Theory-Based Assessment, Treatment, and Prevention of Sexual Aggression.

By Gordon C. Nagayama Hall. New York: Oxford University Press, 1996, 250 pages. Cloth, $39.95.

Reviewed by Cindy Struckman-Johnson, Ph.D., University of South Dakota, Department of Psychology, Vermillion, SD 57069.

Author Gordon Nagayama Hall is a clinical psychologist who has accumulated impressive credentials in the area of sexual aggression. After working five years in a sex offender treatment program in Washington, Hall joined the faculty at Kent State University, where he studied the causes and treatment of sexually aggressive behavior. This volume is a synthesis of his clinical experience, research findings, and often controversial opinions.

The book begins with Hall's personal views on the prevalence and major causes of sexual aggression in American society. Chapter 2 is a brief review of prevalent theories of sexual aggression, including sexual arousal to deviant sexual stimuli, sociobiology, attachment theory, personality development, child abuse, social learning theory, and feminist perspectives.

The core of the book is Hall's own theory--the "quadripartite model" of sexual aggression. The model (detailed in Chapter 3) has four categories of perpetrator subtypes. The physiological aggressor is motivated by sexual arousal and is typified by child molesters who have multiple victims but seldom use physical violence in their sexual actions. Cognitive aggressors are motivated by distorted cognitive reasoning, which justifies their actions. Typified by persons who commit acquaintance rape and incest, their behavior tends to be planned and is less violent than others. The affective perpetrator, motivated by affective dyscontrol, displays impulsive, opportunistic, and violent sexual aggression. Examples are angry adult rapists or depressed child molesters. The category of developmentally related personality problems describes perpetrators who have chronic personality difficulties that often involve a general tendency to break rules. Exemplified by sex offenders with antisocial traits, perpetrators tend to commit violent acts of sexual aggression and have the poorest prognosis for treatment.

Hall argues that sexual aggressors have a lower threshold for action than others. Thus, they are prone to engage in sexual aggression when situational determinants (environmental or self-induced) lower their inhibitions. Perpetrators in each subtype tend to be influenced by particular sets of situations. For example, a person motivated by physiological arousal may molest a child after viewing child pornography. Cognitive category perpetrators may select situations where they are unlikely to be blamed (e.g., the victim was drinking or dressed provocatively). In the affective category, a man may rape a woman following an angry argument.

According to Hall, the results of several MMPI studies of sex offender populations support the validity of subtypes of his model. He also reports supportive evidence from his studies of the physiological sexual arousal patterns of rapists, child molesters, and community men. The weakest evidence may be Hall's own research on sexually aggressive behavior of men in a laboratory setting. Readers may question Hall's measure of sexual aggression-allowing men the opportunity to show sexual stimuli to a female confederate. Although Hall admits that a procedural variation of this study was biased by a demand characteristic, he nonetheless cites the results as supportive of his model.

In a turn from theory to clinical application, Chapters 4 to 6 are devoted to prediction, assessment, and treatment of sex offenders in the criminal justice system. Hall discusses assessment of perpetrator characteristics such as cognitive distortions, penile response to sexual stimuli, emotional states, and anti-social traits. One of this book's important contributions is the review of treatment options for sex offenders. Hall's meta-analyses of treatment programs suggest that cognitive behavioral therapies and hormonal treatments (e.g., antiandrogren drug therapies, castration) are more effective than behavioral treatment or no treatment. It is recommended that treatment be tailored for perpetrators based upon their categorization in the quadripartite model.

In the final chapters on prevention, Hall reviews risk factors for the development of sexually aggressive behavior and the "protective" factors of religiosity and positive cultural influences such as those found in Asian-American communities. He advocates interventions in high-risk families, schools at all levels, and community environments to promote healthy personalities, good communication, and values of harmony and cooperation.

I have reservations about numerous aspects of this book. First, Hall defines sexual perpetrators as "male" and refutes the notion of female sexual aggression. I find this definition troubling, as I have discovered in my research that as many as 30% of college-age men have experienced pressured and forced sexual contact from female adults (Struckman-Johnson & Struckman-Johnson, 1994). However, Hall discounts several studies revealing females as perpetrators of child and adult sexual abuse, stating that an emphasis on female perpetrators 64may serve to divert attention from critical issues involving the men who are most commonly perpetrators" (p. 12). He also does not discuss sexual assault of adult men by other males that occurs in prison inmate and gay populations. By limiting his perspective to male perpetrator-female victim sexual aggression, Hall has compromised his investigation of causes and treatment.

In what amounts to sexism, Hall holds large numbers of men accountable for the actions of a minority. For example, in his opening paragraph, Hall writes that, based upon the work of Koss, Gidycz, and Wisniewski (1987), approximately 25% of adult men have perpetrated sexual aggression. This generalization from a survey of college men unfairly tars a substantial number of American men as sexual aggressors. Throughout the book, Hall asserts that male citizens are in general responsible for the norms, media, and laws that contribute to sexual aggression. He is even suspect of men who want to reduce sexual aggression, saying it is like having the "fox guarding the chicken coop" (p. 8).

I also have concerns with some assumptions of the quadripartite model. Although the model represents an advance in the description and understanding of sexual offender types, the independence of the subtypes may be debatable. It seems conceivable that there exist sex offenders with antisocial traits (developmental category) who also exhibit cognitive distortions (cognitive category) and/or are attracted to deviant sexual stimuli (physiological category). Malamuth, Linz, Heavey, Barnes, and Acker (1995) have criticized Hall's model on this point, suggesting that not one characteristic but the "confluence" of several mutually enhancing variables (e.g., hostile masculinity, preference for impersonal sex) motivates sexually aggressive men.

Another concern is that Hall's model is based on the assumption that most sexual aggression is linked to social-environmental conditions. Only one category--physiological arousal--reflects underlying biological influences. However, research in the 1980s and 1990s suggests that neurocognitive deficits and endocrine abnormalities (including libido) are characteristic of some sex offender populations (Langevin & Watson, 1996). In contrast to Hall's view that antisocial traits are acquired through developmental experiences, new research suggests that elements of the antisocial personality may be at least 50% inheritable (Miles & Carey, 1997). Recognition of the contributing role of biology in sexual aggression is essential for determination of appropriate treatment and prevention efforts.

I am also uncomfortable with Hall's convention of grouping convicted rapists and child molesters into the same population as men who are defined as sexually aggressive based upon their responses to college and campus surveys. It seems inappropriate to equate convicted violence-prone rapists and sexually aggressive college men, who are more likely to use verbal pressure or intoxication rather than physical force. Hall himself vacillates between declaring sexually aggressive college men as motivated by a range of motives common to convicted rapists (p. 52) or as motivated primarily by cognitive distortions (pp. 52, 191).

Despite these criticisms, I recommend this book for professionals who are interested in the burgeoning field of sex offender treatment. Hall's expertise in this area seems substantial. Clinical practitioners will appreciate the detailed information on assessment strategies, including interview tactics for countering denial and cognitive distortions of offenders. Hall's clinical interview questionnaire and outlines of his preferred approaches for treatment and relapse prevention are presented. Researchers will be awed by the tremendous barriers to documenting a successful treatment approach for sex offenders. Problems include the selection bias in the types of offenders who are allowed into treatment, the high dropout rates in the more arduous (and potentially more effective) programs, and the difficulty of producing statistically significant differences, given low base rates of rearrests.

Finally, those who read this book will be stirred to think about social policy and ethical issues surrounding sex offender treatment. For example, should sex offenders be rehabilitated or punished in the criminal justice system? Is it humane to banish them to prison settings where they are generally despised (and at some higher risk for sexual assault)? Is an 8% reduction in rearrest rates sufficient justification for the effort and costs of treatment? Is it justice to give long sentences or deny parole to all sex offenders, when many of them may never reoffend? And what level of risk of reoffending are we willing to accept, given that one relapse by a sex offender may have serious consequences for a victim? As Hall raises these unsettling questions, he challenges professionals to search for treatments that will give offenders sufficient self-control and self-monitoring abilities for a safer reentry into society.

References

Koss, M. P., Gidycz, C. A., & Wisniewski, N. (1987). The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Journal of Consulting and Clinical Psychology, 55, 841-843.

Langevin, R., & Watson, R. J. (1996). Major factors in the assessment of paraphilic and sex offenders. Journal of Offender Rehabilitation, Sex Offender Treatment (Special issue), 23, 39-70.

Malamuth, N. M., Linz, D., Heavey, C. L., Barnes, G., & Acker, M. (1995). Using the confluence model of sexual aggression to predict men's conflict with women: A 10-year follow-up study. Journal of Personality and Social Psychology, 69, 353-369.

Miles, D. R., & Carey, G. (1997). Genetic and environmental architecture of human aggression. Journal of Personality and Social Psychology, 72, 207-217.

Struckman-Johnson, C. J., & Struckman-Johnson, D. (1994). Men pressured and forced into sexual experiences. Archives of Sexual Behavior, 23, 93-114.