Arousal Management Techniques, Effectiveness and Therapeutic Applications in Sexual Offending Treatment: A Review

Abstract

Techniques aimed at modifying or managing paraphilic sexual interests have been a mainstay of many sexual offending treatment programs internationally for a number of decades, based largely on behavioral traditions. However, research interest and innovation with regard to these techniques has notably stagnated over time. The current narrative review aimed to explore arousal management techniques used in contemporary rehabilitative practice, to consider current evidence regarding the effectiveness of such methods, as well as to overview available guidance regarding the suitability of therapeutic applications of the techniques with different populations of those who have been apprehended for perpetrating sexual offenses. Overall conclusions support the inclusion of some form of arousal modification and management targets in programs for selected individuals, largely based on recent meta-analytic findings regarding the effectiveness of relevant techniques in reducing paraphilic interest, as well as their empirical association with reduced sexual reoffending. The need for fresh research in this area is also highlighted.

The rehabilitation of individuals who have sexually offended, aimed at preventing or reducing the likelihood of further such behavior, poses challenges to justice and correctional systems worldwide. Complicating factors are many and varied and include, for example, the extent an individual acknowledges their offending behavior and is motivated for rehabilitation, their level of reoffense risk, demographic factors such as gender, age, and cultural background, and the presence of coexisting concerns such as mental health diagnoses or low cognitive functioning. Beyond these considerations, there is also the complex question of what aspects should be targeted for change in rehabilitation programs.

Bonta and Andrews’ (2023) Need Principle provides essential guidance, stating that the most important treatment targets will be those factors that have been shown through research to bear the strongest empirical relationship with the relevant type of reoffending – in this case, sexual reoffending. It has also been argued (e.g., Heffernan & Ward, 2015; Mann et al., 2010) that when seeking a specific behavior change such as decreased sexual offending, understanding and addressing the etiological sources of such behavior is likewise important.

When it comes to sexual offending, one factor meeting both of these guiding principles is what has often previously been termed deviant sexual interest (Mann et al., 2010). The concept of sexual deviancy referred to unusual imagery or acts being linked to sexual excitement for an individual (Eysenck & Gudjonsson, 1989). This would include the paraphilias described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatric Association, 2022), including pedophilia comprising recurrent and intensely sexually arousing fantasies, urges, or behaviors involving a prepubescent child or children. Note that hereafter within the current paper, following updated best practice guidelines published by the Association for the Treatment and Prevention of Sexual Abuse (2025), we have where possible chosen to use alternative language such as ‘paraphilic’ in place of ‘deviant,’ to avoid pejorative connotations. In terms of the Need Principle, paraphilic sexual arousal patterns have been highlighted in influential reviews and meta-analyses as having among the strongest statistical associations with sexual recidivism (Hanson & Morton-Bourgon, 2005; Mann et al., 2010; McPhail et al., 2019). Paraphilic arousal also features prominently in leading theoretical perspectives regarding the etiology of sexual offending behaviors (e.g., Seto, 2019; Ward & Beech, 2006; Ward & Siegert, 2002). For these reasons, attempts to directly target such patterns for change have been a key feature of both traditional and contemporary treatment approaches with those who have committed sexual offenses. That said, one thing that is clear from both empirical and theoretical scholarship (e.g., Seto, 2018; Ward & Siegert, 2002) is that individuals who have committed sexual offenses are not a homogenous group, and that for many individuals, needs related to paraphilic arousal patterns may have been either absent or not the primary drivers of offending behaviors.

In fact, while it is now much better understood that sexual offending is a complex and multiply-determined behavior requiring a breadth of targets within a comprehensive program (particularly for those at high risk of reoffending), earlier interventions developed predominantly in the 1970s and 1980s tended to subscribe to much simpler, solely behavioral explanations; as such, paraphilic sexual arousal patterns were the primary or only target, and techniques were purely behavioral (Fernandez et al., 2006). Ware et al. (2021) described the behavioral theoretical underpinnings, including most notably Laws and Marshall’s (1990) conditioning theory, which built on previous behavioral models to hold that paraphilic sexual arousal patterns are learned, through a combination of classical (pairing of stimuli with arousal) and operant (repeated reinforcement via masturbation) conditioning processes in addition to social learning. Ware et al. (2021) also noted the relevance of Masters and Johnson’s (1966) model of the human sexual response cycle comprising the four stages of excitement, plateau, orgasm, and resolution to behaviorally based treatment techniques. As noted by Marshall and Laws (2003), subsequent decades (from the 1970s and 1980s on) brought the influence of the cognitive model to the field, followed by the relapse prevention approach, and there were increasing calls to incorporate a broader range of targets into therapeutic approaches with those who had sexually offended. Comprehensive programs thus tended to also begin to include procedures aimed at (for example): changing distorted cognitions; building coping and self-management skills; and increasing knowledge about healthy sexual functioning and about the features and benefits of enhanced intimacy (Marshall et al., 1999; McGrath et al., 2010). Given such expansion, according to Miner and Munns (2021), except for a small number of ongoing case studies there was little or no research on behavioral interventions in particular after the late 1980s. Nonetheless, use of various techniques based on understandings of behavioral influences on the development of paraphilic arousal patterns and sexual offending continued in practice settings internationally though not as a sole focus. For example, a large scale survey of practices in the field in North America found that although over half of all programs for males included arousal control as a treatment target, along with three-quarters of residential and one-third to one-half of community-based programs for males in Canada, these figures were not as high as those for other targets including victim empathy, social skills, and intimacy skills (McGrath et al., 2010).

Although Fernandez et al. (2006) advocated for a balanced approach integrating both the newer, broader range of treatment targets and techniques (i.e., including those from a cognitive paradigm) alongside a renewed focus on behavioral models, Marshall and Fernandez (2003) in contrast directly considered the question of whether attempts to measure and modify sexual arousal patterns were necessary or even useful components in sexual offending treatment. Marshall and Fernandez highlighted concerns with the reliability, ecological and criterion validity of phallometric assessment (the traditional means of assessing for the presence of paraphilic arousal), as well as the lack of standardization across settings – however they did note that agreement across studies was much greater in relation to those who had child as opposed to adult victims. Regarding the evidence for behavioral modification procedures, Marshall and Fernandez concluded that while there appeared (at that time) to be encouraging albeit limited evidence for the use of some combination of covert sensitization, directed masturbation, and satiation techniques for individuals with paraphilic arousal (note that these techniques are expanded on below), they also described limited research findings and anecdotal reports suggesting that similar scale reductions in paraphilic phallometric responding could occur coincidentally alongside comprehensive programs that had not included any direct attempts to alter sexual arousal patterns. These reasons led Marshall and Fernandez (2003) to suggest that interventions directed specifically at modifying such patterns may not be essential features of effective sexual offending treatment.

More recently, the field has seen some renewed interest in considerations regarding the use and effectiveness of arousal modification techniques within sexual offending treatment. With research into such techniques having stagnated since the late 1980s but their use in many practice settings having continued (as previously noted), Gannon et al. (2019) took the opportunity to evaluate the impact of including arousal reconditioning components within sexual offending treatment programs. They did so within their large-scale treatment effectiveness meta-analysis: Specialized sexual offense programs were coded dichotomously according to whether or not they incorporated some form of arousal reconditioning, with the resulting variable being included as one of several potential moderator variables investigated for their association with recidivism outcomes. Gannon et al. found that programs incorporating arousal reconditioning demonstrated greater effectiveness in terms of relatively larger reductions in sexual recidivism compared to programs that did not include any such techniques. Gannon et al.’s analyses, however, did not differentiate which specific techniques falling under the umbrella of arousal reconditioning were used by the programs studied, nor did they explore whether the reconditioning treatment components had any direct impacts on paraphilic sexual arousal patterns. Another recent relevant meta-analytic review, by McPhail and Olver (2020), did take a direct approach exploring these questions, although unlike Gannon et al. their analyses did not extend to recidivism outcomes. McPhail and Olver analyzed the effectiveness of various arousal modification approaches, focusing on studies in which arousal patterns were assessed phallometrically prior to and following interventions that targeted arousal towards children. McPhail and Olver’s findings in general supported the effectiveness of a range of intervention types including behavioral reconditioning techniques, at significantly reducing phallometric responding towards child stimuli.

These two recent meta-analyses, each with their differing and limited but complementary scopes, have therefore offered encouraging findings. Given the ongoing importance of pursuing continuous improvement in sexual offending rehabilitation efforts, it is timely to return to the topic of arousal management approaches with a targeted narrative review, to draw together information and provide integrative commentary regarding specific techniques, therapeutic applications, and up-to-date effectiveness research.

Review Aims and Method

The aims of the current review are to investigate the range of arousal management techniques used in contemporary practice in correctional rehabilitative settings internationally, consider up to date empirical evidence regarding the effectiveness of such methods, and overview the suitability of therapeutic applications of the techniques with different populations of those who have perpetrated sexual offenses. Review methodology involved carrying out a series of searches utilizing Google Scholar and the University of Canterbury Library multisearch function, which incorporates and accumulates all resources from key databases for psychology including PsychInfo, PsycArticles, Sage Journals, PubMed, Scopus, ScienceDirect, SpringerLink, and Wiley online library in addition to the university library collections. Search terms included, for example, “deviant sexual interest”; “deviant sexual arousal”; “sex* offen* treatment”; “arousal management”; “arousal reconditioning”; and “pedophil* treat*”. Titles and abstracts were screened for relevance; the reference lists of identified articles were also screened for additional relevant resources. Finally, a request was submitted to the Listserv of the Association for the Treatment of Sexual Abuse (ATSA) seeking to identify further resources relevant to the review not otherwise obtained.

Review Findings

This section proceeds with the following structure: First, the range of arousal management techniques that have been described in the literature as having therapeutic applications with individuals who have sexually offended will be introduced and described. These include, but are not limited to, reconditioning techniques drawing on behavioral theory. Following this, extant literature regarding the effectiveness of such methods will be overviewed, along with any empirical guidance on applicability parameters. Application guidance for enhancing technique effectiveness will be overviewed, and finally, overall conclusions will be drawn.

Overview of Techniques

As noted, the initial research origins of therapeutic techniques that could be applied to address paraphilic sexual arousal patterns among individuals who had sexually offended stemmed from behavioral theory. As such, the majority of techniques described below are behavioral in nature. However, non-behavioral methods have also been applied (i.e., pharmacological; eye movement desensitization and reprocessing or EMDR), and are included below following the descriptions of specific behavioral techniques. It is also important to note here that the best supported contemporary approaches to sexual offending treatment involve comprehensive cognitive-behavioral programs with multiple targets, acknowledging the complex etiology of such behavior (Hanson et al., 2002; Schmucker & Lösel, 2015). Approaches involving too narrow a focus on any single factor, including paraphilic sexual arousal, would not be expected to effectively address the range of supported contributing factors across heterogenous groups of individuals who have sexually offended.

Behavioral Techniques

According to McPhail and Olver (2020), the general aim of behavioral arousal management techniques is to provide the individual with skills to manage or inhibit in their daily life the sexual arousal that they experience towards inappropriate targets such as children. As noted above, traditional techniques draw on principles of operant learning and/or classical conditioning (Fernandez et al., 2006).

Marshall et al. (1999) identified that procedures employed to modify paraphilic fantasy have tended to include either some form of masturbatory reconditioning, which Marshall and Fernandez (2003) described as referring to “procedures that employ masturbation prior to orgasm to increase the incidence and valence of appropriate fantasies, or during the post-orgasm refractory period to diminish the attractiveness of deviant thoughts” (p. 136), or some form of aversion therapy. The advantages of masturbatory procedures, as noted by Marshall et al. (2016), include the ready availability as a common practice across age groups, the use of natural processes (as opposed to aversion impositions which are invariably artificial), and the potential for durable changes given that masturbation is thought by some to be at least in part the means by which paraphilic arousal patterns are acquired; the effects of aversive consequences (as a form of punishment) in contrast could be expected to be more transitory.

Aversion Therapy

Utilizing a positive punishment contingency, aversion therapy involves the pairing of noxious stimuli such as a nausea-inducing agent, unpleasant odor, or electric shock, with the specific arousal that is being targeted for change (e.g., arousal to children). Olfactory aversion, involving nasal ingestion of a foul odor following presentation of the paraphilic stimuli, has been noted to typically produce acquired revulsion towards the stimuli within three to four sessions, however empirical support has been derived primarily from case studies (Marshall et al., 2016). Marshall et al. (1999, 2016) also described the use of ammonia inhalants (smelling salts). Such stimuli operate via the pain system as opposed to the olfactory system, and their use as a self-management technique is intended to interrupt a person from thoughts and feelings associated with paraphilic arousal, enabling them to reappraise their actions and abort a potential offense sequence. According to Marshall et al. (2016), while aversion procedures involving nausea and shocks have largely fallen out of favor, olfactory and ammonia aversion and covert sensitization (see below) have had some empirical support and continue to be used (particularly covert sensitization).

Covert Sensitization

A form of aversion therapy in which the aversive consequences are imagined as opposed to tangible. Covert sensitization was identified as the most commonly used of the behavioral techniques in McGrath et al.’s (2010) survey of practices in the field. The technique involves the individual evoking paraphilic imagery/fantasy, followed immediately by imagined aversive but realistic consequences (Marshall et al., 2011). Marshall et al. (2009) advised that the consequences selected should be personally relevant, meaningful to the individual, and realistic, such as being caught in the act of abuse, being identified in the media as a sexual offender, losing friends and family, and being sent to prison. It is possible to combine the consequence phase of covert sensitization with a simultaneous non-imagined aversive stimulus such as olfactory aversion, which has been referred to as assisted covert sensitization (Marshall et al., 2009). Finally, noting that the mechanism of action appeared to be the pairing of paraphilic fantasy with consequences, as opposed to the aversiveness of those consequences, Marshall (2007) described a modified procedure referred to as covert association, in which progressively earlier steps in the sequence can be paired with the imagined aversion, using individualized offense sequences replicating the behavioral/emotional/thought chains of their past offenses or their typical paraphilic fantasies, each divided into sections and written on cards with the consequences on the reverse.

Directed Masturbation

Utilizing a positive reinforcement contingency, this technique is aimed at increasing arousal to non-paraphilic stimuli, and involves the direct pairing of age appropriate and consensual sexual fantasy with the reinforcement of masturbation and orgasm, as part of a conditioning process. The stimuli being conditioned could be either watched or imagined, and the strategy must be employed for an individual’s every incidence of masturbation. If necessary, the individual can be assisted to develop their initial appropriate fantasy material using prepared scripts, and/or visual aids (Abracen & Looman, 2016). While reaching orgasm was highlighted as part of the technique, according to Marshall et al. (2009) the crucial association is actually between sexually appropriate thoughts and significant sexual arousal, which they stated is best achieved within the plateau phase of the sexual response cycle.

Thematic Shift

A variant of directed masturbation, involving the individual initiating arousal using their preferred (i.e., paraphilic) fantasy, followed by a switch or ‘shift’ to a previously agreed upon non-paraphilic (i.e., age appropriate and consenting) image, continued until orgasm. The shift should be made once arousal has reached to near the ‘plateau’ phase of the sexual response cycle, or in other words when arousal is greater than 30% of a full erection (Marshall et al., 2016). Over time with this procedure the individual can be guided to make the fantasy shift successively earlier in the masturbation sequence (Laws & Marshall, 1991). As stated by Marshall et al. (2009), whilst according to behavioral theory consistent pairing brought about by repeated application of either technique (directed masturbation or the thematic shift variant) should result in the enhanced sexual attractiveness of the non-paraphilic stimuli for the individual, there is not a strong published evidence base.

Fantasy Alternation

This procedure is another variant on directed masturbation aimed at increasing arousal to non-paraphilic stimuli. As described by Abracen and Looman (2016), in fantasy alternation the individual participates in a series of masturbatory treatment sessions in a phallometry laboratory. Sessions in which they are instructed to masturbate to a paraphilic theme are alternated with sessions in which they are instructed to masturbate to a non-paraphilic theme (note that unlike the thematic shift procedure, in the fantasy alternation technique fantasy content is not altered within a session). Between laboratory sessions, the individual is encouraged to only use appropriate fantasy. The hypothesized mechanism of action for fantasy alternation is the individual being triggered to re-examine their self-attributions regarding the direction of their sexual interest once they discover through the laboratory sessions that they do in fact have the ability to become aroused to age appropriate and consensual stimuli.

Notably, a review by Miner and Munns (2021) concluded that versions of masturbatory reconditioning that do not involve the presentation of paraphilic themes in treatment sessions are the most promising, given the “theoretical confusion” underlying fantasy alternation (p. 257; i.e., theoretical confusion refers to the proposed mechanism of action underlying the fantasy alternation technique appearing somewhat paradoxical, given that according to basic behavioral principles reinforcing paraphilic themes via masturbation should increase rather than decrease paraphilic interest).

Satiation/Verbal Satiation

Satiation procedures are aimed at extinguishing arousal to paraphilic stimuli, and are designed to work as follows: Directly following masturbatory orgasm, during the ‘refractory period’ that is incompatible with arousal therefore providing a period of non-reward, the individual either attempts to continue masturbating (in the original satiation procedure) while imagining and rehearsing aloud all variants of their paraphilic fantasies; or, in the modified verbal-only version (developed as a result of high refusal rates; Marshall et al., 2009; and framed as more “client-friendly” by Marshall et al., 2016, p. 1379) the verbal rehearsal is not accompanied by ongoing masturbation (Marshall et al., 2009; Marshall & Fernandez, 2003). The mechanism of action underlying satiation techniques is the expectation that the repeated association between paraphilic thoughts/images and sexual unresponsiveness should act to extinguish the capacity of such stimuli to evoke arousal. Marshall et al. (2009) highlighted that since satiation effectiveness relies on the client self-producing a refractory state via masturbation, it is sensible for satiation and directed masturbation to be employed in combination, such that the refractory state is produced via non-paraphilic as opposed to paraphilic fantasy and paraphilic fantasy is not reinforced.

Non-Behavioral Techniques

Pharmacology

Pharmacological approaches stem from the medical and psychiatric traditions, and are sometimes utilized as an adjunct or alternative to behavioral procedures (McPhail & Olver, 2020). Medications used in this manner are intended to act on underlying biological factors in order to attenuate paraphilic sexual fantasies and/or problematically high libido levels, which often co-occur. Elliott et al. (2018) discussed medication as a means of support for individuals who struggle to manage elevated levels of sexual preoccupation or hypersexuality, noting the recent introduction of availability of medication to manage sexual arousal into the prison system in the UK.

Most research relevant to this area of pharmacology has focused on individuals who had sexually offended and been convicted (Turner & Briken, 2021). Medications that have been used include hormonal antilibidinals (such as medroxyprogesterone acetate, or leuprolide acetate; Gallo et al., 2019), and selective-serotonin-reuptake-inhibitors (SSRIs; Landgren et al., 2022). A recent review of relevant randomized control trials (Landgren et al., 2022) noted the meagre research basis for current clinical decision-making, however concluded that testosterone-lowering drugs do reduce sexual activity in people with pedophilic disorder. Nonetheless, it remained to be explored whether this translated into outcomes such as reduced sexual offending behavior or improved quality of life. In line with this, Saleh (2009) cautioned that medication should in no way be viewed as a panacea for eliminating sexual offending behavior. Also noting the potential for side-effects, Saleh highlighted the importance of a comprehensive process of informed consent. Turner and Briken (2021) emphasized that pharmacological agents do not directly influence the content of what is sexually arousing to an individual, purely the general reduction of sexual fantasies, urges, and behaviors (both paraphilic and non-paraphilic). They noted, however, that in some cases pharmacology may be a necessary first step in order to enable the individual to benefit from psychotherapeutic interventions. Guidance from Saleh (2009) included that testosterone-lowering medication should only be used in carefully selected cases and must be closely monitored.

Eye Movement Desensitization and Reprocessing (EMDR)

In her chapter exploring future directions in sexual self-regulation treatment approaches with those who have sexually offended, Smid (2022) noted that EMDR, a validated and well-known method of treating trauma, had been experimentally adapted in some parts of the world as a possible technique to directly influence paraphilic arousal. As described by Smid, EMDR in this context would involve an individual recalling an arousing paraphilic memory or fantasy, while being guided by the specially trained therapist to perform specific repetitive eye movements (i.e., by following horizontal movements of the therapist’s hand). This procedure ultimately aims to disconnect the stimulus from its sexually arousing qualities, by reducing their vividness and positive emotional charge.

Effectiveness of Techniques

Whilst as noted, there is a long history in the field of sexual offending rehabilitation of focusing efforts on trying to alter paraphilic sexual arousal patterns, in more recent years Seto (2012) and others (e.g., Grundmann et al., 2016) have begun to subscribe to the view that preferential sexual arousal towards children (i.e., pedophilia) may be akin to an orientation – that is, a sexual age orientation, that would be expected to have stability across time for an individual in a similar way to a person’s gender orientation such as heterosexuality. Seto has further pointed to other parallels between age orientation and gender orientation, such as an early onset, and correlations with sexual and romantic behavior. Other authors (notably, Cantor, 2018, p. 203) have referred to a scientific “consensus” regarding the failure to date of any therapeutic attempts to convert pedophilia to teleiophilia (orientation towards adults), and the appropriate aims of treatment therefore centering more around management of the paraphilic arousal and developing secure self-regulation of behaviors so as to not offend.

The question of whether pedophilic arousal patterns can change or should be considered immutable has in fact attracted some debate and controversy in recent years. Cantor (2018), for example, published a critical review questioning data and conclusions of an earlier study by Müller et al. (2014) that had reported significantly decreased pedophilic responding and increased non-paraphilic responding, measured phallometrically over two time points, for approximately half of their sample of 43 men diagnosed with pedophilia. Cantor and others (including Mokros & Habermeyer, 2016) noted that such findings would be expected simply due to regression to the mean. Cantor cautioned strongly against creating false hope for the possibility of sexual orientation change, which he viewed as having the potential to undermine the likelihood of people with pedophilia understanding the importance of developing skills to manage their pedophilia. On the other side of the debate, Tozdan and colleagues (Tozdan & Briken, 2015; Tozdan et al., 2018) noted the importance of the concept of self-efficacy for successful behavior change efforts and for motivation, and argued that a more responsible clinical approach would entail, at least in the absence of sufficient scientific evidence, clinicians and researchers avoiding absolute statements regarding sexual arousal towards children being immutable – both to clients and to the general public.

The question then turns to what the extant evidence base currently indicates with regard to the effectiveness of therapeutic attempts to influence paraphilic sexual arousal patterns among those who have committed sexual offenses. When considering this question, it is important to consider what is the desirable outcome or outcomes. If alteration of the direction of sexual arousal is sought, this may be evaluated by self-report or tested directly with procedures such as phallometric assessment. On the other hand, given that the ultimate purpose of applying such techniques is to aid in the rehabilitation and prevention of sexual offending behavior, it could be argued that ultimately, reduced recidivism is the key outcome of interest. Both of these will be canvassed below. Key findings from the two aforementioned relatively recent and influential meta-analyses (Gannon et al., 2019; McPhail & Olver, 2020) are drawn on heavily in this section (on effectiveness) and the next (on therapeutic applications with different populations), with the current narrative review offering synthesization as well as integration with other previous literature, and commentary.

McPhail and Olver (2020) carried out a meta-analysis exploring the effectiveness of a range of intervention types focusing on paraphilic sexual arousal amongst individuals who had sexually offended. Noting the possibility that self-report could be subject to a self-presentation bias in such a context, they opted to limit inclusion to studies utilizing phallometry to measure outcomes. McPhail and Olver’s analyses encompassed 41 individual studies (23 with within-group designs, and an additional 18 single-case design studies), involving an overall pooled sample size of N = 1,071 individuals. Across 14 and six studies respectively (including amalgamated effects from relevant single-case studies), McPhail and Olver found general support for behavioral techniques in reducing pedophilic and pedohebephilic arousal (i.e., towards prepubescent and/or early pubescent children). Specifically, the fixed effect size metric, providing an adjusted estimate of the difference between mean pre- and post-treatment responding, was g = 0.66, 95% CI = [0.54, 0.78] for pedohebephilic arousal, and g = 0.84, 95% CI = [0.58, 1.10] for pedophilic arousal. The effect size estimates being greater than zero indicated an average treatment response in the intended direction, and neither confidence interval included zero, indicating statistical significance. Both effect sizes (i.e., for pedohebephilic and for pedophilic arousal reduction) were clinically and significantly greater than what would be expected due to natural remission, and the authors further noted that when results were restricted to effect sizes derived from the samples’ highest response to child stimuli, the positive effect for behavioral techniques met criteria to be considered large in magnitude.

In contrast to the promising above set of findings in relation to reducing sexual arousal towards children, the treatments investigated by McPhail and Olver (2020) were generally not well supported in terms of increasing arousal to teleiophilic (adult) stimuli. In relation to behavioral treatment, for example, the fixed effect size was non-significant (g = −0.10, 95% CI = [−.29, 0.08]).

Aside from behavioral approaches, McPhail and Olver’s (2020) meta-analysis also evaluated pharmacological treatments, and comprehensive treatment approaches (encompassing a range of risk-related targets in addition to arousal management). Across four studies, pharmacological treatment showed a similar pattern of results as those reported above for behavioral, with respect to reducing pedohebephilic arousal (g = 0.65, 95% CI = [0.31, 0.99]); the effect was greater than what would be expected from natural remission. Pharmacological treatments were not analyzed with respect to increasing adult arousal given that increased responding in any direction would not be an expected effect of such medications. Comprehensive treatments showed small effects with respect to reducing pedohebephilic and pedophilic arousal and increasing teleiophilic arousal (reported fixed effect g values were 0.20, 0.12, and 0.20 respectively), however these effects were found to not be significantly greater than what would be expected based on natural remission.

Finally, McPhail and Olver’s (2020) meta-analysis included two studies in which EMDR techniques were evaluated in terms of changes to phallometric response patterns. A significant positive treatment effect was found with respect to reduced pedohebephilic arousal (g = 0.64, 95% CI = [0.14, 1.14]), however the effect was not significantly different from that expected based on natural remission. Nonetheless, given the limited research interest this newer approach has received to date, these findings may be promising enough to warrant further investigation, a conclusion also reached by Smid (2022).

McPhail and Olver (2020) rightly noted the potential usefulness in terms of individualized treatment planning of findings indicating differential effectiveness of techniques for different subgroups, such as those who have offended against specific victim types, and those with differing levels of pre-treatment paraphilic arousal. Their meta-analytic study design therefore included exploration of these questions. Most notably for the purposes of the current review, in terms of moderation effects they found that individuals with higher levels of pedohebephilic arousal at pre-treatment showed the greatest reductions by the time of their second phallometric assessment, relative to those with lower initial levels. This finding provides an important consideration when it comes to specific targeting of techniques aimed at altering arousal patterns, or in other words, the question of who in particular should have such approaches included within their treatment plans (and who should not), discussed in the next section. McPhail and Olver also explored treatment impact (in terms of changed phallometric response patterns) separately amongst different subgroups of men who had sexually offended against children. Again they found little evidence for increased arousal towards adults. Although behavioral treatments demonstrated success at reducing pedohebephilic arousal across all subgroups tested, it is notable that for the subgroup whose victims were intrafamilial, the effect did not significantly exceed that which would be expected based on natural remission.

McPhail and Olver (2020) discussed their findings in relation to the aforementioned debate around the malleability or otherwise of pedophilic arousal patterns (e.g., Cantor, 2018; Tozdan & Briken, 2015). They helpfully clarified that while their findings had clear relevance to that conversation, in their view the phallometric change evidence they reviewed may be most realistically conceptualized as “a change in a person’s ability to monitor and manage their arousal as opposed to representing a shift in sexual interest or orientation per se” (p. 1334). This perspective also differentiates the use of behavioral techniques in this context from harmful practices known as conversion therapy, a distinction that has also been drawn by others (e.g., Prescott et al., 2020). Whilst a full discussion regarding ethical considerations with regard to the application of arousal modification techniques in forensic settings is beyond the scope of the current review, the interested reader may be directed initially towards Prescott et al. (2020), who raised a range of considerations relevant to practice in this area whilst noting that discussion on these issues “has not yet occurred in any meaningful fashion.”

As encouraging as McPhail and Olver’s (2020) meta-analytic findings are with regard to the idea that levels of paraphilic sexual arousal patterns may be amenable to some level of change (if not wholesale re-orientation), as noted earlier, considerations of effectiveness may go beyond laboratory-based phallometric results at two time points. Questions remain regarding whether such changes will be maintained in the long-term, whether they will be generalized to an individual’s daily life outside of the laboratory and treatment setting, and ultimately, whether they result in the overarching desired behavioral outcome of no reoffenses (it is worth noting again here that many sexual offenses and reoffenses are not driven by paraphilic arousal). McPhail and Olver (2020) did report on two studies included in their meta-analysis that included follow-up phallometric reassessment, an average of 111 days following post-treatment assessment. Encouragingly, treatment gains in arousal management were supported as having been maintained between post-treatment and follow-up. McPhail and Olver (2020) did not include consideration of recidivism outcomes in their meta-analysis. However, it is relevant to note here that phallometric assessment results with regard to paraphilic arousal have been previously shown to be strongly linked with sexual recidivism (McPhail et al., 2019). Further, Beggs and Grace (2011) demonstrated in a New Zealand study that treatment changes in a positive direction regarding patterns of sexual fantasy (measured using self-report psychometric scales), and changes in clinician ratings with regard to ‘Sexual Deviance’ (measured using the Violence Risk Scale-Sexual Offense version, VRS-SO; Olver et al., 2007), were significantly associated with reduced sexual recidivism – the latter having the highest area under the curve of all change measures tested in their comparative validity study (AUC = .71). Whilst these findings (in conjunction with other similar findings internationally as reviewed and synthesized by Olver & Stockdale, 2020) provide some confidence that changes evident within treatment with regard to sexual fantasy themes and the direction and management of sexual arousal patterns are meaningful in terms of reducing an individual’s propensity to offend (and suggest also that such changes can be maintained into the long term), Beggs and Grace’s study did not consider the methods by which measured changes were achieved.

More recently, an important contribution to the offending treatment evidence base was provided in the form of an ambitious and comprehensive international meta-analysis carried out by Gannon et al. (2019). Whilst Gannon et al.’s findings provided encouraging support for offending treatment effectiveness generally, most pertinent to the scope of the current review were specific additional analyses regarding program variables associated with optimized effectiveness; that is, the most substantially decreased recidivism rates. Specific moderator analyses examined whether the inclusion of behavioral arousal reconditioning techniques in sexual offense treatment impacted treatment effectiveness. Results across 44 studies indicated a significant impact: Programs that included some form of arousal reconditioning demonstrated a 43% reduction in sexual reoffending rates (odds ratio, OR = 0.57), while programs that did not demonstrated a weaker effect with only an eight percent reduction, or a 27% reduction with one large ineffective outlier program excluded from the analysis (OR = 0.92 or 0.73 respectively). Gannon et al.’s study was broad in scope and did not specifically focus on samples with any specific patterns of sexual arousal (such as pedohebephilia) or specific sexual offense victim types (such as children). As such, their conclusions regarding the utility of arousal management techniques in sexual offending treatment are also not limited in scope, and could reasonably also include persons with hypersexuality or compulsive sexual behavior problems and/or those who have offended against adults. Gannon et al. called for best practice guidelines in the area to be revised to include “further commentary on – and expansion of – the evidence base around behavioral reconditioning as a treatment tool” (p. 14) on the basis of their findings.

Notably, Gannon et al.’s (2019) study did not attempt to analyze differential impacts of specific behavioral techniques in relation to each other with regard to sexual recidivism reductions. Inclusion or otherwise of any kind of arousal reconditioning was simply coded categorically along with a number of other potential moderators. McPhail and Olver’s (2020) meta-analysis, however, did make specific comparisons between techniques with regard to change in phallometric responding. Their reported results are summarized in Table 1. As can be seen, these data do not provide obvious clarity regarding which specific behavioral method/s should be most recommended to address paraphilic sexual arousal patterns, however Marshall and Fernandez’s (2003) earlier conclusions come to mind, that some combination of covert sensitization (i.e., following the principle of aversion), satiation (extinction), and directed masturbation (positive reinforcement) techniques appear supported. Marshall et al. (2016) added the additional guidance that in their view, aversive procedures should not be the first choice but should be used only when others have failed, given the potential for them to be detrimental to a therapeutic relationship or even promote aggression given they utilize a punishment contingency. However, it has been noted by Fernandez et al. (2006) that punishers that are self-administered (as would typically be the case with ammonia aversion as well as covert sensitization) should not have these detrimental effects.

Table 1.

Summary of McPhail and Olver’s (2020) Meta-Analytic Effect Size Findings for Various Arousal Modification Techniques on Sexual Interests as Measured Phallometrically

Technique	Pedohebephilic (reduced)	Pedophilic (reduced)	Teleiophilic (increased)
Aversion (olfactory)	Large a b		ns b
Covert/Vicarious sensitization	Moderate a b
Satiation	Moderate a	Large a b	ns b
Combined: Positive reinforcement and extinction	Moderate a
Combined: Aversion and extinction	Moderate a b	Small b	Small b
Combined: Signaled punishment and biofeedback	Small b
Combined: Positive reinforcement, aversion, and extinction	Small b		Small b
Directed masturbation			ns b

Note. Blank cells indicate no relevant findings were reported in the meta-analysis. Combined behavioral interventions were grouped according to underlying conditioning principles.

^aDenotes that the effect magnitude was significantly greater than a natural history benchmark (i.e., greater than change due to natural remission).

^bDenotes a small number of studies included in the calculation (k ≤ 2).

Therapeutic Applications

Who Should the Techniques Be Applied With?

As noted by Ware et al. (2021), with regard to behavioral procedures targeting paraphilic arousal patterns, a crucial initial question is whether or not they are indicated for use with a particular individual. For many individuals who have sexually offended, paraphilic arousal patterns are not present (averaging around 50% across studies but varying depending on methodology; Seto, 2018). Therefore, it follows that these individuals’ offending actions were driven by other factors; as such there may be little to be gained by undertaking any of the specific treatment strategies designed to target paraphilic arousal.

Routine use of arousal reconditioning techniques for all who are in treatment in relation to sexual offending may therefore not be supported. However, Marshall et al. (2011) were very clear that “when [paraphilic arousal] is evident it should be addressed in treatment because it has been shown to be a criminogenic factor” (p. 152). This view has been echoed by Ware et al. (2021), who wrote that despite the limited nature of the evidence base for particular techniques (which might now be considered bolstered by the combined findings of the McPhail & Olver, 2020, and Gannon et al., 2019, meta-analyses), on the basis of robust empirical support for sexual self-regulation and paraphilic sexual arousal as dynamic risk factors, masturbatory procedures should be incorporated into the treatment plans for individuals with persistent relevant needs. Such needs could be evident from one or more of a range of indicants beyond phallometric testing, including self-report or behavioral history evidencing persistence. Marshall et al. (2009) devised a helpful set of criteria to assist clinicians to identify when and if a specific individual may require interventions designed to address problematic patterns of arousal, which in addition to the above noted indicators also included when individuals display persistently sexualized behaviors toward others (i.e., staff, or other prisoners). Marshall et al.’s criteria are as follows:

• (1) Sexual history reveals high rates of paraphilic acts that are persistent over an extended period of time.

• (2) Phallometric evaluations reveal either: (a) equal or greater arousal to paraphilic than to normative sexual acts, or (b) arousal to paraphilic acts is equal or greater than 30% full erection.

• (3) The individual reports persistent paraphilic sexual fantasies that they cannot resist.

• (4) Displays of sexualized behavior towards staff, as reported by staff or by the individual.

• (5) Collecting inappropriate images (e.g., from magazines and newspapers), or persistently watching shows depicting a preferred class of victims, as reported by staff.

• (6) Institutional records show the client has previously attempted to sexually assault staff or other inmates.

Aside from individually identified need, Ware et al. (2021) discussed specific sub-groups of individuals who have sexually offended with whom behavioral procedures to target paraphilic arousal have been used and may be indicated – however it is important to be clear here that both the Gannon et al. (2019) and McPhail and Olver (2020) meta-analyses involved primarily males from mainstream convicted populations. This caveat in mind, Ware et al. identified that behavioral procedures have often been employed with: females; adolescents; individuals with intellectual or developmental disabilities; and individuals whose sexual offense histories involved online behaviors.

With regard to those whose sexual offenses have been limited to assaults or non-contact offenses against adults (as opposed to child victims), Marshall et al. (2016) cautioned against the routine use of arousal reconditioning procedures in recognition that these groups have been shown to be less likely to demonstrate paraphilic arousal patterns via phallometric testing. Regardless, in cases in which paraphilic arousal patterns or sexual self-regulation problems are identified as a treatment need (e.g., via the above listed criteria offered by Marshall et al., 2009), such procedures may be indicated. Although McPhail and Olver’s (2020) meta-analytic findings regarding effectiveness pertained only to those who had offended against children, this was not the case for Gannon et al.’s (2019) study: Their meta-analytic finding of greater recidivism reductions for treatment programs incorporating availability of some form of arousal reconditioning was based on samples inclusive of those with adult and/or child victims (as previously noted). Thakker and Gannon (2010) considered specifically the potential applicability of techniques such as satiation, masturbatory reconditioning and covert sensitization in the treatment of individuals with rape convictions. They noted that for many rape offenses, factors such as anger and aggression are theorized to have played a much more significant motivating role as opposed to any specific sexual interests. In other words, many individuals may have committed rape “despite the lack of consent and not because of it” (p. 234). However in other cases, the element of coercion (for example) may have been specifically arousing to the individual and may in fact have been a precipitating factor to the offending in and of itself. In these cases, paraphilic sexual fantasy and arousal may be pertinent and risk-relevant treatment targets. Thakker and Gannon noted that it is the therapist’s responsibility to formulate the role and function (if any) of paraphilic sexual arousal and fantasy in offending patterns, the intensity and context of any such fantasy and/or urges, as well as ultimately the individual’s motivation to engage with arousal management techniques, in making decisions regarding appropriate treatment targets for individuals who have sexually offended against adults. Such guidance could be readily applied more broadly to all individuals being assessed for sexual offense specific treatment needs regardless of the age of those they have victimized.

Regarding client age, Ware et al. (2021) noted that although advancing age may decrease risk along with sexual arousal response in general for some individuals, for others sexual functioning remains high and therefore they advocated for an individualized approach to determining whether behavioral procedures may still be relevant. Regarding adolescents, while excluded from Gannon et al.’s (2019) recidivism analyses, the use of behavioral treatments with juveniles who had sexually offended against children was supported by McPhail and Olver’s (2020) meta-analysis of phallometric change evaluations. It is important to note, however, that current guidelines from the Association for the Treatment and Prevention of Sexual Abuse (ATSA, 2017) recommend against the use of phallometric assessment with adolescents under the age of 18 on the basis of ethical concerns coupled with the lack of research validation and appropriate norms.

Ware et al. (2021) noted that behavioral procedures may also have particular importance for those whose sexual behaviors have involved online offenses, and individuals with intellectual or developmental disabilities who have sexually offended (citing Lindsay, 2009). With regard to the latter, Lindsay et al. (2018) highlighted the importance of interventions with these groups being primarily rehabilitative, as opposed to restrictive. This guidance mirrors Marshall et al.’s (2006) recommendation in relation to mainstream programs, that targets relevant to developing appropriate prosocial means of meeting sexual and relevant needs (such as relationship skills training) are also included wherever paraphilic arousal patterns are targeted for reduction. Noting the behavioral basis of foundational comprehensive programs designed for individuals with intellectual or developmental disabilities, Lindsay et al. (2018) identified the importance of all components of treatment being integrated, as well as linked to formulation and the ongoing assessment of need and risk. Against that backdrop, Lindsay et al. noted that covert sensitization remained a common treatment component for such groups, and described how it could be employed in a group setting as a means of promoting self-restraint in relation to harmful sexual behavior. With regard to individuals with online sexual offense histories, Ware et al. highlighted de Almeida Neto et al.’s (2013) observation that in some cases of online sexual offending, the pairing of internet use with sexual arousal has been so frequently repeated that merely sitting at a computer can become a conditioned stimulus for arousal, making the theoretical behavioral processes underlying the use of reconditioning techniques potentially especially salient for this group.

Findings regarding there being very limited support (at best) for the effectiveness of techniques aimed at increasing teleiophilic arousal (McPhail & Olver, 2020), considered in conjunction with the clear recommendation from Marshall et al. (2006) that paraphilic arousal reduction techniques be undertaken only in conjunction with targets aimed at developing means to meet sexual needs prosocially, give pause with regard to whether or not arousal modification procedures ought to be employed or not with individuals whose pedophilic arousal patterns are exclusive. No clear guidance on this issue was apparent from the reviewed literature. In weighing up this question, two further considerations that it may be pertinent to note are that (as discussed above) modification procedures demonstrate their strongest effects amongst those with greater levels of pre-treatment pedohebephilic arousal (McPhail & Olver, 2020), and that exclusive pedophilia has been linked with greater levels of both risk and recidivism (Eher et al., 2015). As such, to withhold access in a blanket fashion to therapeutic techniques that may assist an individual to manage their arousal to children (as per McPhail & Olver’s conceptualization) from the very people who may stand to benefit most, may not be justified at present (see also Tozdan & Briken, 2015). That said, taking into account responsivity considerations (expanded on in the next section) and ethical best practice, it may be most appropriate that modification techniques be included as part of an individual’s treatment plan on a voluntary opt-in basis only, following collaborative therapeutic discussions. It may also be that the appropriate focus of treatment for such individuals becomes strategies for managing and living contentedly with (as opposed to attempting to modify) paraphilic arousal. A range of potential therapeutic foci designed to support such directions have been described by Beggs Christofferson et al. (2025), and include for example: strengthening commitment to an offense-free life; addressing any maladaptive thoughts/schemas surrounding child sexual abuse; strengthening skills for sexual and general self-regulation, emotion management, and coping with stress; building self-efficacy; promoting self-acceptance; and exploring stigma and strategies to navigate stigma.

How Can the Techniques be Applied to Maximize Effectiveness?

While empirical evidence of effectiveness is a crucial consideration in selecting treatment approaches, targets, and techniques, it is important to note that such an evidence base alone is not sufficient. Fernandez et al. (2006) highlighted how fundamental principles of learning were often ignored in previous applications of methods such as aversive therapies to the modification of paraphilic sexuality, or how specific procedures were employed somewhat naively. In contrast, these authors stressed that effectiveness and generalizability of behavioral techniques could be maximized if careful attention was given to constructing any aversive procedures used, utilizing naturalistic stimuli and relevant consequences. Fernandez et al. further advised that the long-term maintenance of any changes effected by behavioral techniques to reduce arousal towards paraphilic stimuli would be dependent on corresponding efforts to increase competing (i.e., replacement) behaviors. As such, programs must incorporate components such as skills training in ways to meet one’s sociosexual needs in non-paraphilic, prosocial ways.

Similarly, Marshall et al. (2011) stressed the importance of understanding (and facilitating clients to understand) the embeddedness of such procedures within the wider context of broader treatment goals for change, for example in areas such as relationship skills, healthy sexuality, coping skills, and prosocial sexual attitudes. Marshall et al. (2006) had previously identified that the broader elements of treatment were not always well integrated with procedures aimed at modifying sexual arousal patterns, which were often modularized, viewed as single-goal oriented and completed quite separately from the context of the rest of therapy aimed at prosocial goals and skill-building. The risk with such modularization is that it may not promote recognition that all treatment elements relate in an integrated way to the goal of developing cognitive, affective, and behavioral skills necessary to live prosocial and effective lives (Marshall et al., 2006).

McPhail and Olver (2020) as well as Ware et al. (2021) have highlighted the importance of concepts relevant to Bonta and Andrews’ (2023) responsivity principle in the application of arousal management techniques, noting in particular that clinical skill, sensitivity, and discretion will be likely to enhance client engagement and thereby in turn promote more positive changes in sexual self-regulation. Along these same lines, Walton (2021) has advocated that therapeutic interventions in this area need to be highly sensitive to stressors such as childhood adversity impacts, and stigmatization, both of which are prevalent amongst imprisoned individuals who experience paraphilic sexual arousal.

Summary and Conclusions

This literature review has outlined and described a range of arousal management techniques used in a variety of settings (e.g., correctional rehabilitative settings, community-based treatment programs, forensic mental health centers) with individuals who have sexually offended, along with the theoretical models that underlie them. The current state of the empirical evidence in relation to the effectiveness of such techniques has been discussed, both with regard to producing changes in paraphilic sexual arousal, and with regard to the association with sexual reoffending rates. The narrative review approach has afforded the opportunity to synthesize a range of existing literature in this regard, as well as provide broader contributions including research-informed commentary as to who should be treated using these techniques, with reference to ethical considerations, and considerations for maximizing effectiveness in practice.

Overall, the combined meta-analytic findings of McPhail and Olver (2020) and Gannon et al. (2019) are persuasive: Despite research attention and innovation having stagnated in recent decades, and despite serious questions being raised about the true malleability of pedophilic arousal patterns, current evidence indicates that arousal modification procedures in the context of sexual offending treatment can not only effect significant change in arousal patterns but their inclusion is associated with lower levels of sexual reoffending. Therefore, it would appear that programs are well justified currently in including such targets, at least for individuals with relevant indicated needs (i.e., where paraphilic arousal and/or persistent sexual self-regulation concerns are apparent).

Future Directions

The need for further research and modern innovation in this area has been stressed across recent years by a number of authors, including for example Allen et al. (2020), Gannon et al. (2019), and Ware et al. (2021), and cannot be understated. McPhail and Olver (2020) noted that most studies in their meta-analytic review had been carried out over two decades prior. They highlighted the need for modern innovation that could take into account developing understandings about human sexuality, provide choices for clients (who may be unwilling to undergo aversive procedures, for example), and potentially integrate more recent psychotherapeutic developments that may hold value in supporting individuals to live with paraphilic arousal. Overall, the current review points towards several important directions for future research. Firstly, outside of the reassuring but somewhat blunt apparent empirical association with reduced recidivism, there has to date been much less research into the maintenance of changes achieved via arousal management techniques, compared with the measurement of change in the short term. Future effectiveness research should endeavor to include longer follow-up.

Next, research should work towards building clarity that is currently lacking regarding whether or not arousal modification techniques should be included in treatment plans for those who are exclusively attracted to children. This issue dovetails with the question of whether teleiophilic arousal can be increased. McPhail and Olver (2020) found only limited/weak evidence for this (only with specific combinations of behavioral techniques, based on only a small number of studies), and there is general consensus against the ethics or likely success of attempting to reduce arousal in one direction without realistic means of increasing replacement behaviors. McPhail and Olver noted, however, the possibility that their null findings regarding teleiophilic change were due to difficulties with detecting the motivation and ability to increase arousal towards adults when this is already present to some degree. Examining effects separately amongst subgroups with respect to exclusivity could help to tease apart these issues and provide clarity for the field.

Finally, innovation in this area has been notably stagnant for too long. It would be beneficial for research to turn towards investigating and developing potential new techniques for reducing and managing paraphilic arousal. Ideally, a focus would be given to ethical approaches that are acceptable and appealing to clients and do not threaten the therapeutic relationship. EMDR, for example, has achieved promising preliminary support and warrants further research attention.

ORCID iD

Sarah M. Beggs Christofferson https://orcid.org/0000-0002-8600-9182

Ethical Considerations

Research ethics approval was not applicable for this review manuscript.