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HTA Report Treatment for Convicted Adult Male Sex Offenders HTA Report Treatment for Convicted Adult Male Sex Offenders July 2010 INSTITUTE OF HEALTH ECONOMICS The Institute of Health Economics (IHE) is an independent, not-for-profit organization that performs research in health economics and synthesizes evidence in health technology assessment to assist health policy making and best medical practices. IHE BOARD OF DIRECTORS Chair Dr. Lorne Tyrrell – Chair, Institute of Health Economics and Professor and CIHR/GSK, Chair in Virology, University of Alberta Government Mr. Jay Ramotar – Deputy Minister, Alberta Health and Wellness Ms. Annette Trimbee – Deputy Minister, Advanced Education and Technology Dr. Jacques Magnan – Interim President and CEO, Alberta Innovates Health Solutions Academia Dr. Renée Elio – Associate VP Research, University of Alberta Dr. Tom Feasby – Dean of Medicine, University of Calgary Dr. Philip Baker – Dean of Medicine, University of Alberta Dr. Tom Noseworthy – Professor and Head, Community Health Sciences, University of Calgary Dr. James Kehrer – Dean of Pharmacy, University of Alberta Dr. Herb Emery Svare – Chair, Health Economics, University of Calgary Dr. Doug West – Chair, Department of Economics, University of Alberta Industry Mr. Terry McCool – Vice President, Corporate Affairs, Eli Lilly Canada Inc. Mr. Gregg Szabo – Executive Director, Corporate Affairs, Merck Frosst Canada Ltd. Dr. Bernard Prigent – Vice President & Medical Director, Pfizer Canada Inc. Mr. Grant Perry – Director, Public Affairs, GlaxoSmithKline Inc. Mr. William Charnetski – Vice President, Corporate Affairs, AstraZeneca Canada Inc. Other Mr. Chris Mazurkewich – Executive Vice President & CFO, Alberta Health Services CEO Dr. Egon Jonsson - Executive Director and CEO, Institute of Health Economics, Professor, University of Alberta, University of Calgary IHE Mr. Doug Gilpin – Chair, Audit & Finance Committee Board Secretary Dr. Egon Jonsson – Executive Director and CEO, Institute of Health Economics, Professor, University of Alberta, University of Calgary TREATMENT FOR CONVICTED ADULT MALE SEX OFFENDERS Prepared by: Paula Corabian, BSc, MPH Maria Ospina, BSc, MSc Christa Harstall, BSc, MLS, MHSA Reproduction, redistribution, or modification of the information for any purposes is prohibited without the express written permission of the Institute of Health Economics © Institute of Health Economics, 2010 www.ihe.ca Treatment of Convicted Adult Male Sex Offenders i ACKNOWLEDGMENTS The Institute of Health Economics is most grateful for the following individuals for review and provision of information and comments on the draft report. The views expressed in the final report are those of the Institute. —— Dr. R. Karl Hanson, Corrections Research, Public Safety Canada, Ottawa, Ontario —— Dr. David Moher, Ottawa Hospital Research Institute, Ottawa Methods Centre, The Ottawa Hospital General Campus, Ottawa, Ontario INFORMATION SERVICES SUPPORT The literature search for the review was undertaken by Ms Liz Dennett, Information Specialist, Institute of Health Economics, University of Alberta, Edmonton, Canada. COMPETING INTEREST The author(s) of this report declared no competing interest. Production of this document has been made possible by a financial contribution from Health and Wellness and under the auspices of the Alberta Health Technologies Decision Process initiative: the Alberta Model for health technology assessment and policy analysis. The views expressed herein do not necessarily represent the official policy of Alberta Health and Wellness. ii Treatment of Convicted Adult Male Sex Offenders EXECUTIVE SUMMARY BACKGROUND Sexual offending has become a major challenge for social policy because of the high human and financial costs to victims and the social and health services as well as the high public investment in policing, prosecuting, and incarcerating sex offenders. There is an expectation that the correctional systems should make reasonable efforts to reduce the potential that convicted sex offenders will reoffend. One common approach to sex offenders’ management in countries with developed market economies is to provide specialized treatment programs. A number of different sex offender treatment (SOT) programs have been developed and are currently operating, but there continues to be controversy regarding how well they work. ObJECTIVES To evaluate the effectiveness of psychotherapy and pharmacotherapy interventions delivered within SOT programs to reduce the likelihood of reoffending in convicted adult male sex offenders. RESULTS Eight systematic reviews (SRs) conducted on the effectiveness of SOT interventions and programs met the inclusion criteria of this overview. All eight SRs focused on the use of psychotherapy for convicted sex offenders, whereas one also included surgical castration and hormonal medication. In these studies there was considerable variability in how interventions were classified, the types of sex offenders involved, and the definition of outcomes. According to the reviewed evidence, studies in the area of SOT outcome research have improved over the past 10 years. However, the need for more rigour remains. The following are highlights from the reviewed evidence. —— Although the debate in the scientific literature on what SOT interventions and programs are most effective for convicted adult male sex offenders remains, the results from seven moderate- to-high quality SRs show small but statistically significant reductions in sexual and general recidivism rates among convicted adult male sex offenders treated with various cognitive behavioural therapy (CBT) approaches. —— The most recently published high quality SR found that SOT programs using CBT approaches that adhered to the risk/need/responsivity (RNR) model for offender assessment and rehabilitation were most effective in reducing the risk of recidivism in convicted male sexual offenders. On average, programs that followed all three RNR principles reported recidivism rates that were less than half the recidivism rates for comparison groups. In contrast, there was no effect on recidivism rates for programs that did not follow the RNR model. Treatment of Convicted Adult Male Sex Offenders iii —— Confidence in these findings, however, must be tempered as the available evidence is based mostly on poor quality primary research studies. —— Although one SR of moderate quality reported promising results on the use of hormonal treatments as an adjuvant to psychotherapy, well- conducted and reported controlled studies are needed to establish the effectiveness of adjuvant hormonal treatment to reduce the risk of recidivism among sex offenders. —— Overall, the results reported by the selected SRs provide little direction regarding how to improve current treatment practices. • It is still not clear whether all sex offenders require treatment or whether current interventions are more appropriate for certain subgroups and typologies of offenders. • There are still uncertainties regarding the most useful elements and components of a SOT program for convicted adult male sex offenders. • There is no clear answer on whether the setting of the SOT program affects its impact on recidivism rates. CONCLUSIONS While the evidence from seven moderate-to-high quality SRs suggests that SOT has the potential to reduce sexual and nonsexual recidivism, the reported findings provide stronger support for the effectiveness of CBT approaches and for programs adhering to the RNR model. Any conclusions drawn from this overview of SRs remain tentative. Given the methodological problems of the available primary research, it is difficult to draw strong conclusions about the effectiveness of SOT programs using various CBT approaches for such a heterogeneous population. The reviewed evidence does not provide clear answers to what are the components of an optimal SOT program and to whether where the program is delivered matters. All SRs concluded that more and better research is needed to clearly answer these questions. METHODOLOGY SRs that by virtue of design and quality of reporting were most likely to provide high levels of evidence, were selected to formulate the evidence base for this overview. All SRs were identified through a systematic search of the relevant scientific literature published in English between January 1998 and June 2010. The searched databases included: MEDLINE, EMBASE, The Cochrane Library, The Campbell Collaboration Library, CRD Databases (HTA, DARE), PsycINFO, Violence and Abuse Abstracts, iv Treatment of Convicted Adult Male Sex Offenders Criminal Justice Abstracts, Sociological Abstracts, SocINDEX with Full Text, Social Work Abstracts, Social Services Abstracts, Gender Studies Database, National Criminal Justice Reference Service Abstracts, and Web of Science. Also searched were the University of Alberta library catalogue, clinical trials websites, websites of pertinent agencies and departments of corrections, health technology assessment (HTA) agency websites. In addition, the Internet was searched using the Google search engine. The methodological quality of the SRs included in this overview was appraised independently by two reviewers using the AMSTAR quality assessment tool. One reviewer extracted the data from the selected SRs and a second reviewer verified the data extraction. The evidence was qualitatively synthesized and is presented in summary tables. Treatment of Convicted Adult Male Sex Offenders v ABBREVIATIONS All abbreviations that have been used in this report are listed below unless the abbreviation is
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