Sexual assault physically and psychologically damages victims and forces the government to assume a considerable financial burden. According to Articles 20, 21 and 22 of the Sexual Assault Crime Prevention Act, sexual offenders that return to society, whether by parole, probation, completion of sentence, pardon, suspension of prosecution or exemption are required to receive physical and psychological treatment or counseling education organized by the community for up to three years. If the recidivism risk assessments for sexual offenders are only based on unchangeable past events, group treatment has no means to adjust these risk factors. Despite the recent emphasis on “dynamic factors” in risk assessments and treatment for sexual offenders because sexual assault is a behavior type of low background incidence, recidivism predictions often result in false positives. Furthermore, is prison group treatment for offenders of forcible rape cost-effective? An integrated exploration is thus needed. This study discusses the relevant results based on working data for existing sexual offender physical and psychological treatment and counseling education.
Sexual assault not only damages or impairs a victim’s body (through disfigurement, loss of ability to have children, loss of hearing or vision, paralysis or HIV infection) but can also cause serious psychological trauma including an increased fear of further assault symptoms of post-traumatic stress disorder such as depression, anger, crying alone, and substance abuse, nightmares and feelings of depression, anxiety, fear and powerlessness . A large-scale meta-analysis of 80 independent comparisons of a range of sex offenders (n=22,181) in institutional settings who were exposed to different types of treatment interventions (CBT, psychosocial and organic treatment modes) yielded results indicating a positive and significant effect of sex offender treatment: 11.1% of the treated offenders recidivated sexually compared to 17.5% of the offenders in the control groups . The needs for sexual offenders to undergo necessary and compulsory physical and psychological treatment and counseling education is considered a commonly held belief. Behavioral therapy, psychotherapy, psychiatric treatment and cognitive model reestablishment may reduce the possibility of recidivism . In Taiwan, therefore, based on the Article 20, Sexual Assault Crime Prevention Act, “Should the offender fall into one of the following categories, and it is considered to be necessary after examination the competent authority of the municipality or county (city) should order the offender to receive physical and psychological treatment or counselling education”, It implies that in addition to criminal punishment, sexual offenders are also required to undergo compulsory treatment. The types of compulsory treatment for sexual offenders include compulsory treatment in the sentence, compulsory treatment after the penalty and community treatment. The timeframe for this compulsory treatment has changed from before to after prison release. Post-prison release treatment is expected to not only improve treatment results but actually help sexual offenders reintegrate into society and connect with community treatment without interrupting their course of treatment, thereby reducing the chance of recidivism . Regardless of whether the evaluation is before or after the completion of a sexual offender’s sentence, an offender identified as at risk of recidivism is required to undergo compulsory treatment. Therefore the evaluation and post-prison release treatment are vital to current cases involving sexual offenders.
In Taiwan, based on the Annual Report of the National Police Agency (http://www.npa.gov.tw) there were estimated 4,245 and 3,752 reported sexual assault cases in 2012 and 2013 respectively with the high clearance rate both in 2012 (96.06%) and 2013 (96.06%). According to the Annual Taiwan Crime Statistics Report published by the Taiwan Criminal Investigation Bureau, approximately 70% of forcible rape cases occurred in a residential setting and more than 90% of offenders were convicted over the last decade. Despite this exceptional conviction rate, experts estimate that unreported incidents (the so-called “dark figure of crime”) outnumber reported cases by 7-10 fold. Therefore, the statistics for forcible rape in Taiwan is obviously underestimated in the overall rate of sexual assault cases. By the beginning of 21st Century two women on average are forcibly raped every hour in Taiwan. In the official, academic and public perceptions, the time has come to prudently deal with sexual assault in Taiwan [4,5].
Between 2000 and 2005, newly incarcerated sexual offenders increased from 190 to 636 and the total population of incarcerated sexual offenders increased from 747 to 1541, while sexual offenders released on parole decreased from 195 to 140. In 2005 alone, the number of new incarcerated sexual offenders and the incarcerated population of sexual offenders both increased by 113 (636) and 212 (1,541), respectively, compared to 2004 . In 1997, Taiwan enacted the Sexual Assault Crime Prevention Act, amending it with numerous provisions in 2005. The Sexual Harassment Prevention Act was also enacted in 2005 and amended in January 2006. The passage of these two acts offered a comprehensive safeguard for the protection of personal security, physical autonomy and privacy. These laws protecting personal security expanded the level of public attention around an issue that in the past was seen as a private concern. Furthermore, these acts provide a policy basis for implementing sexual assault prevention programs, including developing prevention networks, establishing treatment procedures, providing protection and support to victim, punishing and treating offenders and increasing prevention awareness .
Sexual offenders not only receive criminal punishment and treatment during their sentence, but may also receive pre-prison release compulsory treatment (for incidents occurring between April 23, 1999 and June 30, 2006) or post-prison release compulsory treatment (for incidents occurring after July 1, 2006). The first two kinds of sanctions are security measures for restricting personal freedoms, while post-prison release compulsory treatment follows the type of absolutely indeterminate statutory punishment. Furthermore, according to Articles 20, 21 and 22 of the Sexual Assault Crime Prevention Act, sexual offenders that return to society, whether by parole, probation, completion of sentence, pardon, suspension of prosecution, or exemption, are required to receive physical and psychological treatment or counseling education organized by the community for up to three years.
Sexual assault differs from other crimes. First, sexual assault is highly private and commonly lacks third-party eye witnesses, requiring the victim to describe the event him/herself and to collect biological evidence from his/her body as soon as possible after the incident occurs . Additionally, while physical injury typically includes minor injuries such as bruises, scratches, bites and sprains, the psychological damage and fear of assault is immense . According to past empirical research that tracked subjects on average for 7-9 years, the cumulative recidivism rate for sexual offenders in Taiwan was between 8% and 13% . Comparatively, Karl Hanson compiled and analyzed overall sexual offender recidivism rates for US, UK and Canada between 1998 and 2004 finding that recidivism rates were between 10% and 15% after 5 years but increased to approximately 20% after 10 years [9,10]. However previous meta-analytic research about sexual offender recidivism offered very heterogeneous results which were sometimes difficult to interpret [11,12]. Most meta-analyses report recidivism rates ranging from about 10-25% over an averaged follow-up period of about 5 years . Despite not being a perfect comparison due to inconsistencies in tracking interval limits, tracking time controls and treatment mechanisms, Taiwan’s average recidivism rates are slightly lower than the recidivism rates in other countries over the same interval .
Beyond the essential legal punishment, the treatment of sexual assault recidivism in recent years has evolved from purely legal-based judgments, such as receiving probation or therapy education in prison, to the introduction of sexual assault psychopathology, which emphasizes the “pathology” in the offender’s “psychology” that elicits sexual assault behaviors and therefore requires supplemental treatment support . The theoretical basis for sexual assault prevention in Taiwan primarily stems from sexual assault prevention policies in the United States . Law governs people according to its understanding of human nature. The evolution of prevention policy for sexual offences particularly involves re-understanding sexual offender’s human nature. The management of mentally ill offenders has transited from expert discipline of dangerousness to administrative governance of risk. Following the United States trend, Taiwan’s policy making in sexual offence prevention have sluggishness and irregularity. As governmentality includes both risk governance and precautionary principle, the irregularity of Taiwan's sexual offence prevention policy argues that the irregularity in adopting risk governance policy originates from the fragmented configurations of human nature .
The 2005 revision to the 1997 Sexual Assault Crime Prevention Act in Taiwan set the length of general physical and psychological treatment and counseling education at three years and strengthened control measures for sexual offenders under probation and supervision, such as arranging appointments and visits collecting urine, restricting accommodation, curfew or proximity to certain locations of people and when necessary, carrying out electronic monitoring or a lie detector test. Furthermore, forcible rape offenders who have yet to or have already completed the imprisonment term or who have left the rehabilitative disposition places are required to regularly report to the police and register information such as their identity, enrollment, employment, driver’s license and details of movement for up to seven years after leaving prison or leaving the rehabilitative disposition places. According to Article 22 of the Sexual Assault Crime Prevention Act, for offenders who have been identified and evaluated as being unsuccessful in restraining oneself from committing again after accepting physical and psychological treatment or counseling education, the municipality or county (city) authorities should submit the relevant evaluation report to the prosecutor or military prosecutor and force the offender into treatment by law. Based on the legislative reasoning to the amendment, “the purpose of compulsory treatment for offenders is to correct abnormal behavior through governmental rationality and sexual assault prevention policy and behavior, by learning self-control to prevent recidivism. In contrast to unusual disease treatment, scholars and the medical community acknowledge that there is no cure in sexual assault treatment and therefore the timeframe for treatment should be determined by whether the purpose of compulsory treatment, ‘the significant reduction in the risk of recidivism’ is achieved. However, annual evaluation is needed to avoid long-term incarceration impacting the rights of offenders”. The latest revisions to the Sexual Assault Crime Prevention Act, the Criminal Code and numerous related administrative rules in Taiwan have already introduced the concept of risk governance into Taiwan’s sexual assault prevention policy . Not only the treatment is strategically oriented toward preventing recidivism, believing that the abnormal personality and behavior of sexual offenders may never be cured, but the very objective of treatment is to reduce the risk of recidivism, requiring constant engagement in evaluating or managing the offender’s risk of reoffending. Taiwanese scholars also show that the current process of diagnosing and treating sexual offenders in Taiwan uses surveys to evaluate the offender’s risk of reoffending and the possible severity of harm . Therefore, “statistical numbers” have already gradually become a key source of information, offering a new type of management tool different from past forensic psychiatric operations. The specific results of physical and psychological treatment intervention have led both the judicial system and medical units to believe that to effectively reduce recidivism, the sexual assault treatment model must not only include rehabilitation and reform but also physical and psychological treatment support. Furthermore, effectively reducing the “sexual assault recidivism” rate involves not only inhibiting or preventing deviant behavior that leads to recidivism, but also requires changing sexual assault behavior and actively cultivating correct responses through physical and psychological treatment. Therefore, for sexual offender “risk of recidivism” evaluation to be comprehensive, the content must take into account both recidivism prevention and treatment .
Research on sexual offending focuses on two main questions: how sexual offending behavior occurs and how to prevent sexual offending behavior from occurring or reduce the potential of it reoccurring . Past research has attempted to find high risk factors that trigger sexual offending behavior and to determine how these risk factors are interwoven to form sexual offending [16-21]. Research has also attempted to identify the protective factors that inhibit or prevent sexual offending behavior from occurring . Sexual assault risk evaluations should at least include the following features:
• Understand the details and contexts surrounding sexual assault behavior
• Understand how sexual assault behavior occurs and its history of development
• Predict the probability that a sexual offender will reoffend without interventional treatment
• Provide treatment guidelines
• Provide community approaches 
A complete risk evaluation does not simply predict the extent and probability that a sexual offender will reoffend but includes the likelihood that the offender accepts treatment, a treatment plan and directions and evaluations for community approaches .
Sexual offending triggers could involve internal psychological mechanisms, including static and dynamic risk factors . Static risk factors are variables found in the trajectory of the sexual offender’s personal life history that are significantly related to committing sexual offenses again. These factors include criminal records, connotation around past criminal behavior, deviant behavior as a child or adolescent and whether the victim was a stranger . Because these factors are part of the sexual offender’s personal history, their primary characteristic is that they are unchangeable. These factors can be used to predict the potential that the sexual offender will reoffend, but they do not form the complete picture of the sexual offense . In the past, risk of recidivism evaluations primarily used static data from the offender’s history to predict the extent of re-offense (such as Static-99) , but most of the static content was based on crime-related data. While historical data provides a certain degree of inference validity toward future, behavior it is still insufficient compared to the psychopathological foundation and criminal social psychology course required for treatment and inhibiting recidivism. The term “static historical data” alone is not only an approach for actual applications of treatment or crime prevention .
Based on Pennington’s theory of psychopathology , a comprehensive account of human behavior/psychopathology requires consideration of at least four levels of analysis:
• An aetiological level concerned with the influence of genetic and environmental factors in causing psychopathology
• Brain mechanisms concerned with the effects of aetiological factors on the development of the brain and its subsequent functioning
• Neuropsychological analysis concerned with the brain-based psychological systems generating human behaviour (e.g., spatial perception and language production) - it is this third level of neuropsychological functioning that is particularly important from an explanatory perspective as it directly informs researchers of the possible psychological mechanisms generating offender’s psychological symptoms and problems
• A symptom or phenomenological level of analysis concerned with the clinical phenomena thought to characterize the various forms of psychopathology under investigation (e.g., deviant sexual arousal, mood disturbances, hallucinations) 
The pre-existing risk factors come from early life experiences (such as unhealthy dependency or abandonment). These experiences shape the individual’s preferences and needs and also create a sense of remoteness from sexual assault behaviors. The subsequent advancing risk factors are negative events experienced later in life (such as frustrations with heterosexual intercourse or suffering from sexual assault) that deepen deviant personal tendencies (such as myths about women or deviant attitudes toward sex) and form certain types of internally stable qualities and needs that are risk factors for sexual assault. In adulthood, these undesirable qualities and specific needs are prone to “trigger” particular factors when under stress. These factors are called “stable dynamic risk factors” because once triggered, they will cause the offender to fall further toward a “state of offense/re-offense risk” . As for the specific trigger risk factors before the incident, facing immediate pressure or frustration motivates the offender to commit the crime, pushing the offender into a state of offense/re-offense risk (such as physiological excitement or sexual fantasies). These factors are called “acute dynamic risk factors,” as the offender is in a current high risk state for reoffending and could commit sexual assault at any time .
Hanson and Harris used retrospective comparison to analyze the data for approximately 400 sexual offenders under community monitoring . By comparing the data for recidivist offenders with non-recidivist offenders months before the former reoffended, they found five core categories that influence the potential of re-offence: “problems with emotions/sexual self-regulation” “intimacy deficits,” “negative social influences,” “attitudes toward recognizing sexual assault” and “general problems with self-regulation or self-control”. These five categories of factors are all dynamic factors triggering offenders to offend or reoffend, indicating that they are each related to each other . Polaschek and Hudson used interview data from sexual offender’s criminal history and discovered that 58% of sexual offenders originally tend to exhibit emotion-based coping to avoid or eliminate internal negative emotions created by stress from human interactions . This coping causes the offender to move toward the sexual assault target and increases the risk of sexual offense, which supports the five category interaction model . Additionally, Beech, Friendship, Erickson & Hanson examined 140 child sexual offenders in prisons of the United Kingdom and found dynamic risk factors related to sexual offense recidivism, including :
• Deviant sexual interest: sexual offenders were easily sexually aroused by sexual deviations from normal sexual behavior, such as content related to minors or scenes of sexual assault.
• Social competence: sexual offenders adapt poorly to human interactions, possessing characteristics that inhibit smooth interpersonal relations, such as low self-esteem, indecisive interactive tendencies, internal feelings of loneliness and isolation, and an inability to regulate negative emotions.
• Pro-offending attitudes: offenders tend to have distorted perceptions and interpretations of incidents of sexual offense, such as rape myths, defending or preferring to attribute sexual offending to external factors .
Thorton measured nine indicators in 158 adult sexual offenders from prisons in the United Kingdom and found four dynamic risk factors related to sexual offense :
• Deviant sexual interests
• Social and emotional functioning
• Distorted attitudes toward sex
Sexual offenders clearly have problems with “impulse control” and fail to consider the consequences of their actions, only taking into account their personal catharsis at that moment .
In Taiwan, Shen & Lin designed and used a “Taiwan Sexual Offender Dynamic Risk Evaluation Scale” based on the theory of the sexual offending cycle to analyze the relationship between sexual offense and re-offense .
The evaluation comprised two levels of assessment:
• The “stable dynamic risk factors,” which included seven questions about factors related to personal qualities such as sexual self-regulation, intimacy deficit and attitude toward sex
• The “acute dynamic risk factors”, which included eight questions about variables related to entering the state of sexual offense such as depression, hostility toward people, and opportunities 
The study contended that stable sexual assault risk qualities easily transform into a state of urgent risk of recidivism under certain environmental interaction factors, thereby increasing the possibility of the offender losing impulse control . For risk factors that change with the state and circumstances of the offender, “stable dynamic recidivism risk” factors are primarily qualities of the offender and of re-offense, especially psychological and social qualities related to the occurrence of sexual assault. Stable sexual assault risk qualities easily transform into a state of urgent recidivism risk under the trigger of certain environmental interaction factors. Once the offender has entered a state of urgent risk, without active intervention or interference, the offender characteristically falls into a high risk state. Once the offender is in a high risk state the desire to attain some kind of personal need through sexual assault is similar to a drug addicts state of “craving”, without instant external suppression, a sexual assault relapse is to be expected. However, the role of risk factors related to sexual offense recidivism in the group therapy is still unclear in Taiwan.
After a sexual offender is incarcerated, social workers and clinical psychologists arranged by the prison evaluate the possible motivations, objectives and methods, such as the use of violence, coercion, deception or money during the act of sexual assault to better understand the intentions of the sexual offender. Individual and group treatment is then organized according to the case. After the compulsory treatment, a determination is then made based on the individual case’s risk of recidivism, change in cognitive distortion and cooperative attitude, as to whether to close the case, offer parole or request that a prosecutor petition for further compulsory treatment . The need for sexual offenders to undergo necessary and compulsory physical and psychological treatment and counseling education is already a commonly held belief. Behavioral therapy, psychotherapy, psychiatric treatment and cognitive model reestablishment reduce the chances of recidivism. Therefore, in addition to receiving criminal sanctions, sexual offenders are also required to undergo compulsory treatment. The timeframe for this compulsory treatment has been changed from pre-prison release treatment to post-prison release treatment. Post-prison release treatment is expected to not only improve treatment results but actually help sexual offenders reintegrate into society and connect with community treatment without interrupting their course of treatment, thereby reducing the chance of recidivism . In terms of crime prevention, efforts should not only be directed toward the criminal, but should strengthen links with social control mechanisms and focus on the impact of the external community environment on opportunities for crime. Based on the situational crime prevention perspective, empirical evidence increasingly indicates that sexual offenses against victims are significantly mediated by opportunities and other environmental . For sexual offenders already released from prison, connection with their prison therapists and community therapists should be strengthened, careful and coherent community monitoring should be maintained, regular long-term tracking should be conducted, community security and maintenance measures should be strengthened, and chances of victimization should be severed . The ordained guardian, who is responsible for the offender during probation, must accept particular duties, including appointing a place of residence, establishing curfew, conducting lie detector tests, forbidding proximity to certain locations or people, and referring to appropriate organizations or groups, and must support electronic monitoring. The guardian first must seek respective permission from the prosecutor or military prosecutor. The group treatment model can indeed impact the offender to a certain extent and can help group members adjust to their new life more stably. After going through a year of group treatment group, members have been found to be more willing to play a proactive role in the group, regularly sharing during group sessions, feeling a strong sense of participation, believing they have the ability to participate in group discussions, or regularly helping others make decisions, and are more hopeful about the future and have a more optimistic explanatory style . Different stages of group treatment have a significant effect on cognitive transformation . However, changes to motivation remain varied among sexual offenders as a group . This is the dilemma that community treatment of sexual offenders in Taiwan currently faces .
Numerous complex background factors can lead to sexual offenses:
• Biological factors: Issues with glands can increase sexual needs and cause a lack of self-control, while brain damage or mental deficiencies can create hostility toward the victim, both of which could lead to sexual offense behavior [37,38].
• Cultural factors: Individuals who grew up in a sub-culture of violence are vulnerable to peer pressure to prove they are a man’s man and improve their status by conquering women or sexually assaulting victims .
• Personal psychological factors: Individuals with personal feelings of inferiority or who were subjected to ridicule or sexual abuse in their youth are more likely to use sexual assault as a means to regain self-respect or exact revenge; alternatively, poor communication skills and an inability to interact with the opposite sex could plant the seed for sexual offense behavior in the future .
• Incidental factors: alcoholism or viewing pornographic videos or publications can compromise self-control and lead to sexual offense behavior [41,42]
• Victim factors: Revealing outfits or a flirtatious demeanor can potentially expose an individual to sexual attacks .
Due to the variety and range of factors that could cause sexual offense, no single law should dictate that all sexual offenders, should undergo compulsory treatment. Instead, the individual factors for each offender such as the presence of aggressive behavior or abnormal personality or thinking, should be considered to determine whether an offender requires compulsory treatment.
In Taiwan, the annual costs associated with sexual assault include 382.31 million New Taiwan Dollars (NTD) in policing 3.2 million NTD in legal fees and 2.43 million NTD in court fees, for a cost of 387.94 million NTD to the entire criminal justice system. Prison costs, compulsory treatment costs and electronic monitoring costs amount to 18.19 million NTD, 11.45 million NTD and 21.72 million NTD, respectively, for a total cost of 51.36 million NTD spent on the sexual offender. Additionally, the government pays 33.43 million NTD annually on sexual assault victim support, for a total national cost of 472.7 million NTD per year on sexual assault . Unlike criminals engaged in property crime, who can be examined using rational choice theory, sexual offenders frequently commit sexual assault due to psychological factors and therefore urgently require counseling and treatment. Nonetheless, the Taiwanese government only spends 11% on related treatment .
Conventional sexual offender treatment consists of psychotherapy and cognitive behavioral therapy. In recent years, therapy to reduce deviant sexual arousal, strengthen social skills and correct deviant thoughts is also often used. These treatments are conducted simultaneously in prison and in the community. Drake, Aos and Miller conducted a meta-analysis of six rigorous results of adult sex offender treatment with aftercare and indicated that related programs average reduced recidivism by 9.6 % . In addition, these programs produced a net return on investment of more than $4,000 per program participant that is more than $1.30 in benefits per participant for every $1 spent . Sexual assault physically and psychologically damages victims and forces the government to assume a considerable financial burden. If the recidivism risk assessments for sexual offenders are only based on unchangeable past events, group treatment has no means to adjust these risk factors. Despite the recent emphasis on “dynamic factors” in risk assessments and treatment for sexual offenders, these risk factors vary based on personal or environmental regulations and therefore require identifying treatment or measures needs based on the sexual offender’s particular risk; the treatment and measures are planned based on this “risk/need” assessment [45,46].
Findings from single studies of sex offender treatment conducted within the past 10 years remain somewhat inconsistent, but the weight of the evidence from more rigorous studies suggests that treatment-particularly cognitive behavioral approaches-can have a positive effect .
The groups currently engaged in community treatment for sexual offenders in Taiwan demonstrate insufficient professional knowledge on sexual offenders and clinical experience in therapy, leading to less effective community programs than expected. Related authorities urgently need a systematic reinforcement and relevant laws and regulations should be revised to limit the qualifications for community treatment participants and the requirements for necessary courses . According to Article 3 and Article 6 of the Sexual Assault Crime Prevention Act, county (city) authorities should set up Sexual Assault Prevention Centers. However, most prevention centers only focus on administrative work and lack consensus on the detailed implementation of treatment programs for each sexual offender in community treatment, leading to inconsistent group treatment. The fundamental spirit of the community treatment model is based on coordination between units and cooperation between group members, especially the cooperation of experts. Therefore, numerous practical difficulties emerge without an expert who has the administrative authority to manage the units or personnel involved.
While sexual offenders are difficult to change, the cost or opportunity associate with offense is changeable. Crime prevention efforts should not only be directed toward the criminal but should strengthen links with social control mechanisms and focus on the impact of the external community environment on opportunities for crime . For sexual offenders already released from prison, connection with their prison therapists and community therapists should be strengthened, careful and coherent community monitoring should be maintained, regular long-term tracking should be conducted, community security and maintenance measures should be strengthened, and chances of victimization should be severed . Furthermore, most offenders of forcible rape serve time in prison, which not only includes criminal justice proceedings costs, but also correctional system costs, such as incarceration and treatment.
However, are the huge costs of long-term incarceration economically beneficial? Is there a more cost-effective method than compulsory treatment in prison? The results of operating community treatment in Taiwan are incomplete and there has yet to be an official assessment. The community treatment model is still relatively new and numerous basic supporting elements are not yet mature (such as the lack of a reliable recidivism risk assessment tool or personnel who have been trained in comprehensive assessments). Therefore, assessing the treatment results using an objective standard is difficult. Furthermore, numerous difficulties and problems still exist in organizing groups, the expertise and executive skills of personnel, the scientific approach and standardization of treatment and monitoring and the relevant legal and institutional levels in community treatment and monitoring processes . Additional integrated explorations into the execution and results of community treatment remain to be conducted.
Citation: Tung T-H, Lin K-L, Huang C, Shen S-A (2017) An Assessment of the Effects of Sexual Offender Physical and Psychological Treatment and Counseling Education in Taiwan. J Forensic Leg Investig Sci 3: 015.
Copyright: © 2017 Tao-Hsin Tung, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.