Title: Treatment Approaches with Pedophiles
Author(s): David Crawford
Affiliation: Broadmoor Hospital, Crowthorne, England
Citation: Crawford, D., “Treatment approaches with pedophiles,” in Cook, M. & Howells, K. (eds.), Adult sexual interest in children, London: Academic Press, 1981, pp. 181-217.
The author begins with the following disclaimer:
Offering treatment for a particular behavior pattern identifies it as a problem and the individual as deviant. The therapist’s behavior serves to maintain the status quo and is seen by some as forcing the patient to conform to society’s standards when they would argue his time should be spent in helping his client adjust to, and cope with, his sexual orientation…The very language one uses to discuss these problems, “patient,” “deviance,” “treatment,” is value laden and carries prejudicial connotations. These problems have been most clearly illustrated in the case of homosexuality but the same questions must be asked with attempts to change sexual behavior, or indeed any behavior. Is the therapist acting on behalf of the patient or society? How does one separate treatment from punishment? How can one obtain free and informed consent from individuals who have lost their liberty? (pp. 181-182)
However, his rationale for providing treatment is as follows: “…the therapist must consider the ethics of withholding treatment from individuals who are genuinely seeking help and are as disturbed by their own behavior as is the rest of society.” The article then describes several treatment methods that have been or are being used.
Castration was used at the end of the eighteenth century as a treatment for hypersexuality, and clinicians reported favorable results. Some European countries still use it with certain sex offenders, but it is illegal in England. Studies have found between 67% and 97% of men who are castrated become asexual.
Common side effects include hot flushes, sweating, changes in metabolism, development of fatter breasts and hips, soft skin, and diminishing body hair. Psychological consequences have not been generally reported, but a 1968 study said sex offenders were “nearly always very happy.” Another study found that 19% experienced serious and lasting physical or psychological pain.
The author writes, “Whatever ethical, physical, or psychological problems castration might pose, from a criminological point of view it is effective.” In 1964, Sand et al. wrote that castration “must be looked upon as the best social measure for and treatment of sexual criminals and abnormal sexuals in general. It is the most humane in relation to the single subject and most effective from a criminal-therapeutical and social point of view.”
Sometimes castration has been offered as an alternative to long incarceration. In these cases, the patient cannot genuinely give free and voluntary consent. If used at all, it seems appropriate only for offenders with a drive so strong they cannot control it. This is not the case with most pedophiles; their feelings forward children are more often ones of love and tenderness—feelings which are not eliminated by castration.
Estrogen has been used to effectively decrease sex drive, fantasies, sexual pleasure, and erections. It must be taken for the patient’s lifetime, since sex drive will return when use of the drug is terminated. Estrogen has serious side effects, including feminization (with growth of breasts and risk of breast cancer), severe nausea and vomiting, and possibly irreversible damage to the gonads. Estrogen implants have eliminated nausea and vomiting but not the other side effects.
Benperidol also decreases sex drive, but has had mixed results. One study showed it resulted in a 50% decrease in sexual activity, another showed only a slight reduction in sexual thoughts. Side effects include drowsiness and effects on the extra-pyramidal nervous system, causing Parkinson-like symtoms.
Cyproterone Acetate blocks androgen and reduces sex drive much like estrogen does. Side effects include non-severe tiredness, growth of breasts, and weight gain. The drug must be taken for the patient’s lifetime.
For all drug treatments, the long-term results are unknown and may be irreversible. Since they are administered to imprisoned offenders, free consent does not exist. The drugs control rather than cure, and in a very blunt manner. Very different deviances (incest, bestiality, fetishism, and pedophilia) are combined and assumed to have the same cause—excessive sex drive—which is clearly not the case with pedophilia.
This approach is based on the assumption that pedophilia is related to the Oedipus complex. Psychoanalysis is time consuming and expensive, and there have been no scientific attempts to assess its validity or effectiveness.
Individual psychotherapy is generally thought to be ineffective because offenders are assumed to suffer from denial, lack of motivation to change, and unwillingness to cooperate with voluntary treatment. Suspicion and lack of rapport also interfere with effective psychotherapy. Thus, there are few reports on psychotherapy with pedophiles. Professionals report pessimistic views with respect to deviants in general.
However, group psychotherapy is widely used with offenders against children, but there is little data on its effectiveness. One study showed reduced recidivism, but there is a lack of replicable, controlled studies.
This method is based on the assumption that pedophiles choose children because they see adults as threatening. There is no scientific data on its effectiveness.
Aversion therapy is an old, simple technique which attempts to make unpleasant a previously attractive sexual stimulus or behavior by using a noxious stimulus. The patient is presented with a deviant stimulus along with an unpleasant (aversive) stimulus to produce anxiety. Nausea-inducing drugs, electric shock, and pungent smelling chemicals have been used as the aversive stimuli. The method is controversial; arguments concern its theoretical basis and ethical issues.
The method was originally used in 1935 to attempt to eliminate homosexuality, but was not used regularly until the 1960s. The few studies of its effectiveness have involved a very small number of subjects, and have indicated small effects. Success rates with transvestites, homosexuals, and other “sexually disordered people” have been reported to be between 30% and 57%.
One study on pedophiles reported that one of the four subjects showed “lasting improvement,” another reported that 8 of 12 were “successfully treated,” another found that 4 of 7 deviants improved (including both pedophiles), and still another said that in all ten child molesters treated, there was a small, mostly insignificant increase in their preference for adults.
Like castration and drug treatment, aversion therapy does not consider the factors that motivate adults to interact sexually with children. In addition, it is unlikely to help pedophiles develop adult sexual relationships. Minimal side effects are reported, and it seems not to interfere with normal sexual functioning. However, long-term effects are unknown.
Orgasmic reconditioning is a method in which the patient is aroused by his deviant fantasy, then switches to a normal fantasy immediately before orgasm. Presumably, this causes him to associate the pleasure of orgasm with the acceptable fantasy. A variation used with pedophiles involves them gradually increasing the age of the child in their sexual fantasies. Some case studies have indicated success.
Exposure to explicit normal heterosexual films may in itself cause the deviant person to experience arousal. The resulting pleasant feelings may then reinforce normal fantasies. One study found that this method did increase normal heterosexual arousal in three homosexuals and one pedophile.
Classical conditioning involves the pairing of an arousing deviant stimulus with a non-arousing normal stimulus in an attempt to increase arousal to the normal stimulus. Only very small scale studies of effectiveness have been conducted, and have shown mixed results. In cases where success seemed to occur, it was not clear that the results were due to the treatment.
In one study, a homosexual man was deprived of water, then rewarded with lime juice when he showed arousal to heterosexual stimulus. He reportedly showed an increase in heterosexual arousal. In another study, homosexual men were shown photos of nude men, and during arousal the photos were faded into those of nude women. This method seemed effective at increasing arousal to heterosexual stimuli. A similar method was attempted unsuccessfully with pedophiles.
Biofeedback methods have been attempted in which the patient is shown an electronic indication of his arousal level, which he then attempts to control. One study found it successful for impotentence but not for homosexuality.
Aversion relief is a method which attempts to associate a non-deviant stimulus with the pleasurable effect of terminating an electric shock. There is no evidence for its effectiveness.
Systematic desensitization is a method intended to reduce anxiety over adult heterosexual behavior. It has been used for various sexual dysfunctions and deviations, but its effectiveness at increasing non-deviant arousal has not been demonstrated.
Covert sensitization was developed in the 1960s. Its goal is to pair the description of an unpleasant stimulus with deviant thoughts or behaviors to render them aversive. The description is that of an extremely noxious, often nauseating scene.
Studies of this method have involved very small numbers of subjects. One study found that it decreased arousal in one homosexual and one pedophile, but arousal returned to its original level when treatment was stopped. Another study found the method slightly more effective than electric-shock aversion therapy. A third study found that use of psychologically aversive stimuli, such as feelings of shame and guilt, were more effective than use of physically aversive stimuli.
Masturbatory satiation involves overexposing the patient to his deviant masturbatory fantasy so that through boredom it will lose its arousing property. The patient is instructed to masturbate while verbalizing his fantasy, for up to an hour, continuing even after orgasm. A few very small studies showed short-term success with pedophiles.
This approach is based on the realization that sexual behavior involves more than penile response. Social skills are crucial for the patient to successfully implement his newly acquired normal sexual arousal. This approach teaches the individual how to express his emotions, and to cope with confrontations, job interviews, and general problems of living. Instruction, modeling, role-playing, and group feedback are the methods used.
One study used a questionnaire and role-play tests to assess the effectiveness of the approach. It found an improvement in social functioning two years after the training was provided, but provided no data on sexual behavior. Research is still needed to determine the specific social deficits of the different kinds of offenders.
Sex education is intended to rectify the incorrect or inadequate sexual knowledge many offenders exhibit. This is thought to be a particular problem for pedophiles who lack adult experience. Sexual ignorance may increase anxiety toward adult sexuality.
One study showed the approach successfully increased sexual knowledge and decreased sexual anxiety. Another study reported that the use of a trained sexual surrogate partner was effective with one pedophile.
The author recommends using multiple methods, noting one study which reported that such an approach was effective with homosexuals: “Multi-component assessment multi-targeted treatment procedures appear to be the most promising approach to enhancing the effectiveness of sexual reorientation procedures.”
There is also a need for improved assessment. Currently almost all programs combine sex offenders as if they were all the same. Yet even within the group of pedophiles, there are differences in arousal patterns, in levels of aggressiveness, and in many other characteristics. Different treatments are needed for different offenders.
The author argues for greater use of community-based programs rather than institutional ones because the majority of offenders are not violent and do not attack their victims. The non-dangerous majority could more cheaply and effectively be treated in the community. Self-help groups are also useful.
More research is needed because of the dearth of adequately controlled studies on treatment effectiveness at modifying sexual preference. No current studies have adequate long-term follow up. The idea of prevention is novel in this area and ignorance here is even greater than that regarding treatment methods. More effort should be made in helping adolescents deal with the problems of heterosexual adjustment to prevent them from becoming pedophiles.