Men with learning disabilities at risk of sexual

Men with learning disabilities at risk of sexual offending: the effectiveness of treatment Glynis Murphy Institute for Health Research University of Lancaster

The plan z. What is known about non-disabled sex offenders z. Treatment for non-disabled sex offenders: what it consists of and whether it works z. What is known about sex offenders with learning disabilities z. Treatment for sex offenders with learning disabilities

Effects of sexual abuse on victims z Not all studies use good samples, standardised measures or control groups (see Browne & Finklehor, 1986; Tufts 1984; Russell, 1986) z Initial effects (within 2 yrs): 40 -60% have sleeping & eating problems, fears & phobias, guilt & shame, anger, disruptive behaviour & aggro (kids), sexualised behaviour (kids), running away (kids) z Long-term effects: ~25% have depression; many show anxiety attacks, sleeping difficulties, feeling stigmatised, low self-esteem, fear of intimacy, sexual problems & they are more likely to be abused again. z Worse if longer, if perpetrator is father &/or is older, if force used, if penetration occurs, if victim is pre-pubertal.

Sexual offending by non-disabled men z Grossly under-reported to police (fewer than 10% sex crimes lead to conviction) z Victim surveys suggest very high rates (eg 50% women victims of exhibitionism; USA study of college students showed 15% women victims of rape; further 12% victims of attempted rape)- see Marshall, 1999. z > 95% of sex offenders are men z Offenders often engage in grooming & stalking of victims; may do complex planning of offending z Used to be thought sex offenders usually have one paraphilia (deviant sexual interest), only target 1 age group, and target either inside or outside family. Recent data challenges these views.

Sexual offending by non-disabled men z Most studies look at convicted men (biased samples), interviewed in CJS settings, where men reveal only 5% of offences (Kaplan, 1985) z Abel & Rouleau (1990): sample of 561 men, voluntary, anonymous, confidentiality guaranteed z Age: mean 32 yrs (range 13 -76 yrs) z All socioeconomic groups represented; 67% working z Often early onset: Over 50% said they had one or more deviant sexual interest before age 18 yrs z Of these 50%, on average they had committed 380 offences by the time they were adult

Abel & Rouleau data Paraphilia No. of acts committed Paedophilia – F. No. men asked 224 5, 197 Total victims 4, 435 Paedophilia – M. 153 43, 100 22, 981 Paedophilia – F. I. 159 12, 927 286 Paedophilia – M. I. 44 2, 741 75 Rape 126 907 882 142 71, 696 72, 974 62 29, 090 26, 648 62 52, 669 55, 887 Exhibitionism Voyeurism Frottage

Treatment for non-disabled sex offenders: recent years z 1960 s & 1970 s: Sexual abuse seen as result of deviant sexual interests & arousal (there was also some occasional recognition of role of poor social skills) z Led to techniques such as aversion therapy, orgasmic reconditioning & covert sensitisation - basically behavioural techniques z Considerable belief in medical model & antiandrogens z Little evidence of effectiveness z Under-provision of treatment

Wolf’s (1985) model of cycle of offending

The role of cognitions z 1980 s: Recognition of role of cognitions & cognitive distortions in sexual offending (denial, victim blaming, minimisation, etc) eg Finklehor, Abel, Marshall z Denial: ‘It wasn’t me, they’ve got wrong guy’ z Victim blaming: ‘He led me on all the time’, ‘She wanted me to’ z Minimisation: ‘It’s good for children to learn about love this way’ or ‘I didn’t hurt her - it was just a bit of fun’ z Importance of peer challenges in changing these distortions

Finklehor’s 4 pre-conditions 1. Offender must be motivated to offend 2. He must overcome internal inhibitions (e. g. by telling himself it is just a bit of fun) 3. He must overcome external obstacles to offending (eg by finding privacy & victim) 4. He must overcome the victim’s resistance (eg by ‘befriending’ them)

Marshall’s model of sex offending

Components of cognitive behavioural treatment z. Enhancing self-esteem z. Challenging & changing cognitive distortions z. Developing victim empathy z. Developing social functioning z. Modifying sexual preferences z. Ensuring relapse prevention See Marshall et al. ’s book for an excellent guide

But does it work? (Hanson et al, 2002) z Meta-analysis of 43 studies of sex offender treatment (over 9, 000 participants overall) z Sexual offence recidivism rate: 12% for treated men vs 17% for untreated men z General offence recidivism rate: 28% for treated men vs 39% for untreated men z Early forms of treatment ineffective; but current cognitive-behavioural treatment seems effective: 10% vs 17% treated vs untreated recidivism

Men with learning disabilities at risk of sexual offending: numbers z Methodological difficulties: different samples (prison, hospital, community); ignoring filtres & diversion in CJS; suggestibility & evasion issues z Early studies: ? high prevalence of offending but v. poor methodology (eg. prison studies; & Walker & Mc. Cabe (1973) study) z 50% of perpetrators of sexual abuse in LD services themselves have LD (Brown et al, 1995) z Susan Hayes (1991): Prison survey found 4% of offenders with LD had been convicted of a sex offence (& ditto for non-LD)

Men with learning disabilities at risk of sexual offending z Recidivism: Klimecki et al (1994) found recidivism rate was 31% in men with LD convicted of sex offences (Austr. ) - about 2 -3 X as high as that of non-disabled men z Types of offence: all kinds, but maybe fewer penetrative offences – Murrey et al, 1992 (or more often caught early because more closely supervised? ) z History of abuse: Lindsay et al (2001) found 38% of sex offenders with LD had been abused c. f. 13% non-sex offenders with LD

Men with learning disabilities at risk of sexual offending (cont’d) z Victims mainly children or other people with LD (less often non-disabled adults) z Victims very likely to be known to the perpetrator z Offences more opportunistic & less planned (less grooming & stalking) z Often long history of sexual problems & multiple placements z Often ‘offences’ not reported to police z Even when reported, men mostly not prosecuted nor treated

Cognitive behavioural treatment for men with & without LD in UK z For men without LD, group CBT recognised as the leading method of treatment (Hanson et al) z Beckett et al. have evaluated: CBT for convicted sex offenders in prison sentenced to 4 yrs+ (SOTP) & community-based programmes (STEP), run by probation, clinical psych & SW z Men with LD mostly excluded from these: group CBT in few places only - some prisons (ASOTP), Janet Shaw clinic in Solihull (ASOTP), Northgate hosp programme near Newcastle, Bill Lindsay’s programme in Scotland

Does group CBT work for men with LD? z Lindsay et al (1998 a, b) showed some improvements in 6 men with LD & paedophilic offences & 4 men with LD & exhibitionism, after CBT z Lindsay & Smith (1998): showed 2 years CBT was more effective than 1 yr CBT for men with LD on probation z Rose et al (2002): CBT 2 hrs/week for 16 weeks, for 5 men; found reduced (improved) scores but changes not significant

SOTSEC-ID z Sex Offender Treatment Services Collaborative Intellectual Disability z About 12 sets of therapists providing sex offender treatment for people with intellectual disabilities in England z Run training & meet about every 6 to 8 weeks z Setting up sex offender treatment groups (last 1 year; 2 hr sessions, once per week, closed groups) z Sharing core assessments measures z Research funded by Do. H

Core assessments z Once only: measures of IQ, adaptive behaviour, language, & autism z Pre & Post group treatment: - Sexual Knowledge & Attitude Scale (SAKS) - Victim Empathy scale, adapted (Beckett & Fisher) - Sex Offender Self-Appraisal Scale (Bray & Foreshaw’s SOSAS) - Questionnaire on Attitudes Consistent with Sex Offending (Bill Lindsay et al. ’s QACSO) z Recidivism

Treatment content z. Group purpose, rule setting z. Human relations & sex education z. The cognitive model z. Sexual offending model z. General empathy & victim empathy z. Relapse prevention z. Groups last ~52 weeks; mostly 2 hour sessions; closed groups

Results: first 5 groups (31 men) z About 60% men offered treatment not required to come by law (rest on MHA or CRO) z WAIS-R: mean IQ is approx 60 z About 30% have Asperger’s syndrome or on autistic continuum; few with mental illness z Offences: stalking, sexual assault, exposure; rape; victims kids/adults z Process: Closed groups; met once per week (2 hr session incl. break); over 12 mths; 2 facilitators (m & f)

Cognitive distortions, sexual knowledge & empathy z Sexual Attitude and Knowledge Scale (SAKS) Most men near top of scale; significant increases by end of group z QACSO (Lindsay) Significant improvements in men’s scores z Sex Offenders Self- Appraisal Scale (Bray) Reductions in most men’s scores (not signif yet) z Victim Empathy (Beckett & Fisher) Significant reduction in scores - but big variation in degree of reduction

Service user views from first group Good understanding of basic facts (duration, venue, facilitators, & rules, e. g. confidentiality rule) Good understanding why referred: ‘Because of my probation because of my sex offence to see if it would do me any good’ ‘To help my sex urges and keep them under control; to be a better person when meeting women in the community’ ‘To help us stop getting into trouble with the police; because I go out to masturbate’

Service user views (cont’d) Most could list some of what they did in group (not very coherently) What they learnt: ‘Stopped me touching girls’ ‘How people feel about us masturbating’ (in public) ‘Learnt not to go after women’ ‘Learnt. . to put a condom on’ ‘Learnt to help other people in the group’ ‘What the police do when they arrest you’

Service user views (cont’d) Best things z ‘Having support every week’ z ‘We … talked about feelings about things, sorting the problems out’ z ‘Working together, helping each other’ z ‘We helped each other discuss. . . work on ways of preventing problems in the future’ Worst things z ‘Telling people very private stuff, keeping people on trust’ z ‘Some didn’t talk’

Conclusions z. Men with learning disabilities do commit sexual offences z. Exact prevalence is not known but seems to be broadly similar to non-disabled men z. Offences more opportunistic but otherwise similar to non-disabled men z. Treatment using cognitive behaviour therapy really only just getting going – SOTSEC-ID only controlled trial as yet

Key references z Browne, A. & Finklehor, D. (1986) Impact of child sexual abuse: a review of the research. Psychological Bulletin, 99, 66 -77. z Hanson, R. K. et al (2002) 1 st report of the collaborative outcome data project (etc. ) Sexual Abuse: Journal of Research & Treatment, 14, 169 -194. z Journal of Applied Research in Intellectual Disabilities (Several articles in issue, 15 (2), 2002) z Lindsay, W. R. (2002) Research & literature on sex offenders with intellectual and developmental disabilities. Journal of Intellectual Disability Research, 46, 74 -85. z Marshall, W. L. , Laws, D. R. , Barbaree, H. E. (1990) Handbook of Sexual Assault: Issues, Theories & Treatment of the Offender. NY: Plenum Press z Marshall, W. L. et al. (1999) Cognitive Behavioural Treatment of Sexual Offenders. Wiley.