A detailed treatment regimen for sexual murderers is not currently possible because of limited clinical experience with such offenders, insufficient treatment-related knowledge about them, the rarity of their crimes, and variation in their profiles. The imprecision of the key concepts of sexual murder has hindered the development of reliable diagnostic criteria and interventions adapted to the severity and intensity of such extreme criminal behaviors. The chapter contains a section that distinguishes between sadistic sexual aggressors, most of whom do not commit murder, and sadistic sexual murderers, for whom killing is a central expression of their need to exercise power over their victims as a sexual release. "Angry" sexual murderers, in contrast to sadistic sexual murderers, tend to be less sadistic but react more defensively to perceived threats to their worth and power. A discussion of the therapeutic framework for sexual murderers indicates that it is usually long-term incarceration that provides sufficient time for assessment and psychotherapeutic work. Treatment plans must take into account the safety of the staff, the client, and other inmates. After discussing the initial evaluation, the chapter considers the analysis of the crime scenario as the initial focus of treatment, with attention to analysis of the function of the victim. Clinical issues addressed are the client's early relational problems and guilt, as well as intervention goals and limitations. Case studies of treatment for a sadistic murderer and an angry murderer focus on the short-term and long-term treatment objectives as well as the therapeutic course.