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Abstract

People with a sexual interest in children face significant barriers to seeking and receiving mental health treatment.
This review aims to bridge the gap between the treatment needs and experiences of pedohebephiles, and the services aiming to support them.
Reviewers screened 1705 database hits and extracted findings from 22 qualitative, 15 quantitative, and 3 mixed-method studies on the treatment needs and experiences of pedohebephiles.
Research suggests that this population experiences significant levels of distress, depression, and anxiety related to their sexual interest.
Many individuals belonging to this population would seek (median=42.3%), or have sought (median=46.5%), treatment to cope with their sexual interest or with potential related mental health repercussions.
Their experiences in treatment have been mixed, with some reporting positive experiences with empathic therapists and others reporting rejection. Most frequently, pedohebephiles report fear of exposure and rejection as barriers to seeking treatment, in addition to fear of the legal repercussions.
The current study is the first to summarize and discuss previous findings on the treatment needs and experiences of pedohebephiles. The findings indicate that the treatment needs of pedohebephiles often remain unaddressed. Suggestions to increase the fit between treatment services and the needs of pedohebephiles are put forward.

Introduction

[... ... ...]
[...] The terms “pedohebephile” and “pedohebephilia” — defined as primary or exclusive attraction to pubescent and/or prepubescentchildren — will be utilized throughout the current review, in addition to — and synonymous with — “people with a sexualinterest in children.” [...]

When discussing this population, it is important to differentiate between actionand attraction. While all pedohebephiles experience sexual attraction towards pubescent and/or prepubescent children, some of them perpetrate sexual offenses against children, and others refrain from ever doing so. Although pedohebephilic interest is a risk factor for child sexual abuse (...), it does not mean that pedohebephiles are doomed to commit child sex offences. Infact, there are large communities of people with a sexual interest in children that are aware of their interests and take steps to avoid acting on them. [... ...]

Method

[Here summarized as: Literature review]

Results

 Most (70%) of the studies were conducted in a community setting with self-identified pedohebephiles, but several forensic, clinical, and mixed samples were also included. [.. ....]

Treatment Intrerest

[Here summarized as:]
Research reported from 14 community settings, 2 clinical setings, and 2 mixed settings are given in Table 3, which gives percentages of Interest in Treatment: from 8.4 onto 85%, and about Participation in Treatment from 14.4 onto 86%.

Treatment Motives

[...] Pedo-hebephiles most commonly reported needing treatment or support for 

• mental health problems, 
• distress related to their sexual interest, 
• depression, 
• anxiety, 
• suicidality, 
• addiction, 
• to get help coping with their sexual attraction, and/or
• addressing the effects of social stigma.

• While participants from a community setting were more likely to report needs related to their mental health, 
• participants from clinical and forensic setting reported seeking treatment due to pressures felt from their families, friends, or partners (...). They had multiple motives for entering treatment related to legal repercussions such as mandated treatment, entering treatment because of an ongoing or recent criminal case, or the inability to abstain from using CSAM. 
• Finally, forensic and clinical (or mixed) samples more commonly reported needing support with abstaining from offending (...) ,or gaining a sense of mastery over their actions (...) ,than did community samples.

There was one motive for seeking treatment that was highly contentious, namely, changing their sexual attraction to children. [...]

However, as time went on, many came to realize that their attractions were enduring and redirected their goals towards managing  them and finding ways to live productive and meaningful lives (...). [...]

Treatment Experiences

[...] There were no substantial differences between samples in the incidence of positive or negative experiences; however, there were differences in  the nature of their experiences.

• Specifically, some of Vogt’s (2006) sample reported that therapy was compulsory and thus perceived negatively. [*]
  [* < https://www.ipce.info/library/author/336 >]
  
• Drapeau et al. (2005a) participants reported negative experiences in the context of group therapy. They also felt their risk of recidivism was not declining in spite of the therapeutic process. 
• Some of Morris’ (2023) sample and one participant from Wagner et al. (2016) reported that they had previously (not during the studies in question, but in their past help-seeking experiences)received some form of aversion therapy which they found to be very negative. Aversion therapy is a psychological treatment designed to reduce or eliminate sexual arousal to children by assoiating it with negative stimuli or experiences (...).

Participants from studies classified as clinical, forensic, or mixed, reported on experiences with chemical treatments such as androgen deprivation therapy (...) or gonadotropin releasing hormone antagonists (...).

In these cases,

• positive experiences were largely reported to be the calming effects of the chemicals, abstinence from offending ,and improvedmentalhealth andwell-being.
• The negative experiences included physical side effects, depression, and guilt.

Interestingly, within these samples, the inability to become aroused was reported as a positive treatment effect by some and a negative treatment effect by others. 

In the studies on community samples,

• positive experiences were reported when participants had access ton non-judgmental care with a therapis tthey felt listened to them. According to participants, these experiences led to improved mental health, cognitive ability, and self-control, among others.
• Common negative experiences included feelings  rejction and hostility, the therapists’ perceived lack of competence with pedohebephilia, and treatment goals that do not align with the goals of the client (i.e., the client is interested in learning coping skills, yet the therapist is prevention-oriented (...)

Treatment Barriers and Facilitators

Barriers and facilitators to treatment was the most commonly researched category in this review (...), and the results were overwhelmingly skewed towards barriers. The factors that pedohebephiles discussed as facilitators of treatment included 

• knowing a therapist had experience with pedohebephilia and provided a safe and empathetic environment. 
• In addition, some participants mentioned more general factors outside the therapeutic environment that would have encouraged them to seek help, and these included dispelling negative messaging in media and support campaigns aimed at pedohebephiles and replacing them with hopeful messaging(...).
• Others reported that reading testimonials from previous patients or clients of support and prevention organizations was a potential motivator for seeking help themselves.

Barriers were commonly marked by fears relating to the repercussions of seeking treatment.

• Many participants were afraid that they would be reported or outed, and thus lose their livelihoods, autonomy, and relationships. 
• Others feared rejection and stigmatization from the theapist, with some participants in Jahnke et al. (2023) feeling stigmatized as a result of receiving prevention-aimed offers. 
• Other barriers included lack of information about resources or financial and geo- graphical inaccessibility. 
• Finally, pedohebephiles reported that they felt there was a lack of professional resources available, and called into question the quality of said resources in treating pedohebephilic individuals specifically.
  

There were limited differences between sample types regarding barriers and facilitators, with the brunt of them focused on the specifics of group therapy in forensic contexts and a perceived lack of continuity in support when leaving the prison system.

Discussion

[... ... ...]
There were [...] marked differences in the needs and experiences of people with a sexual interest in children from different samples. 

Clinical and forensic samples tended to be motivated to seek treatment by incarceration-related factors (i.e., to regain their freedom in court-mandated cases, to gain mastery over their impulses and abstain from reoffending). They also reported feeling pressure from family and even staff to enter treatment. 

This was never the case with community samples, the motives of which were more centered on their mental well-being and gaining the skills to live fulfilling lives. 

The experiences in treatment of those in clinical and forensic samples were often focused on a specific treatment program (the pros and cons of group therapy, the effects of chemical treatments). 

Community samples, having typically had no experience in such contexts, more often discussed the common factors in treatment such as empathy, openness, and specialized knowledge. 

Finally, in terms of barriers and facilitators, clinical and forensic samples once again reported factors specific to their contexts such as the pros and cons of the treatment programs they were participating in and the lack of continuity in treatment after incarceration. 

Community samples discussed common factors in treatment, or lack thereof.

The discrepancy between different samples was due to the limited number of clinical and forensic samples that included the perspectives of pedohebephiles, as opposed to, e.g., outcome measures assessing mental health or risk factors for child sexual offending.
This may in part be due to participants in forensic settings denying pedohebephilic interest. In this case, it would not make sense to ask study participants about barriers to seeking treatment for a sexual interest that they deny having.
It may also indicate pervasive social stigma related to pedohebephilia and sexual offending, which may contribute to distrust towards this population, reluctance to assess their perspectives, or lack of advocacy or public funding for such research efforts. However, it is less clear why few studies in forensic settings assessed study participants’ perception of or experiences with the treatment that was provided. The absence of such research may inhibit the development of more tailored interventions, which may increase the effectiveness of psychotherapy programs.

The results of the current review also stand in contrast to the perspectives of practitioners in regard to treatment. 

For instance, Bayram et al. (2023) found that health care practitioners’ main goal would be preventing child sexual abuse, followed by understanding pedophilia, increasing quality of life, protecting society, and ceasing the use of CSAM. When asked about the goals of their pedohebephilic patients, they reported that preventing harm would be the first on the list, followed by changing sexual interest, understanding pedophilia, using treatment as an excuse to justify immorality, and finding companionship. 

Similarly, Lievesley et al. (2023) found that practitioners valued controlling behavior much more highly than pedohebephiles did. When it comes to barriers, there seems to be a consensus between practitioners and the perspectives of pedohebephiles. Fear of disclosure due to personal and legal consequences, as well as lack of availability of professional help (or knowledge of where it can be found) are commonly reported as the main concerns when seeking treatment by therapists (Parr & Pearson, 2019). 

The practitioners in the study also go on to suggest that these barriers may be reduced by increasing publicity, education and training regarding pedohebephilia. These improvements align with some of the facilitators synthesized in the present literature review, such as having knowledgeable and empathic clinicians. 

Additionally, Goodier and Lievesley, (2018) looked at the needs of individuals at risk from practitioners’ perspectives and reported lack of trust in services as the main barrier to intervention, followed by anonymity – that many individuals at risk are undetected and can therefore not be reached for intervention. 

Although here seems to be a mutual understanding regarding the barriers to seeking help, one commonly identified barrier is, in fact, the discrepancy between the treatment goals of the patient and the practitioner, fueled at least in part by a misunderstanding of the motives for which people with a sexual interest in children want to seek help in the first place. Recognizing that the motives for which pedohebephile seek treatment are as diverse as any other individual is a first step in bridging the gap and offering effective support.

Strengths and Limitations

While the review offers valuable insights, it is essential for readers to understand its inherent limitations. 

[1] Publication bias occurs when the decision to publish a study is influenced by the direction or significance of the study’s findings and is a frequent problem in literature reviews (...). Although we have done our best to circumvent publication bias via manual searches and the inclusion of grey and non-English literature, it is still possible that relevant literature could have eluded our efforts to identify it. 

[2] The second limitation is that the majority of participants in the studies were self-identified pedohebephiles recruited online via forums and networks such as B4U-ACT and VirPed, thus resulting in a potentially significant degree of overlap between the samples.
In addition, these samples are more likely to capture participants with a specific profile, (i.e., non- offending, seeking support, etc.). Results may differ if based on other forums or pedohebephiles who do not engage is such forums at all.
The only population-based sample (Dombert et al., 2016) found the lowest rate of interest in treatment, which could indicate that the studies based on community members may inflate that figure. 

[3] Third, the quality assessment of the included studies revealed methodological challenges such as poor representation of the target population due to recruitment through self-referral, and lack of rigor in data collection and analysis in both quantitative and qualitative reports (...). [... ...]

[4] Furthermore, the majority of studies have been conducted with Western samples, most of which were English-speaking online communities. This suggests a potential lack of generalizability to non-Western samples or those less likely to be found on online forums. Strengths of the current review include the large number of included studies and the minimization of selection bias via the broad systematic search (including research published in non-English languages and grey literature), required reviewer consensus from screening to extraction, and substantial inter-rater reliability.

Implications for Research and Clinical Practice

With respect to community-based treatment, some experts have proposed to balance well-being goals and prevention goals, but the extent to which either should take precedence remains contested. [...] 

One way to balance the goals of offense prevention and individual well-being could be the use of the Good-lives-model, which seeks to encourage individuals to pursue meaningful and prosocial life goals (Willis & Ward, 2013) [*], rather than deficit-oriented approaches like relapse prevention. However, it stands to reason that there should be more services with a stronger or even exclusive commitment to well-being goals, given that there are pedohebephiles with low risks of sexual offending.

Furthermore, this review has identified that fear of rejection, fear of being reported and lack of trust are significant barriers to help-seeking for people with a sexual interest in children. These are important considerations for any therapist working with this client group, one which may make disclosures about sexual interests that would typically expose them to stigma and moral outrage (...). 

As highlighted in the review it is important for pedohebephiles to have a safe space in which to share experiences, particularly as it is likely to evoke significant levels of stigma, shame, and judgment (...). The onus, then, is on the therapist to create a safe and non-judgmental environment which fosters a therapeutic relationship characterised by warmth, respect, genuineness, and empathy (...). 

The therapist contribution to the therapeutic alliance, how supportive it is perceived and how trusting it is experienced, is crucially important for psychotherapeutic outcomes (...). Patterson (1984) concluded that evidence for the necessity of therapist displays of empathy, respect and warmth was “incontrovertible” (p. 437). 

Thus, therapists working with this client group need to understand their mental health and treatment needs in order to provide effective, ethical, and compassionate services for this stigmatised and hard-to-reach population.

Creating a compassionate and non-shaming therapeutic environment is especially important to pedohebephiles in order for them to share openly their experiences, and the impact their sexual attraction has had on them (...). 

One form of therapy which appears particularly well suited to this client group is Compassion Focused Therapy (CFT) (Hocken & Taylor, 2021). [*]
[* Compassion-focused therapy as an intervention for sexual offending. In B. Winder, N. Blagden, L. Hamilton, & S. Scott (Eds.), Forensic interventions for therapy and rehabilitation (pp. 189–221). Routledge. [**]
[** < https://www.routledge.com/Forensic-Interventions-for-Therapy-and-Rehabilitation-Case-Studies-and-Analysis/Winder-Blagden-Hamilton-Scott/p/book/9780367205362?srsltid=AfmBOoqtMPjk_3YZPXcBNBilbAiOMuLiyctWMU4IOdTlgbySejc4HtI3 >

CFT was initially developed for people whose elevated levels of shame rendered them unable to benefit from traditional CBT [Cognitive Behavior Therapy] (Gilbert, 2014). 

CFT can be understood as a motivation focused therapy, based on evolutionary and cognitive systems, which helps people to access and stimulate the affiliative emotions, motives and competencies underpinning compassion. The combination of these capacities plays a significant role in threat regulation, well-being, and pro-social behavior (... ...). 

Within CFT, the relationships individuals have with themselves, especially in the forms of shame and self-criticism — highly relevant to pedohebephiles — underpin a wide range of mental health problems (...). There is emergent evidence that compassion-based interventions can reduce shame and help pedohebephilic individuals towards meaningful clinical change (...). As Gilbert (2014) contends “compassion moves us to wanting to take responsibility for change and do what we can to engage with and help with the suffering of ourselves and others” (p. 30).

Future Directions

[...] Future research should aim to report the perspectives of patients regarding treatments as opposed to only outcomes such as recidivism or offending behavior. In this way, the success of future interventions can be measured as a comparison between the fulfillment of clients’ goals and that of the practitioners.

Further investigation is also warranted into the needs and experiences of pedohebephiles stemming from different settings and how treatment goals and strategies can be adapted to this end. 

Strikingly, the present review was only able to identify a few studies from a forensic context that have assessed participants experiences with or attitudes towards treatment, and among the few, the extent to which their perspectives were included was minimal. This is unfortunate, as client experiences could give important clues as to how the effectiveness of treatment could be improved. 

Finally, it would be highly beneficial for any future study in the field to report outcomes separately based on attraction to different age groups (as well as exclusivity of attraction) of their participants to investigate any potential similarities and differences.

Conclusion

Although the literature on treatment of people who are sexually attracted to children has grown considerably in the recent decade (...), there is still much uncertainty around what constitutes best practice for this group, particularly in non-mandated settings. 

By understanding the perspectives and experiences of people who are sexually attracted to children, mental health services can be better equipped to provide appropriate and effective support, ultimately contributing to the well-being of both pedohebephilic individuals struggling with these attractions as well as the broader community.