuming case management responsibilities.
C O R E A R E AS O F T H ER A PEU T I C F O C U S
Treatment of sexually abusive youth should be individualized and based on

an understanding of the nature and etiology of his or her sexual behavior
problem. It should also reflect the focused address of related comorbid con-
ditions, such as depression and PTSD. While treatment should be tailored
to the specific needs of the youth, there is core subject matter that should be
addressed in the majority of cases. One such area is social skills training. It is
believed that a number of sexually abusive youth suffer from poor social self-
esteem and turn to younger children in compensation for the absence of sat-
isfactory relationships with peers (Hunter, 2006). Younger children may seem
less threatening and easier to impress than same-age youth. The fear of rejec-
tion may be much lower. Youth with problems in this area benefit from the
strengthening of social competency and self-confidence. The therapeutic work
typically begins with the building of fundamental social skills, like listening
and starting a conversation, and progresses to more advanced skills such as
asking someone out for a date and expressing complex emotions like jealousy
or envy. Group therapy often proves to be a helpful format for teaching social
skills. The author typically uses a cognitive-behavioral therapy format wherein

critical social skills are identified and discussed, modeled by the therapist, and
then behaviorally rehearsed via role-play exercises (Hunter, 2011a). Feedback
can be enhanced by the video-taping and subsequent review of behaviorally
rehearsed skills. Work in group therapy can be supplemented by the assign-
ment of homework (Hunter, 2011b).
Impulse control problems are also common to sexually abusive youth and
a frequent target of intervention. An adapted form of covert sensitization is
sometimes used to enhance sexual impulse control and judgment. This inter-
vention involves teaching youth to identify antecedents of their sexual acting
out, including linked thoughts, feelings, and behaviors. Youth are taught to
interrupt deviant sexual fantasies by switching to their natural consequences
(e.g., arrest). The intervention also involves the mental rehearsal of practicing
good impulse control and judgment, and then imagining the natural positive
results of the same. The specifics of this intervention, and others reviewed in
this section of the chapter, can be found in Hunter (2011).
The teaching of healthy masculinity and sexuality is also a common theme
in the treatment of sexually abusive youth (Walker & McCormick, 2004).
Many sexually abusive adolescent males have grown up without positive
male role models and harbor distorted views of manhood. This may include
endorsement of aggression and violence as the best way to resolve interper-
sonal conflicts. Youth may also believe that males should dominate females
interpersonally, and they may have prejudiced views of gays and lesbians. Such
youth often benefit from mentoring and the fostering of prosocial values. The
teaching of healthy sexuality includes sex education and the correction of dis-
torted sexual cognitions. It also involves the critical examination of values
and morals underlying societal laws and mores on sexual behavior. In support
of the cessation of sexually abusive behavior, youth need to understand why
their behavior was wrong and how it violated moral principles and values. In
the course of this work, youth often realize that they not only violated legal
statutes in the commission of their sexual offenses but also their family and
personal values. Thus, values clarification helps youth develop a deeper and
keener appreciation of the wrongfulness of their behavior and the importance
of positive life change.
The teaching of anger management skills is also fundamental to the
treatment of most sexually abusive youth (Becker & Hunter, 1997; Walker &
McCormick, 2004). Anger, both directly expressed and displaced, is often a
prominent dynamic in sexual offending against both younger children and
peers. Sibling incest is often fused with jealousy and resentment of the victim-
ized child. Sexual offenses against adolescent or adult females are frequently
associated with a resentment and distrust of the same. In general, anger
appears to lower sexual inhibitions and help the youth justify or rationalize
his or her misbehavior.
Many youth have anger management problems that go well beyond their
sexual behavior issues. For example, they may frequently get in fights with
peers and verbally or physically aggress against teachers or parents. Anger can
also be internalized and contribute to depression and substance abuse. Anger
management training should include teaching the following skills: cue recog-
nition, methods of stress reduction, identification and practice in correcting
maladaptive cognitions, assertiveness, and conflict resolution.
Victim empathy enhancement is another core component of most treatment
programs for sexually abusive youth (Walker & McCormick, 2004). Th is typi-
cally involves identifying barriers to empathy and helping the offending youth
gain a deeper appreciation of the negative impact of his or her behavior on the
victim. Some programs have the youth write a victim empathy letter. Under
certain circumstances, it may involve the reading of this letter to the victim in
a family therapy session. However, the latter is not recommended unless the
therapists treating the perpetrator and victim are of the opinion that each is
emotionally ready for this experience. Furthermore, the victims therapist and
his/her family must be of the opinion that such sessions could facilitate the
victims recovery. To conduct such sessions in the absence of readiness on the
part of either party (i.e., victim and perpetrator) can produce adverse effects.
Relapse prevention is yet another core element of most treatment programs
for sexually abusive youth (Hunter & Longo, 2004). Relapse prevention is
designed to help the sexually abusive youth gain a clearer understanding of
the dynamics of his or her sexual offending behavior, and how to reduce the
risk of its recurrence. It typically encompasses work in three interrelated areas:
(1) understanding the cycle of thoughts, feelings, and behaviors/events that
led to the sexual acting out; (2) awareness of factors (both internal states and
external situations) that increase the youths risk of reoffending; and (3) iden-
tification and mastery of key coping skills. At the completion of work in this
realm, the youth has a written relapse prevention plan that can be shared with
his or her family and involved agency professionals. This plan can be helpful to
parents and the courts in establishing supervisory structures and behavioral
guidelines.
Adjunctive Therapies
Individual youth may require adjunctive psychotherapies, depending on the

nature of their presenting problems. Sexually abusive youth who evidence per-
sistent paraphilic interests, such as sexual arousal to prepubescent children,
may benefit from verbal satiation therapy. The latter is a cognitive-behavioral

therapy that intends to promote extinction of conditioned sexual arousal to
inappropriate stimuli (e.g., young child) via repeated and prolonged mental
exposure to the image. In verbal satiation, unlike traditional masturbatory
satiation, there is not an attempt to strengthen arousal to age-appropriate
stimuli by pairing it with genital stimulation. In verbal satiation, the youth
simply repeatedly imagines the targeted sexual behavior (in the absence of
manual sexual stimulation or image reinforcement) until habituation or
extinction of arousal is attained (note: typically a period of 3060 minutes).
Satiation therapy is extensively reviewed in Hunter, Ram, and Ryback (2004).
The authors experience is that this therapy works relatively well with older and
well-motivated adolescents, and less well with younger adolescents and those
with severe attention deficits.
As previously stated, sexually abusive youth often present with significant
psychiatric comorbidity. Providers are encouraged to actively address relevant
comorbid conditions in the course of treatment of the sexual behavior prob-
lem. Depending on the primary providers training and preferences, this can
be accomplished by either directly providing the required adjunctive therapy
or referring the patient to another qualified provider. In the case of the latter,
it is imperative that providers work in a collaborative manner to ensure proper
integration and coordination of care.
Whenever possible, comorbid issues should be addressed with evidenced-
based interventions. The author has written about the successful treatment
of comorbid PTSD in adolescent male sex offenders, using prolonged expo-
sure (PE) (Hunter, 2010). PE is a cognitive-behavioral intervention based
on emotional processing theory, as espoused by Foa and Rothbaum (1998).
As a treatment for PTSD, PE aims to change the underlying fear structures
that maintain anxiety by targeting the unrealistic stimulus-stimulus and
stimulus-response associations (and dysfunctional beliefs) that support it
(Foa & Rothbaum, 1998). This is accomplished through in vivo and ima-
ginal exposure exercises, and cognitive restructuring. Foa, Chrestman, and
Gilboa-Schechtman (2009) have developed an adolescent version of PE. The
adolescent version accommodates for developmental differences between
adults and adolescents in therapy formatting and presentation style. The ado-
lescent version of PE both targets PTSD-specific fear processes and addresses
the more general affect-dysregulatory problems of many PTSD-afflicted
youth. The author has found PE to be a very helpful adjunct in the holistic
treatment of sexually abusive youth with trauma backgrounds. The successful
treatment of PTSD appears to help improve overall mood and foster positive
therapistclient treatment alliances (Hunter, 2010).
T R E AT M EN T O U TC O M ES
Unfortunately, there are relatively few randomized clinical trials assessing

the effectiveness of treatment for sexually abusive youth. In one of the few
such studies, Letourneau and colleagues (2009) randomly assigned over 120
predominantly adolescent males with histories of sexual offenses to either
multisystemic therapy (MST) or treatment as usual (TAU). The vast majority
of the TAU group of youth received sex offenderspecific treatment delivered
by the juvenile sexual offender unit of the juvenile probation department. The
MST-treated youth received an adapted form of MST that included attention to
the following: (1) youth and caregiver denial, (2) safety planning to minimize
the perpetrators access to potential victims, and (3) the promotion of nor-
mative social experiences with peers. One-year follow-up results showed that
the MST-treated youth evidenced greater reductions in sexual behavior prob-
lems and general delinquency relative to the TAU youth. They also engaged in
less substance abuse. The researchers concluded that MST held considerable
promise in the treatment of this population.
There are a number of nonexperimental program outcome studies that
suggest that the majority of juvenile sex offenders do not sexually reoffend
following treatment. However, these data do not portend as well for cessa-
tion of engagement in nonsexual delinquency post treatment. For example,
Waite et al. (2005) found that out of 261 male juvenile sex offenders treated in
a state-corrections juvenile sex offender program, less than 5% had sexually
reoffended over a 211-year follow-up period. However, the rate of posttreat-
ment arrest for nonsexual delinquency was much higher (roughly 30%50%).
Kemper and Kistner (2007) similarly found that over 40% of treated juvenile
sex offenders were subsequently arrested for nonsexual crimes, but only
about 6% for sexual crimes. Alexander (1999), in her review of 79 treatment
outcome studies on juvenile sex offenders, found that the sexual recidivism
rate for treated juvenile sex offenders was only 7%. Worling and Curwen
(2000) found that approximately 5% of treated juvenile sex offenders, versus
18% of nontreated youth, sexually reoffended over 210 years of follow-up.
In a recent follow-up to this study, Worling, Litteljohn, and Bookalam (2010)
found that the treatment effect held over a 20-year follow-up period. Namely,
only 9% of treated juvenile sex offenders, as opposed to 21% of nontreated such
youth, sexually reoffended. Consistent with the above, Walker, McGovern,
Poey, and Otis (2004), and Reitzel and Carbonell (2006), conducted meta-
analyses of juvenile sex offender treatment studies and concluded that the
results were quite encouraging and supportive of treatment effectiveness
(average weighted effect sizes = .37 and .43, respectively).
In summary, available data suggest that the majority of sexually abusive

youth do not reengage in such behavior following specialized sex offender
treatment. Specialized sex offender treatment, possibly in contrast to broader
treatments for antisocial youth like MST, may not be as effective in reducing
the risk of subsequent engagement in nonsexual delinquency by this popula-
tion. Between one-fourth and one-half of sexually abusive youth engage in
nonsexual delinquency following treatment. Therefore, presently available
data support the contention that sexual behavior problems in youth are often
embedded in broader psychopathology and systemic dysfunction, and that
intervention must extend beyond the manifest sexual behavior problem to be
effective in helping these youth learn to lead productive lives.
R EFER EN C ES
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Journal of Research and Treatment, 11(2), 101116.
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psychology (pp. 177197). New York: Plenum Press.
Borduin, C. M. (1999). Multisystemic treatment of criminality and violence in ado-
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242249.
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Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral
therapy for PTSD. New York: The Guilford Press.
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(2005). Juvenile sex offender re-arrest rates for sexual, violent nonsexual and prop-
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9
Biological and Pharmacologic

Treatment of Sexually
Aberrant Behavior
CAS E 1
Julie is an 8-year-old adopted girl found engaging in sexual activity with the
family dog by her mother. Psychiatric evaluation includes obtaining rating scales
from teachers, which indicate significant distractibility, impulsivity, low frustra-
tion tolerance, and hyperactivity. While formal cognitive testing has not been
obtained, she appears to be of at least average intelligence; her grades are good,
and she is quite loquacious and articulate. There is no indication of a major
mood or anxiety disorder, and she is not suicidal. Biological family history is
unknown. Julie was adopted at 1 year of age after being abandoned by her bio-
logical mother. There is no history of sexual abuse or exposure to pornography.
You prescribe individual psychotherapy and plan to gather additional informa-
tion, especially with respect to family functioning and the possibility of sexual
abuse, to help inform treatment. Julie comes regularly to individual therapy,
and although the parents work schedules and insurance obstacles preclude the
level of involvement that you recommend, you have met regularly with Julies
mother and have also met infrequently with her father. While there are clearly
boundary issues which are being addressed in therapy (Julie sleeping with par-
ents individually and together because she is afraid of the dark and will not sleep
in her own room), you do not uncover any evidence of current or past sexual
abuse. Of note is the fact that despite strong recommendations for Julie to be
supervised and not be allowed to be alone in the basement or her room with the
dog, supervision at home has been quite lax. Julie is very forthcoming about her
behaviors in therapy. She freely admits that she taught the dog to perform cun-
nilingus, and that while she knows it is wrong, she likes how it feels and there-
fore has sneaked away with the dog on several occasions. Julie also reveals that
several times she has coerced a cousin who is a year older than her to perform
cunnilingus with threats to tell on her for having stolen a dollar from Julies
mothers purse. The cousin has been living with Julies family while her own par-
ents are receiving residential substance abuse treatment. As therapy progresses,
Julie reveals that while the feelings engendered by her sexual behavior with the
family dog are pleasurable, she has been trying very hard to desist from engaging
in the behavior but cant stop. She appears genuinely distressed and ashamed,
and tearfully claims, I cant stop myself.
CAS E 2
Robbie is a 16-year-old boy charged as an adult with five felonies, including

rape and sodomy. He allegedly molested boys between the ages of 4 and 7 at
a church preschool where he was volunteering. He has a history of engaging in
sexually abusive behavior as early as age 11 with prepubescent boys. Several
earlier charges were pled down to nonsexual assault and battery convictions in
juvenile court, and he received counseling and probation. At that time Robbie
was adamantly denying that he had engaged in any sexual behavior, and his
therapist (who did not have any training or expertise with juvenile sex offend-
ers) did not have access to any police records, witness statements, or court
documents. The therapist focused on Robbies chronic depressive symptoms and
family dysfunction. Currently, Robbie admits to a preferential sexual attraction
to prepubescent males, masturbating frequently to fantasies of sex with young
boys. He is not attracted to same-age peers of either sex. There is no history of
other antisocial behaviors, and he does not have a psychopathic personality ori-
entation. Family history is significant for numerous maternal and paternal rela-
tives with depression and anxiety disorders, and completed suicide in a cousin
and paternal grandfather, who was depressed and an alcoholic. Robbie claims
that he was molested around age 5 several times by a teenage male babysit-
ter who has since moved away. He did not tell his parents secondary to threats
from the babysitter to harm him and his family. Robbie does meet criteria for
recurrent major depression and dysthymia. He is extremely anxious regarding
his current situation, resulting in the additional diagnosis of adjustment disor-
der with anxious mood versus anxiety disorder, not otherwise specified. Robbie
Biological and Pharmacologic Treatment 195
appears genuinely remorseful regarding his behavior but evidences the typical
cognitive distortions exhibited by adults with pedophilia, for example, claim-
ing that he never hurt the children, and that he would have stopped had they
only asked him to. Robbies parents indicate that they will do anything to keep
him out of adult prison and specifically request chemical castration. They have
discussed this with Robbie who eagerly agrees that this is preferable to being
gang-raped in prison.
OV ERV I E W
This chapter reviews biological treatments, primarily pharmacological, in the

management of sexual offenders, especially those with paraphilias. Because
there is so little research on biological treatments for sex offending adolescents
with paraphilias, most of this chapter is a review of the adult literature on
biological therapies. Why include this chapter in a book on juvenile sexual
offending, especially given the fact that most juvenile sex offenders do not have
a paraphilia and do not go on to become sex offenders? The reality is that some
adolescents do suffer from a paraphilia and therefore will be at higher risk
for reoffending sexually in adulthood, especially if they are not treated. The
increasingly harsh sentences given to youth who commit sexual offenses fur-
ther legitimizes the question of what other medical options might be afforded
to sexually violent youth and the potential risks and benefits associated with
them. How might biological treatments that are efficacious in controlling
paraphilic/pedophilic urges in adults be appropriately and inappropriately
utilized in adolescent sex offenders, most of whom are not pedophiles and
are at low risk for reoffending sexually? What is the role of pharmacology, if
any, in the treatment of sexually abusive youth? Should biological treatments
even be considered given the fact that the adolescent brain is still develop-
ing? How does one begin to tackle the complex issues involved in medicating
an adolescent primarily for sexual deviance? First, it should be acknowledged
that there is a huge void in our knowledge of what therapies (pharmacological
and nonpharmacological) have empirical support in the treatment of sexually
abusive behaviors in general and sexual deviance specifically. Second, clini-
cians involved with this population should be aware of their own opinions
and biases regarding a variety of matters directly and indirectly related to this
area, including labeling youth with psychiatric disorders; the overreliance
on medication for treating psychiatric symptomatology; the cavalier man-
ner in which psychotropic agents are sometimes prescribed in children and
youth; the transfer of adolescents to the adult criminal system; harsher pen-
alties for youth who commit criminal offenses generally and sexual offenses
in particular; and a myriad of other important scientific, medical, legal, and

public policy issues. These biases may influence ones opinion regarding treat-
ment in general and pharmacological therapies specifically.
It is important to clarify at the outset that the quality of the evidence base
(almost entirely with adults) supporting the efficacy of treatments for sexual
offenders is poor. However, a meta-analysis of 80 studies comparing treated
and untreated sex offenders (N = 22,181) indicated a positive treatment effect
with sexual recidivism in 11.1% of treated offenders and 17.5% of controls.
While surgical castration showed the strongest effect, other approaches also
revealed a positive effect (Schmucker & Losel, 2008). Recently, guidelines
on the biological treatment of adults with paraphilias were published by the
World Federation of Societies of Biological Psychiatry (WFSBP) (Thibaut
et al., 2010).
Despite the fact that there is little to no research on the efficacy of psy-
chopharmacologic and hormonal agents on paraphilias in youth, coexisting
mental disorders in this population should be treated aggressively using a
variety of evidence-based treatments, as well as with methods that have gar-
nered a significant amount of support for their use. While it is important not
to misperceive paraphilic sex offending as a symptom of a mental illness,
which will abate when the psychiatric disorder is adequately treated, it is just
as crucial not to neglect psychiatric symptomatology that may exacerbate the
frequency and intensity of sexual acting out.
PED I AT R I C PH A R M AC O LO GY
The gold standard for a design demonstrating drug efficacy in pediatric psy-
chopharmacology is generally a placebo-controlled trial. While there have
been notable strides in psychopharmacological research in children and
adolescents, the pediatric psychopharmacology research base is significantly
weaker than that for adults. A variety of reasons for this have been suggested,
including regulatory obstacles (Jensen, Vitiello, Leonard, & Laughren, 1994;
Vitiello & Jensen, 1997). As would be expected, there is an even greater paucity
of research on pharmacologic treatments targeting paraphilias and impulsive
and compulsive sexual behaviors in youth. The status of juvenile offenders as
a special population, (children) within a larger special population (incarcer-
ated persons), and therefore even more vulnerable to coercion and abuse in
the research setting, undoubtedly plays a role in the lack of controlled studies.
Another limitation to sex offender research in general includes sampling
biases (Bradford, 2001; Guay, 2009). Most researchers obtain their subjects
from prisons or legally mandated sex offender treatment programs. Subjects in
these settings may be unwilling to honestly complete self-report surveys and/

or participate in research that may yield potentially incriminating informa-
tion. This is particularly true in prisons in states where civil commitment after
sentence completion is a possibility.1
The use of pharmacologic treatments in adolescents specifically for the
purpose of altering sexually aberrant behavior is controversial at best. While
serotonin reuptake inhibitors have been used with the goal of decreasing
sexual obsessions and compulsive sexual behaviors, there remains a paucity
of well-designed research in this area with adults and no large-scale, well-
designed studies with youth. As is the case with many pediatric disorders,
and especially disorders related to disorders of mood, thinking, and behav-
ior, clinicians attempt to extrapolate from the adult research and literature.
The Food and Drug Administration (FDA) does not regulate the practice of
medicine, and therefore physicians are free to use their medical judgment in
the prescribing of medications, including medications that have not been offi-
cially approved for the illnesses in question or approved for the indications or
populations for which they are being prescribed. Th is practice is called off-
label use, and it is a common practice for the prescribing of many medica-
tions for both children and adults. There are difficulties with this approach,
however. Although prescribing off label is not illegal, there is the perception
of increased liability to prescribers. In pediatric psychopharmacology, the
majority of prescribing is likely to be off label (Laughren, 1996). The FDA initi-
ated labeling initiatives emphasizing the possibility of extrapolating data from
adults to children (Laughren, 1996). Those labeling initiatives were updated
again in 2007, and there have been numerous labeling changes, including the
antidepressant black box warnings, in the last decade. The FDA has officially
approved only one antidepressant, fluoxetine, for the treatment of depression
in children. Escitalopram is approved for the treatment of depression in adoles-
cents age 12 and older. The antidepressants fluoxetine, sertraline, fluvoxamine,
and clomipramine are FDA approved to treat obsessive-compulsive disorder
(OCD) in children (Food and Drug Administration, 2005). Increasing concerns
1. In the Virginia Department of Corrections, information contained in the prison record

regarding sex offender treatment, including results of phallometric testing (plethysmog-
raphy), is available for review for psychologists and psychiatrists who are performing
evaluations on inmates who are being considered for civil commitment under Virginias
Sexually Violent Predator legislation. Virginia is one of 20 states with a civil commitment law
that calls for sex offenders deemed too dangerous for release to be confined in a treatment
center after theyve served their prison sentences. Under Virginias law, a committee reviews
a sex offenders case within 10 months of his release date. If the committee recommends the
offender for civil commitment, the Virginia Attorney Generals office petitions a court to
have the offender committed (Code of Virginia, July 1, 2010).
around potential hazards of prescribing psychotropic agents to children and

adolescents without adequate research demonstrating efficacy and safety have
only intensified a reluctance to consider pharmacologic agents, especially
hormonal agents in youth, even with those youth with clearly demonstrated
deviant sexual arousal and who have repeatedly engaged in deviant behaviors
that have resulted in legal charges.
Despite the fact that adolescents who commit sexual offenses, particularly
against young children, are increasingly being tried as adults and being
required to register as sex offenders in online databases, there remains a reluc-
tance to offer pharmacologic treatment to adolescent sex offenders, including
those who clearly meet criteria for a paraphilia and have repeatedly engaged
in sexual behaviors with legal consequences. This is not surprising given the
wastebasket approach of the legal system to categorizing youth who sexually
offend. Although most youth who sexually offend will not go on to reoffend
sexually as adults, clearly some of these youth have deviant sexual arousal (with
the most concerning areas being sexual arousal toward children and forced
sexual activity). For those youth with measured deviant arousal who have not
responded to specific psychotherapies designed for sexual offending, what then?
Should antiandrogen agents be withheld from consideration in the treatment
of a 16-year-old with preferential sexual arousal toward prepubescent children
who is aware of the potential short-term and long-term risks but is still willing,
and perhaps even impatient, to begin treatment with such agents?
Basic questions regarding pharmacologic treatment in this population
revolve around the following:
1. When is it appropriate to consider and use pharmacologic manage-

ment in youth?
2. What agents should be considered?
3. With what youth should pharmacologic agents be considered?
PH A R M AC O LO G I C T R E AT M EN T O F S E X UA L
D E V I A N C E I N A D U LTS
The three main types of pharmacologic treatment that will be discussed in this
chapter include the following:
1. Psychotropic medications with an emphasis on the selective serotonin

reuptake inhibitors (SSRIs).
2. The antiandrogen and hormonal agents, with medroxyprogesterone
actetate (MPA) being the most commonly used agent in the United
States and cyproterone acetate (CPA) the most commonly used in

Canada and Europe.
3. The luteinizing hormone-releasing hormone (LHRH) agonists, which
are also known as gonadotropin-releasing hormone (GnRH) analogues,
include leuprolide acetate or leuprorelin, gosrelin acetate, and triptore-
lin acetate.
Bradford developed a six-level algorithm for the pharmacologic treatment

of the paraphilias in adults (Bradford, 2000, 2001; Bradford & Fedoroff, 2006),
which was based on the DSM-III-R (American Psychiatric Association, 1987)
and updated in the WFSBP guidelines (Thibaut, 2010):
Level 1: Cognitive-behavioral treatment and relapse prevention treat-

mentalways provided regardless of the severity of the paraphilia.
Level 2: Pharmacological treatment starts with SSRIsindicated in most
cases of mild paraphilias.
Level 3: If SSRIs are not effective in 4 to 6 weeks at adequate dosage levels,
then a small dose of an antiandrogen is added to the SSRI, for example,
50 mg of MPA daily. This level of treatment is used in mild and moderate
paraphilias.
Level 4: Full antiandrogen treatment or hormonal treatment is given orally,
for example, 50 to 300 mg of MPA per day, or 50 to 300 mg of CPA per
day. This level of treatment is used in moderate cases and in some cases of
severe paraphilias.
Level 5: Full antiandrogen treatment or hormonal treatment is given intra-
muscularly, such as 300 mg of MPA given intramuscularly per week, or
200 mg of CPA every two weeks for the first month. This level of treatment
is used in severe cases of paraphilias.
Level 6: Complete androgen suppression and sex drive suppression is
achieved (for example, by giving CPA intramuscularly 200 to 400 mg
weekly or intramuscular MPA 300 to 500 mg weekly, plus an LHRH
(treptorelin or leuprolide 11.25 mg intramuscularly every 3 months). This
level of treatment is for severe cases of paraphilia and the only treatment in
catastrophic cases.
The impact of this treatment algorithm on sexual behavior is as follows

(Bradford, 2000, 2001; Bradford & Fedoroff, 2006):
1. Levels 1 and 2 treatment suppress deviant sexual fantasies, urges, and

behavior with a minor impact on sexual drive. Levels 1 and 2 would be
implemented for all paraphilias and will probably be sufficient for most
hands-off paraphilias such as exhibitionism and voyeurism.

behavior along with a moderate reduction in sexual drive. Normal sex-
ual behavior will occur but at a low level. Suppression is dose dependent.
For paraphilias that involve direct physical contact with victims such as
frotteurism and pedophilia, treatment would begin at Levels 1 and 2 but
promptly move to Levels 3 and 4 depending on how the patient responds
as well as the severity of the paraphilia. Level 3 is utilized for hands-on
paraphilias without penetration and without fantasies of sexual sadism.

behavior with a severe reduction of sexual drive, so that normal sexual
behavior occurs but at a very low level. Level 4 treatment is used where
there is a moderate and high risk of sexual violence, including severe
paraphilias with intrusive fondling and a limited number of victims, with
progression to Level 5 treatment. Level 5 treatment is utilized for moder-
ate and severe cases of pedophilia involving sexual sadism fantasies or
behavior and/or physical violence.
4. The impact of Level 6 treatment is complete suppression of sexual drive

with elimination of paraphilic and normal sexual behavior, creating an
asexual individual. Therefore, this level of treatment is used for severe
cases and is the only treatment available in catastrophic cases of paraphil-
ias (involving sexual sadism).
Bradford highlighted the importance of a thorough evaluation prior to

initiating treatment interventions and considering other variables that impact
on the sexually deviant behavior, including substance abuse, psychiatric
disorders, and noncompliance with treatment, as well as noncompliance with
pharmacological treatments (Bradford, 2000).
B I O LO G I C D E T ER M I N A N TS O F S E X UA L B EH AV I O R
Sex is a biologically determined drive and, like other biological drives such
as hunger and aggression, can find its fulfillment in abnormal behaviors.
Although clearly sexual behavior has a societal component, it is determined
in large part by biologic mechanisms, specifically hormones and neurotrans-
mitters (Bancroft, 2002). Biologic treatments, therefore, include hormonal
treatments and psychotropic medications that act on neurotransmitters
proposed to be important in sexual behavior. A brief review of what is known

regarding biological influences on sexual behavior is helpful to understand
the purported mechanisms of action of various agents used to treat sexually
deviant behavior.
Androgens are steroid hormones, of which testosterone is the most impor-
tant. Androgens are released from the testes, ovaries, and adrenal glands,
and are the hormones that stimulate or control male sexual characteristics
by binding to androgen receptors. In males, the majority of testosterone is
produced by Leydig cells in the testes (Christine Knickmeyer & Baron-Cohen,
2006; Clifton, 2010; Sajjad, 2010). The anabolic effects of testosterone include
growth and strength of muscle mass, and increased bone density and strength.
Virulizing effects include maturation of sex organs, growth of facial and axil-
lary hair, and deepening of voice. Androgens are also precursors of estrogens,
the female sex hormone.
The androgens produced by the adrenal glands (including testosterone and
5-dehydroepiandosterone) have a relatively small effect in males compared to
testicular androgens. The adrenals are separated into two distinct structures,
both of which receive regulatory input from the nervous system. The adre-
nal medulla is the central part of the adrenal gland and is surrounded by the
adrenal cortex. Chromaffin cells in the adrenal medulla are the bodys main
producers of the catecholamine hormones, epinephrine and norepinephrine,
as well as dopamine, another catecholamine. The medulla is considered part
of the ganglia of the sympathetic nervous system and releases its secretions
directly into the blood. The adrenal cortex is responsible for the production
of corticosteroid hormones from cholesterol. Some cells synthesize cortisol.
Other cells produce androgens such as testosterone, and others regulate water
and electrolyte concentrations by secreting the hormone aldosterone. While
the adrenal medulla is directly innervated by the nervous system, the adrenal
cortex is regulated by the neuroendocrine hormones that are secreted by the
pituitary gland and the hypothalamus.
In male animals, the effect of androgens is on the limbic system (especially
the anterior hypothalamus), the penis, and the spinal cord. Androgens affect
sexual interest and fantasies, erections, and sexual behavior (Bancroft, 2002).
Testosterone is a steroid hormone from the androgen group and is the major
male sex hormone and anabolic steroid. As a result of having a Y chromosome,
male fetuses develop functioning testes prior to birth. In utero, the testosterone
produced by the testes causes what would otherwise become the labia majora
in females to become the male scrotum, and what would be the clitoris in
females to become the penis (Biason-Lauber, 2010). About 95% of testos-
terone is produced in the testes, and 5% percent is produced by the adrenal
glands. In humans, testosterone is the hormone primarily responsible for
the development and maintenance of male sexual characteristics, and it also

plays a major role in sexuality and aggression (Rubinow & Schmidt, 1996).
Testosterones secretion is regulated by a hypothalamic-pituitary-testicular
axis feedback loop (Fig. 9.1).
The hypothalamus, located below the thalamus and above the brainstem, is
about the size of an almond. Its primary function is maintaining homeosta-
sis. Blood pressure, body temperature, fluid and electrolyte balance, and body
weight are held to a value called the set-point. The hypothalamus also con-
trols hunger, thirst, fatigue, anger, and circadian rhythms. While an individu-
als set-point can change over time, on a day-to-day basis it is quite fi xed. The
hypothalamus links the nervous system to the endocrine system by way of the
pituitary gland. The hypothalamus produces gonadotropin-releasing hormone
(GnRH), sometimes called LHRH, which then stimulates the pituitary gland
to produce luteinizing hormone (LH), follicle-stimulating hormone (FSH),
and adrenocorticotophic hormone (ACTH). Luteinizing hormone stimulates
the release of testosterone from the testes. In a feedback loop, testosterone then
Higher cerebral centers
ds
ioi s +

Op ine
m
ola +

te ch
Ca
Hypothalamus
LHRH
(GnRH)

Anterior
pituitary

FSH LH
Inhibin B
Sertoli cells Leydig cells
LH receptor
Testes
Mature
sperm
Testosterone
5 reductase
ro
m at a s e DHT
a
Estradiol
Figure 9.1 The Hypothalamic-Pituitary-Testicular Axis Feedback Loop.

inhibits the hypothalamus and pituitary from continued production of GnRH/

LHRH and LH, which in turn decreases the production of testosterone. The
physiologic effects of testosterone and its metabolite, 5-dihydrotestosterone,
appear to be mediated through their action on the intracellular androgen
receptor. Sertoli cells in the testes transduce signals from testosterone and FSH
into the production of factors that are required for spermatogenesis (Walker
& Cheng, 2005). ACTH passes through the bloodstream from the pituitary to
the adrenals to stimulate the production of testosterone (in much lower quan-
tities than in the testes) as well as other adrenal hormones (Krone, Hanley,
& Arlt, 2007).
A certain level of testosterone appears to be necessary for sexual desire in
males, above which testosterone levels do not appear to be correlated with
sexual desire or drive (Gerardin & Thibaut, 2004). A healthy, young adult male
can maintain adequate sexual interest and capacity with testosterone levels
between 275875 ng of testosterone per 100 dL of blood, with levels signifi-
cantly below 275 ng/100 dL almost always associated with decreased sexual
desire and behavior (Berlin, 2008). Penile erection and detumescence appear to
be androgen dependent to some degree. However, while erections in response
to auditory erotic stimuli are androgen dependent, erections in response to
visual stimulation are not. It remains controversial as to whether and to what
extent erections as a result of fantasies and tactile stimulation are androgen
dependent (Meston & Frohlich, 2000).
While it is acknowledged that testosterone plays some role with respect to
mediating aggression in humans, its precise role in aggression is equivocal
(Archer, 2006). In animals, testosterone plays a major role in aggression between
males (Archer, 1991). Evidence for the role of testosterone in sexually aggres-
sive human behavior is conflicting and unclear (Archer, 1991, 2006; Bagatell,
Heiman, Rivier, & Bremner, 1994; Christiansen & Knussmann, 1987). While
some studies have found a relatively high level of testosterone in violent sex
offenders, meta-analyses have suggested a more modest relationship between
testosterone and aggression (Book, Starzyk, & Quinsey, 2001). A recent study
by Fedoroff and colleagues, in which 838 adult male sexual offenders (rapists,
child molesters, incest offenders, exhibitionists, and mixed offenders) were
assessed over a 10-year period, included biochemical assay measures of total
testosterone, free testosterone, LH, and FSH. The results indicated that LH and
FSH were significantly associated with self-reported hostility and recidivism,
and that LH was significantly more accurate than total testosterone in predict-
ing all types of recidivism (violent, sexual, and criminal). LH more accurately
predicted violent and criminal recidivism than FSH, and FSH was more accu-
rate in predicting sexual recidivism when compared to total testosterone. The
authors postulated that perhaps anterior pituitary hormones (LH and FSH)
are a more sensitive marker than peripheral hormones (testosterone), and/or

that elevated pituitary hormones signal a breakdown in the normal circadian
rhythm of testosterone and indicate a failure of the negative feedback loop
(Fedoroff, Kingston, Curry, Bradford, & Seto, 2010). It has been suggested that
cortisol may exert a moderating effect on the relationship between testoster-
one and overt aggression in delinquent male adolescents (Popma et al., 2007).
Despite the use of psychotropic agents to curb deviant sexual behavior, the
reality is that the medications that most reliably and consistently decrease
sexual desire and behavior are those that lower testosterone (Berlin, 2008).
With youth, however, the risk/benefit ratio of using testosterone-lowering
medications must be carefully considered. Pharmacologic treatment is tilted
toward the use of other interventions, especially in youth under age 17 years
for whom puberty and bone growth is not completed.
M ED I CAT I O N S U S ED I N T H E T R E AT M EN T O F
S E X UA L O F F E N D I N G
Psychotropic agents are utilized in the sexually offending population to

decrease libido. As previously noted, there is a dearth of methodologically
sound research on the use of psychopharmacologic agents for sexual devi-
ant behavior in general, and even less research on aberrant sexual behavior
in youth. Most of the minimal research done with biological agents has been
done with adult sex offenders. In the following discussions, findings in the
adult literature will be differentiated from the extremely sparse pediatric
research. Prescribing medications specifically for the purpose of decreasing
deviant sexual arousal would be considered an off-label use, and this should be
explained to the patient and guardians prior to initiating the medication. The
limited data on their efficacy and use for this indication with this population
must be clarified, as well as the potential risks and benefits of pharmacologic
treatment, versus other forms of treatment (which also lack clear research
evidence of efficacy), versus no treatment. Especially if there is consideration
of antiandrogen drugs in adolescents, it is useful to request an ethics con-
sult as well as a second opinion regarding the prudence of such treatment and
whether other less restrictive and invasive methods have been or should be
further explored.
In adults, emerging data indicate that paraphilias may be associated with
major psychiatric disorders such as depression and OCD. It should come as
no surprise that paraphilias do not confer immunity against major mental
illness and may actually create additional risk factors, particularly in the case
of mood disorders. The difficulty arises when there is the assumption (often
erroneously) that the psychiatric disorder caused the deviant behavior.

Bipolar disorder, with its well-recognized symptoms during manic episodes
of increased impulsivity, decreased inhibitions, lowered frustration tolerance,
and hypersexuality, is sometimes cited as a reason for sexually offending.
Each case is different, and sometimes mania is a major factor in sexual offend-
ing, but it is typically an overly simplistic explanation to see mania, or any
other mood disorder, as the sole cause for aberrant sexual behavior. As one
would expect, the situation becomes more difficult when one is assessing
children and adolescents.
Psychosocial immaturity and immaturity in the areas of judgment and
decision making may complicate the picture. Adolescents have been described
as drivers with a supercharged turbo engine without adequate brakes (Dahl,
2004). This analogy can be applied to the area of sexual behavior in adoles-
cents. Some of adolescents inappropriate sexual behavior can be attributed in
part to their psychosocial immaturity and developmentally based deficits in
judgment and decision making. However, some sexually offending youth will
also suffer from major Axis I mental disorders, including paraphilias, with or
without the complication of incipient personality pathology.
In the World Federation of Societies of Biological Psychiatry (WFSBP)
Guidelines for the biological treatment of paraphilias (Thibaut et al., 2010), the
authors state that the purposes of treatment for the paraphilias are as follows:
1. To control paraphilic fantasies and behavior in order to decrease the

risk of recidivism
2. To control deviant sexual urges
3. To decrease the level of distress of the patient with the paraphilia(s)
The authors note that the patients medical history, his or her compliance
with treatment, the severity of paraphilic sexual fantasies, and the risk of sex-
ual violence should guide treatment choice (Thibaut et al., 2010). Biological
therapies should only be a part of a comprehensive treatment plan that in
youth includes intensive therapy (family, individual cognitive-behavioral, and
group work) and environmental manipulation as indicated to decrease risk.
Mood Stabilizers and Anticonvulsants
Lithium
While lithium may be helpful in the management of paraphilias with
comorbid mood disorders, it appears that further investigation of lithium
specifically for paraphilias is not warranted (Balon, 2000). There are case
reports describing positive responses to lithium in three adult males with

paraphilias and nonparaphilic sexual addictions, as well as mood disorders
(Kafk a, 1991a; Ward, 1975). Ward described the cessation of transvestism
in a 24-year-old man with bipolar disorder, which had been maintained for
2 years prior to the initiation of lithium and was not resumed during the
1-year follow-up period on lithium. The authors acknowledged the unusual
therapeutic response of lithium on the transvestism, noting possible dynamic
and behavioral explanations (Ward, 1975). Kafk a treated a 30-year-old with
dysthymia and early-onset social phobia, as well as ego-dystonic homosex-
uality and exhibitionism, with lithium and imipramine, and used lithium
in a 37-year-old with bipolar disorder as well as voyeurism and addiction
to masturbation and phone sex. Posttreatment measures of depression and
sexual symptomatology were significantly improved. Claims of the efficacy
of lithium in several other open-label trials (Bartova, Nahunek, Svestka,
& Hajnova, 1979; Zourkova, 2000) are difficult to interpret given the lack of
adequate outcome measures and lack of information regarding the presence
or absence of mood disorders in the study subjects (Balon, 2000).
Divalproex Sodium
Nelson and colleagues (Nelson et al., 2001) reviewed the records of 18 bipolar
adult sex offenders in a residential rehabilitation program who received a ther-
apeutic divalproex trial. The mean length of trial was 4.71 months. Sixteen
of the eighteen patients (88.9%) were experiencing manic symptoms at the
time that the divalproex was started, and two patients (11.1%) were depressed.
Of the 16 manic patients, five (16.2%) had full-blown mania, 10 (62.5%) were
hypomanic, and one (6.3%) met criteria for brief hypomania. Nine patients
(57%) exhibited mixed symptoms, and seven patients (44%) had pure mania.
Seventeen out of the 18 bipolar sex offenders also met DSM criteria for paraphil-
ias (59% pedophilia, 35% paraphilia NOS, and 6% frotteurism). Two patients
were already receiving SSRIs for paraphilic urges prior to the addition of
divalproex, and both were started on divalproex after exhibiting mixed manic
symptomatology after SSRI initiation. Two patients out of 16 (11%) responded
to divalproex for mania within 1 month of treatment. Six of the 16 (38%) who
received at least 2 months of treatment responded. Two of 10 patients (20%)
responded after 3 months, and seven out of 16 patients (44%) were considered
responders after their final month of treatment with divalproex. Pure mania
responded significantly better than mixed mania (75% of pure manic patients
responded, versus 13% with mixed mania). Of note is the fact that the drug was
not effective for paraphilic symptoms. Only nine of the 18 patients admitted to
paraphilic urges at the outset of treatment with divalproex, and these were the
only patients analyzed for response of these symptoms to treatment. One out
of nine patients (11%) reported response at 1 month; two out of eight (25%) at
2 months; one out of seven (14%) at 3 months; and two out of nine (22%) after
the final month of divalproex. This study was limited by its retrospective open-
label design, lack of systematically assessing manic and paraphilic symptoms,
and small sample size. The conclusion was that divalproex may be helpful in
the treatment of a (primarily manic) subset of sex offenders, but there was no
indication of a specific effect on paraphilic symptoms in bipolar sex offenders.
Topiramate
Given studies indicating the effectiveness in disorders associated with dif-
ficulties with impulse control, such as kleptomania and alcoholism (Dannon,
2003; Dannon, Lowengrub, Musin, Gonopolsky, & Kotler, 2007; Johnson
& Ait-Daoud, 2010), topiramate is an agent that deserves further study;
however, no prospective trials have been conducted in sex offenders. Only
case studies have described topiramates effectiveness in decreasing unwanted
sexual behaviors such as compulsive masturbation, viewing of pornogra-
phy, and frequenting of prostitutes, with dosages of 50200 mg day for 2
to 6 weeks (Fong, De La Garza, & Newton, 2005; Khazaal & Zullino, 2006;
Shiah, Chao, Mao, & Chuang, 2006). Another case report indicated efficacy
of topiramate at 400 mg a day (initially as an augmenting agent to citalopram,
which was gradually reduced and discontinued) in a man with compulsive
masturbation and frequenting of prostitutes (Marazziti & DellOsso, 2006).
A placebo-controlled double-blind trial of topiramate augmentation of an
SSRI in treatment-resistant OCD in 36 adults (not sex offenders) showed a
significant positive effect in compulsions, but not obsessions (Berlin et al.,
2011).
Antipsychotics
Antipsychotics are indicated in those rare cases in which sex offenses are
related to delusions. There is no indication that antipsychotic medications
are efficacious in the treatment of paraphilias. An 18-week trial comparing
chlorpromazine 125 mg/day, benperidol (a highly potent butyrophenone
derivative) 1.25 mg/day, and placebo in 12 pedophiles at a forensic hospital
revealed no statistical differences (Murray, Bancroft, Anderson, Tennent,
& Carr, 1975). Fluphenazine decanote 12.525 mg every 2 to 3 weeks intra-
muscularly was used for 4 months in 10 patients, with a discontinuation of
deviant sexual interests in four patients, and a reduction in five patients, but
eight of the subjects had significant side effects, specifically extrapyramidal
symptoms and orthostasis (Bartova, Nahunek, & Svestka, 1978).
Antidepressants
While meta-analyses of the efficacy of treatment for sexual offenders indicate

that no randomized placebo-controlled studies on antidepressants have been
published (Schmucker & Losel, 2008; White, Bradley, Ferriter, & Hatzipetrou,
2000), their use has been reported to be efficacious in the treatment of sexually
deviant behavior. The SSRIs have received the most attention. The well-known
decrease in sexual desire is an unwanted side effect of the SSRIs when used to
treat mood and anxiety disorders, including OCD, in the absence of sexually
compulsive behaviors. This side effect can have advantages in the treatment of
paraphilias in both adults and youth (Bradford, 2001). It has been proposed
that the paraphilias exist along the OCD spectrum (Bradford, 1999). SSRIs
are well known and used frequently in the treatment of mood and anxiety
disorders, including OCD, in adults (Pigott & Seay, 1999) and children (Garcia
et al., 2010; Geller et al., 2003). Decreased brain serotonin (5-HT) in animals
results in increased sex drive and aggression. Drugs that increase brain sero-
tonin levels, including the SSRIs, have been used to treat paraphilias.
Debate continues as to whether the paraphilias are on the obsessive-
compulsive continuum (with deviant fantasies considered to be obsessive and
deviant behaviors compulsive), fueled in part by the use of SSRIs in paraphilias.
Fluoxetine, sertraline, and fluvoxamine have been the most commonly used
SSRIs in the treatment of paraphilias as well as nonparaphilic hypersexuality
(Bourget & Bradford, 2008; Bradford, 2001).
Serotonin is involved in the neurobiology of many mental illnesses,
most notably the mood and anxiety disorders, including OCD, but also in
schizophrenia and eating disorders. Sexually deviant behavior (paraphilias)
and compulsive nonparaphilic sexual behavior have also responded to the
pharmacologic manipulation of serotonin levels (Bradford, 1999). Bradford and
others (Bradford, 2001; Mick & Hollander, 2006) have noted the similarities
between OCD and paraphilic and nonparaphilic sexual disorders. Bradford
indicated the following similarities between OCD and sexual disorders
(Bradford, 1999):
Obsessions and paraphilic and nonparaphilic fantasies are similar.

Compulsive sexual behaviors are similar to other nonsexual
paraphilic and nonparaphilic behaviors.
There is substantial comorbidity between OCD and sexual disorders.
Depression and anxiety are common in both groups.
There is significant overlap between OCD and paraphilic and non-
paraphilic sexual disorders at the neurobiological and neuropharma-
cologic levels.
While there is not yet a consensus as to whether the paraphilias and

compulsive nonparaphilic behavior should be included among OCD spec-
trum disorders, it makes sense clinically to use the SSRIs in the treatment
of paraphilic and nonparaphilic behavior, particularly where there is a com-
pulsive element. Numerous studies have noted the role of serotonin in the
neurobiology of sexual behavior (Ayala, 2009; Chan et al., 2008; Hull,
Muschamp, & Sato, 2004; Maciag, Coppinger, & Paul, 2006; Sajith, Morgan,
& Clarke, 2008), and the OCD model is not necessary to understand the effi-
cacy of the SSRIs in the treatment of sexually deviant behavior. For reasons
that remain unclear, fluoxetine is more likely to inhibit sexual desire than
paroxetine (Berlin, 2008). Studies on the use of antidepressants in the treat-
ment of paraphilias and nonparaphilic sexual deviance have been suffered
from a variety of methodological limitations, including small sample size,
open-label designs, and lack of systematic assessment.
Tricyclic Antidepressants
A positive response to an unspecified tricyclic antidepressant at an unspecified
dose was noted in an adult male exhibitionist (Snaith & Collins, 1981). A posi-
tive response to clomipramine at dosages of 150 to 200 mg daily was observed
in two elderly demented males with exhibitionism and compulsive mastur-
bation (Leo & Kim, 1995). Kreusi and colleagues conducted a double-blind
cross-over comparison of clomipramine (a potent serotonin reuptake inhibi-
tor) versus desipramine (a norepinephrine reuptake inhibitor) in 15 adult males
with various paraphilias (Kruesi, Fine, Valladares, Phillips, & Rapoport, 1992).
After a 2-week single-blind study, four patients were dropped from the study
when they responded to placebo. Three patients failed to complete the study,
and eight finished. There was no preferential response to the more selective
serotonin reuptake inhibitor, clomipramine, than to desipramine.
Selective Serotonin Reuptake Inhibitors

Numerous single case reports, case series, retrospective studies, and open-label
studies describe a positive response to SSRIs in paraphilic and nonparaphilic
sexual behaviors in adults (Abouesh & Clayton, 1999; Aguirre, 1999; Bianchi,
1990; Bourgeois & Klein, 1996; Bradford, Greenberg, Gojer, Martindale,
& Goldberg, 1995; Bradford & Gratzer, 1995; Chow & Choy, 2002; Coleman,
Cesnik, Moore, & Dwyer, 1992; Emmanuel, Lydiard, & Ballenger, 1991;
D. M. Greenberg, Bradford, Curry, & ORourke, 1996; Jorgensen, 1990; Kafk a,
1991a, 1991b; Lorefice, 1991; Perilstein, Lipper, & Friedman, 1991; Stein et al.,
1992; Zohar, Kaplan, & Benjamin, 1994). However, despite promising results
in the aforementioned studies and their widespread use in paraphilic and non-
paraphilic sexual deviance, no randomized placebo-controlled studies of the
use of SSRIs in the treatment of paraphilias have been published. Because of

the methodological limitations, a critical analysis of all studies concluded that
there is only minimal research-based evidence to support the efficacy of SSRIs
in the treatment of paraphilias (Thibaut et al., 2010). Their favorable side effect
profile and ease of use, however, make them the most practical pharmacologic
agents for use currently in sexually offending youth.
Kafka and Prentky (1992) treated 10 adult men with nonparaphilic sexual
addictions and 10 men with paraphilias in an open-label trial using fluoxetine.
Most of these men in both groups met criteria for dysthymia or major depres-
sion. Sixteen patients completed the trial (nine with paraphilias and seven
with nonparaphilic sexual addictions). Subjects were evaluated for depres-
sion and abnormal sexual behaviors at baseline and then every 4 weeks for 12
weeks. Fluoxetine was started at 20 mg daily and titrated every 4 weeks to a
maximum of 60 mg daily. Fluoxetine significantly decreased paraphilic and
nonparaphilic sexual behaviors in the men reporting mild to severe depres-
sive symptoms. Yet the treatment outcome of paraphilias and nonparaphilias
was independent of baseline depression scores. For the most part, there was a
marked initial drop in sexual behaviors by week 4, followed by a more gradual
decline. In an open, uncontrolled, retrospective study of 16 male outpatients
with a variety of paraphilias treated with SSRIs and psychotherapy, there was
a marked reduction in paraphilic symptoms noted (Kraus et al., 2007).
In an open study of 24 men with paraphilias or paraphilia-related disorders
treated with sertraline at a mean dose of 100 mg/day, clinically significant
improvement (reduction in sexual activity) was reported in about half the men
who complied with at least 4 weeks of sertraline therapy (Kafka, 1994). The
nine men who failed to respond to sertraline were then treated with fluoxetine
(mean dose 50 mg/day with a mean duration of 50 weeks), with six of those men
reporting significant improvement. Overall, 71% of subjects (17 men) reported
improvement. Bradford (Bradford et al., 1995; Bradford, 2001) reported on an
open-label 12-week trial of sertraline (mean effective dose = 131 mg daily) in
the treatment of 20 males with pedophilia. While two subjects dropped out, all
deviant sexual behaviors were reduced by sertraline, and there was an increase
in normophilic sexual arousal (arousal to sex with consenting adults) as noted
by physiological measures. No statistical analysis was presented. A retrospec-
tive study of three different SSRIs (sertraline, fluoxetine, and fluvoxamine)
used to treat 58 adult men with a variety of paraphilias indicated that all three
were equally effective in reducing deviant sexual fantasies urges, and behav-
iors, with the greatest effect on deviant sexual fantasies (Greenberg et al., 1996).
In another retrospective study, Greenberg and colleagues examined a sample
of 95 paraphilic males treated with SSRIs compared with a control group
(N =104) receiving only cognitive-behavioral therapy (CBT). Assessment after
the initial 12 weeks of treatment showed a significant decrease in the frequency

and severity of deviant sexual interests in the SSRI-treated group as compared
to the control CBT group (Greenberg & Bradford, 1997).
The only double-blind study of an SSRI compared 20 to 60 mg of citalo-
pram to placebo in 28 homosexual men with compulsive sexual behavior
(characterized by loss of control over sexual behavior and repeated negative
consequences, including unsafe sex) in a 12-week trial. The Yale-Brown OCD
scale was used to measure treatment effects. Significant improvements were
noted with respect to decreased sexual desire and drive, frequency of mastur-
bation, and pornography use (Wainberg et al., 2006).
Despite the fact that SSRIs are used with some frequency in the treatment
of youth who sexually offend, especially those with deviant sexual arousal,
a review of the extant literature contains only two open-label trials of an SSRI
(fluoxetine) targeting sexual symptomatology (Aguirre, 1999; Galli, Raute,
McConville, & McElroy, 1998). In an open-label trial of fluoxetine in one
16-year-old with compulsive paraphilic sexual behavior (Aguirre, 1999), flu-
oxetine was initiated at 10 mg a day and increased to 60 mg within a week.
Behavior was noted to be much improved with a decrease in sexual symp-
toms and thoughts and a decrease in the daily serum testosterone level as
fluoxetine dosage increased. Galli and colleagues reported on a 17-year-old
male sex offender who met DSM-IV criteria (except for the age criteria) for
multiple paraphilias, bipolar type II disorder, and OCD, whose paraphilic
urges and behaviors (with which he had struggled since age 10), depression,
and violent obsessions responded to open-label fluoxetine after failing to
respond to long-term residential treatment (Galli et al., 1998).
The controversy/debate on whether antidepressants may cause some children
and adolescents to have suicidal thoughts and/or engage in suicidal behavior
continues. In 2004, the U.S. Food and Drug Administration (FDA) issued
a warning that antidepressants posed a small but increased risk of suicidality
for children and adolescents who used antidepressants, and labeling changes
(the back box warning) were instituted (Food and Drug Administration,
2004). In 2007, a similar warning was issued and labeling updates were pro-
posed to include warnings about increased risks of suicidal thinking and
behavior in young adults ages 1824 (FDA Pharmacologic Drugs and Pediatric
Advisory Committees, 2007; Food and Drug Administration, 2007). Careful
monitoring is recommended for children and adolescents receiving any psy-
chotropic medication. Adverse reactions to antidepressants usually occur
within the first several weeks after initiation of an antidepressant, but they
may occur months later. In some children and adolescents with bipolar dis-
order or a vulnerability to a bipolar spectrum disorder, antidepressants may
worsen or precipitate manic symptoms.
Despite the poor evidence base in support of the use of SSRIs in the
treatment of paraphilias and other sexually deviant behaviors, they are
included in some depth here because children are never appropriate candi-
dates for hormonal treatments, and adolescents are only very rarely considered
appropriate candidates for hormonal treatments (only when puberty and
bone growth is complete, when other appropriately applied treatments
have failed, and paraphilic behavior is severe). The American Academy of
Child and Adolescent Psychiatry practice parameters for the assessment and
treatment of children who are sexually abusive of others recommend cogni-
tive-behavioral and psychosocial interventions and SSRIs and discourage the
use of antiandrogens in youth under age 17 (Shaw, 1999).
Other Antidepressants
In a retrospective open-label trial of nefazadone (a drug that reversibly
inhibits serotonin reuptake and is chemically unrelated to the tricyclic or
tetracyclic antidepressants, or SSRIs) in 14 adult males with nonparaphilic
sexual obsessions and compulsions (Coleman, Gratzer, Nesvacil, & Raymond,
2000), dosages ranged from 50 mg/d to 200 mg/d, with a mean daily dose of
200 mg. Nine of the patients (64%) had a concurrent mood disorder. A rating
scale of 1 to 4 was used to quantitate response. One patient withdrew from the
study secondary to poor compliance, and two patients withdrew because of
side effects (headache and bloating). Eleven patients continued on the medica-
tion long term (mean 13.4 months). Among the 11 patients who completed the
study 45% reported complete remission of sexual obsessions and compulsions
and 55% reported good control.
Stimulants
The adjunctive use of stimulant medication was reported in 26 adult male

subjects (14 with paraphilias and 12 with paraphilia-related disorders)
treated with SSRIs in an open-label trial lasting 3 years (Kafka & Hennen,
2000). Nineteen patients were treated with fluoxetine (mean dose 49 mg/d),
three with sertraline (mean dose 110 mg/d), two with paroxetine (mean dose
35 mg/d), and two with fluvoxamine (mean dose 100 mg/d). Of the 26 patients,
17 had attention-deficit/hyperactivity disorder (ADHD), and 16 had persistent
depressive symptoms even with SSRI treatment. Slow-release methylphenidate
(mean dose 40 mg/d) was added. A mean of 8.8 months of SSRI treatment
was associated with significant decrease in the sexual outlet score (by 65%
from baseline) and the mean amount of time per day spent involved in devi-
ant sexual fantasy or behavior (by 75%). A mean of 9.6 months of adjunctive
treatment with methylphenidate resulted in a significant decrease in sexually

deviant behavior by 39% in total sexual outlet scores and by 44% in mean time
spent on sexually deviant behavior. For depression and ADHD, 82% of patients
had improved scores by clinician and patient global impressions of change.
Naltrexone
Neuroscience research suggests that opiates may play a role in sexually

motivated behaviors, and some researchers have noted that sexually compul-
sive behaviors share characteristics with other addictive behaviors (Berlin,
2008, 2009; Leung & Cottler, 2009; McIntosh, Vallano, & Barfield, 1980;
Raymond, Coleman, & Miner, 2003; Szechtman, Hershkowitz, & Simantov,
1981). The opiate antagonist naltrexone was used in an open-label prospective
trial with 21 adjudicated adolescent (1317 years of age) male sex offenders
in an inpatient adolescent sex offender program (Ryback, 2004). They had
offended against children ages 212 and had a range of 1 to 37 victims. One
youth had offended against his dog, and one had offended against his mother.
Inclusion criteria included masturbation more than three times daily; feeling
unable to control sexual arousal; spending greater than 30% of time in sexual
fantasy; and having sexual fantasies or behaviors that regularly intruded into
and interfered with functioning in a residential treatment program. A positive
response was defined as greater than a 30% decrease in any self-reported crite-
rion specific to the patient and that the benefit lasted at least 4 months. Fifteen
of 21 patients (71%) at a mean dose of 160 mg/d had a positive response. In poor
responders an increase in dose to 200 mg did not improve response. Thirteen
of the 15 responders relapsed when the naltrexone was tapered to 50 mg a day.
Five of the six naltrexone nonresponders (83%) benefitted further from adding
leuprolide acetate (3.757.5 mg monthly intramuscularly). No abnormalities in
liver function tests were noted. No statistical analysis was performed.
Raymond and colleagues conducted a retrospective record review of 19 male
patients with compulsive sexual behavior who were treated with naltrexone
at an outpatient adult sexual health clinic (Raymond, Grant, & Coleman, 2010).
Nearly all patients were already taking other psychotropic medications when
naltrexone was initiated. Seventeen (89%) of the 19 patients reported a reduction
in compulsive sexual behavior symptoms when taking naltrexone for a period
ranging from 2 months to 2.3 years, as judged by Clinical Global Impression
scores of 1 or 2, indicating very much improved or much improved. Five
(26%) of the 19 patients chose to discontinue the medication. The authors
concluded that naltrexone may be a useful adjunctive treatment for compulsive
sexual behavior (Raymond et al., 2010), but more robust evidence is lacking.
H O R M O N A L AG EN TS
Medroxyprogesterone Acetate
Medroxyprogesterone acetate (MPA) was the first pharmacologic treatment

to be used specifically to decrease libido in the United States. Dr. John Money
at Johns Hopkins first used MPA to decrease sex drive in nonparaphilic sex
offenders (Money, 1971). It remains the most common pharmacologic agent
prescribed for sex offenders in the United States. However, it is also used exten-
sively as a depot contraceptive and in the treatment of a variety of disorders,
including hormone-dependent cancers and endometriosis. MPA is a proges-
tational agent, which induces production of testosterone 5--reductase in the
liver, an enzyme responsible for the catabolism of testosterone. The end result
is an increased clearance of testosterone, decreased testosterone secretion by
the testes, decreased testosterone levels in serum and tissues, and decreased
gonadotropin secretion. Because MPA does not compete for androgen recep-
tors, it is not a true antiandrogen (Guay, 2009). Mean plasma concentrations
of LH and total testosterone were significantly reduced when measured in
published studies, but FSH levels remained unchanged (Guay, 2009).
Dosage
Variable dosages were used in the studies reported. While oral MPA can be
used (dosages 100 to 500 mg per day), erratic bioavailability noted in cancer
patients receiving the drug has made the intramuscular form preferable in the
sex offending population (Guay, 2009). Loading doses can be administered at
500 mg per week for 4 weeks. Patients are then maintained on 100 mg to 800
mg a week thereafter. The dosage is titrated by measuring sexual response.
MPA reduces recidivism during treatment, but paraphilic behavior returns
when stopping the drug. Cooper recommended continuation of MPA for at
least 2 years (Cooper, 1986).
Studies
Although MPA has been extensively used (more than 600 subjects among
various studies), most studies were not controlled, and potential biases are
noted related to small sample sizes, short duration of follow-up, cross-over
study design, and retrospective study design. The use of MPA has been discon-
tinued in Europe, as the severity of side effects and poor risk/benefit ratio did
not favor its use (Thibaut et al., 2010). However, in the United States, cypro-
terone acetate (CPA) is unavailable for use secondary to concerns regarding
hepatoxicity (Giordano, Nardi, Santacroce, Geraci, & Gennari, 2001; Miquel
et al., 2007; Savidou et al., 2006; Thole, Manso, Salgueiro, Revuelta, & Hidalgo,
2004), and MPA is the most frequently used hormonal agent in the treatment
of paraphilias.
Berlin and Mienecke studied 20 paraphilic males in an open clinical trial in
which MPA (200400 mg intramuscularly) was effective in decreasing sexu-
ally deviant fantasies and behavior; however, three patients relapsed while
taking MPA, and 10 out of 11 patients who discontinued the MPA against
medical advise relapsed (Berlin & Meinecke, 1981).
In an open clinical, 48 adult male subjects with long-standing histories of
deviant sexual behavior received MPA and milieu therapy for up to 12 months.
Within 3 weeks, 40 subjects responded positively, with diminished frequency
of sexual fantasies and arousal, decreased desire for deviant sexual behav-
ior, increased control over sexual urges, and improvement in psychosocial
functioning. There was no evidence of permanent physiological changes, and
improvement in deviant sexual behavior and psychosocial functioning was
maintained after treatment ended (Gagne, 1981).
Gottesman and Schubert used a low dose (60 mg of oral MPA daily) in seven
paraphilic subjects for 15 months in an open trial (Gottesman & Schubert,
1993). A significant reduction in plasma testosterone levels from baseline was
reported, as well as a reduction in paraphilic fantasies.
An open-label study of 45 males ages 14 to 72 years of age with six subjects
under age 19, and 21 of the 39 adults reporting that their sex offending had
begun before or during adolescence, was divided into two parts (McConaghy,
Blaszczynski, Armstrong, & Kidson, 1989). The first part of the study was with
psychotherapy alone (covert desensitization and imaginal desensitization).
The second part of the study divided the group into three groupsMPA alone,
150 mg intramuscularly per month for 4 months; psychotherapy alone; and
MPA plus psychotherapy. Subjects were randomly allocated to receive covert
sensitization, imaginal desensitization, MPA, or imaginal desensitization plus
MPA. Seven of the 39 adult subjects required additional treatment, three being
charged with additional sexual offenses. Four of the six adolescents required
additional treatment, three being charged with further sexual offenses. The
authors postulated that adolescent sexual offenders might be more resistant to
treatment because their sexual urges are under more direct hormonal control
than adults (McConaghy et al., 1989). Another possibility is that adolescent sex
offenders do not respond as well to interventions designed for adults because
they are not just a younger version of adult sex offenders.
MPA was used in a single-case experimental design, which included
a double-blind procedure, in three adult male pedophilic sex offenders over
a minimum of 3 months (Wincze, Bansal, & Malamud, 1986). The authors
noted that subjects self-report of arousal outside of the laboratory setting was
unreliable as a measure of drug effect; however, within the laboratory setting,
a significant reduction was reported in arousal to erotic stimuli while genital

arousal decreased only slightly. There was also a significant decrease in noc-
turnal penile tumescence, which appeared to be related to decreases in total
testosterone.
In an open trial, MPA at doses of 100 to 400 mg/wk intramuscularly for
6 months or longer was administered to nine adult males, three with antisocial
behavior and six with sexually offensive behavior (Meyer et al., 1977). Of the
six sex offenders, three had pedophilia, two transvestism, two exhibitionism,
one voyeurism, and one homosexual incest. Five of the subjects were studied
before and after treatment; four subjects were only studied during treatment.
Results indicated a significant drop in total serum testosterone concentrations,
LH, and mean 24-hour integrated concentrations of cortisol. Serum FSH con-
centrations were not affected. MPA treatment did not affect the rise in plasma
cortisol after insulin-induced hypoglycemia. Although MPA treatment has
a suppressive effect on the HPA axis, it does not appear to be clinically signifi-
cant in that it can still respond to stress. Although the circadian rhythm in
plasma cortisol was suppressed, it was not eliminated.
In another open trial that did include adolescents, 40 males, ages 16 to 78
years, with sex offending behavior (23 pedophiles, 7 rapists, 10 exhibitionists),
were treated with combined MPA, group therapy, and individual psychother-
apy (Meyer, Cole, & Emory, 1992). Five subjects had sex offending behavior
that began after head trauma. The duration of MPA therapy (400 mg intramus-
cularly weekly) ranged from 6 months to 12 years, usually more than 2 years.
These subjects were compared with a control group of 21 men who refused
MPA therapy and had similar types of sex offending behavior. The subjects
who refused MPA were treated with psychotherapy alone with follow-up for
a period that ranged from 2 to 12 years. MPA-related side effects included
malaise, excessive weight gain, migraine headaches, severe leg cramps, ele-
vated blood pressure, gastrointestinal complaints, gallbladder stones, and
diabetes mellitus. Eighteen percent reoffended while receiving MPA therapy,
and 35% reoffended after stopping MPA. However, 58% of the control patients
reoffended. The authors identified risk factors for reoffending in their sample,
including elevated baseline testosterone, previous head injury, never forming
an intimate long-term relationship, and alcohol and drug abuse (Meyer et al.,
1992).
In another study, a sample of 100 men accused of sexual assault on a child
and referred to a forensic clinic were approached for assessment and treat-
ment in a double-blind study of MPA, with a total of 48 men completing
assessment and 18 agreeing to participate in the drug trial (Hucker, Langevin,
& Bain, 1988). Only 11 subjects completed a 3-month course of MPA or pla-
cebo therapy. MPA led to more depression and excess salivation than did
the placebo, although the frequency of fatigue was also notable. The authors
concluded MPA appeared as a useful medication for reducing sex drive, with
few side effects; however, compliance in taking the drug was seen as a major
obstacle in its use with pedophiles (Hucker et al., 1988).
Maletsky and colleagues reported results from a retrospective study of the
first 275 men who were evaluated under House Bill 2500 enacted in Oregon
in 1999, which required selected sex offenders to be evaluated prior to their
release from prison to determine whether treatment with MPA was indi-
cated to reduce their risk of recidivism. Data were collected on diagnoses and
outcome on three groups of offendersmen judged to need MPA who even-
tually went on to actually receive it; men recommended to receive MPA who,
for a variety of reasons, did not receive the medication; and men deemed not
to need MPA. Outcome measures included recidivism data, including reof-
fenses, parole violations, and reincarcerations, and whether these were sexual
in nature. Data were also collected on employment and whether supervising
officers believed the men in each group were doing well. Significant differ-
ences emerged among the three groups. Men who received MPA committed
no new sexual offenses and also committed fewer overall offenses and viola-
tions compared to the other two groups during a 5-year follow-up program.
Almost one-third of men judged to need medication but who did not receive
it committed a new offense, and almost 60% of those offenses were sexual in
nature (Maletzky, Tolan, & McFarland, 2006).
In a double-blind cross-over study, eight adult male court-committed sex
offenders (each serving as his own control) received 100 to 400 mg/week MPA
for 16 weeks versus placebo (saline intramuscularly) (Kiersch, 1990). The dura-
tion of follow-up was 22 to 64 weeks. Outcome measures included self-reports,
testosterone levels, and plethysmography. The authors reported a reduction in
testosterone levels with MPA. Six subjects had a reduction in the frequency of
masturbation and in arousal response to deviant and nondeviant sexual stim-
uli, which was maintained while in the placebo phase. One subject reported an
increase in deviant fantasies while on MPA, and one subject reoffended while
on placebo.
Side Effects
Treatment with MPA is associated with a variety of possible side effects (Gagne,
1981; Kravitz et al., 1995; Krueger, Hembree, & Hill, 2006; Maletzky et al.,
2006; Meyer et al., 1977; Meyer, Walker, Emory, & Smith, 1985) including the
following:
Deep vein thrombosis, with pulmonary embolism being the most

serious side effect reported
Decrease in spermatogenesis
Weight gain
Changes in insulin response without changes in glucose tolerance and
infrequently diabetes mellitus
Osteoporosis
Soreness at the injection site
Gynecomastia (less frequent than with cyproterone acetate)
Hot flashes
Nausea
Vomiting
Headaches
Gallbladder dysfunction, including chololithiasis
Adrenal suppression and Cushings syndrome
Positive side effects for patients with paraphilias (Berlin, 2009; Berlin
& Meinecke, 1981; Gagne, 1981; Saleh & Berlin, 2003; Thibaut et al., 2010)
include the following:
Decreased sex drive

Decrease in sexual fantasy
Decreased sexual activity
Decreased nocturnal penile tumescence
Decreased arousal to erotic stimuli
Research findings suggest that sex offenders treated with MPA may experi-
ence a suppression of deviant sexual fantasies and behaviors earlier in treat-
ment (1 to 2 weeks) than suppression of nondeviant fantasies and behaviors
(Kravitz et al., 1995). Candidates for oral MPA include individuals over age
16 with completed puberty and bone age who admit to hands-on sexual
offenses and struggle with compelling sexual fantasies that they find upsetting
and wish to decrease or eliminate (Level 4 and 5). Offenders with severe sexual
fantasies and deviance for whom compliance is a concern are candidates for
intramuscular MPA.
Cyproterone Acetate
Cyproterone acetate (CPA) is not approved for use in the United States;
however, it is used for a variety of indications throughout the world. It is
the most extensively studied antiandrogen for the treatment of sexual devia-
tion (Bradford, 2001), and it has been used extensively for this purpose in
Canada and Europe since the 1970s (Bradford & Pawlak, 1987, 1993a, 1993b).
The literature contains reports of its use for precocious puberty and polycys-
tic ovarian syndrome with hirsutism, as well as in the treatment paraphilias
(Almeida et al., 2008; Bradford, 2001; Van der Spuy & le Roux, 2003). CPA
has powerful antigonadotrophic and antiandrogenic properties. It blocks
hypothalamic androgen receptors and competes with testosterone at target
organ sites, thereby blocking the effect of both endogenous and exogenous
androgen on the androgen receptors. Its primary mode of action in treating
paraphilias is on the androgen receptors, where it blocks the intracellular
uptake and metabolism of testosterone and dihydrotestosterone (Bradford,
1983; Neumann & Kalmus, 1991). CPAs strong progestational properties
reduce levels of LH and FSH, resulting in a decrease in sexual behavior,
including interest, fantasies, and drives. CPA competitively inhibits tes-
tosterone and dihydrotestosterone at androgen receptors throughout the
body. It is mildly antiestrogenic and has little to no effect on the secretion
of adrenocoticotrophin (ACTH) or the adrenal cortex (Davies, 1974). There
is a rapid decrease in libido and a gradual decrease in sperm production,
resulting in an eventual absence of ejaculate. When treatment with the drug
is stopped, there is rapid recovery of libido and sperm production. CPAs
blockade of androgen receptors leads to a decrease in all sexual behaviors,
including normal and deviant behaviors, sexual fantasies, masturbation,
and intercourse. However, Bradford has suggested that CPA may diminish
pedophilic arousal while enhancing nondeviant arousal (Bradford & Pawlak,
1993b).
Dosage
Effects on sexual behavior are dose dependent and correlate with the decrease
in plasma testosterone. Oral dosage for adult males is 50300 mg daily (Bourget
& Bradford, 2008; Guay, 2009; Laschet & Laschet, 1975). Intramuscular dosage
varies from about 200400 mg every 1 to 3 weeks (Bourget & Bradford, 2008),
although higher doses 300600 mg every 1 to 3 weeks are sometimes used
(Guay, 2009).
Studies
Ten studies of CPA to treat sexually deviant and/or paraphilic behavior have
been reported, of which two were double-blind cross-over studies, comparing
CPA with ethinyl estradiol (Bancroft, Tennent, Loucas, & Cass, 1974) and CPA
with MPA (Cooper, Sandhu, Losztyn, & Cernovsky, 1992); two were double-
blind cross-over studies comparing CPA with placebo (Bradford & Pawlak,
1993a; Cooper, 1981); one was a single-blind study (Cooper & Cernovovsky,
1992); and five were open studies or case reports (Bradford & Pawlak, 1993b;
Cooper, Cernovsky, & Magnus, 1992; Davies, 1974; Laschet & Laschet, 1975;
Menghini & Ernst, 1991).
Bancroft and colleagues studied 12 male sex offenders, ages 22 to 34 years,

comparing 100 mg day CPA versus 0.01 mg/day ethinyl estradiol in a protocol
that contained three periods of 6 weeks on CPA, estradiol, or no treatment.
Both CPA and estradiol significantly decreased sexual interest, but only when
on CPA 100 mg/day was there a reduction in response to erotic stimuli as
measured by plethysmography (Bancroft et al., 1974). One subject had to be
terminated secondary to depression on day 3 of the study.
CPA reduced testosterone levels, sexual activity, number of erections,
orgasm, and sexual interest in nine adult male sex offenders (hypersexuality,
exhibitionism, voyeurism, fetishism, and incest) in a study lasting 20 weeks
(4 weeks of no treatment, 4 weeks of placebo, 8 weeks of CPA, and another
4 weeks of placebo). The effects of CPA were reversible within 30 days of ces-
sation. Side effects were reported (Cooper, 1981). In a single-blind cross-over
study, Cooper and colleagues used CPA 100 mg/day or placebo with five male
pedophiles, ages 21 to 31 years; three of the subjects had IQs of 7589. The
study protocol was placebo 4 weeks, CPA 8 weeks, and placebo 4 weeks, with
a 16-week follow-up. There was a decrease in nocturnal erections by 62% and
of erections after sexual stimuli (67% reduction with video stimuli and 23%
reduction with audio stimuli), and a significant decrease in the number of
erections, orgasm, and sexual interest, and testosterone, LH, and FSH levels
during CPA treatment, which were reversible upon cessation of the CPA. Side
effects were not reported (Cooper & Cernovovsky, 1992).
In a double-blind cross-over study with seven pedophiles (three dropped
out during the initial placebo period), ages 23 to 37 years, with additional
paraphilias, including exhibitionism, sexual sadism, rape, fetishism, zoophilia,
and transvestism, CPA was compared to MPA and placebo in dosages of 100 to
200 mg/day in a study with seven phases, each lasting 4 weeks (Cooper et al.,
1992). Results indicated that CPA and MPA were equally effective, and efficacy
was dose dependent. There was a decrease in testosterone, LH, and FSH with
both drugs, and levels returned to normal after 3 weeks on placebo. There was
a decrease in sexual fantasies, masturbation, morning erections, and penile
response to erotic stimuli as measured by plethysmography. A reduced volume
of ejaculate in five of the subjects was noted, but no other side effects were
reported; a majority of subjects (three out of five) preferred MPA to CPA.
In an open study of 20 males, ages 18 to 60 years (15 with pedophilia, three
incest offenders, two with pedophilia and exhibitionism), CPA at doses of 50
to 200 mg was utilized; duration of follow-up was 9 to 12 weeks (Bradford
& Pawlak, 1993b). There was a decrease in testosterone, mostly in subjects
with a higher baseline level of testosterone; a decrease in penile tumescence
as measured by plethysmography (with greater decrease in arousal to devi-
ant versus nondeviant visual stimuli); and a decrease in spontaneous erections
and nondeviant fantasies. No side effects were reported. Bradford and Pawlack
(1993a) performed a double-blind cross-over study with 19 males ages 19 to
45 years with a variety of paraphilias, including pedophilia, frotteurism,
rape, fetishism, incest, and exhibitionism using CPA 50 to 200 mg/day versus
placebo. The protocol included four 3-month treatment periods. It is one of the
few studies in which statistical analysis was performed. There was a significant
reduction in testosterone and FSH; no change in LH; a significant increase in
prolactin levels; and a significant decrease in sexual arousal, sexual fantasies,
and sexual activity. There was no statistical difference in side effects for placebo
versus CPA, but there was a mean weight gain of 1.3 kg reported with CPA.
Davies (1974) found CPA to diminish male hypersexuality without signifi-
cant side effects in 50 male patients over a 5-year period. The cohort was quite
heterogeneous, including four subjects with sexual hyperactivity attributed
to chromosome disorders, six subjects characterized as intellectually sub-
normal, and 16 subjects convicted of repeated sexual assaults on women or
children.
Side Effects
Potential side effects (Bourget & Bradford, 2008; Cooper & Cernovovsky, 1992;
Cooper, Cernovsky, & Magnus, 1992; Cooper, Sandhu et al., 1992; Czerny,
Briken, & Berner, 2002; Giltay & Gooren, 2009; Gooren, Lips, & Gijs, 2001;
Guay, 2009; Heinemann, Will-Shahab, van Kesteren, Gooren, & Collaborating
Centers, 1997; Hill et al., 2010; Laron & Kauli, 2000; Neumann & Kalmus,
1991; Thibaut et al., 2010) include the following:
Severe hepatotoxicity (<1%)

Depression
Fatigue
Shortness of breath
Nausea, vomiting, and diarrhea
Hypertension
Leg cramps
Hot flashes
Osteoporosis
Adrenal insufficiency or hyperplasia (0.5%generally reported in
juveniles)
Feminization with gynecomastia (20% and usually reversible)
Decrease in body hair with increase in scalp hair
General side effects of fatigue, hypersomnia, general malaise, and
transient depression
Weight gain
Decreased glucose tolerance

Anemia
Pituitary dysfunction
Venous thromboembolism, especially in patients with prostate cancer
Animal research has shown an association between CPA and liver cell
carcinoma in rats (Kasper, 2001); however, in a long-term follow-up of 2,506
patients (602 followed for longer than 10 years), no malignant liver tumors
were found. In a subset of 1,685 patients that had reported liver tests, 9.6%
had elevated liver enzymes at some point, but there were no cases in which
CPA had to be discontinued secondary to a severe liver problem (Heinemann
et al., 1997).
Luteinizing HormoneReleasing Hormone Agonists
LHRH, also known as GnRH, is peptide hormone responsible for the release
of FSH and LH from the anterior pituitary. GnRH (LHRH) is synthesized and
released from neurons in the hypothalamus. LHRH agonists work by exhaust-
ing the hypothalamic pituitary axis by overstimulation. In the normal adult
male, androgen homeostasis is achieved through the pulsatile release by the
hypothalamus of GnRH/LHRH to the anterior pituitary gland (Gomella,
2009). The interaction between GnRH/LHRH and LH receptors in the
pituitary gland promotes the release of LH into the blood, which in turn stim-
ulates testosterone production by binding to receptors on Leydig cells in the
testes. Testosterone then exerts negative feedback of GnRH/LHRH through
androgen receptors on the hypothalamus and pituitary glands (Gomella,
2009). LHRH agonists or analogs produce complete chemical castration, but
the effect is reversible. They are used in the palliative treatment of hormone-
dependent prostate cancer, reducing testosterone levels in treated patients to
the level seen in surgically castrated men within 28 days (Marberger et al.,
2010). Normal serum testosterone ranges (which may vary slightly from labo-
ratory to laboratory) are 300 to 1,000 ng/dL (10.434.7 nmol/L) for men aged
17 years and older (Hellstrom, Paduch, & Donatucci, 2010; Wierman et al.,
2006). Most patients will achieve and maintain a serum testosterone level of
lower than 20 ng/dL after bilateral orchiectomy (Gomella, 2009).
LHRH agonists constantly stimulate the anterior pituitary gland, which
in turn decreases LH and testosterone production (Gomella, 2009). After the
initiation of treatment with an LHRH agonist, LH release is transiently increased
for up to 2 weeks after the initial dose, referred to as the flare effect or hor-
monal surge. After this transient increase in LH, and thus testosterone levels,
the LH and FSH production is down-regulated and testosterone production

is inhibited (Gomella, 2009). The initial use of a nonsteroidal antiandrogen
such as bicalutamide or flutamide for 12 months can be effective in block-
ing the clinical flare and can be stopped once this phase is over (Guay, 2009).
LHRH analogs currently available in the United States include formulations
of leuprolide, goserelin, histrelin, and triptorelin. Long-acting injections are
given monthly. It appears that in adult sex offenders treatment with LHRH
agonists is becoming increasingly popular because of fewer side effects than
with the antiandrogens.
Studies
There are a number of single case reports on the use of LHRH analogs or
agonists (leuprorelin, triptorelin, and goserelin) in the treatment of sexual
deviations (Brahams, 1988; Briken, 2002; Briken, Hill, & Berner, 2003, 2004;
Cooper & Cernovsky, 1994; Czerny et al., 2002; Dickey, 1992, 2002; Grasswick
& Bradford, 2003; Hoogeveen & Van der Veer, 2008; Rousseau, Couture,
Dupont, Labrie, & Couture, 1990; Saleh, Niel, & Fishman, 2004).
Leuprorelin and gosrelin are synthetic analogs of LHRH and can be given
as monthly or daily intramuscular injections. Rousseau and colleagues noted
that 70% of 44 normal patients (without sexual deviance or sex offending) with
advanced prostate cancer noted a significant decrease in sexual interest after
treatment with an LHRH agonist (leuprolide acetate) and flutamide. Only 18%
of patients maintained an interest for sexual intercourse. Despite this dramatic
decrease in sexual activity in most patients, complete antiandrogen blockade
left some sexual activity in approximately 20% of patients. The authors sug-
gested that combined androgen blockade could be beneficial for the treatment
of sex offenders (Rousseau, Dupont, Labrie, & Couture, 1988). Subsequently,
Rousseau treated an adult male with severe exhibitionism with a combination
of an LHRH agonist and the antiandrogen flutamide, with a complete cessa-
tion in exhibitionistic behavior and markedly decreased sexual fantasies and
activities, especially masturbation, without significant side effects (Rousseau
et al., 1990).
Triptorelin is a synthetic decapeptide agonist and long-acting analog of
LHRH. It was recently approved in Europe for the treatment of sexual devia-
tions in adult men (Thibaut et al., 2010). An open-label trial of triptorelin was
conducted with six males ages 15 to 39 years with severe paraphilias (Thibaut,
Cordier, & Kuhn, 1996). The subjects were treated with triptorelin 3.75 mg
per month intramuscularly. The 15-year-old was the only juvenile among the
six subjects. Three patients had mild to moderate mental retardation; one was
diagnosed with borderline personality disorder, one with mixed bipolar disor-
der (treated), and one with histrionic personality disorder. Four patients had
received oral cyproterone acetate (CPA) previously (and concurrently during

this trial) at a mean oral dose of 200 mg/d for 10 days to a year. Of those
patients previously treated with CPA, treatment was partially successful with
one patient (undefined); two patients had no improvement, and one withdrew.
The authors reported that five of the six patients (83%) experienced cessation
of all deviant sexual behavior and markedly decreased sexual fantasies and
activities. Clinical improvement paralleled the gradual decrease in testosterone
levels to castrate levels within the first month of treatment. Side effects other
than those related to hypoandrogenism were not noted. Beneficial effects
were maintained at follow-up varying from 7 months to 3 years. One patient
stopped treatment at the end of the first year and relapsed within 10 weeks. No
statistical analysis was performed.
Thibaut and colleagues performed another open-label study with six male
ages 17 to 43 years with severe paraphilias, again using triptorelin 3.75 mg
intramuscularly monthly (Thibaut, Cordier, & Kuhn, 1993). CPA was initiated
orally at 200 mg/day 1 week before the initial triptorelin dose and continued
for 5 weeks minimum (mean 19.7 weeks) to prevent flare. They reported that
five of the six subjects (83%) experienced cessation of deviant sexual behav-
ior and markedly reduced sexual fantasies and activities for the 1- to 7-year
follow-up period. Mean serum testosterone levels fell to castrate levels, and LH
and 17 estradiol concentrations also decreased. Two patients abruptly dis-
continued treatment after 1 and 5 years, respectively, and relapsed within 8 to
10 weeks. One patient complained of hot flashes and weakness.
In a placebo-controlled study comparing cognitive-behavioral therapy
(CBT) alone with leuprolide combined with CBT in five pedophilic men (12
months of treatment followed by 12 months of placebo), Schober and col-
leagues found that leuprolide significantly decreased serum testosterone levels,
and CBT plus leuprolide significantly decreased pedophilic urges, fantasies,
and masturbation (Schober et al., 2005). Plethysmography and visual reaction
times supported the self-reports of decreased sexual arousal. Physiological
arousal returned as early as 3 months after discontinuation of the leuprolide.
No men offended over the course of the 2-year study.
Side Effects
Potential side effects (Briken et al., 2003; Briken & Kafka, 2007; Guay, 2009;
Hill, Briken, Kraus, Strohm, & Berner, 2003) include the following:
Reduction in bone mineral density (most concerning and seen

in almost 100% of treated patients). Prophylaxis and treatment
strategies under investigation include Vitamin D supplementation,
biophosphonate, and/or parathyroid hormone.
Hypogonadism
Decreased facial and pubic hair growth
Hot flashes related to vasomotor instability
Mood changes
Fatigue and malaise
Weight gain
Gynecomastia
Injection site granulomas
Burning, redness, and itching at the injection site
CAST R AT I O N
A brief discussion of surgical castration is included for historical interest, as it

is unlikely to be allowed or even proposed on a voluntary or involuntary basis
for even the most recidivistic and severe juvenile offenders.
While surgical castration has been around since ancient times, it is first
known to have been utilized for therapeutic purposes in 1892 in Switzerland
for a patient with mental retardation, neuralgic pain of the testes, and hyper-
sexuality (Sturup, 1971). Surgical castration for some sex offenders was utilized
in the United States and in Europe and was noted to result in a significant
reduction in sexual recidivism; however, by the early 1970s its use had all but
ceased in Europe, with the exception of Germany, where it is still available for
some sex offenders with a variety of safeguards and oversight (Thibaut et al.,
2010). In surgical castration, the testes, where 95% of circulating testosterone is
produced, are removed. Much of our current knowledge regarding hormonal
treatments comes from information resulting from the surgical castration of
sex offenders (Thibaut et al., 2010).
Heim and Hursch, while concluding that there is no ethical or scientific
basis for the surgical castration of sex offenders, noted that in 1,200 sex
offender castrates, rearrest or reconviction rates were 2.5%7.5% compared
to 60%84% before castration with a maximum follow-up of 20 years. There
was no change in the focus of the subjects sexual interest, and 35% of young
castrates maintained sexual functioning (Heim & Hursch, 1979). Weinbergers
review of studies of castrated sex offenders reported a very low level of recidi-
vism, with one Danish study of 900 offenders reporting a recidivism risk of
1% (Weinberger, Sreenivasan, Garrick, & Osran, 2005). Despite its effective-
ness, surgical castration was associated with numerous uncomfortable and
potentially dangerous side effects. Removal of the testes decreased the level of
circulating testosterone and diminished sex drive, but complications ensued,
including decreased protein and bone calcium levels, redistribution of fat,

decreased body and facial hair, and hot flashes (Codispoti, 2008). There are
currently other forms of treatment that are less invasive and better tolerated.
The pros and cons of surgical castration as a potential treatment/sentence
for adult sex offenders in the United States has resurfaced with the enactment
of Sexually Violent Predator/Sexually Dangerous Person (SVP/SDP) Acts in
numerous states throughout this country. Surgical castration became legal in
the some states in 1996 (Weinberger et al., 2005).
Pharmacologic interventions may be helpful in the treatment of juvenile sex

offenders, but they should be carefully considered and utilized judiciously.
It is important to recognize that youth who sexually offend may also have
co-occurring psychiatric disorders such as mood disorders, ADHD, thought
disorders, and anxiety disorders. Unless mental disorders are treated appro-
priately, individuals may be unable to participate fully in sexual offender
treatment programs. Treatment with pharmacologic agents that target sex-
ually deviant behavior should always be provided on a voluntary basis, and
patients and guardians should be make aware of both the lack of FDA approval
for the use these medications for the indication of sexually deviant behavior
in youth, as well as the encouraging, yet limited, research regarding potential
efficacy. There is no research validation for the use of medication targeting
sexually deviant behavior in youth and only limited methodologically sound
research to guide us in the treatment of adults. Nonetheless, there is cause for
encouragement. Future research should focus on biological treatments for all
sex offenders, including youth and females.
Case 1
While the case of Julie is a rather unusual one, most pediatric clinicians have
encountered children who are very sexually preoccupied and engage in preco-
cious and/or excessive sexual behaviors. For those of us who trained in the
era before the widespread potential availability of pornography to children
through the Internet and on television through cable or dish programming,
there was the belief that children who exhibited precocious sexual behavior
were always victims of some form of sexual abuse. While the possibility of
sexual abuse should remain high in ones differential regarding etiology of
precocious and developmentally inappropriate sexual behavior, the issue has
become more complicated. Todays children are more likely to have access to
and be accidently exposed to graphic sexual materials in their own homes
or in the homes of friends, relatives, childcare providers, and so on. As with
sexual abuse, the younger and more sexually naive the child is, the less likely
he or she is to experience shame or guilt around the activity and may be more
likely to publicly act out sexually. However, in Julies case exposure to pornog-
raphy, sexual activity, and abuse are denied.
A thorough diagnostic evaluation of Julie may well reveal that she meets
criteria for both ADHD and OCD. The fact that she is only age 8 should be
taken into consideration when considering pharmacologic intervention, as
should the fact that her untreated ADHD and OCD symptomatology may
be contributing to her distress and dysfunction. While several medications
are FDA approved for the treatment of OCD in children and adolescents (i.e.,
fluoxetine, sertraline, fluvoxamine, and clomipramine), a comprehensive
treatment plan may consider beginning with psychotherapeutic treatments
(cognitive/behavioral and family) delivered by therapists with specific exper-
tise in treating children with these disorders. Perhaps treating the ADHD
pharmacologically will increase the success of cognitive-behavioral therapy.
The importance of family therapy (during which the issues of supervision
and boundaries are tackled) is obvious in Julies case.
Case 2
Robbies situation illustrates some of the problems involved when sexu-

ally abusive behavior is not thoroughly assessed and appropriately treated.
Automatically regarding sexual misbehavior as generic acting out and treat-
ing it with nonspecialized counseling is a disservice to the child and to the
community. From the brief description provided in this case, the probability
of a pedophilic sexual orientation seems likely. A thorough assessment and
targeted outpatient treatment by an expert in children who are sexually abu-
sive should have been initiated several years earlier when his behavior was first
discovered. Robbies parents fears that he will be tried as an adult and sent to
an adult prison are not misplaced. Youth placed in adult prison are at increased
risk for both sexual and physical abuse in prison. Depending on his state of
residence, Robbie may spend years in an adult prison and after finishing his
sentence qualify as a sexually violent predator and face commitment proceed-
ings. In reality, it is unlikely that a prosecutor will accept treatment with an
antiandrogen drug or GnRH/LHRH analog as part of a plea agreement to keep
Robbie out of the adult system. However, in this theoretical case a number of
factors must be addressed in the consideration of hormonal treatment:
1. Is Robbie giving genuine informed consent, or is his assent compromised

by an undue level of influence from his parents, as well as perhaps poorly
informed fears of what the legal system has in store for him? Hopefully
Robbies attorney is knowledgeable about the issues in play and willing to
invest the time necessary to assess the risks and benefits of various strate-
gies and convey them accurately to Robbie and his family.
2. Although Robbie does not meet criteria for a major depression or anxi-
ety disorder, pharmacologically, treatment with an SSRI may be helpful,
targeting the chronic depressive symptoms noted, as well as any com-
pulsive tendencies. Additionally, a decrease in libido may be a useful
side effect. It should be kept in mind that SSRIs may inhibit the ability to
orgasm, which can increase sexual frustration and may be a factor in the
continuation of sexually acting out behaviors or noncompliance. Hence,
it is important to encourage open dialog regarding side effects.
3. The serious nature of Robbies offenses (multiple acts in which there

is penetration) may warrant consideration of hormonal agents if inten-
sive cognitive-behavioral therapy, family therapy, and treatment with
an SSRI increased to the highest tolerated dosage are ineffective, and if
he is able and willing to consent. However, puberty and bone growth
must be completely achieved prior to initiation, and a full clinical assess-
ment, as previously described, must be performed and regular follow-up
insured. A medical workup should include a complete history and physi-
cal examination, EKG, hematological and chemistry laboratory testing,
and hormonal testing (free testosterone, estradiol, LH, FSH, sex hormone
binding globulin, prolactin, and thyroid function tests), as well as bone
density testing.
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INDEX
Abel Assessment for Sexual mentally handicapped, 6768

Interests2, 178 personality pathology, 6667
Abel Screen, 178 pharmacologic treatment, 198200
Actuarial assessment psychopathology, 6467
clinically adjusted, 125 recidivism, 59, 127
juvenile sex offender, 124125 review, 5859
risk of sexual offending, 162163 risk assessment, 127
Acute dynamic factors, sexual risk factors for reoffending,
reoffending in adults, 128129 128129
Adam Walsh Child Protection and sexual abuse histories, 82
Safety Act, 8 Aggravated sexual battery, case study,
Adjunctive therapies, treatment, 101102
187188 Aggressive sexual behavior
Adolescent nature and evolution, 150152
mental disorders, 6872 testosterone and biology, 203204
sexual behavior, 2630 Alaska, sex offender registration, 10
sexual behavior prior to, 2526 Alcohol abuse
sexually abusive females, 3537 juvenile sex offenders, 79
sexually abusive males, 3739 sexual offending case, 5657, 9091
Adolescent-onset experimenters, 39 American Academy of Child and
Adolescent sexual behavior Adolescent Psychiatry (AACAP)
ethnicity and locality differences, 29 evaluation guidelines, 119120
first intercourse, 2627 treatment of children, 212
masturbation, 28 American Academy of Forensic
oral sex, 28 Psychiatry, impartiality, 104n.1
sexual activity, 2729 American Psychiatric Association,
sexual orientation, 2829 sexually abusive/offending
time and generation differences, 30 behavior, 2
Adult sex offenders Anal sex, adolescents, 28
beginnings of, 1 Anamestic assessment, juvenile sex
developmentally disabled, 6768 offender, 123
divalproex sodium, 206 Androgens, sexual behavior, 201
240 INDEX
Anger management, treatment, sexual abuse history, 148150

186187 sexual history, 147148
Anticonvulsants sexually aggressive behavior,
divalproex sodium, 206207 150152
topiramate, 207 timing and location of interviews
Antidepressants with youth, 135136
case study, 55, 88 youth and family, 130133
nefazadone, 212 ATSA Task Force on Children with
obsessive-compulsive disorder Sexual Behavior Problems, 31
(OCD), 197, 208209 Attachment style, personality
selective serotonin reuptake construct, 37
inhibitors (SSRIs), 198, 209212 Attention-deficit/hyperactivity
sexual offender treatment, 208212 disorder (ADHD), 55, 57, 102, 227
tricyclic, 209 Aspergers and ADHD, 8688
Antipsychotics, 207 comorbid with bipolar disorder and
Antisocial orientation, risk factor, OCD, 54, 84
40, 41 delinquent youth, 69
Antisocial personality disorder (APD), juvenile sex offenders, 79
delinquent youth, 71 residential treatment, 184
Antisocial sexual behavior, stimulants, 212213
England, 67 Attorney consultation, forensic
Anxiety disorders, juvenile sex evaluations, 112113
offenders, 76 Autistic spectrum disorders (ASD)
Aspergers disorder, case of, and Aspergers disorder and ADHD,
ADHD, 55, 8688 8688
Assault, neuropsychiatric pathology, juvenile sex offenders, 83
7576 Automatic transfer, juveniles to adult
Assessment. See also Risk assessment court, 67
active, phase, 131132
characteristics of youth, 120121 Background information
clarifying questions and goals of, forensic evaluations, 113
134135 record review, 135
communication of findings, 153 Beck Depression Inventory (BDI), 70
concluding the, 132133 Behavior, normal, 2122
developmental history, 139144 Behavioral genetic research,
educational history, 144145 callous-unemotional (CU) traits,
follow-up, 153 40
interviewing parents, 137139 Biological treatment. See also
interviewing youth, 136137 Pharmacologic treatment
legal history, 146147 case studies, 193195, 226228
medical history, 145, 146 management of sexual offenders,
mental status examination, 152153 195196
preassessment phase, 131 Biology
psychiatric history, 145146 androgens, 201
psychological testing, 153 determinants of sexual behavior,
records review, 135 200204
Index 241
hormones, 200204 Clinical evaluation. See also Forensic

testosterone, 201204 evaluation
Bipolar disorder, 37, 54, 55, 56, forensic vs., 106, 107
84, 101 Clinical Global Impression, 213
Bush, President George W., Adam Clinical guidelines, level-of-care
Walsh Child Protection and decisions, 176177
Safety Act, 8 Clinical judgment based on history,
juvenile sex offender, 123
California, statistics, 12 Clinically adjusted actuarial judgment,
California Psychological Inventory, juvenile sex offender, 125
adolescent male sexual Clinical services, legal management
offenders, 38 and, 180
California Supreme Court, duty to Clomipramine, 197
protect, 107n.2 Cognitive-behavioral therapy
Callous-unemotional (CU) traits, sexual behavior problems, 35
youth, 4041 treatment, 210211, 224
Canada Collateral sources, interviews of, 114
cyproterone acetate (CPA), 199, Communication
218222 assessment findings, 153
juvenile sex offenders, 77 forensic evaluation, 109, 114115
Caretakers, youth development, Community-based treatment
142143 advantages over residential care, 179
Castration, 225226 alternative placement, 182184
Catchphrases, 5 clinical and legal management
Catecholamine hormones, 201 services, 180
Center for Sex Offender Management model programming, 180181
(CSOM), 3, 176 Competency to stand trial (CST),
Centers for Disease Control and evaluation, 134
Prevention, 26 Compulsive sexual behavior, 213
Childhood Conduct disorder (CD), 71, 7980
development, 141142 Confidentiality, forensic evaluation,
exposure to pornography, 4647 107108, 139
exposure to violence, 4546 Confluence model, hostile masculinity,
sexual behaviors in early, 2324 4344
sexual behaviors in middle, Consent, definition, 4
2426 Corroboration, forensic evaluation, 114
sexual victimization, 4445 Court decisions, recent, 7
Child Protective Services, 4, 135 Court order, forensic evaluations,
Children 111112, 132n.1
prepubescent, with sexual behavior Criminal management
problems, 3435 recent court decisions, 7
sexual life, 139140 youth, 57
Child safety, Megans Laws, 8 Cruel and Unusual Punishments
Child Sexual Behavior Inventory Clause, 7
(CSBI), parent survey, 23 Culture, adolescent sexual
Citalopram, 211 behavior, 29
242 INDEX
Currently sexually active, definition, social, 143

27 youth assessment, 139144
Cycle of abuse, 149 Developmentally disabled
Cycle of sexual offending, adult offenders, 6768
model of, 60 Aspergers disorder and ADHD, 55,
Cyproterone acetate (CPA) 8688
dosage, 219 youth offenders, 8283
hormonal agent, 199, 218222 Deviant sexual interests, risk factor,
side effects, 221222 4143
studies, 219221 Diagnostic Interview Schedule for
Children, 69, 70
Decision making, level-of-care, Discovery, 113, 113n.3
178179 Distorted sexual cognitions, risk
Defendants factor, 4344
forensic evaluations, 110 Divalproex sodium, 206207
interviews of, 113114 Doctor-patient relationship, 105106
Delinquency, negative peer influences, Drope v. Missouri 1975, 115
4748 DSM-III-R, 7475, 119
Delinquent youth. See also Juvenile DSM-IV, 70, 211
sex offenders DSM-IV-R, 41-42
family instability, 7374 Dusky v. United States 1960, 115
interviewing families of, 138139 Duty to protect, 107n.2
mental disorders, 6872 Dynamic risk factors, sexual
mood disorders, 70 reoffending in adults, 128129
personality development and
pathology, 71 Educational history, youth, 144145
posttraumatic stress disorder Educational reports, review, 135
(PTSD), 7172 Egotistical-antagonistic construct,
substance abuse, 71 adolescent males, 38
suicidality, 72 Eighth Amendments, 7
Department of Social Services, 4 Empirically guided clinical judgment,
Deposition, 116n.4 juvenile sex offender, 123124
Depression England, antisocial sexual
antidepressant medication case, behavior, 67
5556, 88 Estimate of Risk of Adolescent Sex
case study, 101102 Offender Recidivism (ERASOR),
delinquent youth, 69 161162, 166168
Depressive disorder, not otherwise Ethnicity, adolescent sexual behavior,
specified (NOS), 57 29
Developmental history Europe, cyproterone acetate (CPA),
caretakers, 142143 199, 218222
early infancy and childhood, Evaluation. See also Assessment;
141142 Clinical evaluation; Forensic
milestones, 143 Evaluation; Risk Assessment
parental history, 141 Academy of Child and Adolescent
prenatal and perinatal history, 141 Psychiatry (AACAP), 119120
Index 243
assessment of youth and family, confidentiality/privilege, 107110

130133 considerations before assessment,
competency to stand trial (CST), 134 129130
considerations prior to assessment, corroboration, 114
129130 court order, 111112, 132n.1
court appointed, 132n.1 custody hearing, 104105
guidelines for sexually abusive deposition, 116n.4
youth, 119121 doctor-patient relationship, 105106
Exhibitionism, 62t evaluator as investigator, 108109
Expert witnesses, courts, 103104 expert witnesses, 103104
impact on defendants, 110
Fact witness, 103, 104 interviewing defendant, 113114
Family objectivity, 108
assessment of youth and, 130133 objectivity and neutrality debate,
parental history, 141 104n.1
parental interview, 137139 potential for malingering, 109
record review, 135 process, 111116
youth development, 143144 purpose, 106
Family instability, juvenile sex recidivism risks, 127
offenders, 7374 referral/court order, 111112, 132n.1
Federal Bureau of Investigation reimbursement, 111, 134135
(FBI), National Incident-Based report writing, 109, 114115
Reporting System (NIBRS), 142 stress, 110111
Females testimony, 109, 116
mental disorders, 6970 Foster homes, placement for treatment,
mental illness and sexual offending 182183
case, 56, 8990 Fourteenth Amendment, 7
sexual abuse, 80, 8182
sexually abusive adolescent, 3537 Generation cohorts, adolescent sexual
Fluoxetine, 197, 208, 210, 211, 212 behavior, 30
Fluvoxamine, 197, 208, 210, 212 Genital behavior, label, 23
Follicle-stimulating hormone (FSH), Gonadotropin-releasing hormone
202203, 222, 223 (GnRH), 199, 202203
Followup, assessment, 153 Gosrelin, 223
Food and Drug Administration (FDA) Graham, Terence, sentence, 7
antidepressants and suicidality, 211 Graham v. Florida 2010, 7
medication approval, 197 Grooming, definition, 152n.2
Forensic evaluation. See also Group homes, placement for
Assessment treatment, 182183
attorney consultation, 112113 Guided clinical judgment, juvenile sex
background information, 113 offender, 123
case study, 101102, 117118
clarifying role in, 103105 Healthy masculinity and sexuality,
communication, 109 treatment, 186
complexity, 107 Hierarchical cluster analysis, sexually
confidentiality, 139 abusive adolescent males, 39
244 INDEX
Hormonal agents Jacob Wetterling Crimes Against

cyproterone acetate (CPA), 199, Children and Sexually Violent
218222 Offenders Registration Act, 8
luteinizing hormone-releasing JSOAP-II (Juvenile Sex Offender
hormone (LHFH) agonists, 199, Assessment Protocol-II), 78,
222225 161162
medroxyprogesterone acetate risk assessment, 164166
(MPA), 214218 risk factor, 43, 48
Hormones, sexual behavior, 200204 Judicial waiver, juveniles to adult
Hostile masculinity court, 6
confluence model, 4344 Just desserts model, juvenile
definition, 38 offenders, 5
Hypersexuality, personality construct, Juvenile arrests, adolescent males, 37
37 Juvenile justice, trends, 57
Hypothalamic-pituitary-testicular axis Juvenile offenders, types, 61
feedback loop, 202 Juvenile sex offenders
Hypothalmus, sexual behavior, abuse histories, 8083
202203 alcohol and substance abuse, 79
anxiety disorders, 76
Identifiable victim, duty to protect, attention-deficit/hyperactivity
107n.2 disorder (ADHD), 79
Illinois Sex Offender Registration conduct disorder (CD), 7980
Act, 11 evaluation, 119121
Impulse control, treatment, 186 family instability, 7374
Infancy, early, and childhood grooming, 152n.2
development, 141142 mood disorders, 76
In re Commitment of J. P. 2001, 14 neuropsychiatric pathology,
In re Commitment of R. S. 2001, 14 7576
In re Detection of Daniel personality pathology, 7679
Holtz 2002, 14 psychopathology, 7280
In re J. W. 2003, 11 registries, 912
In re S.M.M. 1997, 11 term, 4
Intelligence quotient (IQ), adult sex transfer statutes, 1213
offenders, 6768
Intercourse, first, for adolescents, Kanka, Megan, Megans Laws, 8
2627 Kansas v. Hendricks 1997, 1314
Internet, 46, 54, 64, 86, 140, KSADS-E (Kiddie Schedule for
148, 226 Affective Disorders and
Interpersonal involvement, personality Schizophrenia, epidemiologic
construct, 37 version), 74
Interviews
forensic evaluations, 113114 Legal history, youth, 146147
parental, 137139 Legal services, clinical and, 180
youth, 136137 Legislative waiver, juveniles to adult
Investigation, forensic evaluation, court, 67
108109 Leuprorelin, 223
Index 245
Level-of-care Mental abnormality, sexually violent

clinical guidelines, 176177 predator, 1314
criteria for appropriate, 175179 Mental disorders, males vs. females,
decision making, 178179 6970
psychophysiologic assessment Mental health evaluation,
methods, 177178 confidentiality, 139
Libido, medroxyprogesterone acetate Mental health records, review, 135
(MPA), 214 Mental illness, sexual offending case,
Life-course persistent, term, 13 56, 8990
Life-course persistent youth, Mentally handicapped
grouping constructs, 39 adult offenders, 6768
Lifestyle delinquency, sexually abusive youth offenders, 8283
adolescent males, 3839 Mental status examination, youth,
Limbic system, androgens, 201 152153
Lithium, 205206 Methylphenidate, 213
Locality, adolescent sexual behavior, Milestones, youth development, 143
29 Millon Clinical Multiaxial Inventory
Luteinizing hormone-releasing (MCMI)
hormone (LHRH) agonists, 199, juvenile sex offenders, 76
202203 Minnesota Sex Offender Screening
hormonal agent, 222225 Tool (MnSOST), 14
side effects, 224225 Minnesota Sex Offender Screening
studies, 223224 Tool-Revised (MnSOSTR), 14
Mood disorder, not otherwise specified
Males (NOS), 57
mental disorders, 6970 Mood disorders
sexually abusive adolescent, 3739 delinquent youth, 70
Malingering, forensic evaluation, 109 juvenile sex offenders, 76
Marshall and Barbaree model, sexual Mood stabilizers, lithium, 205206
offending, 6061 Multisystemic therapy (MST),
Masculinity, teaching healthy, 186 189190
Massachusetts Supreme Court, sex
offender registration, 11 Naive/experimenters, sexual
Masturbation aggression subgroup, 36
adolescents, 28 Naltrexone, 213
history, 147 National Incident-Based Reporting
Medical history, youth, 145, 146 System (NIBRS), FBI, 142
Medical records, review, 135 National Survey of Family Growth
Medications. See Pharmacologic (NSFG), 26
treatment National Survey of Sexual Health and
Medroxyprogesterone acetate (MPA) Behavior (NSSHB), 26, 2728
dosage, 214 National Task Force on Juvenile Sex
hormonal agent, 198199, 214218 Offending, 2
side effects, 217218 Nefazadone, 212
studies, 214217 Neurobiology, serotonin and sexual
Megans Laws, 8, 9 behavior, 208209
246 INDEX
Neuropsychiatric pathology, youth Personality development, delinquent

offenders, 7576 youth, 71
Nonsexual offending, 59 Personality pathology
Norfolk (VA) Juvenile Court Services adult sex offenders, 6667
Unit, 181 juvenile sex offenders, 7679
Normal behavior, 2122 Pervasively disturbed, sexual
Notification, sex offenders, 1112 aggression subgroup, 36, 37
Phallometric assessment, 177178
Objectivity, forensic evaluation, 108 Pharmacologic treatment
Obsessive-compulsive disorder (OCD), antidepressants, 208212
2, 54, 227 antipsychotics, 207
antidepressants, 197, 208209 case studies, 193195, 226228
Omnibus Crime Control and Safe divalproex sodium, 206207
Streets Act of 1968, 8 hormonal agents, 214225
Oral sex, adolescents, 28 lithium, 205206
luteinizing hormone-releasing
Paraphilias, 62t hormone agonists, 199, 222225
antipsychotics, 207 medications for sexual offending,
deviant sexual arousal, 6268 204213
lithium, 205206 medroxyprogesterone acetate
pharmacologic treatment in adults, (MPA), 198199, 214218
199200, 209210 mood stabilizers and
term, 23, 41 anticonvulsants, 205207
World Federation of Societies of naltrexone, 213
Biological Psychiatry (WFSBP), pediatric pharmacology, 196198
199, 205 sexual deviance in adults, 198200
Parental history, development, 141 stimulants, 212213
Paroxetine, 212 Placement options, treatment, 182184
Pathology, neuropsychiatric, 7576 Play therapy, sexual behavior
Patient-doctor confidentiality, 106 problems, 35
Patient Health Questionnaire (PHQ), Pornography
70 case study, 54
Payment, forensic evaluations, 111 risk factor, 4647
Pediatric pharmacology, 196198 sexual offending and, 148
Pedophilia, 62t Posttraumatic stress disorder (PTSD),
DSM-III-R criteria, 7475 35
intelligence, 6768 case study, 55, 102
prevalence, 2 delinquent youth, 7172
Pedophilic interests, 39 juvenile females, 36, 37
Pedophilic interests/antisocial prolonged exposure (PE), 188
youth, 39 residential treatment, 184
Peer influences, negative, and Preadolescent children, sexually
delinquency, 4748 abusive behavior, 140141
Perinatal history, development, 141 Prenatal history, development, 141
Personality constructs, sexual Prepubescent children, sexual
offenders, 37, 3839 behavior problems, 3435
Index 247
Privilege, forensic evaluation, 107108 distorted sexual beliefs and, 44

Promiscuity, adolescents, 28 Estimate of Risk of Adolescent Sex
Prosecutorial waiver, criminal court, 7 Offender Recidivism (ERASOR),
Psychiatric comorbidity, sexually 161162, 166168
offending youth, 5758 interpersonal factor predicting, 41
Psychiatric disorders, case of Axis I, rate and juvenile sex offenders, 3
8486 risk factors, 128129
Psychiatric history, youth, 145146 risk factors and traits, 78
Psychiatry, adolescent female case, sexual interest predicting, 42
101102 sexual offense, 910
Psychological testing, youth, 153 Referral source
Psychopathology clarifying assessment questions and
adult sex offenders, 6467 goals, 134135
case studies, 5457, 8391 forensic evaluations, 111112
juvenile sexual offenders, 7280 Registration, sex offender, 812
mentally handicapped and Registries, juveniles and sex offender,
developmentally disabled adult 912
offenders, 6768 Rehabilitation, youth as juveniles, 6
paraphilias, 62t Reimbursement, forensic evaluations,
paraphilias and deviant sexual 111, 134135
arousal, 6268 Relapse prevention, treatment, 187
psychiatric comorbidity in sexually Reporting laws, 45
offending youth, 5758 Report of the Task Force on Children
theories in sexual offending With Sexual Behavior Problems,
development, 5961 22
Psychopathy Report writing, forensic evaluation,
measures assessing, 168170 109, 114115
risk factor, 4041 Residential treatment, specialized,
Psychopathy Checklist: Youth Version 184185
(PCL:YV), 7778, 162, 168170 Reverse transfer, adult court, 7
Psychopathy Checklist-Revised Risk assessment. See also
(PCL-R), 168 Assessment
Psychophysiologic assessment, actuarial measures, 162163
177178 adult sex offender, 127
Psychosocial deficits, adolescent anamestic assessment, 123
males, 38 clinical judgment based on history,
Psychosocial immaturity, 123
adolescents, 13 considerations prior to, 129130
Psychotic illness, delinquent youth, 69 empirically guided clinical
judgment, 123124
Rapid Risk Assessment for Sexual Estimate of Risk of Adolescent Sex
Offenses (RRASOR), 14 Offender Recidivism (ERASOR),
Recidivism 161162, 166168
adult sexual offenders, 59, 127 general approaches, 122125
case of Aspergers and ADHD, goals of, 126127
8688 guided clinical judgment, 123
248 INDEX
Risk assessment (Continued) Sex offender registries, juveniles and,

Juvenile Sex Offender Assessment 912
Protocol-II (JSOAP-II), 161162, Sex Offender Risk Appraisal Guide
164166 (SORAG), 14
psychopathy, 168170 Sexual abuse
pure actuarial assessment, 124125 caretakers, 142143
structured clinical judgment, developmentally disabled offenders,
123124 8283
Structured Professional Judgment juvenile sex offenders, 8083
(SPJ), 163164 mentally handicapped offenders,
unstructured clinical judgment, 8283
122123 nature and evolution of aggressive
Risk factors behavior, 150152
childhood sexual victimization, reporting laws, 45
4445 youths history, 148150
deviant sexual interests, 4143 Sexual activity
distorted sexual cognitions, adolescents, 2729
4344 first exposure and evolution of
endogenous, 4044 exposure to, 147148
exogenous, 4448 Sexual aggression
exposure to pornography, 4647 subgroups of youth, 3637
exposure to violence, 4546 term, 2
negative peer influences, 4748 Sexual behaviors
psychopathy and antisocial adolescence, 2630
orientation, 4041 biologic determinants, 200204
recidivism, 128129 compulsive, 213
Roberts, Chief Justice, 7 early childhood, 2324
Roe v. Attorney General 2001, 11 middle childhood, 2426
Roper v. Simmons 2005, 7 neurobiology and serotonin,
208209
Safer sex practices, 30 problems of prepubescent children,
Schedule of Affective Disorders and 3435
Schizophrenia (SADS), 68 treatment algorithm, 199200
Schizophrenia, 55 Sexual cognitions, distorted, as risk
Selective serotonin reuptake factor, 4344
inhibitors (SSRIs), psychotropic Sexual history, youth, 147148
medications, 198, 209212 Sexual intercourse
Self-image, sexual offending, 6061 ethnicity and locality, 29
Serotonin, neurobiology of sexual first, for adolescents, 2627
behavior, 208209 Sexuality, teaching healthy, 186
Sertraline, 197, 208, 210, 212 Sexually abusive youth. See also Risk
Sex drive, medroxyprogesterone assessment
acetate (MPA), 214 guidelines for evaluation of,
Sex Offender Registration and 119121
Notification Act (SORNA), 8 Sexually reactive, term, 141
Index 249
Sexually traumatized, sexual Structured Professional Judgment

aggression subgroup, 36 (SPJ), risk of sexual offending,
Sexually Violent Predator (SVP) 163164
commitment laws, 1314 Substance abuse
Virginia, 197n.1 delinquent youth, 71
Sexually Violent Predator/Sexually juvenile sex offenders, 79
Dangerous Person (SVP/SDP) sexual offending case, 5657, 9091
Acts, 226 Suicidality
Sexual masochism, 62t antidepressants, 211
Sexual offender delinquent youth, 72
castration, 225226 Super-predator, 56, 1213
notifications, 1112 Surgical castration, 225226
registration, 812 Survey data
review of adult, 5859 adolescence, 26, 2729
risk factors, 3948 Child Sexual Behavior Inventory
term, 34, 59 (CSBI), 23
theories, 5961 parents, 23, 25
Sexual offending sexual offenses, 12
medications for treatment, Sweden, self-reported sexual contact,
204213 25
sexual abuse history, 148150
theories of, 5961 Tarasoff v. Regents of University of
Sexual orientation, 2829, 227 California 1976, 107, 107n.2
Sexual sadism, 62t Terminology, 25
Sexual victimization, childhood, as Testimony
risk factor, 4445 deposition, 116n.4
Smith v. Doe 2002, 10 forensic evaluation, 109, 116
Social development, youth, 143 Testosterone
Social skills training, treatment, cyproterone acetate (CPA), 219221
185186 sexual behavior, 201204
Stable dynamic factors, sexual Theories, sexual offending, 5961
reoffending in adults, 128129 Ticking demographic time bomb,
Starting point, sexual behavior, 30 violence, 6
STATIC99, 14 Time, sexual behavior over, 30
STATIC2002, 14 Topiramate, 207
Static risk factors, sexual reoffending Transfer statutes, juvenile sex
in adults, 128 offenders and, 1213
Statistics, 12 Transvestic fetishism, 62t
Stimulants, 212213 Treatment
Stimulus-response association, 188 adjunctive therapies, 187188
Stimulus-stimulus association, 188 alternative placement options,
Stress, forensic evaluations, 1 182184
10111 community-based, 179184
Structured clinical judgment, juvenile core areas of therapeutic focus,
sex offender, 123124 185188
250 INDEX
Treatment (Continued) Wraparound Milwaukee program,

determining appropriate level of 181
care, 175179
outcomes, 189190 Youth. See also Delinquent youth
psychophysiologic assessment assessment of, and family, 130133
methods, 177178 caretakers, 142143
specialized residential, 184185 developmental history, 139144
treatment as usual (TAU), 189 developmentally disabled offenders,
Virginia Department of Juvenile 8283
Justice, 3, 76, 176 developmental milestones, 143
Tricyclic antidepressants, 209 early infancy and childhood,
Triptorelin, 223 141142
educational history, 144145
Unstructured clinical judgment, family, 143144
juvenile sex offender, 122123 interviewing, 136137
juvenile justice and criminal
Verbal satiation therapy, 188 management, 57
Victim empathy, treatment, 187 legal history, 146147
Victimization, childhood sexual, medical history, 145, 146
4445, 8082 mentally handicapped offenders,
Violence 8283
exposure to, 4546 mental status examination,
juvenile arrests, 37 152153
juvenile sex offenders, 7273 parental history, 141
risk assessment objectives, 126127 prenatal and perinatal history, 141
risk factor, 4546 psychiatric history, 145146
Violent crime, juvenile, 56 psychological testing, 153
Virginia Department of Juvenile record review, 135
Justice (VADJJ), 3, 76, 176 sexual abuse history, 148150
Virginias Sexually Violent Predator sexual history, 147148
legislation, 197n.1 sexually aggressive behavior,
Voyeurism, 62t 150152
social development, 143
The Weekly Standard, 6 timing and location of interviews
World Federation of Societies of with, 135136
Biological Psychiatry (WFSBP), Youth Risk Behavior Survey (YRBS),
199, 205 26

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Published by Oxford University Press, Inc.

Oxford is a registered trademark of Oxford University Press, Inc.

All rights reserved. No part of this publication may be reproduced,

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America

To my wife, Linda, whose unflagging support and

1. Changing Perceptions of Juvenile Sexual Offending in Society

2. Placing Sexual Behavior Problems in Context: What Is Normal

3. Patterns of Sexual Offending in Juveniles and Risk Factors 34

4. Juvenile Sexual Offending and Psychopathology 54

5. Forensic Evaluation Versus Clinical Evaluation: How Do They Differ? 101

6. Interviewing, Evaluation, and Risk Assessment of Sexually

7. Assessment Instruments for Juveniles Who Sexually Offend 161

8. Management and Treatment Methods 175

9. Biological and Pharmacologic Treatment of Sexually

Juveniles are responsible for a significant percentage of sexual abuse in the

evaluation and sexual offending. We also anticipate that experienced forensic

Changing Perceptions of Juvenile

Paraphilias are characterized by recurrent, intense sexually arousing fan-

Understanding societys response to youthful sexual offenders requires an

ability to retain jurisdiction regardless of the youths specific circumstances

Recent Court Decisions

Juveniles and Sex Offender Registries

juveniles in the registry should not be automatic. The Massachusetts Supreme

1. Careful consideration of the individual juveniles placement in a sex

Adolescents convicted of sex offenses in criminal court may be subjected to

personality disorder is likely to engage in predatory acts of sexual violence

Redding, R. E. (2003). The effects of adjudicating and sentencing juveniles as

property crimes: A 10-year follow-up. Sexual Abuse: A Journal of Research and

Placing Sexual Behavior

Studies suggest that at virtually every stage of childhood, children engage in

surprisingly, these retrospective reports tend to describe more sexual behavior

a) Compared to preschool children, children of elementary school age

b) A substantial portion of elementary and middle school age youth (as

Compared to the limited data on sexual behaviors in childhood, we have

Overview of Adolescent Sexual Behaviors

Adolescent Sexual Activity

Oral sex is prominent among adolescent sexual behaviors, according to

identified themselves as gay (1.8%). Conversely, many more females identified

Adolescent Sexual Behavior Differs by Ethnicity and Locality

Adolescent Sexual Behavior Differs Over Time

Intuitively, we might assume that rates of teenage sexuality steadily increase

Most juveniles engage in a variety of sexual behaviors beginning in early child-

In determining whether sexual behavior is inappropriate, it is important

In short, considering whether a behavior is normal is just a first step.

Promotion, Indiana University) Center for Sexual Health Promotion, Indiana

Patterns of Sexual Offending in

Youth who engage in sexual offending behavior represent a heterogeneous clin-

Professional and media attention is generally directed at adolescents who

Within the larger population of adolescents who engage in sexually abusive

Adolescent males account for the preponderance of juvenile arrests for

personality traits and behavioral impulsivity. Hierarchical cluster analysis was

Endogenous Risk Factors

Three personality constructs that have received particular attention in the

Psychopathy and Antisocial Orientation

based on punishment paradigms (Frick, 2009). This may be due to neurological

Deviant Sexual Interests

to nondeviant sexual arousal upon phallometric assessment, and the highest

Distorted Sexual Cognitions