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A Brief History of Behavioral and Cognitive Behavioral Approaches to


Sexual Offenders: Part 1. Early Developments
D.R. Laws and W.L. Marshall
Sex Abuse 2003; 15; 75
DOI: 10.1177/107906320301500201

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A Brief History of Behavioral and Cognitive
Behavioral Approaches to Sexual Offenders:
Part 1. Early Developments
D. R. 1,3and W. L. Marshall
Laws 2

This is the first of two papers which briefly outline the development of behavioral
and cognitive behavioral treatment of sexual offenders from the mid-1800s to 1969.
We first consider the historic role of Sigmund Freud and note that a broad scientific
interest in deviant sexual behavior was well established by 1900. In the early to mid-
20th century, two psychologies were prominent in the development of behavioral
approaches, those of John B. Watson and Alfred Kinsey. Behavior therapy for a
variety of problems emerged in the 1950s and soon found application to deviant
sexuality. The development of penile plethysmography helped to focus interest
on deviant sexual preference and behavior. While nonbehavioral approaches to
sexual offenders paralleled these developments, a combination of behavioral and
cognitive behavioral treatments began to emerge in the late 1960s which ultimately
developed into the approaches more commonly seen today.
KEY WORDS: sex offender treatment; historical antecedents; Watson’s behaviorism; Kinsey’s
sexology; behavior therapy.

PRELIMINARY REMARKS

So much has been written and discussed at conferences over the past 30 years
that it is impossible to do justice to the contributions of everyone in two history
papers. We apologize to those whose names we have omitted. It has been especially
difficult for us to see our own work in an objective way but we have tried not to be
too immodest. We decided not to describe the emergence and subsequent growth

1South Island Consulting, Victoria, British Columbia, Canada.


2
R ockwood Psychological Services, Kingston, Ontario, Canada.
To whom correspondence should be addressed at South Island Consulting,
3 PO Box 23036, #4-313
Cook Street, Victoria, British Columbia, Canada V8V 4Z8; email: drlaws@telus.net.

75

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76

of organizations devoted to assessing and treating sexual offenders. Organizations


such as ATSA, NOTA, and IATSO and their conferences have played a very signif-
icant role in promoting work and disseminating knowledge but including a history
of these organizations would make our already extensive papers far too long.
The discussions have been separated into two papers: one covering the history
up to the end of 1969, and the second outlining developments over the subsequent
three decades and in the two years of the new century. It is hoped that these two pa-
pers will provide readers with something of an understanding of how work with sex-
ual offenders emerged, developed, and became widespread by the end of the 1990s.

BACKGROUND ,

In 1896, Sigmund Freud addressed the Vienna Society for Psychiatry and
Neurology where he announced his seduction theory of childhood sexuality. It
was not well received. The chair, the eminent sex researcher Richard von Krafft-
Ebing said to Freud, &dquo;It sounds like a scientific fairy tale&dquo; (Hunt, 1993, p. 181).
Freud eventually abandoned the theory replacing it with an account of reported
childhood sexual abuse that suggested it was a product of the imagination of the
alleged victims. In 1899, while The Interpretation of Dreams (Freud, 1957a) was
in press, he remarked to his colleague Wilhelm Fleiss that &dquo;A theory of sexuality
may become the successor to the dream book&dquo; (Gay, 1988, p. 142). And quite a
successor it was. Freud’s Three Essays on the Theory of Sexuality (Freud, 1957b)

originally published in 1905 was a bombshell. The first essay dealt frankly with
sexual deviations, the second with infantile sexuality, and the third with sexuality in
puberty. Freud was denounced as a pornographer and a pervert in both Europe and
North America but the book was widely discussed in professional circles (Hunt,
1993, p. 191). After years of professional disappointment, Freud began to receive
the acclaim that he had always felt he deserved.
Even today, at the onset of the twenty-first century, many clinicians and
researchers consider Freud to be the father of the study of human sexuality, both
deviant and conventional. This is far from accurate. Gay (1988, pp. 143-144,
passim) has noted that in the latter half of the nineteenth century many scientists
and clinicians were talking and writing about the vagaries of human sexuality. In
1845, a German physician, Adolf Patze, observed a strong sexual drive in children
3-6 years of age. In 1867 the British psychiatrist Henry Maudsley also spoke of
infantile sexuality. The word &dquo;homosexuality&dquo; was introduced in 1869 by Karoly
Maria Benkert; a similar phrase, &dquo;contrary sexual feeling,&dquo; was coined in the same
year by Carl Friedrich Otto Westphal to describe this orientation. In the latter part
of the nineteenth century Richard von Krafft-Ebing (1886) published Psychopathia
Sexualis, which remains one of the most complete descriptions of unconventional
sexual behavior ever published. However, to avoid upsetting Victorian sensibilities,
Kraff-Ebing rendered the most erotic passages in Latin. This was followed by
Albert Moll’s Perversions of the Genital Instinct (Moll, 1893). This type of writing

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77

carried on well in the early twentieth century, notably in the writings of Havelock
Ellis (1915) and Magnus Hirschfeld (1920). Even in such a brief and incomplete
account as the preceding, it is clear that what is today referred to as &dquo;sexology&dquo;
was quite well established by the time Freud published Three Essays.

Attempts to deal with unconventional sexual behavior therapeutically is not


a new idea either. The earliest published account of an attempt to treat homosexu-

ality by what today would be called masturbatory reconditioning was reported by


Charcot and Magnan ( 1882) and Schrenk-Notzing (1895). Moll (1911), through
a series of successive approximations, was able to shift sexual interest in boys to
interest in young women. Just over 60 years later, this technique would be formal-
ized as a shaping procedure called fading (Barlow & Agras, 1973). Even aversive
procedures are not new. The Roman scholar, Pliny the Elder (23-79 A.D.) advocated
the use of these procedures to treat alcoholism and this approach persisted well
into the twentieth century (Rachman & Teasdale, 1969). Variations of aversive
techniques were adapted in the 1960s to eliminate unacceptable sexual interest
(e.g., Thorpe, Schmidt, & Castell, 1964).
In this early period, contrary to the writings of Freud and other psychody-
namicists, there was also a behavioral theoretical stream that attempted to account
for the development of deviant sexuality. In the early 1900s, Alfred Binet (now
best known for developing intelligence tests for children) theorized that sexual
deviations were learned responses. He believed that this learning occurred as ac-
cidental experiences with sexually deviant behavior. Norman (1892) believed that
deviant sexual interest was developed by repeated masturbation to sexual fantasies
of specific deviant behaviors. Both Binet’s and Norman’s accounts are remarkably
similar to the explanation that would be advanced by McGuire, Carlisle, and Young
(1965) over 70 years later. By the mid-twentieth century it was generally acknowl-
edged that the specific expressions of sexual behavior were learned phenomena
(Ford & Beach, 1952; Kinsey, Pomeroy, & Martin, 1948).
Contemporary approaches to sexual deviance owe little to classical psycho-
analytical or psychodynamic theory or practice. Rather they are the result of the
confluence of two psychologies: the radical behaviorism of John B. Watson ( 1913, 9

1919, 1924) and the descriptive taxonomic approach of Alfred Kinsey and his asso-
ciates (Kinsey et al., 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). However,
nonbehavioral research and treatment programs with sexual offenders exerted some
influence on the development of behavioral treatment for these offenders as well.

WATSON’S BEHAVIORISM

As Marshall, Anderson, and Fernandez (1999) have observed, the predomi-


nant philosophy of science in the early twentieth century was logical positivism
associated with the Vienna Circle.

The verificationist perspective of this school essentially declared that the only meaningful
propositions were those that could ... be empirically tested. All propositions that eluded the

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possibility of confirmation or disconfirmation were to be disregarded as ... metaphysical


and unprovable statements... Had this ... principle been rigorously applied to psychology
at that time, behaviourism would have held a distinct advantage over theories that posited
unconscious (and therefore unobservable) processes governing human behaviour. (Marshall
et al., 1999, pp. 9-10).

Fortunately for behaviorism, it developed in the United States at precisely


the opportune historical moment. Morris and Todd (1999) describe several trends
in late nineteenth and early twentieth century history that laid the groundwork for
American behaviorism. The philosopher Ernst Mach (1883, 1886) had offered a
descriptive positivism in which metaphysics was rejected. Science, in Mach’s view,
was not a search for truth, but rather a search for functional relationships between
events. This agreed with the view of William James’ that the goal of science was
prediction and control (James, 1990). If psychology was to become a science, said
James, then this goal had to be adopted. This became the guiding principle for the
work of John B. Watson.
In the United States, two additional influences made Watson’s behaviorism
potentially acceptable. Philosophically, the dominant view was some form of prag-
matism (Thayer, 1964). Initially introduced by C.S. Peirce in 1878 (Turisi, 1997)
then developed by William James (1907) and later by John Dewey (1916), prag-
matism came to be widely understood (although not quite accurately) as the view
that the truth and meaning of a statement is determined by its usefulness. As
this notion of truth was in harmony with the spirit of modem industry, pragma-
tism became very popular. Watson’s behaviorism was consistent with this popular
understanding of pragmatism. Also, during the period 1890-1920 in the United
States, the ideology of Progressivism was popular (Bury, 1920). Essentially this
view regarded progress of almost any kind as both inevitable and inherently good.
This movement stated that progress could only be achieved through science and
technology; that is, by prediction and control (Morris & Todd, 1999, pp. 22-23,
passim). Thus, the historical moment was perfect when John B. Watson fired his
initial salvo in 1913. America was ready for behaviorism.
Two individuals exerted a direct influence on Watson’s psychology: Edward
L. Thorndike who empirically demonstrated laws of learning, and Ivan Pavlov who
empirically demonstrated the laws of classical conditioning. In 1898, Thorndike
published Animal Intelligence, a description of the use of reinforcement theory to
train animals. In this paper, Thorndike offered the initial statement of the Law of
Effect, which simply said that a response followed by pleasant consequences will
increase in frequency whereas a response followed by unpleasant consequences
will decrease in frequency. From German journals, Watson learned of the work
of Ivan Pavlov whose Conditioned Reflexes would not be published in English
until 1927. Watson’s published work shows that he was heavily influenced by
Thorndike’s use of reinforcement (Thorndike, 1898) and he termed Pavlov’s dis-
covery (Pavlov, 1927) of the conditioned reflex &dquo;the keystone arch&dquo; of behaviorist
theory (Hunt, 1993, p. 253).

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79

In 1913, Watson published Psychology as the Behaviorist Views It. This is

commonly referred to as the behaviorist manifesto. The first paragraph of this


paper is a concise description of Watsonian behaviorism:

Psychology as the behaviorist views it is a purely objective experimental branch of natural


science. Its theoretical goal is the prediction and control of behavior. Introspection forms
no essential part of its methods, nor is the scientific value of its data dependent upon the
readiness with which they lend themselves to interpretation in terms of consciousness.
(Watson, 1913, p. 158)

Hunt (1988, p. 258) that, in 56 words, the manifesto proclaimed three


notes
revolutionary principles: (1) the content of psychology should be behavior, not
consciousness; (2) its method should be objective, not introspective; and (3) its goal
should be the prediction and control of behavior, not a fundamental understanding
of mental events. In two subsequent books, Psychology from the Standpoint of a
Behaviorist ( 1919) and Behaviorism ( 1924) Watson continued to expand on these
early themes.
It was precisely this appeal to science, the assertion that behaviorism was the
first scientific psychology, that sold the idea in America. Although many psychol-
ogists would not wish to acknowledge it, in academia at least, behaviorism of one
sort or another was the reigning psychology from 1920 until the late 1960s. It was
scientific. It was experimental. It was practical. It was commonsensical, and it was
useful. In its more modem form, it is still all of these things.

WATSON’S SUCCESSORS

Perhaps the most illustrious successor to Watson was B.F. Skinner (1938,
1953) whose popular and enduring radical behaviorism would have made Watson
proud. Skinner’s operant conditioning principles, however, have not been widely
used in the treatment of sexual deviants with a few exceptions (Bancroft, 1971;
Barlow & Agras, 1973; Quinn, Harbison, & McAllister, 1970).
In 1932, Edward Chace Tolman published Purposive Behavior in Animals and
Men. This was essentially the first statement of what would become social learning
theory, later greatly expanded by Bandura (1977). Tolman spoke of &dquo;cognitive maps
in rats and men&dquo; and designed experiments in which he purported to demonstrate
that organisms think about their behavior while engaging in it. Today this is given
the more elegant name of &dquo;metacognition.&dquo; In sexual offender work, the direct
influence of Tolman is seen in the construction of cognitive behavioral chains
(Nelson & Jackson, 1989).
In 1935, Edwin R. Guthrie published The Psychology of Learning, the first
statement of associationism or contiguity learning. Marshall et al. (1999, p. 13)
describe the application of Guthrie’s theory to treatment:

... in treatment aimed at eliminating undesirable responses, the therapist must ensure
that alternative, preferably incompatible, responses occur in the presence of the eliciting

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80

stimulus ... (T)his could be achieved ... by repeatedly presenting the stimulus at full strength,
thereby continuously evoking the undesirable response. This ... would lead to the exhaus-
tion of the undesirable response such that an alternative response (e.g., fatigue or boredom)
would then come to be associated with the stimulus.

Marshall (1979) and Marshall and Lippens (1977) used a variation of this
procedure which they called satiation aimed at eliminating arousal to deviant sexual
stimuli.
Clark L. Hull (1943) presented an elaborate hypothetico-deductive theory.
Although intricate and intriguing, it has seen little practical application and today
is all but forgotten. In a procedure highly similar to that reported by Marshall (1979)
and Marshall and Lippens (1977), Laws (1995) analyzed a behavior therapy called
verbal satiation in terms of Hull’s proposition of conditioned inhibition.
Skinner’s approach had an enduring impact on both basic research and later on
clinical practice. Interest in Tolman’s and Guthrie’s views faded although in recent
years there has been a significant revival of interest in Tolman’s work (Barker,
2001 ). In American academia, operating conditioning became dominant, but in the
treatment of sexual deviation, Pavlovian (or classical) conditioning was initially
more accepted.

KINSEY’S SEXOLOGY

The other scientific stream that ultimately influenced the treatment of sexual
offenders was the work of Alfred Kinsey and his colleagues. Kinsey, like Freud,
believed that sexuality was a fundamental engine that drove human behavior. He
believed that human sexuality had to be investigated in all of its details, both pleas-
ant and unpleasant, because &dquo;(i)t is desperately strategic that our civilization realize
something of the diversity in human sex behavior, and acquire some sympathetic
understanding of that which is different from one’s own&dquo; (cited in Pomeroy, 1972,
p. 78). As noted, in the late nineteenth and early twentieth centuries, there was
considerable interest in sexuality in academic and medical settings. However, there
was a widespread resistance in society to allow scientists to straightforwardly study
human sexuality, particularly in its more unusual forms. Even the boldest of these
individuals, such as Krafft-Ebing, were timid when it came to describing the exact
details of unconventional sexual behavior. This timidity persisted to Kinsey’s time.
Dickenson and Pierson (1925, cited in Masters & Johnson, 1966, p. v.) urged scien-
tists to risk negative public and professional opinion and &dquo;issue succinct statistics
and physiologic summaries of what we find to be average and what we believe to
be normal.&dquo; In 1938, Kinsey took up that challenge. The comprehensive study of
human sexual diversity begins with Kinsey’s research. Over the years the Kinsey
data have been scorned and attacked from a variety of perspectives. Nonetheless,
over 60 years later, these data remain the largest body of empirical information on

human sexual diversity ever compiled. They are in a very real sense the standard

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81

against which much subsequent work has been compared. In 1948, Kinsey and his
colleagues described the challenge that they had faced.
(A)lthough ... scientists have largely avoided investigations of human sexuality, leaving
this one of the most poorly explored fields in biology, psychology, or sociology, it should
be emphasized that there is no aspect of human behavior about which there has been more
thought, more talk, more books written ... The printed literature is tremendous ... It is,
at once, an interesting reflection of man’s absorbing interest in sex, and his astounding
ignorance of it; his desire to know and his unwillingness to face the facts; his respect for
an objective, scientific approach to the problems involved, and his
overwhelming urge to
be poetic, pornographic, literary, philosophical, traditional, and moral. (Kinsey et al., 1948,
pp. 21-22)

Kinsey had begun his professional life as a biologist studying gall wasps.
Using his biological methodology the Kinsey researchers set about producing
a taxonomic picture of human sexual diversity, classifying sexual behavior
by
experience, preferences, behaviors engaged in, and the like. These data were then
presented statistically in a direct effort to demystify and deromanticize sexual
behavior. The Kinsey group interviewed ordinary American citizens, of all ages, all
ethnic groups, from all walks of life. Kinsey urged his interviewers not to be timid
in their approach. &dquo;Assume that everybody does everything,&dquo; he recommended
(Pomeroy, Flax, & Wheeler, 1982, p. 10).
Gagnon (1975), writing of the social impact of this research, noted that the in-
tellectual roots of Kinsey’s work lay in earlier statistical case studies and in his own
prior biological research. The final form of the research, displayed in Sexual Behav-
ior in the Human Male ( 1948) and Sexual Behavior in the Human Female ( 1953),
were large numbers of case histories, cross-classified on taxonomic variables, the
data presented in statistical summaries. This had never been accomplished prior
to this time. Gagnon (1975) defined the procedure as &dquo;social bookkeeping&dquo; and
called it revolutionary. &dquo;Despite methodological carping,&dquo; wrote Gagnon, &dquo;there
existed for the first time an accountancy for sexual behavior&dquo; (p. 129). As Kinsey
had intended, the research cut a wide swath through the existing poetic, literary,
philosophic, and moral traditions. As had happened to Freud 43 years earlier,
Kinsey was denounced as a pervert and pornographer, a person who meddled
in the affairs of people’s lives that were best kept private. The meddling, of
course, was quite intentional, and the effort succeeded. Gagnon (1975, p. 131 )
concluded

The contest between the imaginative-literate and the scientific-numerate was rejoined ... it
was the canons of proof that were unacceptable, the movement from imagination to science,
from literary to numeracy that was unpalatable.

Pomeroy (1966, 1972) reported that the Kinsey researchers expanded their
research, going beyond the interview work to observe heterosexual and homosexual
behavior directly as well as record it on film. This prefigures Masters and Johnson’ss
research by more than a decade (Masters & Johnson, 1966). As a result of this work
there is a long section in the second book (Kinsey et al., 1953, pp. 574-641) where

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82

precise details of anatomy and physiology of the sexual response in both males
and females is described. According to Pomeroy (1966) these observations were
made in the early stages of setting up a physiological laboratory. This remained
uncompleted at the time of Kinsey’s death in 1955.
The relevance of Kinsey’s work and its ultimate bearing on the assessment and
treatment of sexual offenders is clear. The research showed the absolute necessity
of obtaining complete details on sexual interests, preferences, and practices. In
addition, at the conclusion of his research, Kinsey demonstrated the utility of
making direct measurements of sexual responses in order to obtain a relatively
objective measure of those interests and preferences. Just 2 years after Kinsey’s
death in 1955, such an objective approach applied to sexual deviants would emerge
in the work of Kurt Freund (1957) in Czechoslovakia.

THE EMERGENCE OF BEHAVIOR THERAPY

Similar to the impact of Freud’s Three Essays and the two Kinsey’s books,
Eysenck’s (1952) paper, The effects of psychotherapy, began the process of un-
dermining established beliefs about the value of dynamic psychotherapy. Eysenck
argued that traditional psychotherapy had failed to demonstrate its utility. This
was met with enthusiasm by a small coterie of clinicians, and paved the way for
a revolution in approaches to psychological treatment with the birth of behavior

therapy. The behavior therapy revolution began in South Africa, Britain, and North
America.
In 1958, the South African psychiatrist Joseph Wolpe published Psychother-
apy by Reciprocal Inhibition. From Wolpe’s work there emerged what came to
be known as systematic desensitization, which was immediately successful in the
treatment of anxiety disorders. Subsequently, desensitization was effectively ap-
plied to problems in conventional sex (Brady, 1966; Haslam, 1965; Kraft, 1967;
Kraft & Al-Issa, 1967; Lazarus, 1963) as well as to deviant sexual behavior (Bond
& Hutchinson, 1960; Stevenson & Wolpe, 1960).
Wolpe’s book served as a catalyst, especially in Britain, for the develop-
ment of behavior therapy, centered primarily at the Institute of Psychiatry (as-
sociated with the Maudsley Hospital) in London. These British researchers (led
by H. Gwynn Jones, Victor Meyer, Aubrey Yates, and Monte Shapiro) primarily
based their work on Pavlovian conditioning. The founding behavioral group at
the Maudsley was joined by the psychiatrists Michael Gelder and Isaac Marks
and later by Stanley Rachman and John Bancroft. The latter group expanded the
developing behavioral approaches to the assessment and treatment of the paraphil-
ias (Marks & Gelder, 1967; Marks, Gelder, & Bancroft, 1970; Marks, Rachman,
& Gelder, 1965). Other British researchers of this time, using similar methods,
included Thorpe and Schmidt (1964), McGuire and Vallance (1964), and Barker
( 1965)

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83

Prior to the 1970s, North American clinicians tended to be more influenced by


operant conditioning (Ferster & Skinner, 1957; Skinner, 1938, 1953). Early work
during this time by American researchers such as Lindsley (1960, 1963) with
psychotics, Bijou and Orlando (1961) with developmentally disabled children,
Goldiamond (1962) with stutterers, and Ferster and DeMyer (1961) with autistic
children, provided the impetus for the movement that came to be known initially
as behavior modification and ultimately as applied behavior analysis.

BEHAVIOR THERAPY WITH SEXUAL VARIANTS

The success of the initial work in behavior therapy generated considerable


optimism in both researchers and clinicians (Kazdin, 1978). An array of proce-
dures had been discovered that were scientifically respectable, were derived from
laboratory procedures with animals and, best of all, were practical and relatively
easy to apply. This encouraged the enthusiastic application of these procedures to
a wide variety of human problems (Levis, 1970).
The early descriptions of behavioral interventions for a variety of unusual
sexual behaviors were primarily case studies using some form of aversion ther-
apy. Typically a noxious stimulus of some sort was paired with either images
of the target behavior (Pavlovian conditioning) or the enactment of the deviant
behavior (operant forms of punishment). For example, the injection of a nausea-
inducing agent such as apomorphine was associated with the sexual activities (or
images) of homosexuals (Freund, 1960; James, 1962), transvestites (Blakemore,
Thorpe, Barker, Conway, & Lavin, 1963; Glynn & Harper, 1961), and fetishists
(Raymond, 1956). Electric aversion, where an uncomfortable shock to the arm or
leg was associated with the deviant images or acts, quickly replaced apomorphine.
Two significant problems became evident with the use of nausea-inducing drugs:
it was upsetting to patients and staff, and it was impossible to ensure that the act of
vomiting (the noxious event) could be precisely paired with the deviant image or
act. This was not a problem with electrical shock. Within a short time electric aver-
sion became the procedure of choice in the treatment of homosexuals (Bancroft,
1969; McGuire & Vallance, 1964), as well as transvestites and fetishists (Marks
& Gelder, 1967; McGuire & Vallance, 1964). The use of various other aversive
stimuli was also investigated including foul odors (Colson, 1972), covert aversive
images (Cautela, 1967), and later the use of shame or embarrassment (Serber,
1970, 1972).
Although unfortunately many of these case studies targeted homosexuals,
who were all to often coerced into treatment, their publication led directly to the
application of behavior therapy with sexual offenders. It should be noted, however,
that aversion therapy in any form has never been convincingly demonstrated to
produce permanent changes in sexual behavior (Quinsey & Earls, 1990; Quinsey
& Marshall, 1983).

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84

THE SEXUAL PREFERENCE HYPOTHESIS

A highly influential theoretical article by McGuire, Carlisle, and Young, Sex-


ual deviations as conditioned behavior: A hypothesis, appeared in 1965. This
paper is a clear expression of the radical behaviorist (in this case Pavlovian con-
ditioning) conception of deviant sexuality. At that time, it revolutionized thinking
about behavioral approaches to sexual deviance. McGuire et al. hypothesized that
early sexual experiences were of paramount importance because they provided
the materials for the &dquo;fantasy which invariably accompanied later masturbation&dquo;
(p. 185). According to this view, it was these accidental early sexual experiences,
resulting in the later pairing of masturbatory activity and fantasy, that created sex-
ual preferences. Further, if the fantasy began to lose its evocative power through
repeated use, the person could restimulate arousal by making the fantasy even
more deviant. Through this process of higher order conditioning, McGuire et al.

suggested, deviant preferences became predominant and nondeviant preferences


either dramatically dropped in value or simply faded away.
Marshall et al. (1999) have observed that the sexual preference hypothesis,
however appealing, has never been supported by more than anecdotal evidence
(see also Marshall & Eccles, 1993; O’Donohue & Plaud, 1994). However, the
hypothesis was so appealing that it was rapidly accepted as doctrine and is still
widely embraced nearly 40 years later. Acceptance of this theory demanded that
the focus of treatment be directed at eliminating deviant sexual preferences.

THE EMERGENCE OF PENILE PLETHYSMOGRAPHY

The sexual preference hypothesis required a measurement system to demon-


strate its credibility. In 1957, Kurt Freund in Czechoslovakia developed what he
called a &dquo;phallometric assessment&dquo; procedure that could accurately measure the
amount of penile engorgement during presentations of erotic visual stimuli. Six
years later, the first publication in English appeared (Freund, 1963) and Freund
subsequently introduced the procedure to the staff at the Institute of Psychiatry in
London. As a result, Bancroft, Jones, and Pullan (1966) introduced a much sim-
pler apparatus that measured changes in the circumference of the penis; a variation
of this was later developed in the United States by Barlow, Becker, Leitenberg,
and Agras (1970). The penile plethysmographic (phallometric) procedure was ac-
cepted because it did not seem to be overly influenced by the participants’ voluntary
control, and was thought to provide a more objective, and thereby more accurate
description of the client’s sexual preferences than his self-report. Thus measures
of erectile response quickly became the standard in establishing the degree of
deviance in clients and in evaluating the effectiveness of behavioral interventions.
The penile plethysmography (PPG) literature is now quite extensive and it
is filled with contradictory results. The procedure has always been controversial

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unauthorized distribution.
85

and it is not lacking in either supporters or critics. For example, in a review of the
PPG literature O’Donohue and Letourneau (1992) raised &dquo; ... (b)asic questions
concerning the sexual preference hypothesis, the criterion problem, the lack of
procedural standardization, the kind of test penile tumescence exemplifies, and
potentially problematic inferences involved in penile tumescence assessment ...&dquo;
(p. 123). These are but a few of the problems. O’Donohue and Letourneau note
that despite the fact that a large number of studies can distinguish offenders
from nonoffenders, many of the investigations have severe metholological prob-
lems. This uncertainty has been a hallmark of this literature since its inception.
The positive and negative aspects of the PPG procedure have been examined
from a variety of perspectives over the years (Laws, 2002; McConaghy, 1989;
Murphy & Barbaree, 1994; Simon & Schouten, 1991; Travin, Cullen, & Mellela,
1988). Despite the many criticisms, it remains popular and continues to be widely
used.

NONBEHAVIORAL APPROACHES WITH SEXUAL OFFENDERS

Coverage of these approaches will be brief since the focus of our history
is oncognitive behavioral treatments. However, earlier nonbehavioral treatment
programs were important in establishing that sexual offenders could be engaged in
treatment. This provided a basis on which behavior therapists were able to develop
their programs. The task likely would have been more difficult had behaviorists
been required to establish from scratch that it was possible to treat these offend-
ers. In addition, nonbehavioral research contributed to our understanding of the
characteristics of sexual offenders that might be addressed in treatment.
Several early articles and books established that sexual offending occurred
more frequently than had been thought and also revealed some of the problems
that beset the perpetrators (Frisbie & Dondis, 1965; Gagnon, 1965; Gebhard,
Gagnon, Pomeroy, & Christenson, 1965; Gibbens & Prince, 1963; Kozol, Cohen,
& Garogalo, 1966; Landis, 1956; Revitch & Weiss, 1962). For example, Gebhard
et al. (1965) provided extensive details of the features of sexual offenders, many
of which distinguished them from nonsexual offenders and from nonoffenders.
On these bases Gebhard et al. were able to classify sexual offenders into subtypes
that differed on specific features. This empirically derived classification began
a process that recently resulted in the very sophisticated systems of Knight and

Prentky (1990, 1993). Gebhard et al. (1965) were also among the first researchers
to demonstrate that some child molesters were violent toward their victims, an ob-
servation subsequently confirmed by Marshall and Christie ( 1981 ). Mohr, Turner,
and Jerry (1964), on the other hand, in their study of child molesters concluded that
these offenders were typically &dquo;harmless fondlers,&dquo; but their database was simply
the reports of the offenders. Unfortunately, Mohr et al.’s study gained widespread
publicity and appeared to convince some people in the justice system in Canada

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unauthorized distribution.
86

that child molestation, in all but exceptional cases, did not harm the victims so
extensively that a prison sentence was warranted.
In terms of treatment, there were several nonbehavioral programs operat-
ing prior to 1969. Institutional treatment was described by Cabeen and Coleman
( 1961 ), Castell and Yalom (1972), Pacht, Halleck, and Ehrmann (1962), and Peters,
Pediog, Steg, and McKenna (1968). While most of these early reports suggested
that the treatment was effective, later long-term follow-up studies revealed more
discouraging data. For example, the Peters et al.’s report (Peters et al., 1968) in-
dicated that their program reduced deviant behavior but longer follow-up reports
(Peters & Roether, 1972; Roether & Peters, 1972) indicated quite the contrary;
treated offenders had higher reoffense rates than did the untreated clients. The
same was true in Pacht and Roberts’ follow-up study of their program (Pacht &

Roberts, 1968).
These early programs did, however, set the stage for treatment endeavors
and the data generated by them supported the search for alternative approaches.
Thus they played a role, inadvertently perhaps, in encouraging the development of
behavioral and, subsequently, cognitive behavioral programs for sexual offenders.

BEHAVIORAL TREATMENT FOR SEXUAL OFFENDERS

The earliest behavioral approaches to the modification of sexual offending


reflected the view, developed from the theorizing of McGuire, Carlisle, and Young
(1965), that deviant sexual behavior was a distorted manifestation of sexual desire.
The idea that deviant sexual preferences formed the motivation for pedophilia, rape,
exhibitionism, or a host of other deviant behaviors became the rationale for the
behavioral approach to these problems. A report by Bond and Evans (1967) clearly
illustrates this point of view. &dquo;(I)f they can abstain from their deviant behavior for
a sufficient period of time, normal outlets for the control of sexual arousal will

develop&dquo; (p. 1162). Thus, the reasoning went, the optimal treatment for sexual
deviates would simply involve reducing their deviant sexual responses.
Not surprisingly, as a consequence of these views the primary, and some-
times the exclusive, target in early behavior therapy with sexual offenders was
simply their arousal to deviant images or acts. The approach of some of the British
behavior therapists have already been mentioned but others also adopted this sim-
ple approach. Exhibitionists were treated with electrical aversion (Evans, 1968;
Fookes, 1969) as were child molesters (Bancroft & Marks, 1968). The modifica-
tion of sexual fantasies was the target of efforts applied to a sadist (Davison, 1968)
and to a voyeur (Jackson, 1969). Bancroft (1974) summarized the reports of this
limited approach, including controlled comparative studies, and concluded that
it was effective in reducing deviant sexual resonses. However, there was limited
evidence on the long-terms effects on overt behavior of these techniques. Perhaps
even more important from a procedural point of view, there was, and continues

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unauthorized distribution.
87

to be, no evidence of enduring changes in sexual preferences as a result of these


simple behavioral approaches, although Kelly (1982) concluded that they did have
an immediate effect in reducing deviant arousal.

Today, 30-odd years later, the notion expressed by Bond and Evans (1967)
seems quite naive and simplistic. Although it is evident now that this early theory

(i.e., the sexual preference hypothesis) underpinning behavioral approaches to


deviant sexuality failed to account for the complexity of such behaviors, it it
important to keep in mind the valuable role such theorizing played in the gradual
development of today’s more comprehensive approach. It is the nature of good
science, and good clinical practice, to begin with the simplest account of a problem
and only proceed to more complex conceptualizations as the data dictate. In the
philosophy of science, this is called the principle of parsimony (Klee, 1997), and
it is a dictum that is well illustrated by the history of behavior therapy in general
and the cognitive behavioral treatment of sexual offenders in particular. In clinical
practice and behavioral science, theories are to be admired because they have
practical relevance to both research and treatment, not because they are eventually
shown to be true or false.
For a period of approximately 15-20 years, the sexual preference hypothesis
received some degree of support, and dynamic psychotherapy-based treatments
for sexual offenders were gradually abandoned in favor of behavioral approaches.
As previously noted, in behavioral treatment programs of the late 1960s, efforts
were primarily directed toward phallometric assessments of deviant sexual pref-

erences, followed by behavior therapies aimed at reducing deviant sexual arousal.


However, shortly thereafter, some clinicians also began to focus on interventions
aimed at enhancing appropriate arousal (Marquis, 1970) and in developing social
and communication skills (Barlow, 1974; Marshall, 1971). By having to confront
deviant sexuality as a series of problems in behavior, the poverty of the sexual
preference hypothesis was at last revealed. Deviant sexual preferences and de-
viant sexual arousal were undoubtedly important, but it was clear they formed
a small portion of a much larger picture. By the mid to late 1970s it was clear
that things had to change and that treatment interventions simply had to be-
come more comprehensive if they were to eliminate deviant sexual behavior. In
the second part of this history (Marshall & Laws, 2003) these developments are
outlined.

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