The myth of ‘absolute knowing’: when is the evidence enough?

Note: This blog is a repost from the Centre for Expertise on Child Sexual Abuse. Kieran

By Anna Glinski, Deputy Director for Knowledge and Practice Development at the Centre of Expertise on child sexual abuse.

Over the years that I’ve specialised in sexual abuse work, as a social work practitioner, manager and trainer, and now in my current role at the CSA Centre in developing evidence-based professional practice in child sexual abuse across the country, I am continually struck by two things:

  1. the hard work of committed social workers and other professionals who strive every day to make children safe; and
  • that despite this, they face significant obstacles in trying to evidence concerns about a child being sexually abused.

We know that a great many more children are experiencing sexual abuse than those that come to the attention of statutory services and when they do, sexual abuse is seldom explicitly named or adequately addressed. There are many obstacles that contribute to this stark reality but one that perhaps limits us the most from being proactive is a hesitancy to name child sexual abuse as a concern.

‘What if I’m wrong?’

In cases of child abuse and neglect, social work decisions on whether to act or not rest upon one central question – ‘On the balance of probabilities, do we have the evidence to intervene?’. These are, and should be, complex decisions whatever the nature of suspected abuse; however, when it comes to child sexual abuse, a whole myriad of additional conscious and unconscious thoughts and processes come into play. Our mantra (and that of the people we need to persuade) becomes ‘what if I’m wrong?’, in particular, ‘what if I wrongly accuse someone of this heinous crime?’ 

The implications of being right can be overwhelming – emotionally (thinking the unthinkable, hearing difficult information, considering the sexual abuse of a vulnerable child) and practically (the need to have difficult conversations, ask alleged perpetrators to leave the family, the implications to an already busy caseload). In this context, strong supervision, containing management and organisational support are essential, yet often inconsistent. 

Supervisors and managers often replicate the same emotional and practical reservations, consciously and unconsciously, to the possibility of sexual abuse. The ‘what if I’m wrong?’ becomes ‘where’s your evidence?’, and the unconscious desire to find the answer that proves we are indeed wrong, that sexual abuse is not taking place, can override our decision-making and thought processes.  Identifying an alternative hypothesis for our concerns is easy – they must have seen that behaviour on YouTube; it must be their disability or condition; it’s because of other difficulties in their life (a loss, a move, a trauma, a friendship issue, an argument or fight at home)…and alongside this, they haven’t actually verbally told us they are being abused, so it cannot be abuse. And when we find an alternative explanation to the behaviour of concern, we often fail to keep the sexual abuse hypothesis live.

Sometimes the alternative explanations we consider may well be true, and our concerns of sexual abuse will, of course, not always be founded, but we fail to consider that sexual abuse could be occurring alongside those other factors.  A child can be both on the autistic spectrum and being sexual abused; or experiencing domestic abuse and being sexually abused; or struggling with a friendship and being sexually abused. We must hold in mind all the hypotheses even when there are other possible reasons for our concerns and even when the implications of it being sexual abuse are hard to consider.  We must also be aware of and actively challenge the preconceived ideas about who perpetrates abuse and who the victims are which form our unconscious biases on gender, ethnicity, sexual orientation and class and can mean that some children’s experiences of sexual abuse are less likely to be identified and acted on.

‘Beyond reasonable doubt’

Throughout the investigation process, a common phrase we hear is ‘we don’t have the evidence’, from ourselves, our managers, our police and health colleagues, our legal advice. But what does this actually mean? The police may not have the evidence ‘beyond reasonable doubt’ to be able to take further action, however on the ‘balance of probabilities’ do we, as social workers and social work managers, have the evidence?  On the balance of probabilities, we may have a catalogue of concerns around sexualised behaviour and emotional or behavioural presentation, indications of abusive behaviour from adults or siblings in the home, a child who has disclosed but retracted, or is demonstrating in every which way other than verbally that something harmful is going on for them. That is not evidence beyond reasonable doubt, but it is most certainly evidence of real concern about a child’s wellbeing that needs responding to. 

And anyway, how realistic and achievable is it that we will get evidence beyond reasonable doubt?  How could we absolutely know, without doubt, that abuse has occurred?

  • We saw it happen with our own eyes?
  • Someone else, who is ‘reliable’, saw it happen and reported it?
  • The alleged perpetrator admitted it?
  • The victim clearly, verbally told us what happened with accurate recall on timescales and attention to detail despite the trauma of the incident/s; has managed to repeat the story on at least 2 occasions; has managed to persuade a jury while being questioned by an adult defence lawyer?
  • We have medical evidence that proves sexual abuse took place?
  • We have film footage of the abuse taking place?

What are the chances of any of the above happening?  Sexual abuse is a hidden crime, enacted in secrecy. Getting caught risks the loss of liberty, family, respect and employment and so abusers are unlikely to admit it. The trauma of abuse impacts memory and recall. The process of abuse distorts, disrupts, confuses and silences, meaning victim testimony is often challenged. Medical evidence is often deemed inconclusive – abuse is rarely reported within forensic timescales; if injuries are caused children heal quickly; sexually transmitted infections may have other causes*.  We may have photographs or film footage of abuse, and with the rise of technology there are increasing prosecutions on this basis, but still, many abusers would not risk this approach.

And yet…despite the serious unlikelihood of finding this evidence, we say, repeatedly, and as if it is a good enough reason to take no further action – ‘we haven’t got the evidence’.  This is what I call the myth of absolute knowing – the myth that we will, despite the fact sexual abuse is a hidden crime, where it is most often one person’s view (the child) over another’s (the adult), actually be in a position where we have this level of evidence. It guides our thinking and decision-making in the most unhelpful way, while also giving a sense that we have done all we can to protect a child in the circumstances: ’we haven’t got the evidence, so there is nothing we can do’.

Despite our responsibility and desire as social workers to protect and support children affected by sexual abuse, we seem to have adopted the ‘beyond reasonable doubt’ threshold as if it is our own.  This is somewhat unhelpfully fuelled by the family courts, who, in my experience, often address issues of sexual abuse with a criminal burden of proof, leaving social workers disempowered to protect children they feel certain are at risk of sexual harm.  Recent data on the scale and nature of sexual abuse indicates that on average only 14% of cases of sexual abuse reported to police go to charge (NOTE: this is not just those that get convicted, but those that go to charge) due to a lack of ‘beyond reasonable doubt’ evidence. So what about the remaining 86% of cases (which will include, undoubtedly, those disabled children who struggle to verbally communicate) who on the ‘balance of probabilities’ may be being sexually abused? If we fail to respond in any meaningful way to this majority of children, can we honestly say that we as social workers and managers are doing our job effectively?

What if you’re right?

As a profession, let’s move from asking ‘what if I’m wrong?’ to asking ‘what if I’m right?’, ‘what if this child is being sexually harmed?’, and then ‘what do we need to do, in the absence of ‘solid evidence’, to make this child safer?’

Whilst holding in mind the need to be balanced and to give sufficient weight to all possible hypotheses, we need to apply the current knowledge and existing theory on sexual abuse to our practice. This will allow us to think about all possible pathways to change and safety. Children rarely care about legal thresholds and outcomes – they need us to use the skills we already have as social workers, to sit with the uncertainty, the emotional pain and the practical challenges and to do what we can to support them and protect them from sexual harm.

This, of course, requires knowledge, skills and confidence. The CSA Centre has been trialling different approaches to increase practitioners’ confidence in practice and access to evidence around child sexual abuse, including developing and piloting our Practice Leads’ Programme. It is clear, however, that addressing the current gaps in training on child sexual abuse on both pre- and post-qualifying courses for social workers and other professionals must be a priority.

*There are many benefits of medical examinations where there are concerns about child sexual abuse additional to finding forensic evidence.

Stop it Now! Scotland: Going upstream to prevent Child Sexual Abuse

By Stop it Now Scotland!

Stop It Now! Scotland is a small team based in Edinburgh who works with adults and adolescents who have sexually abused children, viewed child sexual exploitation material or who are worried about their sexual thoughts and feelings towards children. This week we have launched an online resource that distils what we have learned from those who offend or at risk of offending, providing information for communities in Scotland and the professionals who serve them about the practical things we can all do to prevent child sexual abuse in the first place.

The aim of the resource is to help adults who are protective to become more effective in their efforts to prevent sexual abuse and to help those who present a risk of harm to children to make safer choices.

Upstream was funded by the Scottish government and based on a CD-ROM (remember them!) we developed in 2011 to help build the capacity of individuals and communities to prevent child sexual abuse in Scotland.  As time moved on it became apparent that a CD-ROM was no longer fit for purpose. But also we reached a stage where we needed to comprehensively refine and strengthen the Toolkit, properly test and evaluate its fitness as a practical resource to prevent abuse before it might occur, and align us to effectively deliver (in a systematic and evidenced way) primary prevention of child sexual abuse and sexual exploitation in Scotland.

It was at this point that we started to develop the online resource. Whilst the content of the existing toolkit was an important ‘starting point’ in our work we also wanted to include more information and resources to help in the changing task of keeping children safe. A big part of this is strengthening the capacity of adults to safeguard children and also building the resilience of communities to keep children safe.  We also want to help anyone who is around children to identify the risky behaviour of themselves or others to allow them to intervene and prevent child sexual abuse before it occurs. We wanted to include materials on prevention of harmful sexual behaviour in childhood and adolescence. And we wanted to ground all of this in bystander theory – the idea that there are practical things we can do to make a difference when we encounter behaviours that are inappropriate or potentially harmful.

The new resource is broken down into five sections. These are Learn, Identify, Prevent, Act and Engaging Communities. There is also a Get Help section for anyone in a situation that needs immediate action.

The resource gives practical advice based on a wide range of scenarios and frequently asked questions that often come up during our work. “What if I don’t like the way my uncle is playing with my daughter?” or “What are the warning signs that a child is being abused” or “How do I make my church group safer for children?”. We have tried to make the language as accessible as possible without losing some of the detail and nuances of the complex world that we live in. The Engaging Communities section contains a range of resources that professionals can use when engaging the public about prevention.

It was developed specifically for a Scottish audience but we hope this resource can be used more widely. Have a look, and if it is useful, share the resource with colleagues, friends and family or tell people about it on social media. The message of Upstream is simple; together we can protect the next child from harm.

ATSA Annual Conference 2019

By Kieran McCartan, PhD, & David Prescott, LICSW. 

The annual ATSA conference took place from the 6th-9thNovember in Atlanta, Georgia. The conference was a real mix of research, practice, and engagement with over 1,200 participants from the USA, Canada, UK, Australia, New Zealand, Sweden, Netherlands, Norway, France, Belgium, and Israel to name a few. In this blog, we are going to take you on a whistle-stop tour of the event. 

The 2019 ATSA conference had 31 pre-conference presentations covering a range of topics including Risk Assessment, online offending, youth who sexually offend, treatment and interventions as well as a session for students on training and career development. The keynotes this year whereby Professor Teresa Gannon (Are treatment Programs for sexual offending effective), Professor Paul Bloom (Against Empathy), Linda Dahlberg (Going Upstream: The fundamentals, evolution, context, and practice of primary prevention) and a conversation between Kurt Bumby and Kristen Houser on communication/messaging about working in the field of sexual abuse. The main conference had 100 workshop presentations and 36 poster presentations, with approximately 200 speakers presenting, covering prevention, victims, youth, adults, learning disabilities, minor-attracted youths, policy, assessment, risk, management, and community engagement. In addition, this year saw the lifetime significant achievement award go to Jill Levenson, the Gail-Smith Burns award go to David Fowers, and the Early Career Award goes to Kelly Babchishin, Congratulations to all!!! 

For Kieran, the highlight of the conference was the first two keynotes, Teresa Gannon’s & Paul Bloom’s; although very different they talked to core ideas surrounding treatment and intervention. Teresa Gannon gave us an overview of her recent meta-analysis on the success of treatment programs, which showed that treatment can work but to do so the skills and the training for providers matters. Treatment success is about more than just program structure and integrity, the human delivering the treatment matters! This complemented Paul’s keynote on against empathy, which really made us focus on what empathy is and how effective it is in treatment and risk management. Empathy is a controversial topic in treatment programs and interventions for people convicted of a sexual offence, so it was pleasant to hear about it from a philosophy-political-social-psychological point of view, rather than just a treatment one. Do we need our clients/service users to have empathy for their victims to stop them from re-offending or even to stop offending in the first instance? Is it compassion, insight, and self-regulation that we are really looking for in them? Also, how much empathy do we need to have to be competent and skilled therapists, treatment providers and researchers? It was an interesting talk that went beyond pure semantics and allowed us to think about the role of empathy in the field and everyday practice. To Kieran, these keynotes set the tone of the conference as ATSA has always been about reflection and being a critical friend to each other. 

The international roundtable this year was focused around risk assessment, risk management and treatment/interventions with 7 speakers from 7 different countries (USA, Canada, UK, New Zealand, Israel, Netherlands, Belgium). The session ran differently this year with the roundtable focusing on 4 topics and the speakers addressing how each topic was handled in their country, therefore we could see the comparison first hand. Which worked well and stimulated a lot of debate. Again, as in previous years, the roundtable really cements ATSA as an international conference! 

The entire conference was a high point of the year for David. Although pinpointing specific moments is next to impossible, this year was noteworthy for the quality of the participation. At a workshop titled “The Pornography Debate”, those in attendance proved the axiom that intelligence often comes in asking the right questions rather than having the right answers. In this case, these questions came in the form of “Is any porn user ever entirely satiated” and “Is it possible to have a sexual encounter that does not involve at least a little objectification?” Likewise, participants in a workshop on the often traumatic effects of the legal system on clients were open to discussion in ways that are far rarer in other conference situations. This year was a lesson that not only does ATSA boast some of the best workshop experiences in the field, it also has amongst the most knowledgeable and thoughtful attendees. 

One of the primary benefits of being an ATSA member and attending the annual conference is the opportunity to connect with friends, colleagues, and collaborators from around the world. The primary take-away from these conference experiences for the two of us was the importance of working together towards common goals so we could participate in “shaping the future”, as the conference theme appropriately described it. We are looking forward to ATSA 2020 in San Antonio, Texas!!

Prevention of Child Sexual Abuse: Special Issue of the Journal of Interpersonal Violence

By Marcus Erooga &Keith Kaufman (Co-Editors)


Evidence suggests that child sexual abuse remains a significant public health concern across the world. For example, the World Health Organization (2018) reported in 2018 that 20% of women and 8% of men worldwide report having been sexually abused as a child. At the same time, it is widely understood that these and other prevalence estimates represent underestimates of the true incidence of abuse (Royal Commission into Institutional Responses to Child Sexual Abuse, 2017). Of concern are the short- (Beitchman, Zucker, Hood, daCosta, & Akman, 1991) and long-term (Beitchman et al., 1992) adverse effects that are associated with many victims of child sexual abuse. Despite the prevalence and the significant consequences, there has been a relative paucity of prevention efforts to address child sexual abuse.

As part of the efforts to address this, we were invited to edit a designed to highlight a broad international sampling of cutting-edge child sexual abuse prevention articles, in the hope of both spurring additional prevention research and sharing these creative approaches to prevention. The following is a brief synopsis of the content.

In 2017, the Australian Royal Commission into Institutional Responses to Child Sexual Abuse (CSA) published a final report detailing its 5-year investigation process, which represents the most comprehensive public inquiry of its kind ever conducted. The Journal opens with an article based on findings from co-principal investigators’ Professor Keith Kaufman (USA) and Marcus Erooga (UK) comprehensive international literature review examining risk and protective factors related to CSA in institution settings for the Commission (Kaufman et al., 2016), with additional material from Professor Ben Mathews (Australia) and supported by Erin McConnell from Portland State University. This provides suggested preventive directions to address the safety risks identified in the authors’ review of more than 400 publications and reports garnered from research literature in the United States, the United Kingdom, and Australasia.

Second is a study authored by Billie Jo Grant, Ryan Shields, Joan Tabachnick, and Jenny Coleman examining data from Stop It Now!’s U.S. helpline over a 5-year period. This offers insights into the needs of the hidden population of individuals who are at risk to sexually abuse, those who have abused, as well as offenders’ and potential offenders’ friends and family members seeking support.

On the related topic of services for those seeking preventive treatment, Sarah Beggs Christofferson’s New Zealand study explores whether such provision is viable in a discretionary reporting context, that is, in jurisdictions without mandatory reporting, but where risk-related disclosures to authorities are permitted at therapists’ discretion. Based on a survey of New Zealand health professionals, she concludes that if policies and expectations are clearly defined, this could be the best way forward for viable preventive treatment.

This is followed by Professors Jill Levenson and Melissa Grady’s report on a U.S. pilot study to investigate whether it is possible to improve the provision of clinical services to individuals who self-identify as sexually attracted to minors, but who have not yet acted on their attraction. The authors describe the use of an innovative prevention approach designed to alter the knowledge and attitudes of mental health professionals to increase the pool of competent practitioners willing to provide services to this challenging population.

The subsequent article, by Professors Richard Wortley, Benoit Leclerc, Danielle Reynald, and Stephen Smallbone (from the United Kingdom and Australia, respectively), takes a different approach to the prevention of child sexual abuse. It focuses on strategies intended to alter situational dynamics in ways that make CSA less likely to occur, rather than attempting to treat individual factors in the offender (e.g., to change their inappropriate motivations and behavior). The authors suggest that by considering the perspective of the offenders themselves, they can identify significant situational safety risks that can guide the design and implementation of more effective offense-focused CSA prevention approaches.

Finally, the Special Issue concludes with a report detailing a national survey of CSA prevention education programs in Australian primary schools conducted by Professor Kerryann Walsh, Donna Berthelsen, Kirstine Hand, Leisa Brandon, and Jan Nicholson. The survey was distributed to all providers of child sexual abuse prevention programs in Australian primary schools and provides new information about the nature and scope of school-based education programming for the prevention of child sexual abuse. It also provides a template for the development of similar prevention programs in other settings internationally.

It was a real pleasure to be able to work with such highly experienced and knowledgeable authors, each an expert in their respective field and we are excited by the breadth and depth of prevention perspectives reflected in their contributions.

Don’t wait for them to tell us: recognising and responding to signs of child sexual abuse

By Jane Wiffin, Practice improvement advisor, Centre for Expertise in CSA

(Note: This blog was originally posted on the Centre for Expertise on Child Sexual Abuse – Kieran)

The Centre of Expertise on Child Sexual Abuse recently published ‘Key messages from research on identifying and responding to disclosures of child sexual abuse’. In this blog the CSA Centre’s Practice Improvement Advisor for Social Work, Jane Wiffin, reflects on what those key messages mean for the safety of children and young people and what needs to be done within the statutory child protection system to best respond when children signal or speak out about the abuse and harm they are experiencing.

The first major issue raised by current research (and indeed the safeguarding practice environment) is that it is very clear that far more children are being sexually abused and harmed than we are currently identifying or safeguarding.  This should be of major concern.

The current statutory child protection approach to responding to concerns that a child is being sexually abused puts too much responsibility on children and young people to recognise the abuse they are experiencing and then to seek a trusted adult to talk about what is happening to them. This is a heavy, and frankly unrealistic responsibility. Children cannot and should not be the only witnesses to the harm they experience; it is the responsibility of the adults around the child to respond to help-seeking behaviour and to safeguard them.

Talking openly about child sexual abuse

Most professionals work very hard to notice and understand what is happening to the children they are in contact with and to enable them to talk about their concerns and worries including those that relate to experiences of abuse. Children are not always able to recognise that what is happening to them is abuse and so it is important that they are encouraged to speak to a trusted adult whenever something doesn’t feel right or something is upsetting or hurting them. Despite the need for professionals to support and encourage children to tell us when something is worrying or upsetting them, we also know that many children may not be able to articulate their concerns and may demonstrate their unhappiness and discomfort in other ways.  Professionals need to recognise when children might be telling us something is wrong (through their actions as well as their words) and support them to help us understand so we can respond appropriately. 

However, while the importance of identifying and responding to concerns of CSA is embedded in practice, interpretations of child protection guidance which encourages practitioners to avoid asking ‘leading or suggestive questions’ often drives a cautious response which in reality means many practitioners avoid questions altogether.

When professionals notice a child or young person with a bruise or a burn, they would not hesitate to ask what had happened and how the child or young person was feeling. The resulting response would likely lead to a multi-agency holistic assessment process where all aspects of a child and their family’s life and circumstances would be considered; why is child sexual abuse treated differently?

Messages from many serious case reviews find that these concepts of asking leading questions or contaminating evidence (“avoid encouraging a child to talk about the alleged offence” – p28 Achieving Best Evidence in Criminal Proceedings) are not fully explained in guidance or training, and the limitations not explored. It is therefore unclear to practitioners what the difference is between what the guidance warns against and asking professionally curious questions, being child focussed and exploring the child’s lived experience. This caution also introduces a natural uncertainty or hesitancy in the professional response, hardly conducive to creating an environment which supports and enables children to articulate what is happening and feel able to talk openly about such a sensitive and complicated issue. Ultimately this can result in children’s help-seeking behaviour going unidentified, their voices remaining unheard and the child not being safeguarded.

In recent years guidance has been introduced to ensure that professionals ask women about whether they have been subjected to domestic violence when they are pregnant, have small children or where there are safeguarding concerns. This is because there is recognition of the culture of secrecy that surrounds domestic abuse and the implication of coercion and control; why is child sexual abuse treated differently?

Barriers to disclosure

We know that children rarely verbally disclose to professionals (particularly social workers and police officers) that they are being sexually abused; they often wait until adulthood before telling professionals.  In many cases children are more likely to tell a friend, a safe parent or another trusted adult and their reaction and ability to respond to protect the child will impact upon whether the child feels able to repeat their disclosure. Sadly, some children are never able to tell anyone. This should be of concern to us all.

The reasons for not disclosing are many; children may not recognise that abuse is happening; they may not be able to articulate what is wrong but demonstrate their discomfort through their behaviours, they may communicate non-verbally because of their disabilities or cognitive impairments and English may not be their first language. Those who perpetrate abuse may have normalised sexual abuse, children may have been groomed in such a way that they do not recognise the abuse and tactics of threats, coercion, and control that may have been used.

Victims and survivors also say that there are many barriers to telling adults about the harm and abuse they are experiencing. This includes shame, self-blame, fear of what will happen to them and their family after disclosures, fear of reprisals, fear of getting into trouble and not trusting anyone.

Asking the right questions

Research suggests that in order to identify CSA children need to be asked direct questions about what is happening to them and what they are worried about. Children report they did not disclose sexual abuse because they were not asked direct questions. Children want professionals to notice their emotional distress, behavioural difficulties, self-harm, eating disorders, anti-social behaviour, depression, mental health difficulties, social isolation, disruption and criminal behaviour as potential indictors of early trauma, abuse and specifically sexual abuse.  Professionals need to be aware of how their own and wider society’s bias and stereotypes, about different children and different forms of abuse, can result in abuse being minimised or dismissed.  These are not unreasonable requests.

The concept of asking direct questions was endorsed by the 2000 Department of Health publication “Communicating with Vulnerable Children”. This publication advised professionals to ask children:

  • Has anybody done anything that upset you/makes you unhappy?
  • Has any person hurt you/or touched you in a way that you don’t like?
  • Some children talk about being upset or hurt in some way. Has anything like this happened to you?

This is a long way from how the current advice is often interpreted: as a need to be guarded and cautious. This caution appears to have been driven by a belief that professionals could put ideas into children’s heads and criminal proceedings could be compromised. There is currently little evidence that children report sexual abuse when it is not so and it is often a long and painful journey from disclosure to any sort of safeguarding action or criminal conviction. The reality is that very few cases of child sexual abuse currently progress to a prosecution for many reasons and yet we allow a fear of possibly affecting a criminal case, which is unlikely to happen, limit our proactive steps to understand what is happening to a child and act to protect them from that harm.

Improving practice

It is important that everyone who has a stake in working to protect children has the skills and confidence to identify, talk about and act on verbal and non-verbal disclosures from children in order to best safeguard them from further harm and ensure that they feel believed and supported.

When responding to a disclosure of child sexual abuse, practitioners should aim for child-centred practice and ensure that outcomes and next steps are clearly communicated to the child: when children disclose they are not wondering what protection order they will come under or which agency is leading an investigation, they want concern, compassion, action, and protection and that is a joint responsibility for all agencies and adults around the child.

The CSA Centre is working to build the confidence, knowledge, and skills amongst frontline practitioners working with children in order to best identify and respond to children’s help-seeking behaviours and disclosures of sexual abuse. As well as the Key messages from research paper released this week, we have developed and piloted a Practice Leads’ Programme to help ‘lead workers’ in Children’s Services further develop their understanding and confidence around child sexual abuse. One of the core topics of this programme focuses on the disclosure process, the barriers, and enablers. We are also now planning a practice development project looking specifically at how to best support children to disclose abuse and respond effectively to help-seeking behavior.

NOTA Annual Conference 2019

By Kieran McCartan, PhD., & David Prescott, LISCW

The annual NOTA conference took place from the 18th – 20th September in Belfast. NOTA, the National Organisation for the Treatment of Abuse, is a long-time partner to ATSA. This year’s conference was a real mix of research, practice, and engagement with over 300 colleagues from across the UK, Ireland and internationally in attendance (with attendees and speakers from a range of countries including the USA, Gibraltar, Norway, Ireland, and from all four countries of the UK). The conference focused on abuse within and across systems, with even Brexit getting a mention. In this blog, we are going to take you on a whistle-stop tour of the event.

The 2019 plenaries combined research, practice and innovate approaches from a very broad group of speakers. The Conference started on Wednesday with Professor Teresa Gannon presenting the findings of her recent meta-analysis, which included this year’s HMPPS report, on the effectiveness of treatment programs for men convicted of a sexual offence. The headlines from Professor Gannon’s presentation was that treatment does have a positive effect on behaviour change, including recidivism, compared to none and that the role of consistent, well trained and engaged providers is important. Following on from this we had a “conversation with Karl Hanson” whereby Professor Don Grubin discussed with Karl a combination of pre-submitted audience questions and his own thoughts. The topics ranged from risk assessment, treatment, risk management, and professional practice; it was an insightful alternative to a traditional keynote that allowed participants to gain more of an insight into Karl’s work and thinking. The Thursday started with a keynote from Professor Anne-McAlinden on peer-to-peer abuse, based on NOTA research committee funded work (a good reminder of the annual research grant scheme that was also launched at the conference), which indicated that we need to potentially reconceptualize risk in the context that young people live and doing so would enable us to prevent as well as respond to sexual abuse better. The was followed by a trio of Ireland based practice initiatives which where focused on children who committed sexual harm and/or engagement with their families (Carol Carson talking about AIM 3; Rhonda Turner talking about the work of the National Inter Agency Prevention Program; and Gareth McGibbon talking about the development of the Capacity & Ability to Supervise and Protect Framework [CASP]), all of which demonstrated best practice and a series of tools that conference attendees could take home with them. The final day of the conference opened with Professor Erick Janssen discussing research on sex, emotion and risk, followed by a roundtable of police experts (from England, Ireland, Wales, Scotland, Northern & Gibraltar) on the potential impact of Brexit on cross border co-operation and data sharing. The roundtable was fascinating and raised several questions about the impact of a no-deal Brexit and the issues that changing data sharing agreements would have on risk management, background checks, and deportation. The conference closed with a powerful and very relevant piece by the Geese theatre group examining the interactions of abuse within the family system and how it spills into other closely aligned systems (school, sport and the community).. 

The conference had 40 parallel sessions with over 50 speakers across the Wednesday and Thursday afternoon,  spanned a full range of topics and speakers (of which this is just a flavor) including, integration of people who have sexually offended back into the community (Public Protection Arrangements Northern Ireland), people who have committed sexual abuse as service users and hearing their views (Kieran McCartan, David Prescott; Lynn Saunders; Karen Martin), trauma-informed care (Catherine Gallagher, Maggie Tai Rakena); youth who sexually harm (Carol Carson; treatment (David Briggs; Adam Deming; TUSLA; AIM project Eleanor Woodford & Ben Evans; Gallagher; Geraldine Akerman); sibling sexual abuse (Jacqueline Page; Melissa Maltar, Nancy Falls): 3 sessions dedicated to research and another on important issues for practitioners in critically engaging with research by the research committee.

The workshops were a good mix of research, evaluation, practical working, professional learning and knowledge exchange.

In addition to the traditional conference activities NOTA 2019 also had an engagement event that was open to all co-organised with Public Protection Arrangements Northern Ireland and took place away from the conference site. We advertised the engagement event to professionals who have safeguarding as part of their jobs, but that safeguarding is not their main role (and therefore would not be attending the NOTA conference) including, teachers, foster carers, members of charities and NGO’s, etc. We had 60 participants sign up to attend the event, all of whom attended.  The session heard from national (DSI Paula Hamilton, Julie Smyth & Kieran McCartan) and international (Eileen Finnegan & Maia Christopher) speakers about the aetiology, prevention and risk management of people convicted of sexual offences in the community.

NOTA 2019 saw Professor Simon Hackett step down as Chair of NOTA and Professor Sarah Brown take over the role. Unfortunately, Simon could not be in Belfast with us but his contribution to the organisation was applauded in his absence and he was thanked for all his hard work. Also, NOTA 2019 was Gail McGregor’s last conference as conference chair and she too was thanked for all her hard work.

NOTA 2019 fitted a massive amount of material in across three days, which left us informed, refreshed and looking forward to next year’s meeting in Leeds.

The Mersey Care Prevention Service

By Lisa Wright

The Mersey Care Prevention Service, launched last year, developed from discussions between Mersey Forensic Psychology service, part of Mersey Care NHS Foundation Trust, and Merseyside Police. The Police recognised that some of the people they had arrested for sexual abuse may not have gone on to commit these offences if they had received help earlier. Knowledge of our work with convicted adults in the region led them to approach us and we jointly created and funded the new service.

The original idea was a service aimed at adults who had become concerned about their own sexual feelings or behaviours and were motivated to engage in psychological intervention to reduce the chances of them acting in an abusive or illegal manner. The ideal client would not have committed any illegal act but be concerned that they may do so without help. The Police hoped to identify individuals who came to their attention for problematic sexual behaviour but not reach the threshold for prosecution and we also sought referrals from GPs, counselling and mental health services and Social Care. However our criteria was later expanded due to difficulties in recruitment – very few ideal clients came forward!

We based the intervention approach on our prior work with adults who had sexually offended and our smaller client group of those people professionals had considered to pose a risk of sexual offending.

Mersey Forensic Psychology Service is foremost a therapy service, providing formulation based individual psychological therapies aimed at reducing risk of offending or re-offending. This takes place in the community and within North West prisons. The therapy approaches used vary and are based on the methods that we assess as most suited to the client and their formulation. We utilise EMDR and Schema Therapy most frequently as they are best suited to re-processing the trauma that we frequently find lies at the heart of the problematic behaviour we encounter.

These therapies have been used in mental health services to change the emotional and physiological feelings arising from trauma that drive problematic behaviours, including sexual behaviours, and have transitioned well to our setting. Clients feel understood, emotionally connected to the origin of their problems and report significant change in sexual feelings and behaviours.

The range of clients that have been referred to the prevention service has been varied and far from the ideal we had envisaged. Often Social Services have referred men who have raised concerns by behaving in inappropriate ways towards children but have not been prosecuted and are attempting to prove that they are not a risk to their children. They are therefore unlikely to ‘open up’ and engage in intervention. Other clients have already offended, been involved in on-going Police investigations or may believe that they have not offended but it emerges that they have committed a criminal act. These types of cases we are duty bound to discuss with the Police, causing some distress to the individuals involved –  not ideal! These referrals have led to us revising the information provided to prospective clients and referrers to make clearer the remit and legal obligations of the service and avoid any of the above issues recurring.

We have had some more appropriate and successful referrals – men who appear not to have offended and are motivated to understand and change their feelings and behaviours – but they have been the minority of our overall referral list. Therefore in order to generate more interest we publicised the service in the local press.

The reaction to the publicity for the prevention service might help to explain why people we are attempting to reach are not coming forward. The hatred, anger and aggression expressed on social media towards people who might experience a sexual attraction to children was horrific. It’s not surprising that the vast majority of our clients have already come to the attention of a professional and then been referred on rather than deciding independently to seek help.

Increasing awareness of the service, in a way that minimises the risk to potentially interested people and doesn’t create negative publicity, is tricky. Furthermore, the referral process, approaches to safeguarding issues and reporting of information are obviously heavily influenced by both the founding organisations’ policies and procedures, which may be a significant barrier to engagement for some people but is difficult to get around.

We have now expanded the service to include individuals who have convictions for exposure. This was based on Police concerns and case examples of young men who had committed exposure and then later gone on to commit violent sexual contact offences. This has increased the numbers of appropriate referrals and widened the aims of the service.

We are therefore continuing to adapt to the situations we are faced with in trying to provide a meaningful and effective service to those who want it and to make it more attractive to those that currently don’t. The men who have engaged in therapy are progressing well and reporting significant psychological change. Overall then, the results of our intervention for those who have engaged in therapy, are largely positive and we will continue to explore ways of reaching more people who would benefit from the interventions that we can offer.

NOTA 2019 Conference Preview

What is the theme of this year’s conference?

I am giving a flavour of this year’s conference on behalf of the whole conference committee (board members, branch representatives, our general manager, and admin team) and I would like to record my thanks to them all for their enthusiasm, focus, hard work and humour!

This year’s conference is based on the theme of “Sexual Abuse in Systems” and responses to this.  This is picked up in some of the keynotes but particularly in the workshops and seminars that are selected. 

As with most of our recent conferences, we try to include content of interest to our members working with people across the developmental spectrum, in direct practice, in academic and training roles, policy and operational disciplines.

 Why was this theme chosen?

Conference themes are chosen by the planning committee to reflect either feedback on the previous year’s conference from members and delegates or issues and concerns that have emerged in our professional community or the media over the last year (and sometimes both of these).

It is hard not to sound like we’re nagging since we know that as well as being great fun, conference attendance can be emotionally and cognitively taxing and it can be a real effort to give written feedback at the end of a session.  However, workshop and keynote presentation evaluation forms are really influential in evaluating what has or has not worked and planning for the next time.  Thanks to all of you who take the time to give us your thoughts and ideas, whether briefly or in more detail.  We do read and consider them all (usually in October after the conference) and it can be quite a challenge to reconcile feedback which often reflects vastly different reactions to the same presentation!

For me, this underlines the essence of what NOTA conference is about – producing a response from our active engagement with information that can either reinforce our existing knowledge and practice or challenge us to think and act differently. Both processes are valid and affirming regardless of our length of experience.  The conference themes try to offer something for both seasoned professionals with established reputations and for those at the early stages of their careers.

Tell us about the selection of keynotes this year

We consider feedback from members attending all of the NOTA conferences (including Scotland, Wales, Northern Ireland and the Republic of Ireland as well as the international conference) and regional training events.  We also “sample” speakers (we never actually steal ideas wholesale of course!) and gather format ideas from other conferences in related areas and professional journals.  We also include those who have had a major contribution to practice in our field and are “back by popular demand” for those who may not have had the opportunity to hear them before. 

This year we have 2 presentations reworked for NOTA based on ATSA keynotes: Professor Karl Hanson, a familiar presenter but this time in a more informal conversation (although if his co-presenter, our own Emeritus Professor Don Grubin, has his way this might be more informal than any of us had planned!).  Please submit your ideas for “Questions for Karl” and send in the questions you’ve been desperate to ask – anonymously or otherwise (  Professor Erick Janssen presents his research on emotion and sexuality, offering much food for thought and quite a few giggles.  

Professor Theresa Gannon, with her recent meta-analysis data, addresses the vexing theme of the effectiveness of the work we do in our intervention systems and the dent in our collective confidence over the last 2 years.

On Friday morning we will be challenged to consider the ways in which our cross-jurisdiction risk management processes might be affected by the current changes in our political systems in a panel discussion involving a range of police representatives (we are not being incompetently obtuse in our lack of programme details; these are withheld for security reasons).  In a great tradition of both challenging our assumptions and minding our humanity, the closing presentation is by Geese Theatre Company (many of you know by now what they say about the front row in a Geese presentation…….).

Finally, keynotes are chosen to showcase excellence in research, practice and policy development in the regions hosting the conference.  Our Thursday presentations include content from both Belfast (Professor Anne-Marie McAlinden offers her compassionate views on sexual behaviour in peer relational systems) and the Republic of Ireland (Carol Carson, Rhonda Turner, and Gareth McGibbon discuss ideas based on extensive experience of working sensitively in systems dealing with children and young people).  We are also particularly grateful to Maria Quinlan for introducing us to the ideas and experiences resulting in the photo exhibition that she is sharing with us during conference.

What is the role and involvement of the regional branches for Conference?

There is a “standing committee” comprising the Conference Chair, NOTA Vice-Chair/Chair-Elect, the General Manager and our absolutely fabulous conference administrators Andi Wightman and Adelle Henson (what these two impressive women don’t know about organisation isn’t worth knowing….). 

However, the conference would not happen each time without the involvement of branches and branch reps as part of the planning committee – from the initial suggestions for the venue to leadership on regional speakers and day chairs, involvement in breakout selections, organisation of the public engagement events and even the choice of sandwich fillings!  I absolutely don’t have “favourites” when it comes to working with branches but my sincere thanks go to Paul Stephenson, Marcella Leonard, Eileen Finnegan and Julie Smyth for making this year’s process a complete joy.  All I can say is that these are the people organising our Thursday evening social event – be there or regret it!

How are breakout presentations selected?

For the programme selection meetings, held in the early part of the year after the submission closing date, in addition to the conference planning committee above, we also include the chairs of the Research and Training committees (Mitch Waterman and Roger Kennington). 

We have been particularly fortunate this year to have had a high number of submissions from which to choose and we have tried to include as many of these as possible with the room numbers available to us.  We have included more joint presentations this year in order to try to include as much content as we can.  We are really grateful to everyone who does send a submission because we know it takes considerable effort, time and bravery in putting your ideas forward.  The reasons for not accepting a submission tend to be around the number of submissions on similar themes and the need to balance each year’s programme as described above. 

We’re very much looking forward to welcoming as many of you as possible to Belfast this year!

Gail McGregor

Conference Committee Chair

ANZATSA Biennial Conference 2019

By Kieran McCartan, Ph.D.

The biennial ANZATSA conference took place from the 24th – 26th July in Brisbane. The conference was a real mix of research, practice, and engagement with colleagues from across Australia, New Zealand and internationally (with attendees and speakers from a range of countries including the USA, Canada, UK). In this blog, I am going to take you through the conference highlights.

On the first day (Wednesday) there were 11 ½ day workshops that focused on a range of topics, including Risk Assessment (David Thornton; Simon Hackett & Marcella Leonard; Maaike Helmus; Ray Knight & Judith Sims-Knight); the registration and disclosure of information relating to people who had committed sexual offences (Katie Gotch, Margret-Anne Laws, Karla Lopez & Kieran McCartan); the voices of victims on the integration of people who have been convicted of sexual offences back into the community (Kelly Richards, Jodi Death, Carol Ronken & Kieran McCartan); the prevention of sexual abuse (Stephen Smallbone); and treatment/interventions (Richard Parker; Sharon Kelley) The workshops enabled professional, policy and practice conversations to take place in a controlled, informed environment.

The 2019 plenaries combined research, practice and innovate approaches from an international group of speakers, most of whom were from outside Australia and New Zealand. The Thursday keynotes addressed children who had committed Harmful Sexual Behaviour, their client voice and the impact of treatment/interventions, on their life course desistence as well as how we could adapt our practice to better serve them (Simon Hackett). This was followed by a discussion of what matters and what works in risk assessment and how it ties to reducing risk of recidivism (David Thornton), The third keynote on Thursday was a panel discussion on the process and impact of the Australian Royal Commission, which highlighted the challenges of implementing its recommendations in practice (Gary Foster, Kathryn Mandla & Professor Stephen Smallbone).

One of the main themes of the conference was hearing different voices and it’s fitting that the Indigenous voices (Maori, Aboriginal and Tori Strait Islanders) and the victim’s voices (through conversations on the Royal Commission) were front and center in the plenaries as well as in the parallel sessions. These sessions were important and thoughtfully developed, highlighting the ways that Australia and New Zealand where moving forward in the arena of hearing and respecting the Indigenous voices and how we can develop appropriate risk assessment, treatments/interventions, and integration strategies developed with traditional peoples in mind. Which should give all participants, especially from anglophone northern hemisphere countries, pause for thought in the way that we address these issues in our own countries. In addition, it was good to see and hear a focus on the victim’s voice at a treatment and management conference for people convicted of sexual offenses as it reinforced that these two sides of the field are not as detracted from each other as they are often portrayed; the only way to truly understand, respond to and prevent sexual abuse is to hear all voices.

The National Office for Child Safety led two co-design workshops for the development of a National Strategy to Prevent Child Sexual Abuse on the last day of the conference. Which was interesting to attend and quite innovative in the context of a conference as policymakers got to discuss issues with researchers and practitioners, hearing each other’s voices and building approaches that were fit for purpose. These sessions where quite innovative and I would recommend that sister conferences in the field (NOTA, ATSA, ATSA-NL, CoNTRAS-TI & IATSO) would consider doing the same thing.

Other parallel workshops spanned a full range of topics and speakers of which this is just a flavour) including, integration of people who have sexually offended back into the community; public health approaches to sexual abuse and prevention; youth who sexually harm; institutional sexual abuse; & pornography. The parallel sessions were a good mix of research, evaluation, practical working, professional learning and knowledge exchange.

The second day of the conference (Friday) closed with an interesting mix of keynotes, a panel session that focused on the voices of Indigenous peoples (Lynore Geia, Neil Campbell, Carol Vale, & Claire Walker), another that addressed research on typologies of people who commit rape (Ray Knight) and how much we know about undetected sexual abuse (Sharon Kelley). All the keynotes tied together ideas of the importance of assessment, management, and integration in a thoughtful, fit for purpose fashion tying together research, practice and policy effectively.

In addition to the traditional conference activities, ANZATSA 2019 also had an engagement event. This year we changed our focus from members of the public to professionals. We advertised the engagement event to professionals who have safeguarding as part of their jobs, but that safeguarding is not their main role (and therefore would not be attending the ANZATSA conference) including, teachers, foster carers, members of charities and NGO’s, etc. They had approximately 70 participants sign up to attend the event. The session heard from national (Detective Inspector Rouse, Professor Martine Powell & Carol Ronken) speakers, chaired by Nance Haxton (the wandering journo), about how to raise informed and confident children that can discuss sexual abuse, and exploitation, and able to ask for help. The engagement event reinforced the main theme of the conference and highlighted that we as a community need to come together to stop child sexual abuse.

ANZATSA 2019 fitted a massive amount of material in across three days, which left me informed, refreshed and looking forward to 2021’s meeting.

Rehabilitative Climate and the Experience of Imprisonment for Men with Sexual Convictions

Dr Nicholas Blagden, Co-Head Sexual Offences Crime and Misconduct Research Unit, NTU

Ralph Lubkowski, Governor HMP Stafford, Her Majesty’s Prison and Probation Service

For men convicted of a sexual offence life in prison is not easy and can often be a brutal experience. They are despised by all for what they have done. They may have lost, or fear losing, the support of those who care for them. They will be at the bottom of the prison hierarchy, living in constant fear of being identified as a ‘sex offender’ and will often be the victim of physical and verbal assaults (Schwaebe, 2005). The difficulties facing these men are innumerable. Yet, despite all of these issues, we still expect these men to be rehabilitated, to volunteer willingly for, and commit to, treatment where the intimate details of their lives are laid bare (Ware & Blagden, 2016). Treatment must seem like a frightening prospect on many levels. It is important to note that while a populist response to this may be that such individuals ‘deserve’ to feel that way, it does little to help rehabilitate individuals. The goal of prison and prison rehabilitation for such individuals must be to prevent other victims and to help men lead meaningful and pro-social lives, because this is what will keep people leading offence-free lives. We know that harsh environments make people worse and not better and negatively impact both staff and prisoners (Chen & Shapiro, 2007).

However, despite the environment being highly adversarial for those convicted of sexual offences, there is very little research considering the impact. The prison climate and the attitudes of staff in that prison play an important role in successful treatment and rehabilitation of offenders. In an era when the treatment of men with sexual convictions is contested and even questioned, there is a real need to take seriously the environment in which such individuals reside and understand the opportunities within that environment to help men flourish.

Rehabilitative climate of prisons for men with sexual convictions

Men convicted of sexual offences represent around 18% of those serving a prison sentence. This has brought challenges e.g. where to locate such individuals, as many are separated onto ‘vulnerable prisoner units’, but still experience threats and fear from others. One solution in England and Wales has been to increase the number of prisons specifically for men with sexual convictions.

There is some debate as to whether housing men with sexual convictions together is a good idea. Some suggest that they may share deviant fantasies, groom others including staff and create an overly sexualised environment. These are important issues, but the incidence of such events happening is not as frequent as we might think. Recent research (see e.g. Blagden & Wilson, 2019, Blagden et al, 2016) has found incidences to be unexpectedly minor given the sample. Instead in these research studies participants expressed that they were experiencing the prison as a “different world”, one in which they were less anxious and less fearful. This was helping men have the ‘headspace’ to contemplate change.

Prisons for men with sexual convictions with a good rehabilitate prison climate promote constructive and meaningful relationships between prisoners and staff and provide opportunities for meaningful experiences to allow men the possibility to try out new identities. Relationships matter in prison, especially for this client group, as they can be testing grounds for future relationships and identities. An important aspect of meaningful relationships for this client group (and others) is creating opportunities for reciprocal relationships i.e. those that promote shared exchanges, shared learning and understanding. Two things which have been important for creating reciprocity within prison are peer support and active citizenship. Indeed, the reciprocal aspects of these have been found to galvanise staff-prisoner and prisoner-prisoner relationships, which is important as the relational properties of both are linked to the ‘self-change’ process (Mead, Hilton, & Curtis 2001). HMP Stafford is a prison that has an active citizenship focus. Active citizenship at its heart is about creating a community and a shared sense of ownership of the space they inhabit, it helps prisoners to engage more with the people and the world around them, to reintegrate in the community (Edgar et al, 2011). Finally, we will look as what active citizenship looks like in practice.

Rehabilitative Climate in Action – Active citizenship

In 2016 HMP Stafford was rerolled to hold exclusively people convicted of sexual offences (PSOCOs). This dramatic shift in population was closely followed by a new focus on Rehabilitative Culture across the prison estate. Stafford’s approach to these two new opportunities was Active Citizenship, a simple concept of recognising, reinforcing, and recording acts seen to be doing good for the community, environment, and others. Visually striking and simple promotional materials were produced, and staff and resident champions appointed to drive the concept forward.

Initially the result was that residents strived to be in jobs linked to “citizenship” such as carers, listeners, or resident’s council reps. Citizenship was regarded as a position to be attained, and closely linked to employment or activity. There were no financial rewards, nor was it directly linked to the Incentives and Earned Privileges Scheme. The only tangible benefit was a badge, however being recognised as an Active Citizen created a new identity for those willing to do good, and built a momentum behind the idea of contributing to the prison community.

As Active Citizenship embedded, it evolved. Residents looked for new opportunities to contribute, and staff recognised and valued these small acts of kindness. Citizenship became less linked to specific roles or activities, and more of a way of life. Even the badges, albeit still worn proudly by those that received them, became less significant. Contributing to helping others and making Stafford a better place became a shared objective for staff and residents, the act itself being the reward. This has led to a remarkable transformation in the past 18 months. Trust has built between staff and residents, with a progressive and innovative climate resulting in what at times seems like an avalanche of new initiatives and opportunities. Many of these have been created and driven by residents and front line staff, often in their own time and with little or no resource.

Stafford is now a place where residents are given a real opportunity to change and grow, a community where people care for each other and where hope flourishes. We do not shy away from the reality of what our residents did, or what difficulties they will face after prison but Citizenship has created a climate where they can rebuild and renew themselves. They feel valued and empowered, enabling them to confront their previous life and wrongdoing and move forwards. We are still on a journey, and there is more to do, but the foundations have been built allowing us to build something truly remarkable.


Blagden, N., & Wilson, K. (2019). “We’re All the Same Here”—Investigating the Rehabilitative Climate of a Re-Rolled Sexual Offender Prison: A Qualitative Longitudinal Study. Sexual Abuse, DOI: 1079063219839496.

Blagden, N., Winder, B., & Hames, C. (2016). “They treat us like human beings”—Experiencing a therapeutic sex offenders prison: Impact on prisoners and staff and implications for treatment. International journal of offender therapy and comparative criminology60(4), 371-396.

Chen, M. K., & Shapiro, J. M. (2007). Do harsher prison conditions reduce recidivism? A discontinuity-based approach. American Law and Economics Review9(1), 1-29.

Edgar, K., Jacobson, J. and Biggar, K. (2011), “Time well spent: a practical guide to active citizenship and volunteering in prison”, Prison Reform Trust, London, available at: Documents/Time%20Well%20Spent%20report%20lo.pdf (accessed July 8th, 2017)

Mead, S., Hilton, D., & Curtis, L. (2001). Peer support: A theoretical perspective. Psychiatric rehabilitation journal25(2), 134.

Schwaebe, C. (2005). Learning to pass: Sex offenders’ strategies for establishing a viable identity in the prison general population. International Journal of Offender Therapy and Comparative Criminology49(6), 614-625.

Ware, J. & Blagden, N. (2016), “Responding to categorical denial, refusal, and treatment drop-out”, in Boer, D.P. (Ed.), The Wiley Handbook on the Theories, Assessment and Treatment of Sexual Offending, John Wiley & Sons Ltd, West Sussex, pp. 1564-71.