Introduction

Sex offender treatment programs and sex offender specific therapies have proliferated in recent years. With the passage of Megan’s law implementing sex offender registries, the development of Parole Supervision for Life (PSL), Community Supervision for Life (CSL), and Civil Commitment for Sex Offenders; the treatment; and management of those who have committed sexual offenses have been at the forefront of the agenda of the law enforcement agencies entrusted to implement the above mentioned policies and procedures [1]. While the execution and oversight of these strategies have been primarily within the purview of departments of corrections and law enforcement, much of the actual treatment of the offender has been prepared and delivered by those involved in mental health disciplines. Given that most treatment of sex offenders occurs following the discovery (i.e., arrest) of illegal sexual activity, the primary focus of treatment has predominantly consisted of curbing the illegal or offending behaviors/interests. The result is that the development of healthy sexuality has received little attention and has been poorly addressed [2].

This review will examine the current, although limited, literature on the development of healthy sexuality for sex offenders, as well as some of the controversies surrounding sex offender specific therapies. It is our contention that a reconsideration of these areas will lead to better and more effective treatment and management strategies of sex offenders, and an improvement in our ability to assist these offenders in the development of sexually happier and more fulfilling lives while being able to function within the parameters of society’s standards for legal behavior. We recognize that the umbrella term “sex offenders” encompasses diverse individuals and that the goal of developing healthy sexuality will similarly require a broad understanding of this concept.

Treatment Approaches

As mentioned above, there is scant literature regarding the development of healthy sexuality in sex offenders. Perhaps this is not surprising given that suppression of sexual interest, drives, and behaviors has historically been the focus of sex offender treatment. However, there is also little research regarding the development of healthy sexuality in non-offending individuals. According to the World Health Organization [3], healthy sexuality encompasses a positive and respectful approach to sex, as well as the possibility of having pleasurable and safe sexual experiences. On a societal level, this requires access to accurate and comprehensive information about sex, access to sexual health care, and an environment that promotes a respectful approach to sex. According to Marshall, et al. [2], healthy sexuality requires good sexual communication, being able to express sexual needs, and having the ability to initiate wanted sex, and the ability to decline unwanted sex. In essence, Marshall and his colleagues are of the opinion that without such relational know-how, sex offenders often find consensual sex with a partner to be anxiety provoking and unsatisfying. Sex offenders will also need to be able to recognize and define for themselves what is “wanted” and “unwanted” sex.

Unfortunately, most sex offender treatment programs have done a rather meager job of addressing and fostering these skills. A review of sex offender treatment programs suggests that while sex education is offered, such education is focused on sexual anatomy and physiology, sexually transmitted infections, and sexual dysfunctions. In addition, most sex offender treatment programs approach sexual behavior, and sexual behavior change, from an aggressive, confrontational model that emphasizes admitting guilt and halting problematic sexual behavior rather than developing healthier attitudes regarding sexuality and sexual interactions [4, 5]. Relatively little attention is given to the exploration of why those who commit sex offenses do so, and why they have been unable to achieve satisfying sexual relationships through more appropriate, healthy means.

In essence, most models of sex offender treatment do not typically attend to the development of healthy sexuality or healthy sexual behavior, but rather to the control of the offending behavior. Specifically, most programs have tended to focus on eliminating the offending behavior, confronting cognitive distortions that may lead to offending, and reducing the risk of re-offending. As a result, most sex offender specific models of treatment are primarily punitive, sex-negative, and suppression-oriented as opposed to identifying areas of strength and building toward the development of a healthy perspective toward sexuality.

What Is “Healthy Sexuality?”

While the dearth of research and literature on the development of healthy sexuality for sex offenders is clearly problematic, the issue is further complicated by the subjective nature of the concept of healthy sexuality. What exactly is “healthy sexuality?” Who decides what is healthy sexuality as opposed to “unhealthy sexuality?”

Recent revisions to the DSM (DSM5; American Psychiatric Association [6] and the ICD [7]) have highlighted the difficulty that psychiatry and psychology encounter in defining the parameters of healthy and unhealthy sexuality. Paraphilias, broadly defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” [6], were once considered deviant sexual interests that in and of themselves warranted a diagnosis of a mental illness. Now both the DSM 5 and the ICD 11 focus on harm and consent as diagnostic markers of paraphilic disorders, noting that a paraphilia in and of itself no longer warrants a psychiatric diagnosis. Thus, although the DSM 5 continues to list voyeuristic, exhibitionist, and fetishistic disorders in the category of paraphilic disorders, harm and lack of consent are central to the diagnoses. Both the ICD-11and the DSM 5 include a separate diagnostic category of Coercive Sexual Sadism Disorder which requires the infliction of physical or psychological harm on a non-consenting person. Pedophilic disorder requires a sexual interest in prepubescent children that is sustained, recurrent, and intense. Either personal distress or having acted on these sexual urges is required for the diagnosis. Harm and lack of consent are implicit in the choice of children as the erotic target. These revisions to the major diagnostic manuals reflect data attesting to the high prevalence of interest and engagement in consensual power-based sexual practices. Survey data from the USA, Canada, Belgium, and other parts of Western Europe show that a high proportion of men and women are interested in and have engaged in paraphilic sex, most commonly fetish play, group sex, and BDSM–related activities (e.g., restraints, blindfolds, spanking) [8,9,10,11]. The widespread popularity of these fantasies and behaviors raises the question of whether a paraphilia is accurately described as an unusual or atypical sexual interest. While such diagnostic changes have reduced the stigma of pathology associated with some sexual behaviors in non-offending populations, they provide little guidance as to how to ascertain what is meant by “healthy” sexuality. We are left with the vague definition that a sexual interest is healthy if it does not cause distress, and sexual behavior is healthy if it does not involve inflicting harm on a non-consenting person.

More recently, it has been proposed that sex may be more helpfully construed as a leisure activity such that individuals with diverse sexual interests might be able to access guidance without risking the stigmatization often encountered when interacting with medical and psychological professionals. Noting that everyone including sex offenders has a right to leisure, these authors note that the principles of open and honest communication and navigating risk in fulfilling leisure goals may help sex offenders more positively reintegrate into society [12]. In essence these authors are making a bold proposal, that instead of eliminating a dangerous sexual interest, experts might instead consider how such an interest could be safely and legally achieved much as the desire to jump out of an airplane (use a parachute), or jump off a bridge (bungee cords), or soar across a deep gulley (hang glide or zip line) can be safely navigated. Even with this proposed conceptualization, we are still looking to re-shape or control negative or problematic sexual behaviors, as opposed to being able to identify what promotes healthy sexuality. It would appear that every time we try to identify the keys to healthy sexual behavior, we end up defining it as the absence of offending behavior. In other words, our efforts with sex offenders continue to be those of control as opposed to spontaneous enjoyment of sex. As a result, we have often conflated “healthy” sexual behavior with “legal” sexual behavior.

Healthy Sexuality for Sex Offenders

Those in the field of providing therapy and education for sex offenders are still somewhat stymied by the more vexing question of what constitutes healthy sexuality for sex offenders. While an interest in playing with power dynamics is common and healthy for consenting adults, is it healthy for someone convicted of sexual assault? Role playing with an adult partner a fantasy of sex with a naïve young girl or boy may be erotic fun for some couples, but what if one member of the couple has sexually acted out with a child? More importantly, are these behaviors raising the risk that harm will eventually occur to others? There is no ethical way to empirically investigate whether engaging in sexual fantasies of children or other non-consenting partners helps offenders control their behavior or takes them one step closer to acting out. Despite evidence that strongly suggests that paraphilic arousal does not equate to criminal behavior, the treatment of sex offenders has persistently focused on efforts to eliminate their deviant interests instead of attempting to identify those components of healthy (non-offending) sexual behaviors.

There is currently a robust, but limited, debate regarding whether sexual interests and arousal can change. Specifically, the debate centers around claims that pedophilic sexual interests can be eliminated, claims that appear to emanate from only one clinic [13•]. The prevailing professional consensus however is to “accept the sexual interest pattern, and in this instance manage the behaviors it motivates” [14•]. While Federoff cites evidence that sexual orientation and attraction are fluid [15] what he fails to note is that such changes are part of a more complex and comprehensive evolution of developmental, psychological, relational, and situational factors that may lead individuals to experience and explore different sexual interests, behaviors, and relationships. As mental health professionals, we have been much more efficacious in controlling, managing, and/or containing the expression of offending sexual behavior than we have been in helping our patients or clients find erotic intimacy and sexual fulfillment.

A Trauma-Informed Perspective

Rather than a treatment that primarily focuses on stopping or controlling sexually offending behavior without a consideration of what factors or experiences may be driving that behavior, Levenson, Willis, and Prescott [16•] suggest that a deeper understanding of those factors that may actually lead one to offend may guide treatment in a more effective direction. Levenson and her associates believe that much of sexually offending behavior has its roots in early childhood trauma that may be sexual or non-sexual in nature. This is in keeping with the fact that deficits in attachment and coping are both theoretically and empirically identified as key to the motivations for sexual offending [17]. A trauma-focused approach also makes sense given that what appears to be unhealthy about sex offenders’ sexuality is the often-repeated engagement in coercive sex. It is a reasonable hypothesis to assume that an offender’s sexuality developed in a context in which, in addition to a disruption in attachment, there was also an abuse of power.

While childhood sexual abuse is the most often studied trauma in relationship to sex offending, it is important to note the co-occurrence of the various forms of trauma. Most involve a violation of trust, a sense of betrayal, and an impact on one’s sense of personal safety. Sexual and nonsexual childhood trauma (physical abuse, severe neglect) have been linked with adverse sexual outcomes including disinhibited sexuality [18••]. Childhood traumas such as parental neglect, parental loss, parental or caretaker substance abuse, parental or caretaker mental illness, and/or parents who are smothering can all be traumatizing to a child and result in parentification and alienation from the self. Children learn that the world is not a safe place nor a place that will nurture or care for them. They learn to deal with these traumas using immature but adaptive skills that may have helped them survive in their childhood environments. However, these same strategies often work poorly in adult relationships and interfere with a person’s ability to establish intimate connections and relationships with others. This concept has been discussed in detail by Miller [16•, 19, 20•, 21].

Shifting the focus from “behavior as the problem” to behavior is a symptom of traumatic event(s) that allows sex offender treatment to move into a decidedly different treatment paradigm. Trauma therapists have often suggested transforming the question of “What’s wrong with you?” to “What happened to you?” [16•, 21]. This removes much of the punitive, aversive, and control-oriented aspects from treatment and allows for a more individualized approach. It also allows for a more positive, motivational, “strength based” approach as advocated by Marshall et al. [4] that focuses on patient/client strengths and positives rather than patient/client deficits.

An Integrated Approach to Sexual Health in Sex Offender Treatment

If we now return to the comments of Marshall, Hall, and Woo [2], and their assertion that healthy sexuality requires good sexual communication, being able to express sexual needs, the ability to initiate wanted sex, and the ability to decline unwanted sex, we see that simply focusing on the development of such skills, while laudable, may not be sufficient to encourage a healthy sexuality for sex offenders. Many treatment programs have assumed that new interests and desires can be taught or conditioned. Research of therapy outcomes for sex offender specific therapy has not supported this assumption, although several studies have indicated that treatment does, indeed, reduce recidivism [22]. If however we understand Marshall et al. to be saying that the development of healthy sexuality requires the ability to relate to oneself, and perhaps other adults, as a sexual being a trauma-based approach makes sense. A trauma-informed treatment that looks to identify and address early childhood trauma recognizes the trauma response’s once adaptive nature and attends to how such behavior can be problematic in adulthood and may provide an approach to the treatment of sex offenders that allows them to form the intimate, non-exploitive connections that seem to be foundational for the development of healthy sexuality.

If we look to the necessary conditions, according to the WHO, for the development of healthy sexuality we will find another key aspect to add to sex offender treatment, an environment that promotes a positive and respectful approach to sex. Philosophically, sex therapists would describe their approach to understanding sexuality and sexual behavior as “sex-positive.” That is, they approach sexuality through the lens of sex being a positive force and they advocate freedom of sexual expression. This is not to say that they encourage illegal or harmful sexual behavior but they do focus on sexuality as something to be celebrated, expressed, and enjoyed in a positive manner. This stands in contrast to the often punitive or sex negative approach of many sex offender treatments.

Importantly, sex therapy has been a useful treatment approach for individuals seeking to experience sexual pleasure disrupted by a traumatic past. Hall [23••] in her review of the literature notes that dissociation, emotional avoidance, and aversion can disrupt the experience of sexual pleasure, and she argues that sex therapy techniques such as sensate focus and mindfulness can help restore that connection. Indeed, beyond a trauma focus, sex therapy has much to offer and inform regarding the treatment of sex offenders. The treatment literature regarding sexual pain, for example, provides a path to help individuals overcome sexual fears, to reexperience their bodies in a pleasureful way, and to facilitate communication with a partner. The tools to respect boundaries and navigate consent and communication can be found in the literature of the Kink community [24••].

The sex positive approach of sex therapy may help to broaden the range of acceptable sexual activities for sex offenders who may have no interest in having sex with adult partners but may prefer solo sex, online fetish rooms, or role plays. The risk has always been that encouraging exploration of alternate sexual outlets and engaging in deviant sexual fantasies will lead to the likelihood of acting out. As we stated previously, this remains a point of controversy and not one that has the possibility of being empirically tested. However, a discomfort and ignorance of the range of healthy, pleasurable, and consensual sexuality may also drive the restrictive treatment goals.

Unfortunately, sex therapy and sex offender specific therapy are considered to be distinct therapeutic modalities. Sex therapists, who claim expertise in helping people overcome sexual difficulties such that they can have more fulfilling sex lives are reluctant to work with sex offenders [25], while sex offender specialists likely lack the requisite training and expertise in therapeutic approaches to improving sexual pleasure. Sex offender therapists often come from training backgrounds more forensic in nature. The dominant discourse in sex offender specific therapy training is that of sex as deviant or pathological and in need of control. We would hope that sex therapy and sex offender therapy could unite in a shared mission to expand their treatment focus to help traumatized individuals, regardless of their legal status, experience, and express their sexuality in positive and healthy (legal) ways.

Conclusions

Our attention to the management of sexual behaviors has led to a diminished, and perhaps impoverished, curiosity and understanding of what it is that is driving problematic sexual behavior and also moves us further from an understanding of what leads to “healthy” sexual behavior. Sex offender specific therapy has become such a specialized field that it may have become isolated from the larger world of psychotherapy, and its useful conceptualizations of human behavior and existence [26]. If healthy sexuality is a goal for sex offender treatment such isolation must give way to integration. A trauma-informed approach to sex offender treatment would help build the foundation necessary for healthy and pleasurable sex. Incorporating concepts and techniques from sex therapy offers a pathway to expand the experience of sexual pleasure by targeted interventions that help individuals alleviate the anxiety, emotional dysregulation. and dissociation that may disrupt sexual pleasure [23••]. A forensic approach facilitates the maintenance of clear boundaries and behavior. Of course, there are obvious obstacles to helping sex offenders experience fulfilling sex lives, yet rather than deal with those obstacles we stubbornly try to change sexual interests and suppress the offender’s sexual desires. While this approach has met with little success in assisting sex offenders to live happier and more fulfilling lives, we have thus far refused to shift our efforts.