Male Homosexual Attraction to Minors Information Center
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Methods of treatment

Therapy in general

Attempts to change sexual attraction are hampered by a lack of understanding of how attraction develops in general, as well as a lack of understanding of how attraction to minors develops in particular.1 Ron Langevin of the Clarke Institute of Psychiatry in Toronto writes:

There are an abundance of theories about sexual anomalies and a severe shortage of facts...the goal of understanding what we are treating and then applying treatment is not available at present.2

In addition, special care must be taken in locating a possible therapist:3

Types of treatment

Therapy or treatment for sexual attraction to minors comes in three basic forms. More information about these approaches is given in succeeding pages.

  1. Sexual recovery programs - These programs are provided by private organizations, and are intended for those who voluntarily seek help at dealing with their feelings of attraction for minors, and often with any of the other paraphilias. They consider attraction to minors to be a form of sexual addiction. Many do not distinguish between minor-attracted adults and offenders.
  2. Sex offender treatment - Sex offender treatment has a singular purpose: to prevent minor-attracted adults from offending or re-offending. As part of this effort, it attempts to change sexual arousal patterns through behavior conditioning (aversion therapy) techniques, but places little or no emphasis on emotional health. Most men undergoing this kind of treatment have been court-mandated for treatment, so the approach is primarily adversarial.
  3. Counseling or psychotherapy - Little can be found in the literature about the use of counseling or therapy with minor-attracted adults. Those therapists who provide it outside of sex offender programs address issues of self-understanding, positive self-concept, the development of healthy relationships, and methods of coping with oneís sexuality and with societyís reaction to it.

Sexual recovery programs

According to their websites, many sexual recovery programs follow the 12-step addiction recovery model. They assume that feelings of attraction for minors cannot necessarily be eliminated, but attempt to help the individual learn to control his sexual feelings and avoid temptation.

MHAMic has been unable to locate in the scientific literature any published reports on the methods or effectiveness of these programs with men attracted to underage boys. Instead, we provide a list of sexual recovery organizations that work with minor-attracted adults. Their effectiveness has not been proven scientifically.

Sex offender treatment

The most common treatment is cognitive-behavioral sex-offender treatment provided by private, hospital, and university clinics that work in concert with the criminal justice system. Since they do not make a distinction between minor-attracted adults and sex offenders, they treat all minor-attracted adults as offenders.

Their goal is to prevent sexual re-offending, rather than to change sexual attraction or to promote the development of mental health. However, most treatment programs attempt to reduce or eliminate sexual attraction to minors based on findings that some (but not all) sex offenders against minors are preferentially attracted to them.4

Since the development of sexual attraction is not understood, sex offender treatment uses approaches that are chosen for their effectiveness at reducing illegal behavior, without necessarily understanding underlying causes.5

Sex offender treatment usually includes a combination of the methods described in the next pages. These descriptions, along with their side effects and results of studies of effectiveness, are taken from the literature on sex offender treatment.6

Phallometric assessment

Sex offender treatment programs usually assess sexual attraction by attaching a device called a plethysmograph to the individualís penis. The plethysmograph measures and records penile erection as various visual or auditory stimuli are presented. These stimuli may be slides or videos of naked children or adults, and auditory stimuli may be recorded descriptions of sexual acts (consenting or coerced) involving adults and/or children.7

The plethysmograph is used not only to identify those offenders who are sexually attracted to minors, but also to determine whether their attraction has been reduced or eliminated by treatment.

Some professionals write that the plethysmograph is commonly used incorrectly for diagnosis and treatment decisions.8

Castration9

Historically, castration is one method that has been used for sex offenders in general. Its purpose is to eliminate sex drive so that the offender will lose his motivation to offend. However, it does not always reduce sex drive.

Castration is irreversible and controversial, and involves several possible side effects.

If used at all, David Crawford of Broadmoor Hospital in England believes it is appropriate only for offenders with a drive so strong they cannot control it, which, he writes, is not the case with most pedophiles.

He writes that other criminologists have written that castration "must be looked upon as the best social measure for and treatment of sexual criminals and abnormal sexuals in general," and adds, "Whatever ethical, physical, or psychological problems castration might pose, from a criminological point of view it is effective."10

Sex-drive reducing drugs

The purpose of drugs is the same as that for castration: to decrease sex drive, fantasies, and sexual pleasure in order to control behavior. They do not change erotic preference.11 Crawford writes that their use is based on the assumption that very different deviances (incest, bestiality, fetishism, and pedophilia) have the same cause--excessive sex drive--which again is usually not the case with pedophilia.12

Ron Langevin of the Clarke Institute of Psychiatry in Toronto, along with Crawford, writes that the drugs must be taken for the patientís lifetime, since sex drive will return when they are stopped.13 However, criminologist Gordon C.N. Hall writes that they only need to be used for two to five years.14 Since the drugs decrease general sex drive rather than changing erotic preference, they can result in a lack of any sexual outlet at all. Thus, Langevin advocates that they be used only temporarily while some other type of treatment changes erotic preference.15

Use of the drugs is usually invasive as most are administered by intramuscular injection. In addition, most involve several serious side effects and physical risks. Some of the effects of their long-term use are unknown and may be irreversible. The various kinds of drugs and their known risks are as follows:16

Antiandrogen Drugs

Cyproterone Acetate (CPA)

Medroxyprogesterone acetate (MPA, Depo Provera)

Opinions regarding safety and informed consent

Behavioral methods

Behavioral methods have as their goal the reduction or elimination of deviant arousal and the increase of nondeviant arousal. They are based on the assumption that sexual attraction can be modified through the application of principles developed in the early 1900ís by Ivan Pavlov in his studies of dog salivation, and B.F. Skinner in his studies of learning in rats.24

All behavioral methods are based on the idea of conditioning--associating pleasant feelings with desired behavior, and associating unpleasant feelings with undesired behavior. Thus, as applied to pedophilia and ephebophilia, the methods attempt to connect physical or emotional pain, fear, or shame to sexual attraction or behavior involving minors.25

The methods are easy to implement, and have been widely used since the 1930ís with homosexuals, exhibitionists, pedophiles, ephebophiles, voyeurs, and rapists. Although these methods are no longer used with homosexuals, they are still used with the other groups, and researchers say their implementation and effectiveness with these groups have been the same as with homosexuals.26

Aversion therapy

This method was first used in 1935 in an effort to eliminate homosexuality. It attempts to associate in the patientís mind a previously attractive sexual stimulus or behavior with an unpleasant sensation, such as pain, nausea, or fear. The therapist presents the patient with a deviant stimulus (such as a photograph of a nude child, or an audiotape of a child in a sexual context), while simultaneously presenting him with an unpleasant (aversive) stimulus.27

Aversive stimuli have included the following:28

Covert sensitization is a physically safer variation that has also been used with homosexuals and sexual deviants.31

Another variation, shame aversion therapy, involves subjecting the patient to public shame or humiliation in conjunction with his deviant behavior.32

Evaluations of the effectiveness of these methods have been uncontrolled case studies, involving very small numbers of subjects, and have found inconsistent results.33

Other behavioral methods36

Masturbatory satiation

Orgasmic reconditioning

Systematic desensitization

Cognitive methods37

Cognitive methods are based on findings that many sex offenders in general exhibit aggressive sexual behavior, manipulate others, lack empathy for their victims, and minimize, deny, and rationalize their abusive behavior. Cognitive methods assume that their sexual behavior is addictive and results from incorrect beliefs, anti-social attitudes, maladaptive thoughts, a lack of sexual knowledge, and impaired communication and social skills.

Cognitive methods usually involve group discussions led by a therapist who uses workbooks and assigns homework. Discussions usually address the following issues:

Cognitive methods usually rely on the relapse prevention model to help offenders cope with situational variables that may lead to offending, such as negative emotional states, interpersonal conflicts, and tempting environmental factors. This model has been adapted from addiction recovery models, based on the assumption that the offenderís sexual behavior is addictive and compulsive.

Psychotherapy for sex offenders38

Psychotherapy is intended not to decrease or change sexual arousal, but to help the patient understand and control his behavior.

Individual psychotherapy

Group psychotherapy

Use of sex offender treatment on youth39

The American Academy of Child and Adolescent Psychiatry (AACAP) and the Center for Sex Offender Management (CSOM) recommend sex offender therapy for youth and children who engage in sexual activity with others sufficiently younger or smaller than themselves. CSOM writes that some of them may represent cases of early onset pedophilia.

The organizations recommend

CSOM recommends suspending the youthís sentence contingent upon successful completion of treatment. It also notes that controversial areas pose special ethical and legal risks for practitioners:

CSOM writes that clinicians should consider developing additional consent forms to cover the use of the plethysmograph, aversive conditioning, and unapproved drugs, and that clients should understand these procedures are voluntary and that they are free to decline them.

Effectiveness of sex offender treatment

There is as yet no evidence that sexual attraction of any sort can be altered.

Recommendations for sex offender treatment

A combination approch49

Langevin suggests that sex offender treatment use multiple methods since offenders tend to have many problems. David Crawford of Broadmoor Hospital in England concurs, writing that although no approach has proven to be effective at altering sexual arousal, a combination of methods appears promising. However, there are some problems with such an approach:

Castration, sex-drive reducing drugs, and aversion therapy50

Hall writes that since child molesters tend to be motivated by physiological factors (deviant attraction), castration or sex-drive reducing medications and aversion therapy seems most appropriate for them. He notes that although behavioral techniques are not effective at permanently reducing deviant arousal,

Other methods

Counseling

Few articles have been written about counseling approaches outside of sex offender treatment programs.

Alex Van Naerssen and Gertjan van Zessen at the University of Utrecht in the Netherlands provide counseling that has two main purposes:

The approaches they use to meet these goals include cognitive therapy, group counseling, the formation of social support systems, and discussion of affirmative models of relationships with boys.53

Danish sociologist Agner Fog writes that paraphiliacs often suffer from the "isolated minority syndrome," characterized by isolation from others with similar feelings. As a result, they lack models of how to deal with their sexual feelings, and try to suppress them. This can lead to poor mental health, substance abuse, criminal behavior, and inflexible or uncontrolled sexual behavior. Thus, Fog promotes group therapy or self-help organizations in which members serve as role models for each other and help each other live satisfying lives. 54

Similarly, therapist Frans Gieles with the Dutch Association for Sexual Reform criticizes traditional sex offender treatment on ethical and therapeutic grounds. For minor-attracted adults who are able to communicate with others and control themselves, he recommends support groups of peers as well as normal adults. Goals are to help members become conscious of their inner feelings and accept them as a part of themselves, to develop an ethical code, and to find ways of socializing their desires.

Gieles writes that almost all group members remain celibate. Not all of his clients had offended in the first place, but among those who had, the re-offense rate was 6%. He writes that his approach is more humane and less expensive than sex offender treatment.55

As with other methods, none of these counseling programs have been subjected to careful scientific study, so their effectiveness is not proven.

Annotated bibliography

American Academy of Child and Adolescent Psychiatry, "Practice Parameters for the Assessment and Treatment of Children and Adolescents Who Are Sexually Abusive of Others"*, Journal of the American Academy of Child and Adolescent Psychiatry, vol. 38, no. 12 Suppl, 1999, pp. 55S-76S.

The American Academy of Child and Adolescent Psychiatry defines sexual offending among children and adolescents, and describes the components of treatment for those who engage in such activity.

Annon, J.S., "Misuse of Psychophysiological Arousal Measurement Data"*, Issues In Child Abuse Accusations, vol. 5, no. 1, 1993.

Clinical and forensic psychologist Jack S. Annon describes common ways in which the plethysmograph is used incorrectly for diagnosis and treatment decisions.

Center for Sex Offender Management, "Understanding Juvenile Sexual Offending Behavior: Emerging Research, Treatment Approaches and Management Practices"*, December 1999.

The Center for Sex Offender Management describes treatment methods for juvenile sex offenders, and discusses related controversial issues.

Council on Scientific Affairs of the American Medical Association, "Aversion therapy," Journal of the American Medical Association, vol. 258, no. 18 (Nov. 13), 1987, pp. 2562-2565.

The Council on Scientific Affairs of the American Medical Association describes areas in which aversion therapy is used, as well as its effectiveness with homosexuals and sexual deviants.

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

David Crawford of Broadmoor Hospital in England describes the conflicting roles of therapists of sex offenders, and describes various treatment approaches and their effectiveness. He also makes recommendations for research, prevention, and treatment.

Fog, A., "Paraphilias and Therapy," Nordisk Sexologi, vol. 10, no. 4, pp. 236-242, 1992.

Danish Sociologist Agner Fog describes the isolated minority syndrome as seen in sexually deviant persons. He claims that traditional behavioral therapy worsens its symptoms and that the self-help group therapy model is safer, more effective, and more ethical.

Freund, K., "Assessment of pedophilia," in Cook, M. & Howells, K. (eds.), Adult sexual interest in children, London: Academic Press, 1981, pp. 139-179.

Kurt Freund of the University of Toronto describes how he developed the plethysmograph to diagnose homosexuality, and continues to use it to diagnose pedophilia. He also explains its use to determine the effectiveness of treatments to eliminate pedophilia, and evaluates research that claims to support the use of behavioral methods.

Gieles, F.E.J., "Helping people with pedophilic feelings," Lecture at the World Congress of Sexology, Paris, June 2001.

Dutch therapist Frans Gieles addresses ethical, scientific, and therapeutic issues related to sex offender treatment. He describes his 20-year experience using the self-help model with his own clients.

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

Considering adult-minor sexual attraction and interaction to be a form of sexual aggression, Gordon C.N. Hall reviews the various methods used to treat it.

Langevin, R., Sexual strands: Understanding and treating sexual anomalies in men, Hillsdale, NJ: Erlbaum, 1983.

Ron Langevin of the Clarke Institute of Psychiatry in Toronto describes the methods that have been used to treat sexual anomalies in general, then the specific applications of these methods to homosexuality and pedophilia. He provides an overview and criticism of the studies supporting their effectiveness.

Maletzky, B., Treating the sexual offender, Newbury Park, California: Sage Publications, 1991.

Barry Maletzky describes aversion therapy, covert sensitization, and arousal reconditioning in detail.

McConaghy, N., "Unresolved issues in scientific sexology," Archives of sexual behavior, vol. 28, no. 4, 1999, pp. 285-318.

Australian psychiatrist Nathaniel McConaghy describes widespread misuse of circumference plethysmograph measurements in assessing and treating deviant arousal. He also critically reviews studies of the effectiveness of behavioral methods to change deviant sexual arousal, and of relapse prevention methods to decrease re-offending. He urges practitioners to recognize the ineffectiveness of widely used methods and the shortcomings of studies that justify their use.

Tsang, D.C., "Policing 'perversion'", Journal of Homosexuality, vol. 28, nos. 3-4, 1995, pp. 397-426.

Daniel C. Tsang, University of California describes the history of the use of biological means to control sexual deviance, specifically as it applies to medroxyprogesterone acetate (Depo-Provera). He addresses ethical issues surrounding its use.

Van Naerssen, A., "Man-Boy Lovers: Assessment, Counseling, and Psychotherapy," Journal of Homosexuality, vol. 20, nos. 1-2, 1990, pp. 175-188.

Van Naerssen describes his clinical experience with 36 men attracted to boys. He tried to help sixteen of them deal with sexual identity conflicts, and counseled the others on how to handle their relationships with boys. Counseling and psychotherapy addressed various types of interpersonal interactions in their relationships and the ways conflicts could arise within them.

Van Zessen, G., "A Model for Group Counseling with Male Pedophiles," Journal of Homosexuality, vol. 20, nos. 1-2, 1990, pp. 189-198.

Van Zessen describes a six-week, highly structured program involving individual psychotherapy and group counseling. Counseling addressed common psychological and social problems surrounding the attraction to boys and relationships with them. These problems were addressed through social support obtained from interaction with other men attracted to boys.

Sources

1. Freund & Kuban, 1993.
2. Langevin, 1983.
3. Adams, 1997*; Bullough, 2000 (personal email correspondence); Miller, 1992*.
4. Hall, 1996; Maletzky, 1991; Okami & Goldberg, 1992.
5. Hall, 1996.
6. American Academy of Child and Adolescent Psychiatry, 1999*; Center for Sex Offender Management, 1999*; Crawford, 1981; Hall, 1996; Langevin, 1983; Maletzky, 1991.
7. Hall, 1996; Langevin, 1983; Maletzky, 1991.
8. Annon, 1993*; McConaghy, 1999.
9. Crawford, 1981; Langevin, 1983.
10. Crawford, 1981.
11. Langevin, 1983.
12. Crawford, 1981.
13. Crawford, 1981; Langevin, 1983.
14. Hall, 1996.
15. Langevin, 1983.
16. Crawford, 1981; Langevin, 1983.
17. Hall, 1996; Langevin, 1983.
18. Crawford, 1981; Langevin, 1983.
19. Tsang, 1995.
20. American Academy of Child and Adolescent Psychiatry, 1999*; Tsang, 1995; Langevin, 1983.
21. Langevin, 1983.
22. American Academy of Child and Adolescent Psychiatry, 1999*.
23. Crawford, 1981; Hall, 1996.
24. Langevin, 1983.
25. Council on Scientific Affairs of the American Medical Association, 1987; Matson & DiLorenzo, 1984; Hall, 1996; Langevin, 1983.
26. Council on Scientific Affairs of the American Medical Association, 1987; Crawford, 1981; Langevin, 1983; McConaghy, 1999.
27. Council on Scientific Affairs of the American Medical Association, 1987; Matson & DiLorenzo, 1984; Crawford, 1981; Langevin, 1983.
28. Council on Scientific Affairs of the American Medical Association, 1987; Crawford, 1981; Hall, 1996; Langevin, 1983; Maletzky, 1991; Matson & DiLorenzo, 1984.
29. American Academy of Child and Adolescent Psychiatry, 1999*.
30. Maletzky, 1991.
31. American Academy of Child and Adolescent Psychiatry, 1999*; Council on Scientific Affairs of the American Medical Association, 1987; Crawford, 1981; Langevin, 1983; Maletzky, 1991; Matson & DiLorenzo, 1984.
32. Maletzky, 1991; Langevin, 1983.
33. Center for Sex Offender Management, 1999*; Council on Scientific Affairs of the American Medical Association, 1987; Crawford, 1981; Hall, 1996; Langevin, 1983; Matson & DiLorenzo, 1984; McConaghy, 1999.
34. Harris, 1987.
35. Langevin, 1983.
36. American Academy of Child and Adolescent Psychiatry, 1999*; Crawford, 1981; Langevin, 1983; Maletzky, 1991.
37. American Academy of Child and Adolescent Psychiatry, 1999*; Center for Sex Offender Management, 1999*; Crawford, 1981; Hall, 1996.
38. Crawford, 1981; Langevin, 1983.
39. American Academy of Child and Adolescent Psychiatry, 1999*; Center for Sex Offender Management, 1999*.
40. Crawford, 1981.
41. Council on Scientific Affairs of the American Medical Association, 1987; Crawford, 1981; Hall, 1996; Langevin, 1983.
42. Freund, 1981; Hall, 1996; Langevin, 1983.
43. Hall, 1996.
44. Council on Scientific Affairs of the American Medical Association, 1987.
45. McConaghy, 1999.
46. Langevin, 1983.
47. Freund, 1981.
48. Hall, 1996.
49. Crawford, 1981; Hall, 1996; Langevin, 1983.
50. Hall, 1996.
51. Crawford, 1981.
52. Langevin, 1983.
53. Van Naerssen, 1990; Van Zessen, 1990.
54. Fog, 1992.
55. Gieles, 2001.
*offsite article
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