For years David Prescott sat face to face with pedophiles, trying to evaluate if the people before him were making progress in treatment.
Prescott is a licensed therapist who worked in Minnesota, one of the 20 states that have passed civil commitment laws. Courts in these states have the power to confine child molesters, rapists and other sex offenders who have finished their prison sentences but are deemed too dangerous to re-enter the community. The former inmates can stay there indefinitely, or until they prove therapy has made them safe to leave.
"So far, research shows that treatment very definitely can work," Prescott said. But critics of the treatment point out that psychotherapy doesn't work if someone drops out of therapy, or is kicked out. And treatment centers can cost tens of thousands of dollars per person each year. A 2011 government audit showed Minnesota spent $120,000 annually per person in civil commitment.
Two decades of published work with sex offenders haven't produced a cure, Prescott said. Instead, therapists aim to help pedophiles resist their urges.
"We don't know how to change the fact that a person is sexually attracted to children," said Dr. Fred Berlin, director of the Johns Hopkins Sexual Disorders Clinic in Baltimore. "But that doesn't mean there can't be successful treatment."
A New, Challenging Treatment for Pedophiles
In the early 1980s, therapists focused on a pedophile's sexual attractions in harsh and confrontational tones. But research has since shown an empathetic tone is more effective, said Prescott, a past president of the Association for the Treatment of Sexual Abusers who is now the clinical instructor of the Becket Family of Services Center in Maine.
"Let me just be clear, you can be very challenging by being warm and empathic," Prescott said. For instance, Prescott said he might respond to someone resisting group therapy by saying, "You don't like the term sex offender, and yet your victim was willing to testify against you?"
Many pedophiles have issues with their personal boundaries and interpersonal violence, said Robin Wilson, an assistant professor of psychiatry at McMaster University in Hamilton, Ontario. Treating these issues may keep them from abusing others.
But perhaps more important, Wilson said, is for a convicted sex offender to build up the support of people who will hold him accountable for good behavior once he re-enters the community. (Wilson estimates 5 percent or less of pedophiles are female.)
"There's a common misperception that sex offenders are sex offenders all the time. That's not necessarily true. Under certain circumstances they do have normal relationships," Wilson said.
Some pedophiles might be able to turn their sexual attractions toward healthy adult relationships, said Dr. Richard Krueger, who is in the group working on updating the information about pedophilia in the Diagnostic and Statistical Manual of Mental Disorders, the handbook professionals use in diagnosing patients. [Hypersex to Hoarding: 7 New Psychological Disorders]
For example, Krueger argues there is the "hebephilic" type of pedophile, who is sexually attracted to pubescent children, and the "pedohebephilic" type, who is sexually attracted to both prepubescent and pubescent children. People with these attractions can sometimes be nudged into focusing on adults, said Krueger, who is the medical director of the Sexual Behavior Clinic at New York State Psychiatric Institute in New York.
However, pedophiles who fall under the "classic type," and are attracted only to prepubescent children, usually under age 11, often don't change their focus, Krueger said.
"With some pedophiles who are fixated, you can't really make much of a dent; you may not be able to change their sexual interest pattern," Krueger said. "In these situations pretty much you can only repress things, and you would use androgen [drug] therapy to do this." This drug therapy reduces testosterone levels, which in turn curbs sexual appetite.
How to Prove Treatment Works
The gold standard in medical studies requires a control group to go untreated to prove the value of a new drug or treatment. But studies of pedophiles cannot ethically have such a control group in the general community, out of safety concerns.
Instead, researchers look to compare the fate of inmates who by circumstance received treatment or didn't. A 2004 study, which included 109 convicted sex offenders who completed therapy and 37 who dropped out, showed "non-completers" were six times as likely to commit another sexual or violent crime, compared with those who completed therapy. But the researchers, who published in the International Journal of Offender Therapy and Comparative Criminology, noted that sex offenders who completed therapy were not any more likely to show empathy toward their past victims.
In the late 1980s, Berlin tracked 406 men convicted of sex crimes against children in Maryland. Five years after they were discharged, 2.9 percent of men who completed therapy had been arrested for another sex crime. Men who didn't complete therapy re-offended at a rate of 7.4 percent, according to the article, published in the American Journal of Forensic Psychiatry.
"On average, there is a 40 percent reduction of recidivism (or re-offending) by treatment in studies," Krueger said.
Crimes can go unreported, making a true study of treatment efficacy difficult. Moreover, states with civil commitment programs release former inmates at different rates.
No person who was civilly committed in the state of Minnesota since its 1994 law has been discharged, according to 2011 reports by the state Office of the Legislative Auditor. Minnesota has one of the highest per capita civil commitment rates: 575 persons committed thus far.
In Florida, where Wilson served as clinical director of the Florida Civil Commitment Center, about 40,000 incarcerated sex offenders have been screened since civil commitment legislation in 1998. Of those, Wilson said the state civilly committed 1.7 percent, or approximately 700 people. About 30 of those 700 have been released because they finished treatment.
"Surprisingly that makes Florida one of the highest releasers," Wilson said.
"People can look at risks in terms of groups — but I couldn't tell you with any degree of precision which person is more or less likely to offend again," Berlin said. On the other hand, "There's nothing about prison that erases a person's attraction, or heightens their ability to control themselves," he said.
Live Science newsletter
Stay up to date on the latest science news by signing up for our Essentials newsletter.