Stigmatization of People with Pedophilia: A Blind Spot in Stigma Research 

Sara Jahnke and Prof. Dr. Juergen Hoyer

Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany, 2013

Acknowledgements:

This publication was realized within the MiKADO project, funded by the German Federal Ministry of Family Affairs, Senior Citizens, Women and Youth. The authors would like to thank Dr. Stephen Crawcour for his helpful comments and support. 

Abstract 

Stigmatization restricts people’s opportunities in life and has severe consequences on mental health and psychological well-being. This article focuses on stigmatization research on pedophilia. Based on an extensive literature search, it reviews studies that have empirically determined lay theories, stereotypes, prejudices, and discrimination against people with pedophilia, as well as the effect of stigma on this group. The review reveals a scarcity of empirical studies on the subject.

While the majority of studies give at least an indication that stigma against people with pedophilia is highly prevalent, we also identified severe methodological limitations and a lack of a unifying and systematic research agenda. 

We discuss the need for more theory-driven, rigorous, and representative empirical studies and propose perspectives and requirements for the scientific study of stigma against people with pedophilia. 

Keywords: Pedophilia, stigma, discrimination, sexual abuse, labeling 

Theory 

Detrimental effects of stigma have been known and discussed for decades. In his seminal work, Goffman (1963) defines stigma as an undesirable attribute that makes its carrier “different from others, […] in the extreme, a person who is quite thoroughly bad, or dangerous, or weak. He is thus reduced in our minds from a whole and usual person to a tainted, discounted one” (p. 3).

When this deeply discrediting attribute becomes known, it “spoils the social identity of the person carrying it and cuts him off from society and from himself so that he stands a discredited person facing an unaccepting world” (p. 19). 

The initial accounts on stigma have fostered a long-standing empirical research tradition (Heatherton, Kleck, Hebl, & Hull, 2003). The amount of stigma and its negative impact on stigmatized individuals has been comprehensively documented for

• ethnic minorities (Bogardus, 1925; Gillen-O'Neel, Ruble,& Fuligni, 2011),
• obesity (Puhl & Heuer, 2009),
• gender (Spencer, Steele, & Quinn, 1999),
• social status (Croizet &Claire, 1998),
• diseases (Lebel & Devins, 2008; Leiker, Taub, & Gast, 1995), and
• mental disorders (Angermeyer & Dietrich,2006).

Stigmatization has also been investigated with regards to

• homo- and bisexuals (Ahmad & Bhugra, 2010; Bhugra, 1987; Herek, 2002, 2009; Steffens & Wagner, 2004) and, to a lesser degree,
• other sexual minorities like transgender people (King,Winter, & Webster, 2009). 

The stigma process starts with the labeling of a person or group as deviant or fundamentally different from oneself (Link & Phelan, 2001). Therefore, many stigma researchers take an interest in naïve or lay theories of mental disorders (Angermeyer & Dietrich, 2006; Gaebel, Zaske, & Baumann, 2006; Phelan, 2005) or other stigmas (Hodson & Esses, 2005). 

Lay theories can be defined as theories (e.g., about causes and management of mental disorders) that people without expert knowledge use in an everyday context. Although lay theories don’t necessarily lead to stigma, they might help “clarify the psychological basis of stigma” (Haslam, 2005, p. 42).

Public stigma (i.e., the negative reaction of the public towards a discredited minority) consists of three aspects: stereotypes, prejudices, and discrimination (Rusch, Angermeyer, & Corrigan, 2005). Stereotypes are beliefs about perceived or assumed characteristics of a social group (Ashmore & Del Boca, 1981), such as, e.g., the notion that homosexual men are effeminate and work as hairdressers (Madon, 1997).

Being aware of stereotypes about other social groups does not imply agreeing with them (Corrigan & Watson, 2002). However, when an individual member of the community adopts discrediting consensual stereotypes (e.g., that members of the group are dangerous), prejudice ensues (Rusch et al., 2005).

Empirical research further demonstrates that agreement with stereotypes and strong evaluative reactions can promote discrimination against stigmatized groups (Corrigan, Thompson, Lambert, Sangster, Noel, & Campbell, 2003; Page, 1977), and reduce the likelihood of helping behavior (Corrigan & Watson, 2002). 

However, not all potentially stigmatizing characteristics are obvious, and some are easier to conceal than others. When an individual who (knowingly) possesses a stigmatized attribute that is not readily apparent to others manages to keep it secret (e.g., by avoiding situations where others might discover it), this might be referred-to as a “hidden stigma” (Corrigan & O'Shaughnessy, 2007).

People with a minority sexual orientation or a mild mental illness can decide whether or not to disclose their status to other people, while people with, e.g., a cleft lip are easily identifiable as stigmatized and may become a target of discrimination, regardless of their behavior.

However, even people with a hidden stigma may experience threat when confronted with stressors such as “having to make decisions to disclose one’s hidden status, anxiously anticipating the possibility of being found out, being isolated from similarly stigmatized others, and being detached from one’s true self” (Pachankis, 2007, p. 328).

To explain higher rates of mental disorders in the homo- and bisexual population, Meyer’s (2003) minority stress theory convincingly argues that multiple processes besides the direct experience of prejudice and discrimination may act as further sources of stress, such as expectations of rejection and the heightened vigilance it entails, efforts to hide and conceal the stigma, and internalization of stigmatizing views.

Thus, belonging to a stigmatized group may not only reduce the quality of life but might also lead to

• self-harm, including drug abuse (Baiocco, D'Alessio, & Laghi, 2010; Lehavot & Simoni, 2011),
• suicidal behavior (Haas et al., 2011; Liu & Mustanski, 2012; Mustanski, Garofalo, & Emerson, 2010), and
• reluctance to seek help if it includes being labeled as a member of a stigmatized group (Ben-Zeev, Young, & Corrigan, 2010; Vogel & Wade, 2009).

 While stigma against sexual minority orientations or mental illnesses such as depression or schizophrenia is widely recognized as an important problem of modern society, research will need to explore whether the above mentioned consequences of stigma also apply to other relatively hidden stigmas, such as pedophilia.

Pedophilia is a diagnostic term applied to people who are sexually interested in pre-pubescent children (APA, 2000). However, according to a recent article (Seto, 2012), pedophilia also fulfills criteria of a sexual orientation with respect to the age of the desired partners (as opposed to their sex).

Taking position on this controversial issue is beyond the focus of this paper. However, regardless of whether or not pedophilia should be considered a sexual orientation, we believe that stigma against people with pedophilia could be informed by the literature on the experiences of sexual minorities. 

While there is evidence that child sex offenders with a deviant sexual preference are more likely to re-offend than non-paraphilic sex offenders (Hanson & Bussiere, 1998), pedophilia is neither a necessary nor a sufficient condition for child sex offenses. People with pedophilia make up for only 50% (or less) of the offender population (Seto, 2008), and there are those with pedophilia who cope with their sexual urges without committing sexual offenses or harming children (Feelgood & Hoyer, 2008; Hall & Hall, 2007). 

In the general public however, it is to be expected that sexually abusive behavior towards children is often confused with pedophilia as a sexual preference. In the media, people with pedophile or other paraphile interests are often stereotypically portrayed as violent criminals (Diefenbach, 1997; Kitzinger, 2004). The public’s view of sexual offenders is extremely negative (Fortney, Levenson, Brannon, & Baker, 2007).

Agreement with the stereotype that pedophilia often or always coincides with child sex offenses is likely to prompt a high degree of discrimination against people with pedophilia, regardless of their actual behavior. This may have a negative impact on the mental health of a person suffering from pedophilia, and unwanted indirect effects on the likelihood of this person seeking therapy when needed. Both potential consequences may, presumably, put children at risk of child sexual abuse. 

In this article, we will systematically review and summarize research on lay theories and public stigma regarding people with pedophilia. We will also search for indications on the consequences of public stigma on the beliefs and attitudes of a person with pedophilia towards himself. Additionally, we will build on the results of our review by developing ideas and perspectives for a more theory-driven and methodologically rigorous empirical study of stigma against people with pedophilia. 

Method 

Studies were considered for review when they were dealing with

1. lay theories about pedophilia,
2. stereotypes about or prejudice towards people with pedophilia,
3. discrimination of people with pedophilia, and
4. the effect of stigma on individuals with pedophilia.

The articles were also required to be quantitative studies and to be published in English, German, or French.Recent research on pedophilia and sexual abuse has shown a questionable trend to confuse sociolegal and psychopathological classifications (Feelgood & Hoyer, 2008). To avoid this pitfall, we excluded papers dealing with public perception of sexual offenders in general (Fortney et al., 2007) or sex offender registration (Kernsmith, Craun, & Foster, 2009), unless they actually featured pedophilia as a psychopathological category. Studies were excluded in which participants were solely and unambiguously questioned about adult people engaging in sex with children (i.e., sex offenders), even though the authors used the term “pedophile” in their study description (e.g., Marzillier & Davey, 2004; Russell & Giner-Sorolla, 2011). 

We searched the Web of Knowledge and PubMed databases, using a combination of the terms “attitude*”, “perception”, “stereotyp*”, “prejudice”, “social distance”, “discrimination”, “stigma*”, “lay theor*”, “implicittheor*”, “opinion”, “media”, “public”, “label*”, “disgust” and thewords “pedophil*”, “paedophil*”, “paraphil*” or “sexual* devian*”. Web of Science and PubMed are among the most reliable and acknowledged search engines for their respective fields (Falagas, Pitsouni, Malietzis, & Pappas, 2008). However, like most academic search engines, they have the disadvantage of only searching bibliographic records (Jacso, 2005). Therefore, we additionally conducted a full-text search via Google Scholar, using the search terms “stigmatization” and “pedophilia” and limited further inspection to the 100 most relevant findings, including nonperiodical web documents. 

Five hundred and thirty-one publications in Web of Science and 655 in PubMed were identified, but only seven studies met the aforementioned criteria (note that two studies reported in a single article were counted individually). Based on an additional full-text search via Google Scholar, three more studies could be identified. An eleventh study was retrieved via checking reference lists. Ten studies were published in English and one study in German. 

Although we decided to restrict the focus of the present paper to quantitative research, we would like to add that well structured and carefully analyzed qualitative work can be illuminating and worth seeking out both for its own intrinsic value and as a means of generating well focused quantitative research. 

Results 

Overview of the reviewed studies 

Table 1 summarizes the studies that fulfilled inclusion criteria. In the following, we briefly summarize their goals and methodology.

table_1.pdf

1) Feldman and Crandall (2007)  investigated which characteristics across mental disorders lead to stigmatization. They collected social distance ratings (modified by Crandall, 1991) of 40 vignettes, each describing a typical case of a mental disorder listed in the DSM-IV-TR (American Psychiatric Association, 2000) including alcoholism, paranoid schizophrenia, depression and pedophilia. Each participant rated 13.5 disorders on average (range: 9 - 17). 

2) Furnham and Haraldsen (1998) conducted a study to explore the structure, determinants, and relationship between participant’s beliefs about the causes and cures for fetishism, sexual sadism, voyeurism, and pedophilia. Participants rated the importance of 16 possible causes and 14 treatments. 

3) Kramer (2011, August 17) authored two online surveys for people who self-identify as being sexually attracted to children.

• The first survey investigated the development of pedophilic interests, suicidal ideation, and attitudes towards seeking help.
• The second survey aimed at further investigating the experiences of people with pedophilia in the public health system, as well as assessing whether people with pedophilia felt stigmatized by professional writings about them.

Both surveys were conducted by B4U-ACT, a Maryland-based patient advocacy group to promote health care resources for people with pedophilia. More detailed information about the results of both studies could be obtained from their website (B4U-ACT, Inc., 2011, June 22 for study one, and B4U-ACT, Inc., 2011, December 30 for study 2). 

4) Lam, Mitchell and Seto (2010) conducted two studies on how different offense- and offender-related characteristics (such as perceived likelihood of pedophilia, among others) influenced the student’s perceptions of child pornography offenses. Both studies used vignettes which varied with respect to age and gender of the depicted minor (study one) and the offender (study two). 

5) McCartan (2004) sought to determine the relationship between the media and opinions concerning people with pedophilia in a small UK-based opportunistic sample. The author administered a self-developed questionnaire (22 items) to collect data about the respondents’ opinions on various subjects concerning pedophilia (including the treatment of people with pedophilia, and the role of the media). 

6) McCartan (2010) collected responses to two open-ended questions (“What is a paedophile?” and “What attitudes and behaviours do paedophiles typically display?”) and summarized answers thematically. 

7) Stiels-Glenn (2010) examined the availability of outpatient psychotherapy for people with pedophilia. The author sent questionnaires to all licensed psychotherapists in the German city of Essen, asking them whether they were willing to work with different types of offenders and individuals with pedophilia. About half of the respondents made annotations that allow further insights about their standpoint towards treating members of the aforementioned groups. 

8) Twohig and Furnham (1998) investigated lay theories about overcoming each of the four paraphilias fetishism, sexual sadism, voyeurism and pedophilia by asking participantsto rate how important they considered 24 coping strategies  for each of the paraphilias. 

9) Wilson and Cox (1983) used a self-developed questionnaire to assess various aspects of psychosexual development, personality, sexuality, and attitudes towards their condition among members of a London-based self-help group for people with pedophilia. The leaders of the organization distributed the questionnaires via mail . The authors thematically summarized the responses obtained. 

Lay theories about pedophilia 

 In this section, we describe lay theories about the causes and treatment of pedophilia based on the above listed publications. 

With reference to lay concepts of possible causes of paraphilia, a factor analysis carried out for the items in Furnham and Haraldsen’s (1998) study revealed four factors,

• a) Early Relationships (e.g., being beaten or sexually abused as children);
• b) Repressed Emotions;
• c) Lack of Guidance; and
• d) Biology.

Regarding the potential cures, a factor analysis revealed the three factors:

• a) Therapy;
• b) External Control (e.g., belief in God, medication), and
• c) Internal Control (will-power, selfefficacy).

For pedophilia, participants considered

• Early Relationships the most important etiological factor, followed by
• Repressed Emotions,
• Lack of Guidance and
• Biology (F(3, 12) = 3.59, p< .05).

They saw Internal Control and Therapy as more effective cures than External Control (F(2, 11) = 28.76, p< .05). The authors mentioned in a side-note that, despite a high degree of tolerance expressed towards paraphilias in their sample, this liberal attitude did not apply to pedophilia, which “can almost be regarded as belonging to a different genre of paraphilias” (p. 699). 

A factor analysis of Twohig and Furnham’s (1998) coping items revealed three factors

• a) Self-Reliance,
• b) Seeking Help, and
• c) External Control.

While participants perceived Self-Reliance to be important in the cure of fetishism, sadism and voyeurism, they saw

• Seeking Help as the most important factor in dealing with pedophilia, followed by
• Self-Reliance. 

Summary:
Lay theories indicate that pedophilia is mostly attributed to unusual early relationship experiences and inadequate ways of dealing with emotions (Furnham & Haraldsen, 1998). The emphasis on internal factors in curing pedophilia suggests that it is seen as a problem that is coming from within the person. However, whether or not pedophilia is actually caused specifically by early adverse experiences, it continues to be a topic of debate in scientific literature (Freund & Kuban, 1994; Jespersen, Lalumiere, & Seto, 2009).

Moreover, the questioned samples viewed external sources of help and self-reliance as the most important therapeutic means for sexual deviance (Twohig & Furnham, 1998). 

Stereotypes and prejudices concerning people with pedophilia 

Here, stereotypes and prejudices towards people with pedophilia will be listed, as they occurred within the above mentioned publications. 

McCartan (2004) found that most participants agreed that an individual with pedophilia partakes in a variety of

• sexual (e.g., kissing 61%, fondling 90%, masturbation 86%, sex 76%) and
• nonsexual (e.g., spending time 70%, talking 76%) 

activities with the child.

• Seventy-nine percent disagreed that pedophiles are mad, while
• a majority of 58% agreed that pedophiles are evil. 
• Also, only 21% agreed that pedophilia can be successfully treated.
• The perceived re-offense risk was high (with 68% believing that pedophile sex offenders are more likely to re-offend than other offenders).
• The majority (58%) also agreed that the press has created a “witch hunt” in relation to pedophiles. 

McCartan (2010) reported that when asked about which typical traits come to mind when they think of a pedophile,

• most students mentioned “sexually abusing children” (68.6%).
• only a small minority suggested that this might not necessarily be the case (11.8%).
• some stated that pedophiles were
  • “not normal” (7.8%)
  • "criminal" (9.8%),
  • “mentally disordered” (15.7%) and
  • "disgusting" (9.8%).
• no positive traits were mentioned.

Answers to the question regarding typical behaviors or attitudes for this group included notions like, e.g.,

• “appear normal” (25.5%),
• "secretive" (21.6%), and
• “spends time near kids” (21.6%). 

Summary:
In both studies by McCartan (2004, 2010), participants mentioned many very negative and judgmental traits, such as pedophiles being “evil” or “disgusting.” Furthermore, the literature does not support the assumption that sexual (re-)offense rates committed by persons with pedophilia are excruciatingly high (McCartan, 2004, 2010), as recidivism rates in extra-familiar boy-victim sexual offenders – both characteristics indicative of pedophilic sexual interests (Seto & Lalumière, 2001) – were only 35% after 15 years (Harris & Hanson, 2004). Additionally, many participants expressed pessimistic beliefs about the treatability of pedophilia (McCartan, 2004). 

Discrimination of people with pedophilia 

In prison, child sex offenders and people with pedophilia are outcasts prone to victimization at the hands of their fellow inmates (Jewkes, 2005, Vaughn & Sapp, 1989). Though some authors (e.g., Seto, 2008) reported anecdotes of actual – and sometimes even extreme – forms of discriminating behavior against people who were supposedly or actually sexually attracted to children, we found no quantitative study dealing with this topic.

At this point, we would like to acknowledge that there are experts who speak out for a more accepting stance towards people with pedophilia among health care professionals in order to avoid sexual abusive behavior towards children (e.g., Beier et al., 2009; Ward, Mann, & Gannon, 2007). However, there are no studies investigating whether this group or the general public would actually be willing to show prosocial behavior towards people with pedophilia (e.g., the intent to help them to not act upon their sexual impulses involving children). 

Feldman and Crandall (2007) assessed behavioral intentions with the social distance scale, which is considered a proxy for actual discrimination by some authors (e.g., Corrigan, Edwards, Green, Diwan, & Penn, 2001). Participants indicated lower willingness to interact with people with pedophilia than with people suffering from all the other presented disorders, except antisocial personality disorder. 

In Stiels-Glenn’s (2010) study of German psychotherapists,

• 12.8% of the participants indicated to be willing to accept sexual offenders for treatment. However,
• only 4.7% would treat patients with pedophilia, and
• only 3.5% would treat child sex offenders.

Some therapists specified the reasons for their responses with

• a lack of knowledge (20% of all who provided additional information),
• a focus on fields of work other than psychotherapy (13.3%) or
• further reasons that were unrelated to stigmatization.

Other participants justified their refusal with

• negative feelings towards the aforementioned groups (13.3%),
• negative experiences they had had with them in the past (13.3%) or
• doubts regarding their motivation for therapy (11.7%).

A few therapists expressed doubts regarding the appropriateness of the therapeutic setting (6.7%), which hints at fears and uncertainties concerning the treatment of people with pedophilia. 

Summary:
Based on the few studies we could identify, evidence suggests that people with pedophilia are perceived as a threat that must be avoided.

Feldman and Crandall (2007) discovered that individuals with pedophilia were more strongly rejected by students than other mentally ill patients (except for people diagnosed with antisocial personality disorder).

In addition, psychotherapists do not seem inclined to accept people with pedophilia for treatment (Stiels-Glenn, 2010). Studies examining the general public’s behavioral intentions or actual behavior towards people with pedophilia are still missing. 

Factors predicting lay theories, stereotypes, prejudices and behaviors 

The following studies investigated which socio-demographic and psychological characteristics predict lay theories about and public stigma towards people with pedophilia in the broadest sense. Due to the scarcity of studies, they will be summarized here, although their focus and aims differed considerably. 

Furnham and Haraldsen (1998) examined beliefs about the causes and cures of paraphilias and found the factor psychoticism of the Eysenck Personality Questionnaire (Eysenck, Eysenck, & Barrett, 1985) tested in study participants to be associated with a weaker belief in the effectiveness of therapy (r= ?.40). Psychoticism is a personality dimension that is related to traits such as antisociality, unemotionality, and unhelpfulness (Eysenck & Eysenck, 1976).

The more religious the participants rated themselves, the less they believed in the importance of biological and external factors in the cure of paraphilias (r= .25, p< .05).

There was no link between gender or other tested sociodemographic and personality variables and the proposed “cures” for paraphilia. 

In both parts of their study into the assumed links between child pornography and pedophilia, Lam et al. (2010) showed a significant effect (p< .05) of participants’ sex on the perceived likelihood that the child pornography offender had pedophilia (F(1, 230) = 4.17 in the first part, F(1, 245) = 5.3 in the second part), with female participants (67.5% and 67.4%, respectively) being more likely to rate him as such than male participants (58.9% and 58.2%). 

Lam et al. (2010) reported that the likelihood of the described child pornography offenders to be perceived as pedophile was 63.6 % (Study one).

In their two studies, they found significant correlations (p< .05) between

• the perceived likelihood of pedophilia and the perceived severity of the crime (r = .24 in study one, r= .14 in study two),
• the recommended sentence length (not significant in study one, r= .30 in study two),
• the probability of the same re-offense (r = .26 in study one; r=.34 in study two),
• the probability of past sexual contact with a child (r= .54 in study one, r = .26 in study two), and
• the probability of future sexual contact with a child (r= .56 in study one, r = .48 in study two). 

Stiels-Glenn (2010) found that, of the few psychotherapists who would agree to work with patients with pedophilia (13.3%), none was female. 

In Twohig and Furnham’s (1998) study, the participant’s ratings of the importance of Seeking Help as a way of coping with paraphilia was predicted by

• gender (t= 2.33, p< .05) and
• psychoticism (t= -3.17, p< .01).

Men (t= -2.29, p< .05), and a low self-perceived religiousness (t= -2.05, p< .05) were more likely to stress the importance of External Control. 

Religiousness was furthermore correlated with the factor Self-reliance (t= 1.98, p< .05). Neither

• attitudes to sex (Eysenck, 1970),
• political beliefs,
• siblings, nor
• the factors of the Eysenck Personality Questionnaire

had an effect on the ratings of the cure factors. 

Summary:
Information on how personal or demographic variables relate to lay beliefs about and public stigma towards people with pedophilia are few, scattered, and inconsistent.

Researchers have yet to put “classic” traits of stigma research that have repeatedly been shown to affect public attitudes like authoritarianism (Cohen & Struening, 1962) or familiarity with stigmatized people (Link & Cullen, 1986) to the test.

In line with the empirical literature on the subject (Seto, Cantor, & Blanchard, 2006), students mostly see child pornography offenses as a valid indicator for sexual interest in children (Lam et al., 2010). They demanded higher sentencing the more they were convinced that the child pornography offender is pedophilic (Lam et al., 2010), suggesting that child pornography offenders with pedophilia might be socially disadvantaged compared to offenders without pedophilia. Though this assumption is highly speculative at this point, it deserves to be investigated in more detail in future studies.

All therapists who stated their willingness to treat patients with pedophilia were male (Stiels-Glenn, 2010). However, the results only refer to self-reports and do not document actual decisions of therapists to treat (or reject) patients with pedophilia. 

Consequences of public stigma on a person with pedophilia 

Pedophilia has been shown to be associated with higher rates of mood, anxiety, and/or substance abuse disorders compared to the general population

• (Raymond, Coleman, Ohlerking, Christenson, & Miner, 1999; Schaefer et al., 2010).

However, as the evidence for links between pedophilia and mental illness is cross-sectional, it is not clear whether higher rates of mental illness in pedophile samples should be interpreted as a psychopathology being a precursor of the condition, or a consequence of stigma. Among the articles that satisfied our search criteria, only three surveys investigated stigma experiences of people who self-identify as being attracted to minors:

• Kramer, 2011, August 17;
• Wilson & Cox, 1983. 

B4U-ACT, Inc. (2011, June 22) found that

• 46% of the respondents conveyed having seriously considered suicide;
• 32% had plans to carry out suicide; and
• 13% have actually attempted suicide for reasons related to their pedophile sexual interests. 

Of the participants who reported suicide ideation, 67% responded that they were not able to talk about it to another person. 

• Forty percent stated that they had wanted mental health care for a reason related to pedophilia, but did not obtain it.
• While a high number (82%) agreed that sometimes other people with pedophilia may profit from mental health care,
• 88% disagreed that mental health professionals had a good understanding of pedophilia, and
• 59% disagreed that they would seek help from a mental health professional if they had a problem related to their sexual preferences.

Furthermore, about half of the participants doubted that a mental health professional would treat them

• ethically (46%),
• with respect (54%)
• or non-judgmentally (62%),
• or would keep confidentiality (51%).

Forty-two percent of the sample reported having received mental health care for reasons related to their pedophilia sexual interests. Among this subgroup, therapy satisfaction was mixed: 

• 39% satisfied,
• 39% not satisfied. 

In the second survey of the B4U-ACT group (2011, December 30), 58% of the participants agreed that they had once wanted to see a mental health professional for a reason related to their pedophile sexual interests (i.e., coping with the stigma), but failed to do so, mostly for fear that the professional would react negatively, report them or misunderstand their problems. 

• Forty percent indicated that something they had heard or read a mental health professional say had discouraged them from seeking professional help, the majority of complaints relating to stigma.
• A number of 48% (37% uncertain) revealed that not receiving mental health care resulted in negative consequences, e.g.,
  • depression,
  • low self-esteem,
  • suicide attempts and
  • isolation.
• More than half of those who received health care services reported to have hoped to improve
  • their self-concept (67%),
  • deal with public stigma (60%) and
  • figure out ways to live in society as a person with pedophilia (57%).
• In the client’s opinion, the professional less often attempted to address these issues (51%, 30% and 33% respectively), while putting more emphasis on
  • learning to control sexual urges (45%) and
  • reduce or extinguish pedophile attraction (43%).
• These goals were seen as important by only a minority of patients (30% and 17% respectively).
• Especially clients in mandated treatments reported to have been confronted with assumptions they considered inaccurate and stereotyped (67% vs. 43% among clients voluntarily seeking treatment), such as believing the client to have or have had sex with a child, or only seeking sexual gratification from children rather than fulfilling romantic goals. Clients who reported to have been confronted with these statements usually felt that they impeded successful therapy.
• The majority of the participants felt that the presented excerpts from
  • a recent article on pedophilia (pessimism about pedophilia, 2010),
  • the current DSM-IV definition (APA, 2000), and
  • an article in favor of the DSM-V changes with respect to pedophilia (Blanchard, 2010)
• reflected current trends in professional writing, but were inaccurate and promoted unethical treatment that did not befit a good client-professional relationship.
• In contrast, an article on the subject written about a non-forensic sample of persons with a sexual interest in children that will also be featured in this review (Wilson & Cox, 1983) was considered accurate and encouraging an ethical and beneficial treatment of clients with pedophilia. 

In Wilson and Cox’s (1983) survey, participants were divided in their feelings towards their pedophile preference:

• Some mentioned positive feelings:
  • 35% happy, proud, positive,
  • 6% reconciled, but
• many responses were clearly negative:
  • 27% disturbed,
  • 17% frustrated,
  • 14% puzzled,
  • 6% sad/hopeless/depressed,
  • 5% guilty/ashamed and
  • 4% bitter or angry with society.

The authors describe that

• “it was quite often the attitude of society that was the cause of their disturbance or puzzlement rather than their paedophilia per se” (p. 28). 

Summary:
A majority of people with pedophilia appear to have very negative attitudes towards their condition due to public stigma (Wilson & Cox, 1983).

As the results of two online surveys indicate (Kramer, 2011, August 17), many people with pedophilia would not seek professional help for problems related to their sexual interests despite widespread belief that mental health care could sometimes be beneficial. Whether perceived stigmatization increases social isolation or other risk factors for committing offenses besides therapy motivation remains unclear. 

Discussion 

Based on an extensive literature review in medical and social science journals, we can argue that stigma research has a blind spot on pedophilia. Although the studies we found were too scarce, heterogeneous, and unsystematic to provide more than preliminary evidence, they seem to coalesce around the notion that pedophilia is among the most stigmatized human characteristics. In the following sections, we will discuss methodological problems of the studies and empirical and theoretical requirements for future research. 

Only about half of the articles or book chapters that could be identified in this review made pedophilia their main focus (Kramer, 2011, August 17; McCartan, 2004, 2010; Stiels-Glenn, 2010; Wilson & Cox, 1983).

More importantly, only one of these used a well-established stigma measure, i.e., the social distance scale, finding that discrimination of people with pedophilia might compare to that of persons with antisocial personality disorder. (Feldman & Crandall, 2007).

Generally, sample sizes were too small to draw conclusions about lay theories of pedophilia or stigma against individuals with pedophilia in the general public. Also, most samples were biased in favor of young and/or well-educated participants. As stigma research suggests, more educated people tend to express less stigmatizing views towards people suffering from mental illness (Angermeyer & Dietrich, 2006) and towards sexual minorities (Lambert, Ventura, Hall, & Cluse-Tolar, 2006). Thus, a testing of the general population is likely to find even more negative opinions and a more severe discrimination of people with pedophilia.

All studies but one (Stiels-Glenn, 2010) were conducted by British or North American researchers, and their generalizability to cultures that are not Western is unclear, as the acceptance of pedophilia and adult-child sex differs across cultures (Green, 2002). Hence, larger and more representative samples are needed to put stigmatization of people with pedophilia on the map.

Moreover, no single study explicitly asked participants how they would perceive and judge non-offending people with pedophilia or persons with pedophilia enrolled in preventive treatment programs like the Dunkelfeld project (Beier et al., 2009).

It is possible that when people are questioned about their attitudes towards people with pedophilia, many will give information on what they think and feel about child sex offenders, and none of the studies made an effort to counteract this confusion of terms (e.g., by giving a clear definition of the two distinct phenomena).

It is uncertain if and how much the label paraphilia influences people’s perception of individuals tainted with it when other personality traits of a “whole person” (Hayward & Bright, 1997) are brought into play. Students react more favorably to people whom they believe not to pose a danger to the community (Feldman & Crandall, 2007). Hence, offense-related characteristics of the person with pedophilia, such as attitudes towards adult-child sex, self-control, and motivation for therapy, are likely to have an effect on the public’s opinion. However, this can only be true if the community is well-informed about the conceptual differences of pedophilia and child sex offenses, and also willing to differentiate between the two. 

The effect of stigma on the psychological well-being of the person with pedophilia has only been tested in three surveys, with one of them dating back as far as the early 1980's (Kramer, 2011, August 17; Wilson & Cox, 1983).

Their results strongly suggest that many persons with pedophilia struggle with public stigma, and suffer from negative emotional and behavioral problems as a result. Stigma research on people with pedophilia is likely to produce highly different results depending on whether participants were sampled in

• clinical/forensic settings,
• self-help or patient advocacy groups, or
• independently from aforementioned clusters.

All people with pedophilia who participated in the three surveys were recruited via self-help networks/patient advocacy organizations. This strategy might have resulted in a severe sampling bias, as it is possible that these groups disproportionately attract members who are particularly frustrated with the public's or health professionals’ attitudes.

Furthermore, self-reports might have been biased due to hidden political agendas among participants recruited by said initiatives. This is not to say that recruiting people with pedophilia in clinical or forensic settings would lead to more reliable or representative results. In fact, people with psychiatric problems or a criminal history involving child sexual abuse might have an even greater motivation to give biased accounts (Gannon, Keown, & Polaschek, 2007). 

More research is clearly warranted to determine whether there is a link between public stigma and adverse health and behavioral outcomes in diverse samples of people with pedophilia. Yet, a theoretical framework to derive hypotheses about the causes, characteristics, and consequences of stigma against pedophiles is currently missing. Such a framework would be indispensable to help researchers move forward in this under-researched area.

In order to fill this gap in the literature, we suggest using ideas and concepts from stigma research on people with a mental illness (Corrigan & Watson, 2002) or sexual minority orientation (Meyer, 2003) as sophisticated ‘templates’ that might prove to be useful for the study of stigma against pedophiles as well.

Despite differences relating to stereotype content, people with either pedophilia, mental illness, or a homosexual/bisexual orientation, appear to be faced with similar conflicts with society at large. All three groups are clearly stigmatized, and (in the case of mental illness and pedophilia) may refrain from seeking treatment to avoid being labeled. All have a hidden stigma that they may choose to reveal or keep a secret from others. Hence, it is to be expected that they undergo similar psychological processes in response to stigma, and are confronted with similar problems when they consider disclosing their stigma.

Based on these considerations, we are presently developing such a theoretical framework (working title: Framework for the Effects of Stigma Against People With Pedophilia), which we plan to test within a sample of people with pedophilia. While we do in no way wish to downplay or legitimize the severe crime that is child sexual abuse, we have reasonable grounds to believe that stigma against people with pedophilia is doing a disservice to the prevention of this particular form of violence.

Firstly, public stigma is likely to discourage individuals who perceive themselves at risk of committing sexual offenses from seeking help among health professionals or their friends and family (Kramer, 2011, August 17; Seto, 2012), cutting them off from sources of social control and support. Furthermore, a lack of positive identification models (Fog, 1992), reduced self-esteem, or other problems resulting from or maintained by stigmatization (e.g., social phobia; Hoyer, Kunst, & Schmidt, 2001) could lead to less efficient attempts to deal with deviant sexual impulses (Ward, Hudson, & Marshall, 1995). 

Therefore, stigmatization is likely to not only contribute to higher risks of social, emotional and cognitive problems among persons with pedophilia, but also to higher risks of abusive behavior.

Studies exploring the reaction of individuals with pedophilia to stigma would need to devise a research strategy, in which participants not having yet been identified as people with pedophilia by forensic or non-forensic clinical institutions can partake without risking juridical investigations or other adverse effects. Nevertheless, as complicated as the study designing may become, the personal dignity of every respondent is a core element of the rules for Good Scientific Practice. 

An important barrier for research on stigmatization of people with pedophilia is the secretiveness of the phenomenon. However, the hidden nature of conceivable stigmas was not an insurmountable barrier for research on stigma against homosexual, mentally ill or HIV-infected people.

This can be taken as a hint towards an obstacle that seems to lie in the expert community itself. Beyond a few notable exceptions (e.g., Green, 2002; Seto, 2012), many researchers appear to be hesitant to attribute victim status to individuals with pedophilia and reluctant to approach their experiences from a stigma research perspective. At best, people with pedophilia are considered potential offenders (Schaefer et al., 2010), or offenders who have at one point in the past been victims of sexual abuse as well.

This apparent lack of openness towards the effects of ostracism on individuals with pedophilia may partially be explained by biased sampling. People who have committed child sex crimes are arguably harder to empathize with than people who deal with their pedophile needs in ways that are not illegal or harmful to children. However, child sex offenders with pedophilia are virtually the only source of information about people with pedophiles in general (Hall & Hall, 2007).

Simply put, researchers should not ignore stigmatization of pedophilia just because it is controversial or unusual to construe "the pedophile" as a victim of stigmatization instead of a priori labeling the person as an actual or potential offender, let alone as someone who does not deserve respect as a human being. 

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