Can cognitive behavioural therapy reduce harmful sexual behaviour in adolescents?

Background

About one out of every 1000 young people aged 12 to 17 years old engages in harmful sexual behaviour like making other children engage in sexual activities. Some are convicted of a sexual offence. Many treatment programmes include cognitive-behavioural techniques, tailored to individual needs. Cognitive-behavioural therapy (CBT) is based on the theory that changing the way people think helps change behaviour. It has been used for adults, but it is not known if it works for adolescents with harmful sexual behaviour.

Review question

Is CBT better at reducing adolescent harmful sexual behaviour than no treatment or alternative treatment? We looked at evidence about the effect of CBT on offending rates and adverse events such as self-harm. We also examined participants' emotional and psychological well-being, as well as their sexual attitudes and behaviour.

Search date

In June 2019, we searched many databases for randomised controlled trials comparing CBT to no treatment or other treatments. Randomised controlled trials use a random method (like tossing a coin) to decide whether people get different treatments or no treatment.

Study characteristics

We found four small studies including a total of 115 young men exhibiting harmful sexual behaviour. In two studies, participants were aged 12 to 18 years old. In the other two studies the male participants were simply described as "adolescents".

Three studies were conducted in the USA and one in South Africa. Studies were short. One lasted two months; two lasted three months; one lasted six months. We do not know who funded these studies.

Two studies (39 participants) compared CBT to no treatment or treatment as usual. One study (16 participants) compared CBT to a sexual education programme. One study compared CBT (19 participants) with mode deactivation therapy (explicit, systematic, goal-oriented approach to address problematic emotions, behaviours and thoughts) (21 participants) and social skills training (social skills development and role playing) (20 participants). In three studies, CBT was delivered in a residential setting by someone working there. In the fourth, it was provided in community by a licensed therapist studying for a PhD.

Key results

One study (59 participants) examined whether CBT reduced harmful sexual behaviour, or made participants less likely to offend. It provided very low-certainty evidence showing CBT reduced sexual aggression at post-intervention. This was similar to other treatments of mode deactivation therapy and social skills training. No studies examined whether it had unintended consequences such as self-harm.

One study (59 participants) found little to no difference in how CBT improved psychological well-being compared with other treatments (very low-certainty evidence). One study (18 participants) showed CBT meant the young men understood how their behaviour had effected their victims, compared to the no-treatment group (very low-certainty evidence). One study (21 participants) measured this, but reported no usable data.

Two studies examined whether CBT improved the kind of thinking associated with harmful sexual behaviour (sexual attitudes and behaviour). One of these (21 participants) compared CBT with treatment as usual. It found no evidence that it made a difference. Another study (16 participants) compared CBT with sexual education. It found CBT improved some types of cognitive distortions. One study (18 participants) reported no significant difference between CBT and receiving no treatment on general cognitive distortions about sexual behaviour (very low-certainty evidence).

Certainty of the evidence

We cannot tell whether CBT reduces harmful sexual behaviour in male adolescents. The four studies had very small sample sizes. Overall, there is very low-certainty evidence that group-based CBT may improve victim empathy compared to no treatment, and may improve cognitive distortions compared to sexual education, but not treatment as usual. The very low-certainty of this evidence means that the results are likely to change when further studies are carried out. No studies looked at the impact of CBT on girls with harmful sexual behaviour. It was difficult to assess how well the studies were conducted. Available reports did not provide enough information or were rated at high risk of bias in some sections. More, better quality randomised controlled trials of individual and group-based CBT are needed, particularly outside North America. Evaluations need to also include more diverse participants.

Authors' conclusions: 

It is uncertain whether CBT reduces HSB in male adolescents compared to other treatments. All studies had insufficient detail in what they reported to allow for full assessment of risk of bias. 'Risk of bias' judgements were predominantly rated as unclear or high. Sample sizes were very small, and the imprecision of results was significant. There is very low-certainty evidence that group-based CBT may improve victim empathy when compared to no treatment, and may improve cognitive distortions when compared to sexual education, but not treatment as usual. Further research is likely to change the estimate. More robust evaluations of both individual and group-based CBT are required, particularly outside North America, and which look at the effects of CBT on diverse participants.

Read the full abstract...
Background: 

Around 1 in 1000 adolescents aged 12 to 17 years old display problematic or harmful sexual behaviour (HSB). Examples include behaviours occurring more frequently than would be considered developmentally appropriate; accompanied by coercion; involving children of different ages or stages of development; or associated with emotional distress. Some, but not all, young people engaging in HSB come to the attention of authorities for investigation, prosecution or treatment. Depending on policy context, young people with HSB are those whose behaviour has resulted in a formal reprimand or warning, conviction for a sexual offence, or civil measures. Cognitive-behavioural therapy (CBT) interventions are based on the idea that by changing the way a person thinks, and helping them to develop new coping skills, it is possible to change behaviour.

Objectives: 

To evaluate the effects of CBT for young people aged 10 to 18 years who have exhibited HSB.

Search strategy: 

In June 2019, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also examined relevant websites, checked reference lists and contacted authors of relevant articles.

Selection criteria: 

We included all relevant randomised controlled trials (RCTs) using parallel groups. We evaluated CBT treatments compared with no treatment, waiting list or standard care, irrespective of mode of delivery or setting, given to young people aged 10 to 18 years, who had been convicted of a sexual offence or who exhibited HSB.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane.

Main results: 

We found four eligible RCTs (115 participants). Participants in two studies were adolescent males aged 12 to 18 years old. In two studies participants were males simply described as "adolescents."

Three studies took place in the USA and one in South Africa. The four studies were of short duration: one lasted two months; two lasted three months; and one lasted six months. No information was available on funding sources.

Two studies compared group-based CBT respectively to no treatment (18 participants) or treatment as usual (21 participants). The third compared CBT with sexual education (16 participants). The fourth compared CBT (19 participants) with mode-deactivation therapy (21 participants) and social skills training (20 participants). Three interventions delivered treatment in a residential setting by someone working there, and one in a community setting by licensed therapist undertaking a PhD.

CBT compared with no treatment or treatment as usual

Primary outcomes

No study in this comparison reported the impact of CBT on any measure of primary outcomes (recidivism, and adverse events such as self-harm or suicidal behaviour).

Secondary outcomes

There was little to no difference between CBT and treatment as usual on cognitive distortions in general (mean difference (MD) 1.56, 95% confidence interval (CI) -11.54 to 14.66, 1 study, 18 participants; very low-certainty evidence), assessed with Abel and Becker Cognition Scale (higher scores indicate more problematic distortions); and specific cognitive distortions about rape (MD 8.75, 95% CI 2.83 to 14.67, 1 study, 21 participants; very low-certainty evidence), measured with the Bumby Cardsort Rape Scale (higher scores indicate more justifications, minimisations, rationalisations and excuses for HSB).

One study (18 participants) reported very low-certainty evidence that CBT may result in greater improvements in victim empathy (MD 5.56, 95% CI 0.94 to 10.18), measured with the Attitudes Towards Women Scale, compared with no treatment. One additional study also measured this, but provided no usable data.

CBT compared with alternative interventions

Primary outcomes

One study (59 participants) found little to no difference between CBT and alternative treatments on post-treatment sexual aggression scores (MD 0.09, 95% CI -0.18 to 0.37, very low-certainty evidence), assessed using Daily Behaviour Reports and Behaviour Incidence Report Forms. No study in this comparison reported the impact of CBT on any measure of our remaining primary outcomes.

Secondary outcomes

One study (16 participants) provided very low-certainty evidence that, compared to sexual education, mean cognitive distortions pertaining to justification or taking responsibility for actions (MD 3.27, 95% CI −4.77 to −1.77) and apprehension confidence (MD 2.47 95% CI −3.85 to −1.09) may be lower in the CBT group. The same study indicated that mean cognitive distortions pertaining to social-sexual desirability may be lower in the CBT group, and there may be little to no difference between the groups for cognitive distortions pertaining to inappropriate sexual fantasies measured with the Multiphasic Sex Inventory.

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