Adolescence is perceived as a transitional phase of growth and development between childhood and adulthood. This period of development corresponds roughly to the period between the ages of 10 and 19 years, which is consistent with the World Health Organization’s definition of adolescence [1]. In addition, according to Malaysian Child Act, 2001, adolescents are classified as minors because they are under age of eighteen (18) years old.

Sexually active minor means an underage person participates in sexual activities such as intercourse, oral sex, fingering and other. In Malaysia, the law was enacted to protect minors by enforcing statutory rape laws which are called by a plethora of other names refer to those laws that criminal voluntary sexual acts involving minors that would be legal if not for the age of the participants. The premise behind these laws is that until a certain age, young people are incapable of giving their consent for sexual behavior. Age of consent laws, therefore, made it easier to prosecute a person who sexually assaulted minors.

Nowadays, the cases of sexually active among minors are increasing. According to Durex (2002), minors most often have sex with the average of three times a week. The Study by Schutt-Aine and Maddaleno found that almost 50% people under 17 years old were sexually active same as found in the study done by Rector, Johnson and Noyes [2] which found that in the year 1997, United Stated shown about 48% of teenage has been sexually active. In addition, Dixon- Mueller [3] stated minors as early 15 years old in developing countries were sexually active. The same finding was found by Hellerstedt, Peterson-Hickey, Rhodes, and Garwick [4] stated that 4135 American Indian in Minnesota were sexually active with 40% of them are with age 13 to 15 years old while in Malaysia the sexual activity among minors started as early as 11 years old [5].

Along that, there are several factors contribute to sexually active among minor such as stated by Schutt and Maddaleno the change from psychological point where adolescent will present sexual desire, lust and attracted to individual of opposite sex and Durex found that having limited information regarding safe sex is one of contributing factors to sexual activity. Besides that, O’Sullivan et al. [6] found the minors did the sexual activity without thinking the negative consequences.

Therefore, the action of sexually active among minors causes multiple psychological consequences such as causing harm to themselves by taking drugs or experiencing depression [7]. The psychological effects may include guilt feeling to themselves and religious guilt [8] and unwanted pregnancies. Moreover, Tom stated adolescents who are sexually active might fall loss of self-esteem which lead adolescents to involve in even more casual sex that leading to further loss of self-esteem in an oppressive cycle from which it may be hard to break free the cycle. Commonly adolescents who are sexually active may experience depression which will affect the individual function in daily life that may contribute to poor coping skills and negative traits. This associated with risk behaviors and lead to suicide. Therefore, clinical psychologist plays important roles [9] in providing suitable intervention for sexually active minors.

Based on studies and findings obviously seethe phenomenon of sexually active among minors has declined in recent years but the overall rate is still high. This phenomenon has impacts on the psychological aspects so that without appropriate psychological intervention may lead to their dysfunctional role in society or in the family.

Thus it is vital to have structured intervention plan to cater this phenomenon. To date, there are very limited modules or intervention conducted in Malaysia for minors are sexually active. Besides that, studies on psychological interventions on sexually active minors in Malaysia are also limited. Even though the individual session is seen as helpful for minors who are sexually active but Sarnon et al. [10] suggested involving the family in the intervention. This is because family supports offer an opportunity in their future planning and understand their roles in the family. The interventions for improving the coping skill were more effective with parent cooperation or caregiver [9]. This is because support and collaborative works from the parents may create sense of belonging among family members and enhance the percentages of positive changes.

Therefore, more research is needed to have an effective psychological intervention in helping minors who are sexually active. The aim of this paper is to review the effects of psychological interventions especially Person Centered Therapy (PCT) and Rational Emotive Therapy (REBT) in Malaysia and other countries.

The study synthesizes findings that apply the psychological interventions for sexually active minors. The method of systematic review guidelines departs from Preferred Reporting Items for Systematic Reviews (PRISMA) [11]. The search strategy of sources of literature was limited to references published from 1990 to 2017.

The inclusion criteria must be articles of:

a) Psychological intervention.

b) Full text in English or Malay journal.

c) Participants must be minors (age below 18 years old) who are sexually active.

d) Articles published on 1990 until 2017.

Figure 1 presents the PRISMA flow diagram of the steps and procedure used to identify and select records for inclusion in this analysis. The research for psychological interventions for sexually active among minors was located through searching four online databases: (a) PubMed, (b) Cochrane, (c) Scorpus and (d) e-Bangi. Searches were performed in September, 2017 and employed all the following search terms: “sexually active”, “sex offender”, “adolescent”, “minor”, “intervention”, “Rational Emotive Behaviour Therapy (REBT)”, “Person Centered Therapy (PCT)”, “psychological intervention”, “psychotherapy”, and “treatment”. The initial review of the literature revealed 55095 articles based on combinations of the search terms. For each database, the search was restricted to 27 year period between 1990 and 2017. The Table 1 below presented the publications found through the online database that used the term as mentioned above.

Figure 1: presents the PRISMA flow diagram of the steps and procedure used to identify and select records for inclusion in this analysis.

Table 1: Summary search of publications using the term in the online database as listed in the table.

Then, by using the structured systematic review method, a total of 55,095 articles published between 1990 and 2017 underwent initial screening with 131 articles remained after excluding duplicates and excluded on the basis of not a psychological intervention or not having relevant content. The first stage of the selection identified 127 articles for full-text screening.

In the second phase, the remaining 127 articles were further screened by several inclusion criteria’s. The characteristics of the study sample must be minors that discussed the psychological interventions and the primary objective of the intervention was to reduce the problematic sexual behaviour.

The full search yield 55,095 publications, the duplicates and irrelevant publications were removed 54,965 and further 127 publications were full text screened and 122 were removed for not fulfilling the inclusion criteria. The remaining 5 studies were presented in Table 2. All the five studies consist of five interventions from the local and abroad that met the inclusion criteria. There is one study done in Malaysia and others four studies from western countries. The studies mainly focused on the psychological intervention.

Table 2: Summary of relevant research published from 1990 to 2017.

Sarnon et al. [10] research aimed to understand the sexual development of adolescent, the influence of the development until the occurrence of pregnancy and suggest that family intervention can be used. Sarnon et al. [10] found that family support plays important roles to have an effective result. At the same time, Sarnon et al. [10] they also suggest to implement crisis intervention and educate coping skills with family support. The involvement and support from the family help to gain trust among family members that may lead to positive change in the client.

Second research by Whitford and Parr [12] conducted Rational Emotive Behavior Therapy (REBT) with juvenile sex offenders in a group and individual therapy, also with the family members. However, the outcome of the study on the assessment and treatment sometimes leaves much to be desired. In spite of some progress achieved, REBT educates clients a rational belief system that includes self-acceptance, high frustration tolerance, responsible risk-taking that is non-approval seeking, tolerance or fallibility of others and personal responsibility for emotions and behaviours. The plethysmography and galvanic skin response (GSR) assessment are available primarily as part of treatment and are very important as tools used to measure client progress that assists the therapist invalidating the client's self-report. The best group size should not as eight members so that time is available during the group session to work on cognitive and behavioural tasks as well as individual interpersonal conflicts. Therapy for interpersonal conflicts often includes and emphasizes reduction of emotional disturbances such as anger and guilt. The therapy is required on weekly basis for all clients that need to meet twice weekly with homework.

The third article in the series of REBT used in the forensic setting that describes REBT was an effective therapy for the offender because of its active directive style, and because it dealt with practical problems in the present and provided the solution [13]. Kopec [13] stated that REBT provided the new mechanism of coping that they could incorporate into areas of their lives and REBT enabling inmates to overcome the hassles, stresses, and frustration of life were not supported with reference to any empirical evidence. The study same as Seasock [14] described the Identification of Adolescent Sexual Offenders that applied REBT Model. Seasock [14] emphasized the importance of assessing perceptions, inferences, and beliefs in distinguishing between the sex offender and who commits inappropriate sexual behaviour. The article stated low frustration tolerance and demandingness appeared to be the most common irrational beliefs. For example, the presence or absence of dysfunctional cognitive process was best recognized by using the REBT because it may develop the more appropriate client-centered treatment that in turn may show greater success rate in the process by decreasing if not eliminating the possibility of recidivism [14].

The article by Nauth [15] explained REBT ideally suited to therapeutic work with the client to educate the role of beliefs in generating emotional distress and poorly adjusted behaviour thereby encourage the client to accept the responsibility and practice to control their thoughts, feelings, and behaviour. The writer used specific example cases to illustrate her idea, the causal relationship between irrational beliefs and offending behaviour.

Hall [16] carried out a meta-analysis of 12 studies that compared the treatment of sexual offender with a comparison condition between the alternative treatment and no treatment and it provided recidivism data for sexual offenses. Both Cognitive-behavioural and hormonal treatments appeared to be superior to behavioural treatments. The result of the study suggested that the effect of treatment of sexual offenders was robust, albeit small and most effective with adherence to the treatment.

The effectiveness of psychological interventions

Five studies examined the effects of psychological interventions for minors who are sexually active found that the individual counseling is an effective intervention. The individual counseling is effective to improve the social skills [17] and low rate of recidivism [18,19]. The intervention of Cognitive Behaviour Therapy (CBT) model also focused on relapse prevention. The model of CBT believed that behaviour was controlled by cognition. In addition, Seasock [14] also has the same idea that REBT helps in decreasing the possibility of recidivism. Besides that, Rational Emotive Behaviour Therapy (REBT) seen as a unique intervention because it is helpful to overcome the psychological effects in terms of emotions, cognition, and difficulty in gaining trust from others. This is in line with the theory of REBT which emphasize on the biological, psychological, and social factors are involved in the way a person feels and behaves based on the perspective of Biopsychosocial model. REBT also encourages minors who are sexually active to accept responsibility and exercise in controlling the thoughts, feelings, and behavior [15]. Thus, Kopec [13] claimed that REBT is an effective therapy because of its directive style which is focuses on issue in the present moment and provided solutions of the new coping mechanism. Furthermore, family support plays important roles in the development of healing process with minors who are sexually active. The family support can create positive change in the clients because of the trust from the family members [10].

The findings of this systematic review on various literatures have shown that REBT, CBT, and family support significantly provided positive changed. Nowadays, there are many studies on minors who are sexually active used the term sexual offender or juvenile in articles. Most of the studies presented statistical data in terms of causes and factors that contributed to sexual activity. The study also discussed the medical effects such as sexual transmitted diseases (STD) but there are limited studies on psychological interventions. Table 2 contained a summary of five intervention studies in Malaysia and other countries that met the inclusion criteria. The studies mainly focused on REBT but there are also studies focused on CBT and family intervention with crisis intervention.

The reviews show that some interventions are theoretically based. For example, Cognitive Behaviour Therapy (CBT) is a range on a continuum, which they are interventions seeking to change individual’s internal cognitive and emotion, functioning as well as the individual’s overt behaviour. The theoretical researches tend to explain the reason for certain therapy should be used based on the client symptoms or criteria’s. However there are few studies investigated the efficacy of the intervention, for instance, Hall [16] who used comparison condition in comparing the effectiveness of the treatment towards cognitive and behaviour.

In Malaysia, limited research was done to explore and understand the psychological effects among sexually active minors. There are also limited studies done in psychological intervention so that systematic module for minors who are sexually active is hard to develop. Generally, most of the studies in Malaysia focused on reporting the statistical data such as the factors, onset age of the sexual activity. The part related to prevention is mostly more on educating about safe sex and awareness about STD. It is also recommended that psychological effects and psychological interventions should be more specific and comprehensive in order to produce better outcome. There is less of standard psychological interventions module for sexually active minors in Malaysia. It is proposed that future research should focus on psychological intervention.

The systematic review showed that various psychological interventions used in helping sexually active minors such as Rational Emotive Behaviour Therapy (REBT), Cognitive Behaviour Therapy and family support significantly enhanced positive change. The findings support that the REBT, CBT, and family support improved social skills and reduced the rate of recidivism. However, most articles found implemented REBT as a psychological intervention for sex offender among adolescent and juvenile sexual. The intervention of REBT was preferable among psychologist because REBT holistically covered emotions and cognition. Furthermore, the intervention of REBT also significantly proved has a low rate of recidivism. Therefore, psychologists suggested having more studies on the psychological intervention among minors with sexually active in clinical psychology perspective.