Chapter 43. Pedophilia

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Michael C. Seto: Chapter 43. Pedophilia, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O.
Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.261057.
Printed 5/10/2009 from www.psychiatryonline.com
Gabbard’s Treatments of Psychiatric Disorders > Part VIII. Sexual and Gender Identity Disorders >
Chapter 43. Pedophilia
INTRODUCTION
The word pedophilia is derived from the Greek words for love (philia) and young children
(pedeiktos). Pedophilia is defined as a persistent sexual interest in prepubescent children, reflected
in recurrent thoughts, fantasies, urges, sexual arousal, or behavior (American Psychiatric
Association 2000; World Health Organization 1997). In its strongest form, pedophilia reflects an
exclusive sexual preference for prepubescent children, in which the pedophilic individual has no
sexual interest in adults.
Pedophilia is diagnosed after a careful evaluation using multiple sources of information and
multiple methods of data collection. This includes self-report, interviews with others who know the
person, information about any sexual offenses, criminal records, and psychophysiological
assessments of sexual arousal (penile response to sexual stimuli) or sexual interest (viewing time
when presented with sexual stimuli). Details about sexual victim characteristics, child pornography
charges, and psychophysiological assessments are particularly informative (Blanchard et al. 2001;
Seto and Lalumière 2001; Seto et al. 2005). A proxy measure based on sexual victim characteristics
can be used when psychophysiological assessments are not available (Seto and Lalumière 2001;
Seto et al. 2003, 2004).
Additional information to be obtained in a comprehensive evaluation of individuals with pedophilia
is summarized in Table 43–1. In addition to establishing the diagnosis of pedophilia, clinicians are
usually concerned with the pedophilic individual’s likelihood of engaging in sexual contacts with
children, which is related to their propensity for unconventional sexual behavior (indicated by sex
drive and engaging in other paraphilic interests), antisocial behavior in general (indicated by
criminal activity and other conduct problems), and opportunities to have such contacts with
children. Comorbidity in terms of substance abuse and antisocial personality disorder should also be
assessed because of the relevance of these diagnoses for risk to reoffend and case management.
Sex offender risk assessment has advanced greatly in the past decade, and a number of empirically
and independently validated risk assessment scales have been developed (Hanson et al. 2003; Seto
2005). This literature indicates that, all other things being equal, pedophilic sex offenders are at
higher risk for sexual recidivism than nonpedophilic sex offenders.1
Table 43–1. Elements of a comprehensive evaluation for pedophilic individuals
1. Sexual history
a. Officially recorded and self-reported sexual contacts with children
b. Use of pornography, especially child pornography
c. Adult sexual partner history
d. Interest and involvement in other paraphilias, such as sadomasochism, fetishism, exhibitionism, and
voyeurism
2. Antisocial behavior history
a. Childhood behavior problems
b. Criminal behavior as a juvenile and as an adult
c. Substance misuse
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d. Noncriminal risk taking (e.g., gambling, physical thrill seeking)
3. Opportunities to have sexual contacts with children
a. Family composition (e.g., individual or partner has children)
b. Living arrangements
c. Employment and volunteer activities that involve proximity to children
4. Potential protective factors
a. Level of cognitive functioning
b. Availability of support persons
c. Stability of employment, housing, and other aspects of lifestyle
The terms pedophilia and sexual offending against children are often conflated, but they are not
synonymous. Some pedophiles have not committed sexual offenses involving children, and some
sex offenders with child victims are not pedophiles. However, much of what we know about the
treatment of pedophilia comes from research on convicted sex offenders with child victims, and by
necessity this chapter draws heavily from this literature. Much less information is available on
groups such as female sex offenders with child victims and pedophilic individuals who do not come
into contact with the criminal justice system.
I thank Meredith Chivers, Grant Harris, and Martin Lalumière for their helpful comments on an earlier version of this
manuscript.
1Recidivism in terms of new charges or convictions is a conservative estimate of actual sexual offenses against
children. Hanson et al. (2003) have suggested that actual recidivism rates are 10%–15% higher than official
recidivism rates. Most follow-up and treatment outcome research has relied on official records of charges or
convictions.
OVERVIEW OF TREATMENT
The current research evidence is equivocal about the impact of treatment on pedophilia, specifically
in the context of sex offender treatment outcome studies. A recently published meta-analysis has
been highly influential in discussions of sex offender treatment outcome because of its breadth and
conclusions (Hanson et al. 2002). This meta-analysis reviewed 43 published and unpublished
studies of psychological treatments (total N = 9,454) of varying methodological quality and
concluded that treated sex offenders (combining offenders against children and offenders against
adults) had lower recidivism rates than sex offenders in comparison conditions. The difference was
17% versus 12% for sexual recidivism; there was also a difference in nonsexual recidivism
(offenses such as theft, possession of narcotics, or nonsexual assault) as well. Larger differences
were reported for contemporary cognitive-behavioral treatments compared to older and
unstructured treatments. Focusing on the contemporary treatments, there was no difference in the
effect sizes for treatments offered in institutions and treatments offered in the community. Results
for only sex offenders against children (or even more specifically, only pedophilic sex offenders)
were not reported.
The Hanson et al. (2002) meta-analysis has been criticized by Rice and Harris (2003) for the study
quality ratings that were used in the analysis and other coding decisions. For example, Rice and
Harris pointed out that 9 of 12 incidental assignment studies that examined more recent sex
offender treatments (these studies did not randomly assign sex offenders to treatment or control
conditions, but the reasons for group assignment did not appear to be related to offender risk; for
example, no treatment spots were available) included comparison subjects who would have refused
or dropped out of treatment if it had been offered to them, while excluding men who did refuse or
drop out from the treatment group. Because men who refuse treatment or drop out of treatment are
more likely to reoffend (Hanson and Morton-Bourgon 2004), this coding decision creates a selection
bias, independent of any treatment effects, that increases the likelihood of finding fewer reoffenses
among the treatment group. Rice and Harris also noted that two studies rated as lower in
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methodological quality could have, in fact, been informative because the treatment and comparison
subjects were matched on risk factors.
Rice and Harris (2003) reanalyzed data from six studies that they considered to provide meaningful
information about sex offender treatment outcome from the Hanson et al. meta-analysis (Borduin
and Schaeffer 2001; Lindsay and Smith 1998; Marques 1999; Quinsey et al. 1998; Rice et al. 1991;
Romero and Williams 1983). These six studies comprised the four randomized clinical trials and the
two studies using matched comparison groups. Their reanalysis suggested a trend toward
treatment having a deleterious effect on sexual recidivism, with treated sex offenders having a
nonsignificantly higher reoffense rate than sex offenders in the comparison conditions.
A Cochrane Collaboration Review identified nine randomized clinical trials (two were also included
in the Hanson et al. meta-analysis) that evaluated the impact of psychological interventions on a
variety of outcomes, not only recidivism (Kenworthy et al. 2003). All of the studies reviewed by the
Cochrane group involved adult male sex offenders; 52% were offenders against children. For
example, Anderson-Varney (1992) randomly assigned 60 sex offenders against children to
cognitive-behavioral therapy or no treatment conditions; the outcome measures were social
avoidance, empathy, sexual attitudes, sexual knowledge, and self-reported sexual behavior. The
Cochrane Collaboration Review concluded that there was no evidence of a significant impact of sex
offender treatment.
Taken together, these quantitative reviews do not provide clear or consistent support for the
efficacy of current sex offender treatments. Innovative, theoretically informed interventions need
to be developed and evaluated (for a recent review of theories about pedophilia, see Quinsey 2003;
Seto 2004). To assist in the further clinical and theoretical development of pedophilia and sex
offender treatment, I review the literature on psychological, medical, and social interventions in the
following sections.
PSYCHOLOGICAL INTERVENTIONS
Cognitive-Behavioral Treatments
The relapse prevention approach to treating sex offenders was adapted from the addictions field
and is currently the most popular cognitive-behavioral treatment format for adult sex offenders
(Association for the Treatment of Sexual Abusers [ATSA] Professional Issues Committee 2005;
McGrath et al. 2003). Marlatt and Gordon (1985) outlined a strategy for assisting individuals who
have completed treatment to prevent the recurrence of drug taking. The relapse prevention
strategy involves 1) identifying situations in which the individual is at high risk for relapse; 2)
identifying lapses, that is, behaviors that do not constitute full-fledged relapses but do constitute
approximations to drug taking and may be a precursor to a relapse (e.g., spending time in bars
without drinking alcohol); 3) developing strategies for avoiding high-risk situations; and 4)
developing coping strategies that might be used in response to both high-risk situations and lapses
to minimize the chances of a relapse. In the context of sexual offenses against children, high-risk
situations include time spent alone with a child or in places where many children are present, and
lapses include behaviors such as masturbating to sexual fantasies about children.
An excellent example of the relapse prevention approach is the Sex Offender Treatment Evaluation
Project (SOTEP), which was funded by an act of the California state legislature. Because of the
importance of SOTEP in the sex offender treatment outcome literature, this program will be
reviewed in detail here. The SOTEP program was carefully designed, comprehensive, and
impressive in its scope. Its distinctive features include use of random assignment of adult
volunteers to treatment and no-treatment conditions after matching them for age, criminal history,
and victim type; inclusion of a second control group of nonvolunteers; implementation of an
intensive, manualized 2-year cognitive-behavioral program based on relapse prevention principles;
participation in a 1-year aftercare program once offenders were released to the community; and
evaluation of both proximal (within-treatment) and ultimate outcomes. The proximal treatment
goals were to increase statements of personal responsibility for sexual offending, decrease
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rationalizations about sexual offending, decrease atypical sexual arousal, understand relapse
prevention concepts, increase ability to identify high-risk situations, and improve skills in avoiding
and coping with high-risk situations. The ultimate treatment goal was to reduce recidivism.
SOTEP participants met three times a week for 90 minute group therapy sessions and also
participated in individual therapy sessions. Treatment participants were also involved in groups
focusing on sex education, human sexuality, relaxation training, stress and anger management, and
social skills. Other treatment elements were offered on a prescriptive basis. For example, 69% of
the treatment sample had significant substance abuse histories and were therefore required to
complete a relapse prevention group program targeting substance abuse. Pedophilic sex offenders
were offered behavioral treatment targeting their sexual arousal to children.
Treated sex offenders lived in a secure hospital while the two control groups remained in prison.
Although some treatment services were available (e.g., anger management, substance abuse) in
prison, no sex offender treatment was available during the time the SOTEP project ran.
Approximately one-third of eligible sex offenders volunteered to participate in the evaluation
project. The SOTEP project is very informative about treatment of pedophilic sex offenders, because
nearly three-quarters of eligible sex offenders victimized children, and those who victimized
children were more likely to volunteer for treatment.
The final wave of data collection was completed in 2001, with an average follow-up period of 8
years. Recidivism data were obtained from the Federal Bureau of Investigation, California
Department of Justice, and California Department of Corrections. There was no significant
difference in the recidivism of the 204 treated sex offenders, 225 control subjects who volunteered
for treatment but were randomly assigned to the no-treatment condition, and 220 other control
subjects who did not volunteer for treatment (Marques et al. 2005). There was a nonsignificant
trend for sex offenders against children to fare worse in treatment (22% sexual recidivism for
treated offenders vs. 17% for volunteer controls) compared to an opposite trend for sex offenders
against adults (20% for treated offenders vs. 29% for volunteer controls).
There was no significant difference between groups even after excluding the early dropouts, which
could be considered a generous test of the hypothesis that treatment reduces recidivism because
some of the volunteer controls would likely have become early dropouts if they had entered
treatment. As previously noted, those who drop out of treatment tend to be at higher risk for
recidivism. There was also no significant difference between the three groups even after controlling
for inadvertent group differences on the following static risk factors (in addition to offender age,
offense history, and victim type, which were part of the subject matching): having prior sexual
offenses, having convictions for noncontact sexual offenses, having unrelated victims, having
stranger victims, having male victims, younger offender age, and never being married.
Of note, SOTEP did have a significant impact on its stated goals. Treatment participants showed a
significant decrease on self-report measures of minimization of responsibility and phallometric
measures of sexual arousal. The researchers also obtained posttreatment clinician ratings of
relapse prevention skills. Both pre- and posttreatment measures of sexual arousal to male children
were significantly related to sexual recidivism, but the self-report measures and the clinician
ratings were not. This suggests that the treatment program did have the desired impact but that
the treatment targets were mostly unrelated to recidivism. This is consistent with meta-analytic
results suggesting that factors such as acceptance of responsibility and expressions of victim
empathy are not significant predictors of recidivism among sex offenders (Hanson and Bussière
1998; Hanson and Morton-Bourgon 2004). Linked together, these results suggest that these
treatment targets (other than sexual arousal to male children) are not necessary elements of a sex
offender treatment program.
Marques et al. (2005) discussed reasons for why SOTEP did not have a significant impact on
recidivism and suggested several ways in which they would have changed the study and program
design. These changes included recruiting more high-risk offenders, conducting pretreatment
assessments on all offenders, and regularly monitoring treatment progress to ensure that
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treatment participants were learning the concepts and skills being taught.
Despite these caveats, it is important to recognize that a well-designed and -implemented
treatment program that was state of the art at the time and is still very similar to the most
commonly offered sex offender treatment programs did not find any significant effect on recidivism.
Thus, the final evaluation of SOTEP poses a great dilemma for clinicians, because the results of this
high-quality randomized clinical trial suggests that the most commonly available treatment
approach for sex offenders has no impact on recidivism.
Behavioral Treatments
Reviews of the history of behavioral treatments for pedophilia are provided in Laws and Marshall
(2003) and Marshall and Laws (2003). These behavioral treatments directly target sexual arousal
to children, unlike the cognitive-behavioral treatments discussed in the previous section, which
were designed to reduce recidivism among sex offenders against children. Aversive conditioning
techniques were used as early as the 1950s and 1960s for paraphilic interests such as fetishism and
transvestism (e.g., Marks and Gelder 1967; Raymond 1956). The early behavioral treatment
literature also focused on homosexual arousal prior to the declassification of homosexuality as a
mental disorder.
In the behavioral treatment of pedophilia, aversion techniques are used to suppress sexual arousal
to children, while masturbatory reconditioning techniques are used to increase sexual arousal to
adults. In aversion procedures, unpleasant stimuli such as mild electric shock or ammonia odors are
paired with repeated presentations of sexual stimuli depicting children. In a variation called covert
sensitization, the aversive stimulus is imagined (e.g., imagining being discovered by family, friends,
or co-workers while engaging in sexual behavior with a child).
Satiation is a behavioral technique for decreasing pedophilic sexual arousal that does not depend
on the use of aversion. In this procedure, the subject masturbates to ejaculation while stating
variations of his fantasies about children. After ejaculation and throughout the refractory period, he
continues to masturbate to the same fantasies over several long sessions, in order to produce
habituation. Masturbatory reconditioning involves associating sexual arousal with adult stimuli.
Techniques include thematic shift, in which the subject masturbates to a sexual fantasy about a
child until the point of orgasm, and then switches to a fantasy about an adult.
The efficacy of behavioral approaches for changing sexual arousal patterns has been reviewed by
Barbaree et al. (1995) and Barbaree and Seto (1997). Overall, the existing research suggests that
behavioral techniques can decrease sexual arousal to children, but it is unclear how long these
changes are maintained and whether they result in actual changes in pedophilic preferences, as
opposed to greater voluntary control over sexual arousal (e.g., Lalumière and Earls 1992).
Nonbehavioral Treatments
Nonbehavioral treatments include humanistic and psychodynamic therapies, as well as eclectic
psychotherapies that do not have a primary focus on cognitive-behavioral or behavioral techniques.
Nonbehavioral treatments tend to be less structured than cognitive-behavioral and behavioral
treatments and often emphasize insight into the reasons for one’s sexual offending, acceptance of
responsibility for the sexual offenses, and expressions of remorse and victim empathy. Only a few
evaluations of nonbehavioral treatments have been published, and the results are discouraging. Of
the five psychotherapy studies in the Hanson et al. (2002) meta-analysis that were not behavioral
or cognitive-behavioral in approach, four showed a nonsignificant trend toward treated offenders
being more likely to sexually reoffend.
The best-controlled study in this category is by Romero and Williams (1983), who compared sex
offenders on probation (a mixed group mostly of rapists and offenders with child victims) who were
randomly assigned to intensive probation or to psychodynamically oriented group therapy and
probation. Those assigned to psychotherapy tended to have higher rates of rearrest for sexual
offenses than those assigned to only probation. This negative trend was statistically significant for
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those who completed over 40 weeks of treatment. Of note, this sex offender evaluation produced a
similar finding as follow-up studies of general offenders who participate in nonbehavioral
treatments, suggesting that such treatments are contraindicated in the treatment of pedophilic sex
offenders (for a review, see Andrews et al. 1990).
MEDICAL INTERVENTIONS
Drug Therapies
The common aim of drug therapies in the treatment of pedophilia is to suppress sexual urges and
sexual behavior involving children. Much of the initial interest was on antiandrogens that reduced
sex drive, but clinicians and researchers have more recently focused on serotonergic agents.
Evaluation research on the use of these drugs in treating pedophilia and other paraphilias is
summarized below.
Hormonal Agents
It is a logical hypothesis that antiandrogens would have an impact on pedophilic sexual arousal and
behavior, because testosterone plays a critical role in male mammalian sexuality (Davidson et al.
1977). The earliest clinical studies, in Germany, were reported by Laschet and Laschet (1971), who
treated more than 100 paraphilic men; most were pedophiles or exhibitionists. Fifty percent were
sex offenders. Today, the most commonly prescribed agents are cyproterone acetate (CPA; trade
name Androcur) or medroxyprogesterone acetate (MPA; trade name Provera), both of which
interfere with the action of testosterone. CPA blocks intracellular testosterone uptake and thus
reduces plasma testosterone, whereas MPA reduces gonadotropin secretion and catalyzes
testosterone. Side effects of antiandrogens include headaches, nausea, gynecomastia, depression,
and osteoporosis.
There is some support for the efficacy of antiandrogens in reducing the frequency or intensity of
sexual urges and arousal, but there has been a dearth of larger, better-controlled evaluation
studies. Gijs and Gooren (1996) reviewed the literature evaluating CPA or MPA administration,
focusing on methodologically stronger controlled studies (e.g., use of double-blind, placebo
condition, random assignment). Gijs and Gooren identified four controlled studies of CPA and six
such studies of MPA. All four studies of CPA showed a significant reduction in sexual interest,
arousal, and/or behavior, but only one of the six MPA studies showed a significant difference
between subjects in the treatment and comparison conditions. No newer controlled studies have
been reported in PsycInfo or PubMed or identified in a recent review by Bradford (2001).
Hucker et al. (1988) conducted one of the few randomized clinical trials to examine the effect of
antiandrogen treatment. These investigators started with 100 men referred for assessment and
treatment after being accused of sexually offending against a child. Fifty-two men either denied the
allegations or did not complete the assessment. Forty-eight men completed the assessment, and 18
of this subsample agreed to participate in the drug trial. The authors noted that they did not exert
any pressure on the accused to participate in the drug trial, and alternative treatments were
available for those who did not want to take the medication, in keeping with their ethical
guidelines. Demonstrating the problem of attrition and noncompliance in treatment of sex
offenders, only 11 men completed a 12-week trial, 5 receiving MPA and 6 receiving placebo. One
man was excluded for medical reasons after a parathyroid tumor was discovered; he was taking a
placebo. Another man was excluded because sex hormone analysis indicated that he was not taking
the medication. Five other men dropped out of the study, three from the MPA group and two from
the placebo group. Dropouts significantly differed from those who completed the treatment or
placebo phase in reporting more frequent sexual fantasies about children. Men in both the MPA and
placebo conditions reported a decrease in sexual fantasies, but men who received placebo still
reported more fantasies (mean: 28 per month vs. 12 per month for the MPA group). MPA did have
the desired effect on testosterone, with a large drop among those who completed the follow-up,
and there was no change among those who completed the placebo condition. Hucker et al. (1988)
did not report on recidivism as an outcome.
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Serotonergic Agents
Serotonin is involved in the regulation of human sexual behavior, and antidepressant medications
that affect serotonin levels in the brain have long been known to reduce sexual desire and delay
ejaculation in males (for a review, see Meston and Gorzalka 1992). Some clinical investigators have
gone further, on very little empirical evidence, and have suggested that selective serotonin
reuptake inhibitors (SSRIs) such as fluoxetine or buspirone can specifically affect pedophilic sexual
arousal (Fedoroff 1993; Greenberg and Bradford 1997; Kafka 1991).
The interest in serotonergic agents for the treatment of pedophilia appears to be based on
uncontrolled case studies and open trials (see Gijs and Gooren 1996) and has been evaluated in
only one experimental design (Kruesi et al. 1992). Kruesi et al. (1992) reported the results of a
double-blind crossover trial that compared desipramine and clomipramine, preceded by a
single-blind placebo condition. The authors reported that there was a significant reduction of
self-reported paraphilic behavior (predominantly exhibitionism, tranvestism, telephone scatologia,
and fetishism) with either drug, but only 8 of 15 paraphilic men completed the trial. Hampering the
interpretation of these results, 4 patients were dropped because they responded to the placebo,
and 4 did not complete the treatment.
Fedoroff (1995) has argued that a potential advantage of SSRIs over antiandrogens is that
pedophiles may be more willing to take serotonergic agents because there are fewer side effects
and less stigma associated with filling the prescriptions. Of the 59 men who acknowledged active
paraphilic symptoms in his sample of 100 male patients, 7 opted for psychotherapy alone, 41 chose
an SSRI in addition to psychotherapy, and only 1 patient chose an antiandrogen.
Central Hormonal Agents
Gonadotropin-releasing hormone (GnRH) agonists such as leuprolide acetate (Lupron) inhibit the
production of testosterone by overriding pituitary regulation. Research on the effects of GnRH
agonists on paraphilias has been reviewed by Briken et al. (2003). These authors identified 13
articles, with a total of 118 men treated for different paraphilias in open uncontrolled studies.
Forty-three of these men were diagnosed with pedophilia; the sexual preferences of another 59
men from two mixed groups of sex offenders were not reported, but the study descriptions indicate
a substantial proportion had victimized children. Briken et al. (2003) noted that most of the studies
used self-report data; an exception was a crossover-design study by Cooper and Cernowsky (1994),
who treated a pedophile who victimized girls. These researchers found that leuprolide acetate
suppressed self-reported and phallometrically assessed sexual arousal better than CPA or placebo
and reduced plasma testosterone to almost zero. Briken et al. (2003) deemed this evidence to be
preliminary support for use of GnRH agonists. The long-term consequences of treatment with CPA,
MPA, or GnRH agonists are unknown.
Other Drugs
There have been case reports with agents other than SSRIs or antiandrogens. For example, Varela
and Black (2002) reported the case of a middle-aged pedophile who reported a decrease in his
sexual thoughts and behavior over the course of a month after being treated with carbamazepine
and clonazepam (typically prescribed as anticonvulsants).
Surgical Castration
Surgical castration has the same rationale as the use of antiandrogens, but in a more permanent
form. Removal of the testes almost completely eliminates endogenous production of androgens and
thus can lead to the same sex-drive-reducing effects as administering antiandrogens. Although it is
rarely performed now, surgical castration was performed on hundreds of convicted sex offenders in
the Netherlands and in Germany (Wille and Beier 1989). It continues to be used on occasion in the
Czech Republic, Germany, and Switzerland. Surgical castration has become an option for some sex
offenders in the United States, with the passage of legislation in nine states since 1996 mandating
chemical or surgical castration for sex offenders who want to be paroled and released into the
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community. Physical castration is permitted as an alternative to antiandrogens in four states and is
the only option available in Texas. Five states will permit castration only for offenders against child
victims younger than 13 or 14 years of age (Scott and Holmberg 2003).
Wille and Beier (1989) reviewed cases seen from 1970 to 1980 and concluded that castration was
effective because 3% of the 99 castrated men (70% were pedophiles) reported they had
reoffended within an average of 11 years of follow-up, compared to 46% of a comparison group of
35 men who applied for castration during the same period but did not have the surgery (originally
53 men, because 17 men were rejected by the authorizing committee; an additional 30 men
cancelled their application before a committee decision was made, and 6 men cancelled after
receiving committee approval). Wille and Beier (1989) also reported that 75% of the castrated men
reported a substantial decrease in sexual interest, libido, erection, and ejaculation within 6 months;
15% continued to have orgasms but required more intense stimulation for ejaculation to occur, and
10% remained sexually active on only a slightly diminished level. Finally, the authors reviewed 10
previous studies of castrated sex offenders that reported sexual recidivism rates between zero and
11% between 1959 and 1980.
At first glance, Wille and Beier’s findings seem like good evidence of a strong effect of castration on
sex offender recidivism. However, because there was no random assignment, there may have been
important differences in risk between those who were willing to be surgically castrated and those
who were not. Moreover, a higher percentage of comparison group men were unavailable for
follow-up, either because they could not be found by the investigators or refused to be interviewed
once contacted. Finally, Wille and Beier (1989) relied on self-report in their analyses and did not
use or have access to collateral sources such as spouses or official records to confirm group
differences with regard to sexual behavior.
SOCIAL INTERVENTIONS
One of the potential explanations for the lack of efficacy of psychological or medical treatments is
the assumption that pedophilia can be managed when the individual does not want to change his
sexual behavior. The typical sex offender treatment model assumes that the individual is motivated
to refrain from sexual offending and therefore is willing to avoid high-risk situations such as being
alone with a child (Laws et al. 2000) or to take drugs to inhibit sex drive. However, some pedophilic
sex offenders do not intend to refrain from future sexual offenses; instead, they aspire to avoid
being detected. Such men may be more likely to view their sexual contacts with children as part of
ongoing romantic relationships rather than sexual abuse. They may also be more likely to view
children as benefiting from the experience and to see societal reactions as the cause of any
negative effects that occur.
External controls become more important for pedophilic sex offenders who do not want to refrain
from sexual offending. These external controls include sentencing, supervision for offenders living
in the community, and legislated sex offender registration. The intensity of external controls should
range according to the risk posed by sex offenders, with long-term sentences or even indefinite
incapacitation for the highest-risk offenders. However, the efficacy of most external controls has
not yet been empirically demonstrated.
Another way in which society might intervene to prevent child sexual abuse is investing in primary
and secondary sexual abuse prevention programs. Primary prevention refers to (typically
school-based) programs that teach all children about sexual abuse and strategies to avoid sexual
abusers or disclose sexual abuse if it occurs. Other primary prevention programs focus on parent
education and training (e.g., Wurtele et al. 1991). Secondary prevention focuses on at-risk
individuals, such as persons who are likely to develop pedophilia, pedophiles who have not yet had
sexual contact with children, and potential child victims who are vulnerable because of their living
circumstances or personal characteristics.
A meta-analytic review concluded that school-based programs increase knowledge about sexual
abuse and protection strategies, both on posttest and at follow-up (Rispens et al. 1997). Moreover,
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there is some preliminary evidence to suggest that participation in school-based programs is
associated with a decreased occurrence of sexual abuse later in life: Gibson and Leitenberg (2000)
surveyed a sample of college-age women and found that those who had participated in
school-based sexual abuse prevention programs were less likely to be sexually abused later in life
than those who did not. Although participants and nonparticipants were not randomly assigned to
conditions, programs were implemented on a schoolwide basis, and there is no a priori reason to
believe that children at some schools differed substantially in risk from children at other schools, or
that administrative decisions to introduce prevention programs were informed by the risk of
children at particular schools.
Less is known about secondary prevention programs. One example of this approach is the education
campaign of STOP IT NOW!—an American nonprofit organization that uses social marketing to reach
individuals who are at risk of committing sexual offenses against children and convince them to
seek treatment. Another example is the Kempe Center’s pilot program to address potentially
problematic sexual behaviors among elementary school–age children in Colorado. Evaluations of
these efforts, and of other efforts to assist children at risk of sexual abuse, are needed.
DISCUSSION
Summary and Recommendations
There is no strong empirical support for psychological treatments such as relapse prevention in
preventing future sexual contacts with children. Some evaluation studies support the efficacy of
behavioral conditioning techniques in decreasing pedophilic sexual arousal, but the long-term
maintenance of such changes is unknown. Nonbehavioral treatments may actually be harmful,
increasing rather than decreasing the likelihood of new sexual offenses, and are therefore
contraindicated in the treatment of pedophilia.
Despite the intuitive appeal of pharmacological or surgical interventions to reduce sex drive and
thus the likelihood of sexual contacts with children by pedophilic sex offenders, reviews of outcome
studies suggest there is no strong empirical support for the idea that such interventions can reduce
sexual recidivism. Compliance is a major issue in drug treatments, with high refusal rates and high
noncompliance rates among those who do volunteer. Some men who undergo surgical castration
retain the ability to have erections and engage in intercourse; moreover, many sexual offenses
occur without the penis. Sex drive reduction (through antiandrogen treatment or surgical
castration) might not affect men who are sexually attracted to children, feel affectionate toward
them, and fulfill their intimacy needs through engaging in ongoing relationships with children.
Moreover, although the surgical procedure is irreversible, one can illegally obtain testosterone or
other anabolic steroids and reverse the effects of castration. Finally, there is the danger of an
inadvertently harmful effect of pharmacological or surgical interventions because the belief that an
offender’s sex drive has been reduced may induce false confidence that other measures, such as
supervision conditions that preclude sharing a residence with children, can be relaxed.
More and better research on treatment of pedophilia and treatment of pedophilic sex offenders is
clearly needed. But until the results of such research are available, how should clinicians proceed?
My recommendations, based on this review of the treatment literature, are summarized in Table
43–2. Any interventions should be preceded by a risk assessment, in order to prioritize cases and
guide subsequent decisions. For pedophilic sex offenders, the options range from minimal
intervention for the lowest-risk individuals to long-term incapacitation for the highest-risk
individuals. The range of options for pedophilic individuals who are not involved with the criminal
justice system is narrower. The client and, when possible, persons close to him (spouse, family
members, close friends) should be educated about pedophilia and the potential risk to children. This
is likely to be challenging, given the intense negative reactions that pedophiles face in our society
(Jenkins 1998), but the support and monitoring that can be provided by these persons could be
helpful in preventing future sexual offenses against children. The clinician should also be involved
in monitoring of potentially worrisome behaviors such as access to child pornography, unsupervised
contacts with children, and alcohol or drug consumption that leads to disinhibition of behavior. This
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monitoring should involve direct observation or the reports of collateral informants rather than
reliance on the client’s self-report.
Table 43–2. Recommendations for treatment of pedophilia and pedophilic sex offenders
1. Risk assessment using a well-supported measure, for the purpose of triage
2. Education of the client, his spouse or partner, family members, and close friends
3. Behavioral treatments targeting pedophilic sexual arousal, with “booster” sessions as needed
4. Monitoring of pedophilic clients in terms of access to child pornography, unsupervised contacts with
children, and potential disinhibitors such as alcohol or drug use
5. Drug treatments targeting sex drive for higher-risk individuals who are not suitable for incapacitation
because they have already served their sentence or are not formally involved with the criminal justice system
6. Cognitive-behavioral and behavioral treatments targeting general risk factors for criminal behavior such as
antisocial attitudes and beliefs, association with antisocial peers, and substance abuse
There is some support for behavioral treatments targeting pedophilic sexual arousal. Because the
long-term effects are unknown, ongoing follow-up and “booster” sessions may be necessary. There
is only some support for the use of drug therapies; treatment using CPA is recommended for
higher-risk individuals who are not suitable or eligible for incapacitation. There are three reasons
for this recommendation. First, for individuals who believe they need assistance to control their
pedophilic sexual interests, administration of these agents can activate a placebo expectancy
response that may in fact contribute to their ability to do so. Second, treatment with CPA can be
viewed as a strict behavioral test because noncompliance with medication appears to be associated
with a worse prognosis, and this information could be useful in case management. Compliance
should be monitored by assays of testosterone levels rather than reliance on self-report. Third, it is
possible that CPA (and other antiandrogens) can reduce sex drive, and this reduction in sex drive
can lead to a reduction in likelihood to sexually offend against children. Finally, for pedophilic
individuals who are at higher risk for antisocial behavior and thus for acting on their sexual interest
in children, cognitive-behavioral and behavioral treatments drawn from the corrections literature
could have a significant positive impact on general risk factors such as antisocial attitudes and
beliefs (including permissive attitudes about sex with children), association with antisocial peers
(including other pedophiles who endorse and reinforce permissive attitudes about sex with
children), and substance abuse (which can lead to disinhibition of behavior).
Randomized Clinical Trials
This review of the treatment literature on pedophilia has highlighted a need for more
methodologically rigorous evaluations. Westen et al. (2004) have reviewed the methodological and
conceptual issues involved in these designs. Despite potential methodological problems such as
sample representativeness and heterogeneity, inadvertent group nonequivalence in risk for
recidivism or other factors that might moderate treatment outcome, and assumptions about the
complexities of sexual offending and interventions, only randomized clinical trials allow strong
inferences about treatment outcome. Advances in the treatment of pedophilia will be haphazard
and rare without more randomized clinical trials.
In addition to the scientific rationale for conducting randomized clinical trials to evaluate pedophilia
and sex offender treatment, there is a powerful ethical rationale as well. A core principle of the
Hippocratic Oath and many other professional codes of conduct is to “Do no harm.” It has been
suggested by some treatment advocates that it would be unethical to withhold treatment from sex
offenders who are willing to participate, because of the risk posed by offenders who might
otherwise reoffend and the potential harm to their victims (e.g., Marshall and Anderson 2000). This
position does not recognize the possibility that some treatments may in fact be harmful,
unintentionally increasing recidivism.
In the field of medicine, there is a consensus that the potential for harm ethically justifies
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withholding an unproven treatment in randomized clinical trials. There are examples of
psychological treatments that have had unintended consequences. For example, Dishion et al.
(1999) reported a negative effect of the Cambridge Somerville Youth Program, a long-term
program involving counseling, community service, and group activities, on the outcomes of juvenile
delinquents who participated in this program decades earlier. Brooner et al. (1998) randomly
assigned 40 opioid-abusing individuals, all diagnosed with antisocial personality disorder, to usual
treatment or an intensive behavior management program. Individuals in the intensive behavior
management condition were more likely to continue using drugs, rather than less likely, as had
been predicted.
One can imagine a number of ways in which contemporary sex offender treatments might be
inadvertently harmful. Combining sex offenders against children and sex offenders against adults
might expose the former group to the typically more antisocial attitudes, beliefs, and behavior of
the latter group in group therapy interactions. Offender disclosures in acceptance of responsibility
and relapse prevention exercises may expose less experienced and less sophisticated offenders to
new sexual content and new methods for gaining access to victims. The use of victim empathy
exercises may fuel sadistic fantasies among the subgroup for whom the idea of victim suffering and
distress is arousing.
Future Directions
The results of SOTEP suggest that relapse prevention has no effect on recidivism, but it continues to
be a popular format for sex offender treatment and is likely to be provided by many clinicians for
some time to come, in the absence of empirically supported alternatives. This situation creates an
opportunity for evaluating innovative, theoretically informed interventions using a strong inference
design in which offenders are randomly assigned to treatment as usual (relapse prevention) and
experimental treatments.
The experimental treatments should incorporate components identified in proximal outcome
research as having a significant impact on pedophilic sexual arousal and sexual behavior. For
example, do treatments that target acceptance of personal responsibility, victim empathy, and
cognitive distortions have an impact on these factors, and are changes in these factors related to
sexual fantasies, urges, and arousal directed toward children? Demonstrating an impact on these
proximal outcomes does not necessarily mean that the treatment is effective in reducing recidivism,
but it is a necessary step in developing a theoretically informed treatment model. The next
necessary step is to show that changes on proximal treatment targets are related to recidivism.
Failing to demonstrate significant changes on proximal treatment targets, or failing to demonstrate
that changes in proximal treatment targets are associated with sexual recidivism, would rule out
these factors (see Barbaree 2005; Looman et al. 2005; Seto 2003; Seto and Barbaree 1999). This
kind of proximal outcome research could advance both our knowledge of the causes of sexual
offending and the components of effective sex offender treatment.
Experimental sex offender treatments could also benefit greatly by drawing from the more
established literature on correctional interventions that reduce recidivism by offenders in general
(Andrews et al. 1990). Some treatment advocates have argued that sex offenders require
specialized treatment (ATSA Professional Issues Committee 2005). However, of the four
randomized clinical trials reported by Hanson et al. (2002), the two that showed positive effects
evaluated treatments designed for general offenders. Borduin et al. (1990) reported a large
positive effect size, albeit in a small sample of adolescent sex offenders (subsequently replicated in
a slightly larger sample of adolescent sex offenders by Borduin and Schaeffer (2001), and Robinson
(1995) found a positive effect size for sex offenders who participated in a general offender
program, but reported data only for general recidivism. These findings suggest that treatments that
target general factors associated with criminal behavior can have a positive impact on sex offender
recidivism. Correctional intervention research has also demonstrated that treatments are more
effective to the extent that their intensity is matched to risk, that they target changeable factors
associated with recidivism, and that they are matched to the individual offender’s learning style
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and capacity (Andrews and Bonta 2006).
Most psychological treatments focus on self-management skills that might not be used by offenders
who do not wish to refrain from further sexual contact with children. External controls and
prevention efforts are also likely to be necessary in a comprehensive and effective response to the
problem of child sexual abuse. Incorporating accurate risk assessments in decisions about
sentencing and parole can have an impact on reducing recidivism. Appropriate supervision for those
who are released into the community may also have an impact, but evaluation data are needed to
determine whether this is in fact the case. Finally, preliminary evidence on the impact of
school-based prevention programs is encouraging; however, as in many other areas reviewed in
this chapter, more and better evaluations are needed.
Final Comment
This review has identified many questions about the effective treatment and management of
pedophilia and sexual offending against children. These questions include the relevance of common
treatment targets, such as acceptance of personal responsibility, victim empathy, and sex drive;
whether changes in pedophilic sexual arousal as a result of behavioral conditioning translate to
long-term changes in sexual behavior; and the relative importance of general versus specific
treatments for sexual offending against children. Methodologically rigorous evaluations are needed
to answer these important questions, and theoretically informed treatment models that draw from
general correctional research and specific research on pedophilia are needed if we are to develop
empirically supported treatments to reduce the occurrence of child sexual abuse.
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