Comment on Entry for Pedophilia - B4U-ACT

B4U-ACT is a patient advocacy group seeking to improve mental health services for minor-attracted people (MAPs).

The DSM’s diagnostic criteria and accompanying text for pedophilia have a profound influence on the accuracy of the professional literature and on the extent to which minor-attracted people (MAPs) are stigmatized by it, which in turn affects their willingness to seek mental health services.

This comment analyzes the proposed DSM-5 diagnostic criteria and the DSM-IV-TR accompanying text for pedophilia for accuracy and potential sources of stigma. (The DSM-IV-TR accompanying text is examined because the proposed DSM-5 accompanying text has not been made publicly available for comment.) Then, this comment uses survey results to demonstrate the extent to which MAPs actually feel stigmatized by the DSM and related literature, and how this contributes to their reluctance to seek mental health services. Finally, it proposes guidelines for revising the DSM so that it will serve its professed purpose of helping practitioners identify the needs of their clients.

Stigmatizing aspects of the DSM

The DSM-IV-TR and the proposed DSM-5 entry for pedophilia contain implicit assumptions and interpretations that contradict the findings of the non-forensic literature, and that have the potential to significantly stigmatize MAPs and alienate them from mental health services.

First, the DSM-IV-TR assumes and implies, without reliable research evidence, that all or most people attracted to children or young adolescents engage in sexual behavior with them. The accompanying text provides a long list of illegal or manipulative acts without ever describing those who do not engage in them. This contradicts the non-forensic literature suggesting that sizable numbers of MAPs may refrain from sexual interaction with children

• (Hall, Hirschman, & Oliver, 1995; Okami & Goldberg, 1992; Sandfort, 1987; Wilson & Cox, 1983).

The implication that sexual interaction is typical is seen in the use of the term “pedophilia” to refer not to the attraction to children, but to sex offenses.

The text also perpetuates the belief, overwhelmingly refuted by research, that people who are attracted to children or adolescents are violent or aggressive

• (Bradford et al., 1988; Constantine, 1981; Crawford, 1981; Feierman, 1990a; Hall, 1996; Howells, 1981; Ingram, 1981; Okami & Goldberg, 1992; Virkkunen, 1981; West, 1998; West & Woodhouse, 1990; Wilson & Cox, 1982).

In their review of non-forensic research on pedophiles, Okami & Goldberg (1992) concluded that “little clinically significant pathology was found” (p. 297).

Another inaccurate implication is that the attraction to children or adolescents is qualitatively different from that to adults. Non-forensic research shows that these attractions are similar in some important ways, typically involving feelings of affection and being in love

• (Blanchard, 2009; Howells, 1981; Ingram, 1981; Li, 1990; Sandfort, 1987; Wilson & Cox, 1983).

However, the DSM-IV-TR accompanying text and DSM-5 proposed criteria make no mention of the non-sexual feelings that accompany sexual attraction, providing instead only a lengthy list of alleged sexual behaviors. The reader may be left with the misleading impression that sexual attraction to children is devoid of any feelings of love or concern and is therefore something alien and incomprehensible.

The accompanying text also presents questionable interpretations of the motives of MAPs who interact with children. It suggests that any behavior that seems caring should instead be interpreted as malicious in intent. No studies have established that this is typically the intent of MAPs in the general population, and there is no consideration of the alternative possibility suggested by research that MAPs may be attentive to children’s needs because they care about them in a way similar to that of people attracted to adults

• (Ingram, 1981; Li, 1990; Sandfort, 1987; Wilson & Cox, 1983).

The DSM documents may give clinicians and MAPs the impression that the appropriate mental health response is adversarial and focused on social control rather than on appropriate therapeutic intervention because the predominant focus on offenders defines MAPs solely as criminals of the kind most feared and reviled by society. Illegal behaviors are identified as virtually the only symptoms used for diagnosis. The DSM-5 literature review contains no discussion of the diagnostic use or reliability of the single non- criminological criterion (clinically significant distress) as there is for the criminological criteria (sex offenses). No non- criminological criteria, such as feelings of emotional or romantic attraction, have ever been proposed.

It is important to note that professional literature about the attraction to children follows the DSM’s lead and propagate similar inaccurate and potentially stigmatizing assumptions. Such literature provides little to no guidance for addressing the most pressing psychological needs MAPs identified in a survey we conducted last year (B4U-ACT, 2011): figuring out how to live in society with this attraction, dealing with society's negative response, improving self-concept, and dealing with sexual frustration. There is no apparent professional recognition of the feelings of hopelessness and suicidal thoughts experienced by MAPs, including young adolescents.

Reactions of MAPs to the DSM

The vast majority (72-89%) of the approximately 200 MAP respondents to our survey felt that the DSM-IV-TR accompanying text was inaccurate but reflected the understanding of the typical professional, and that it contributed to a professional view that discouraged them from seeking mental health services. The majority said it did not encourage professionals to focus on their psychological well-being but instead contributed to adversarial therapist-client relationships and unethical practices by professionals.

Stigma and reluctance to seek services are serious problems among MAPs; this reluctance occurs even among suicidal MAPs, and intense feelings of stigma and suicide begin at an early age. Our survey found that the median age at which suicide was first considered was 19 and was under 18 for 41% of respondents. Most affirmed that they could benefit from mental health services but did not seek them due to fear that professionals would misunderstand, mistreat, and/or report them.

One respondent wrote that the DSM-IV-TR accompanying text expresses a “view that is unable to allow both the therapist and the client to work towards a positive outcome.” If MAPs perceive the DSM as portraying them as so fundamentally different from other people, so incomprehensible, and so dangerous that containment and control are the only possible responses, then it is unlikely they would ever believe that professionals would address their needs and help them develop fulfilling lives that contribute positively to their communities and society.

Revising the DSM

Non-forensic research demonstrates that the DSM portrayal of MAPs is not the result of objective research, and that the alienation of MAPs from the mental health system is not inevitable. If the DSM’s purpose is to help clinicians identify and understand the mental health needs of MAPs, it seems prudent for those responsible for the DSM-5 entry on pedophilia to make the following specific changes to the diagnostic criteria and accompanying text:

• emphasize the existence of people attracted to children who do not interact sexually with them

• emphasize that apart from the age of the people to whom they are attracted, MAPs are very similar to people attracted to adults: they are similar in other psychological characteristics, in their motives, and in the existence of accompanying feelings of emotional/romantic attraction.

• recognize the severe stigma MAPs face and the mental health needs this stigma may cause

Perhaps the fundamental cause of the inaccuracies in the DSM is its narrow reliance on forensic research, a reliance that actually violates the American Psychiatric Association’s guidelines for DSM-5 development. In general, the DSM-5 paraphilia subworkgroup should heed the following APA principles:

• “[A]ll recommendations should be guided by research evidence” from “diverse perspectives, disciplines, and areas of expertise” (American Psychiatric Association, 2010a and 2011). Non-forensic research free from assumptions and interpretations that are unwarranted or based primarily on forensic data is needed. A narrow focus on sex offenders is inadequate.

• The DSM should clearly “reflect the needs of our patients” (American Psychiatric Association, 2010b) rather than appear to focus on social control. It must take into account the impact of stigma and the life problems MAPs face.

• Patient and family groups should be involved in the revision process (American Psychiatric Association, 2010a). MAPs in the general population and their families have invaluable first-hand knowledge regarding the nature of attraction to children and adolescents, their own feelings and motives, the effects of stigma, their own mental health needs, and the problems they must negotiate living in society.

Revising the DSM in a productive way will require a change in the authors’ perception of MAPs as offenders or potential offenders to individuals with needs and motives similar to those of any others. It is B4U-ACT’s experience that this change requires face-to-face meetings between the authors and MAPs. Unless this happens, many MAPs will likely doubt the DSM’s credibility and perhaps that of the mental health profession and will likely avoid mental health services from clinicians who take the DSM seriously. MAPs will remain in hiding, with no support for living law-abiding lives. Both adolescents and adults will continue to experience depression while many will engage in self-harming behavior including seriously contemplating or attempting suicide. This outcome is unsatisfactory for children, for minor-attracted people, the psychiatric profession, and for society.

 

References

American Psychiatric Association (2010a). Current Activities: Report of the DSM-5 Task Force (March 2009) http://www.dsm5.org/ProgressReports/Pages/CurrentActivitiesReportoftheDS...(March2009).aspx

American Psychiatric Association. (2011). Frequently Asked Questions. Retrieved August 10, 2011 from www.dsm5.org/about/pages/faq.aspx

B4U-ACT (2011). Spring 2011 Survey Results. Retrieved August 10, 2011 from www.b4uact.org/science/survey/01.htm

Blanchard, R. (2009). The DSM diagnostic criteria for pedophilia. Archives of Sexual Behavior. doi:10.1007/s10508-009-9536-0.

Bradford, J. M. W., Bloomberg, B. A., & Bourget, D. (1988). The heterogeneity/homogeneity of pedophilia. Psychiatric Journal of the University of Ottawa, 13(4), 217-226.

Constantine, L.L. (1981). The effects of early sexual experiences: A review and synthesis of research. In L. L. Constantine & F. M. Martinson (Eds.), Children and sex: New findings, new perspectives (pp. 217-244). Boston: Little, Brown & Co.

Crawford, D. (1981). Treatment approaches with pedophiles. In M. Cook & K. Howells (Eds.), Adult sexual interest in children (pp. 181-217). London: Academic Press.

Feierman, J. (1990). Pedophilia: Biosocial Dimensions. New York: Springer-Verlag.

Hall, G. C. N. (1996). Theory-based assessment, treatment, and prevention of sexual aggression. New York: Oxford University Press.

Hall, G. C. N., Hirschman, R., & Oliver, L. L. (1995). Sexual arousal and arousability to pedophilic stimuli in a community sample of normal men. Behavior Therapy, 26, 681-694.

Howells, K. (1981). Adult sexual interest in children: Considerations relevant to theories of aetiology. In M. Cook & K. Howells (Eds.), Adult Sexual Interest in Children (pp. 55-94). London: Academic Press.

Ingram, M. (1981). Participating victims: A study of sexual offenses with boys. In L. L. Constantine & F. M. Martinson (Eds.), Children and Sex: New Findings, New Perspectives (pp. 177-187). Boston: Little, Brown & Co.

Li, C.K. (1990). Some case studies of adult sexual experiences with children. Journal of Homosexuality, 20 (1-2), 129-144.

Okami, P. & Goldberg, A. (1992). Personality correlates of pedophilia: Are they reliable indicators? Journal of Sex Research, 29, 297-328.

Sandfort, T. (1987). Boys on their contacts with men: A study of sexually expressed friendships. New York: Global Academic Publishers.

Virkkunen, M. (1981). The child as participating victim. In M. Cook & K. Howells (Eds.), Adult sexual interest in children (pp. 121-134). London: Academic Press.

West, D. J. (1998). Boys and sexual abuse: An English opinion. Archives of Sexual Behavior, 27, 539-559.

West, D.J. & Woodhouse, T.P. (1990). Sexual encounters between boys and adults. In C. K. Li, D. J. West, & T. P. Woodhouse (Eds.), Children’s sexual encounters with adults (pp. 3-137). London: Duckworth.

Wilson, G. & Cox, D. (1983). The Child-Lovers: A Study of Paedophiles in Society. London: Peter Owen Publishers.Wilson & Cox, 1982