Q&A: What Works in Sex-Offender Treatment

TIME speaks with Dr. Renee Sorrentino of Massachusetts' Institute for Sexual Wellness about sex-offender treatment and her work with pedophiles

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At least 300,000 cases of child sex abuse are reported in the U.S. each year — and the real number of children who are molested is likely far higher. But while laws get tougher all the time, very little is known about how to treat sex offenders in order to prevent these crimes.

Dr. Renee Sorrentino is medical director of the Institute for Sexual Wellness in Massachusetts and a clinical instructor in psychiatry at Harvard Medical School. TIME spoke with her about the research on sex-offender treatment and her work over the past 10 years with these difficult patients.

What do you think causes pedophilia?
There’s a theory that basically something is wrong neuroanatomically. There are some [ideas] that there’s something genetically determined. And there are some [theories] about imprinting, which is the idea that when you [reach] the age of sexual interest or awakening, if there’s a mismatch where you [see] something and masturbate to it, it can imprint to that, like with foot-fetish guys.

Were most offenders themselves sexually abused as children?
The majority of sex offenders do not have a history of child sexual abuse.

What percent of sex offenders are women?
It’s very small. I have maybe 10% women. They tend to be emotionally dysregulated, and if you treat the main problem, then the sexual problem tends to go away in those women.

Are all pedophiles compulsive about the behavior?
Pedophilia is just sexual orientation — it’s no different than saying someone is interested in adult women. It doesn’t say anything about the appetite, just says something about the object of interest.

A pedophile can commit a crime and not be compulsive. Or they can be very much preoccupied by the fantasy but might not even engage in it.

We’re trying to change the brain so there is less focus on [deviant] sexual behavior, not to affect the machinery.

Why did you decide to work with a group that is so stigmatized?
I’m a forensic psychiatrist and most of us specialize. I was interested in doing some part of psychiatry that was more evidence-based. I liked that there’s science to it.

We have three very effective treatments in psychiatry: electroconvulsive therapy for depression, clozapine for schizophrenia and the third is Lupron, which is a hormonal agent [used to treat sex offenders].

I was struck by how effective this medication was and how it had such a profound effect on individual lives. They’re able to live life without being preoccupied, they don’t have the craving anymore. They’re still interested in kids but don’t have to spend time thinking about it [or acting on it].

Is that the drug used for what’s known as “chemical castration?”
We’re not actually trying to cause sexual dysfunction. The idea is to change brain chemistry, not the physiology of reproduction and not to have impairment in getting an erection or performance, but to intervene in higher levels in the brain.

So the idea is to stop the deviant sexual behavior but not preclude consensual sex?
That’s the name of the game when you use Lupron … the idea is to give enough to [stop] the bad behavior and [deviant] thoughts but retain sexual function. That would be the best treatment for anyone with [some] normal sexual interests.

But aren’t pedophiles only attracted to children?
Most pedophiles have some interest in adults. We try to help them therapeutically with making relationships with adults. The hope is that Lupron will diminish sexual thoughts with kids but allow them to function, but it doesn’t always work like that.

What about offenders who are exclusively attracted to children?
In individuals that have no normal sexual interests or are at high risk of recidivism, we may forgo that, and they’re going to have sexual dysfunction.

Why would you even risk letting them have some sexual function?
This is what’s hard for people to understand. When you talk about treating sex offenders, you want to address risk factors. Pedophilia is a risk factor, but so is lack of intimacy or support. People who are not involved in relationships are also higher risk. Working on bolstering those things decreases recidivism.

It’s the same thing that happens with community notification. Some studies show that it can increase risk of recidivism. How it does that is because individuals unable to live anywhere become homeless or unemployed, which are two individual risk factors for recidivism.

(MORE: Understanding Psychopathic and Sadistic Minds)

What is the actual recidivism rate for sex offenders overall?
About 13%. If you show the data about criminal nonsexual offenders and compare, the rates for sex offenders are low, but people don’t tolerate any recidivism.

If Lupron works so well, why isn’t it used more often?
Most offenders don’t have the opportunity for pharmacological intervention for several reasons. Very few psychiatrists do this, so the opportunity doesn’t arise. And second, it’s a huge cost. Just the medication itself is $800 a month, never mind the monitoring. But if you look at cost of civil commitment annually, it’s certainly a cost saver.

Do you have people who take it without being mandated?
People are surprised when I tell them I have several patients who called me asking to be put on Lupron without any court [order]. Unfortunately, I often have to turn them down, which is a terrible thing. We have pedophiles who want treatment but can’t afford it.

Once guys learn about it from other patients, they’re very interested. What a majority of these guys are struggling with is how to live life with a sexual attraction that’s against the law. If you can tell them about something that can actually help, they’re pretty interested.

So, what does the evidence suggest should be done instead, in terms of talk therapy?
We have a model where the focus is on “Let’s help you live a healthy life.” You might have problems with relationships: let’s focus on other risk factors for [reoffending], like intimacy deficits or substance abuse. Don’t just focus on denial. You focus on them, not just on the sex disorder and the problem. The data is now showing that it is superior to the old relapse-prevention model, but only a minority of programs have incorporated that.

MORE: Registries Don’t Keep Sex Offenders From Restricted Areas