What should we do with child sex offenders?

It's very reasonable for Tony Delamothe to stimulate discussion on
what is perhaps society's most pernicious evil. But whilst seeming to ask
for consideration for paedophiles,and appearing critical of expressions of
revulsion among ordinary citizens, he doesn't come up with any
answers.This is an unreasonable luxury and seems to fly in the face of
mounting pressures for more attention to be given to victims rather than
perpetrators of crime. Whilst doctors may have a duty to lead society in
more civilised directions, they also have a duty as its servant to
recognise the feelings of the public.

In many ways, paedophile crimes are worse than murder because of the
terrible psychological damage they do and because the violated victims
frequently adopt the habit themselves, thereby spreading the damage
through society. But just as with alcohol abuse, the British public seems
unwilling to confront paedophilia with the energy the problem deserves.
Indeed, there can be a shocking, sniggering fascination for the crime,
often in the form of tasteless jokes, amongst all classes. This suggests
that Delamothe's vituperative old lady, or the prisoners who assault child
abusers, may merely be looking into a cultural mirror and being revulsed
by what they see.

In fact Delamothe does touch upon the solution. He states "if anti-
libidinal drugs are taken, rates of re-offending are very low". It
wouldn't be difficult to arrange that serious offenders received full life
imprisonment unless willing to accept long-term hormonal implants or even
elect for surgical solutions. The author would do the victims of the
crime, and paedophiles, a better service by conducting a debate as to why
society doesn't have the courage or the will to adopt the evidence he
reminds us of.

I agree with Delamothe's argument that doctors need to do better in
their attitudes and therapeutic approaches to child sex offenders1. The
concern to which sexual offences in particular give rise is a result of
the physical and emotional damage that they cause, but is also influenced
by society's general difficulties in addressing a whole series of issues
connected with sexuality, from adolescent pregnancy or birth control to
sexual diversity among adults. Most sexual assaults and even murders of
children are committed by people known to them. The latter sometimes
includes close family members, even parents. To put it simply, children
are more at risk in their own homes than from random molestation in the
street2.

Multi-factorial models of sexual offending stress the importance of
both individual and socio-cultural factors in sexual abuse, where such
factors are seen as complimentary rather than in opposition to one
another3. Meta-analyses of treatment outcomes have shown that the most
successful programmes are those which target the specific criminogenic
behaviours involved. There is currently a widespread, though by no means
unanimous view that 'offender rehabilitation' can be practical, achievable
and cost-effective. However, the largest treatment provider in the UK for
sexual offenders in the community is the Probation Service4, which runs
accredited programmes that conform to standards of design, range of
methods used, appropriate targeting, sequencing, motivation and
evaluation. NHS and primary care provision is minimal.

Most people who commit sexual offences against children cannot be
accurately described as paedophilic. The latter is a diagnostic category
within psychiatry, requiring the presence of certain characteristics found
only in a proportion of, probably somewhere between 25 and 40%, of
offenders against children5. Contrary to what some might believe, the term
conveys no information whatsoever about an individual's character,
temperament, attitudes, or intellectual level, nor does it convey any
information about either the presence or absence of additional co morbid
psychiatric diagnoses.

The fundamental treatment focus in working with a child sex offender
must be directed toward his/her disordered sexuality. However, it is the
psychiatrist who can provide the necessary lifeline to sex offenders
through a combination of therapeutic confrontation, relapse prevention
guidance, emotional support, and pharmacological treatment that can enable
them to succeed on the Probation Service programmes. It's a pity that we
are not doing so!

1. Delamothe T. What should we do with child sex offenders? BMJ 2011;
343:d6908. (29 October)

2. McGuire J. Pathways to offending behaviour. In: Understanding
psychology and crime. Open University Press, 2006: 96-100.

3. Middleton D. Current treatment Approaches. In: Calder MC, ed. Child
Sexual Abuse and the Internet: tackling the new frontier. Russell House
Publishing Ltd, 2004: 99-112

4. Fisher D, Beech AT. Current Practice in Britain with Sexual Offenders.
Journal of Interpersonal Violence 1999; 14:3, 240-56

5. Grubin D. Sex Offending Against Children: Understanding the Risk.
Police Research Series Paper 99. London: Home Office Policing and Reducing
Crime Unit, 1998.