Episode 093: Forensic Pedophilia

Maddison Ulrich, BS, Akanksha Dadlani, MPH, Tony Angelo, PhD, Michael Cummings MD, David Puder, MD

There are no conflicts of interest for this episode.

History of Pedophilia:

Despite being a topic of interest for millennia, we still do not understand much about how people become attracted sexually to the people they are attracted to (normal and paraphilic attraction). Attraction develops very early in life due to a myriad of exposures. People who develop paraphilias have a hard time describing how they became paraphilic, but it starts early in childhood. Most pedophiles interviewed by Dr. Cummings began experiencing fantasies or urges directed toward inappropriately young partners around the age of puberty. These feelings are then fed by today’s active pornography industry, until they eventually begin to act on those urges, which in turn becomes forensic pedophilia. However, most pedophilic involvements go undiscovered and unpunished. Moreover, the number of victims for true forensic pedophiles is often in the hundreds. 

The only paraphilias prohibited by the law are those that lack consent, thus all pedophilic acts are criminal, as the victims are legally unable to give consent. Other paraphilias are typically not legally prohibited in the US. 

Helmut Kentler

Pedphilic transgressions are an area of the law where things have not been dealt effectively with historically. In the 1970’s, a psychology professor named Helmut Kentler conducted an experiment in which homeless children out of West Berlin were placed in the care of pedophilic men. (Goldenberg, 2020) He “believed” that these homes would provide the care and attention that children needed to be brought up in a loving environment. This study went on for 30 years, and was officially approved and supported by Berlin’s child welfare offices and Senate. (Goldenberg, 2020) The pedophile foster parents even received “care allowances” for the children.  

Today, it has been well accepted that many of the educational institutions that were a part of this unethical “experiment” were parts of a systemic network that condoned and supported pedophilia. Because the discovery of all of this information is outside the statute of limitations, victims have not received any compensation. (Goldenberg, 2020) In fact, the organization which was meant to protect the foster children, Berlin's Department for Education, Youth and Family, was the one who commissioned the study. (Gebhardt, 2020)

A few brave survivors have since been fighting for reparations, but many of their abusers have since died as a result of time. Further, many of the victims are living off of welfare because of the undue distress caused by their upbringing. (Gebhardt, 2020)

It is important to understand how systemic this failure was. In Germany in the 1960’s, sex was becoming a more openly discussed topic. (Gebhardt, 2020) The theory of “emancipating sexual education” was gaining traction. The major proprietor of this movement, Kentler, had gone on TV and radio to speak about it, and wrote multiple books on the topic as well. (Gebhardt, 2020) This “liberal” thinking can be significantly attributed to the history surrounding the era. After the Nazi regime, people began questioning traditional ideas and wanted to “push the envelope”. As such, it became acceptable for pedophiles to pursue their sexual desires. There was also a significant push to make sex with children under the age of 14 legal, though this was never legally approved. (Gebhardt, 2020)

Unfortunately, the Kentler experiment was not the exception at the time in Germany. The Odenwald Boarding School reported that as many as 900 students were sexually abused between 1966 and 1989. (Gebhardt, 2020)

Today, the senator in charge of the case, Sandra Scheeres, expresses her empathy for the survivors. She promised financial compensation for the suffering; however, the current government refuses to investigate  living members of the original youth welfare office. (Gebhardt, 2020) Rightfully, survivors do not feel supported, because in the end, all they did was “defend the system”. (Gebhardt, 2020)

Jeffrey Epstein and California Senate Bill 145

In the US, there are still common instances where pedophillic transgressions are not handled well by the law. There are still areas of the US where the legal age of marriage is 14. We are also still currently seeing cases like Jeffrey Epstein, where underage women are recruited for sexual abuse, and the activity goes on for decades before the perpetrators are finally punished, and then usually not adequately. In our society, wealth can still provide a lot of protection against legal intervention. Pedophiles who commit obvious, severe crimes are typically punished or committed. However, other less clear-cut crimes are dealt with less effectively and often go unpunished. For example, in California, sexual contact with a child between 14 and 18 years of age is called ‘unlawful’, and is not typically as stringently punished. 

The new California law being passed will make any form of sexual contact between a child as young as 14 and an adult as old as 24 a matter of  interpretation and not automatically a criminal violation. State Senator Scott Wiener, who presented the bill, said the existing law “disproportionately targets LGBT young people for mandatory sex offender registration since LGBT people usually cannot engage in vaginal intercourse." (Stringini, 2020) However, “critics of the bill argue that rather than amending existing law to include vaginal intercourse with a minor as an act that requires mandatory sex offender registration, the bill aims to make all criminal sex acts with a minor over 14 equal by providing offenders with an opportunity to evade mandatory registration.” (Stringini, 2020) Part of the difficulty is emotional and social maturity levels of the individuals involved, and the law cannot easily deal with these distinctions. 

Riverdale and Cuties

Our society tends to sexualize very young individuals, which gives an unrealistic and permissive view of underage sex. Many pedophiles interviewed by Dr. Cummings have pointed out that a huge percentage of both pornographic and non-pornographic films depict and normalize sex between older people and younger people. Some of them have thus stated, “well I was only following what society was already endorsing.” At institutions like Patton State Hospital, they cannot keep patients from viewing content like the new film Cuties, or even pornographic material, as long as it does not directly violate the law. That would be an infringement of their first amendment rights.

Prevalence of Pedophilia:

We do not have reliable statistics on pedophiles who act on their sexual desires versus those who do not, as most pedophiles do not openly discuss their condition. Interestingly, a few surveys done in colleges have asked the question to male undergraduate students  “would you have sex with an underage girl (under 18) given the opportunity and without legal consequences?” Around 50% said yes.

In a survey of adult men in Germany, 0.1% reported higher levels of child vs. adult sexual fantasies/behaviors (DSM5 A criterion), and 5.4% reported any sexual interest in prepubescent children. They estimate only 0.6% of those surveyed would qualify as having pedophilic disorder. (Dombert, 2015). This is a very consistent finding of around 5% of the general population having sexual thoughts/fantasies of prepubescent children. Again, as noted previously, this does not in and of itself predict acting on those thoughts and fantasies. In fact, in sexual offending treatment, we make a fairly significant distinction between hands on and hands off offenders; the primary distinction of hands off is typically utilizing child pornography and this is often fed by a cognitive distortion that this is a victimless crime; that is of course not true and is very well highligted in a New York Times article titled: The Price of a Stolen Childhood.

Diagnosis of Pedophilia

DSM5 criteria for pedophilic disorder: (American Psychiatric Association, 2013)

1. Recurrent, intense sexual fantasies, urges, or behaviors involving sexual activity with a prepubescent child (generally age 13 years or younger) for a period of at least 6 months.

2. These sexual urges have been acted on or have caused significant distress or impairment in social, occupational, or other important areas of functioning.

3. The person is at least 16 years old, and at least 5 years older than the child in the first category. However, this does not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.

4. For the condition to be diagnosed, an individual must either (1) act on their sexual urges or (2) experience significant distress or interpersonal difficulty as a result of their urges or fantasies. Without these two criteria, a person may have a pedophilic sexual orientation but not pedophilic disorder.

Prepubertal Versus Postpubertal Pedophilia

People who desire to have sex with prepubertal individuals are psychologically much more abnormal and more likely to be compulsive and violent than those attracted to postpubertal minors. One of the elements of a psychiatric interview when dealing with a pedophilic patient is asking about the content of their urges, including the age, gender, sex, and appearance of their most desirable victim. The more closely that picture describes an age appropriate partner, typically the less pathologic that person’s paraphilia is. 

In pedophiles attracted to prepubertal victims, sexual attraction is fused with elements of desiring power and control over their partner. In other words, they are picking a partner who is less physically and emotionally capable, so often their fantasies involve control and coercion much more so than those who prefer partners with more adult characteristics. On the other hand, another common profile is peodphiles who pick very young victims, because they themselves are very emotionally and intellectually immature (Sex Offender Risk Assessment calls this “Emotional Idenitification with Children” and is considered a signficant risk factor). They often are very unsuccessful in establishing adult intimate relationships, because mature adults are not interested in them.

Penile Plethysmography:

Research

In a recent study using penile plethysmography, “approximately half of the sample (n = 21) displayed a change in PPT results over time. This change was characterized by a significant decrease of sexual arousal in response to pedophilic (child) stimuli and a significant increase of sexual arousal in response to nonpedophilic (adult) stimuli. No differences between sexual interest changers (ICs) and nonchangers (NC) were found for demographic data or for length of time between assessments. However, between group comparisons revealed that ICs had significantly lower pedophilic indices at the initial assessment than NCs. Results from the current study indicate that relative pedophilic interest, as defined by increase in penile circumference in response to nonpedophilic stimuli as measured by PPT, changed in about 50% of men diagnosed with pedophilia who also had initial pedophilic PPT sexual responses. This represents a significant challenge to the hypothesis that sexual interest in men with pedophilia is unchangeable and should be the focus of future studies.” (Müller 2014) Of note, subsequent articles have tried to point out methodological issues with this study.  

Use in Treatment

Penile plethysmography is used clinically at places like Patton State Hospital and Coalinga State Hospital, where most of the legally declared sexually violent predators are housed in California. The Sexually Violent Predator law requires that the person has engaged in establishing relationships for the purpose of sexual victimization, engaged in sexually violent acts, and suffers from a mental disorder that makes it more likely than not that they will pursue further victims to meet criteria. Their commitment term is set for two years, but that sentence can be renewed indefinitely as long as they continue to pose a risk. Penile plethysmography along with the Gene Abel image test is used to judge their response to treatment, and uses a series of computer images of people of different ages in different levels of undress to measure how long they look at each image while also measuring penile circumference to gauge sexual arousal. 

The goal is to help the individuals develop a healthier arousal pattern. Sexual arousal begins subcortically, so it is not something that we can consciously control. EEG studies have shown that specifically an increase in “the P50 wave” occurs when an individual finds something sexually interesting, which is deeply subconscious. These tests are used repeatedly across therapy to provide a subjective measure of any changes in the person’s interests over time.

Comorbidities and Differential Diagnosis:

Psychopathy

The legal conundrum that we currently have is that the bar for sex offenders to be released back into the community is essentially a guarantee to the public that they will never reoffend, which is almost impossible. Thus only a tiny percent of people have ever been released from Coalinga. There is a big difference between the very predatory pedophile with hundreds of victims and the person who may simply have difficulty with impulse control due to substance use, mania, or schizophrenia with only one victim and no established predatory pattern. Those people have a much better chance of being reintegrated into the community safely, because they are not true pedophiles. Note that California’s Sexually Violent Predator law (Welfare and Institutions Code 6600 ad seq) requires convictions of sexually violent crimes against a minimum of at least two victims. In fact, it is even difficult to measure progress using penile plethysmography and the Gene Abel imaging test in individuals who are pedophilic and psychopathic, because they have a decreased affective response in the limbic system.

For “true predators” there is a high rate of comorbidity with psychopathy, as psychopaths typically have a disregard for the welfare of others and will not be bothered by victimizing children. In contrast, pedophiles who are not psychopaths are often tortured by their sexual urges. 

Obsessive Compulsive Disorder

Dr. Puder has seen cases in which patients with OCD notice obsessive unwanted sexual thoughts about children, and these people will often never act on their thoughts. Their compulsions alleviate their anxiety induced by the thought content. In fact, Dr. Cummings has never seen an OCD patient who was a sexual predator or sex offender. 

Schizophrenia 

Similarly, Dr. Puder has seen a patient with schizophrenia who experienced delusional thoughts that he had sexually abused a younger family member. Delusions can even cause a patient with schizophrenia to sexually abuse a minor, however these patients do not have true pedophilic disorder. The third group of patients who can commit forms of sexual abuse due to something other than pedophilia are elderly dementia patients. Their loss of the ability to make social judgements and impair impulses can cause them to do usually less severe crimes comparatively like inappropriate touching. 

Increased Dopamine

Methamphetamines influence sexual drive, as the medial amygdala (sexual arousal) and nucleus accumbens (reward circuit) are in part driven by dopamine. Similarly Parkinson's patients on medication can exhibit inappropriate sexual behavior with increased dopamine levels.

Important Facts About Pedophilia:

Pedophilia Is Not A Choice

Patients who have pedophilic disorder did not choose to have sexual desires toward children. We do not yet understand how people become attracted to the people they are attracted to. These desires are likely a result of subconscious conditioning. However, pedophiles do have a choice about what they do with their sexual urges. The goal of treatment for pedophilia is to help patients control their urges and not act on them. 

Pornography Is Not Harmless

Watching pornography with pedophilic or incestuous themes reinforces and normalizes aberrant urges and desires that pedophiles already have. If a pedophile watches child pornography, their sexual desires are being encouraged and reinforced. One study noted that “child pornography offending is a stronger diagnostic indicator of pedophilia than is sexually offending against child victims.” (Seto, 2006) A similar study adds that “child pornography offenders with prior criminal records were significantly more likely to offend again in any way during the follow-up period. Child pornography offenders who had committed a prior or concurrent contact sexual offense were the most likely to offend again, either generally or sexually.” (Seto, 2005)

A patient may even watch legal adult pornography where the actor is portraing a younger individual, and these themes will build on, even subconsciously, the focus on sexual acts with minors. This in turn will make it more difficult for a pedophile to ignore and deny their sexual urges, and this may eventually result in abusing children. 

Not All Pedophiles Are Sexual Abusers

This statement is a common misunderstanding, because the diagnosis of pedophilia does not actually require sexual abuse. As stated previously, to be diagnosed as a pedophile, a person has to have sexual urges targeting children, and it must at least cause them distress. However, not every pedophile acts on their urges. For example, Virtuous Pedophiles is an organization created by pedophiles who have never abused a child or watched child pornpgraphy. They want to show people that pedophiles have the opportunity to live normal and safe lives. (https://virped.org/)

Destigmatizing the Diagnosis of Pedophilia

In the US, the public still has a skewed view of pedophilia. Take for example the recent TedX talk produced in 2018 that received such backlash it had to be taken down. Interestingly, the speaker’s point, like what Dr. Cummings shares in this podcast, is that not all pedophiles are sexual abusers. At one point, the speaker says, “It is our responsibility to reflect and overcome our negative feelings about pedophiles, and to treat them with the same respect that we treat other people with. We should accept that pedophiles are people who have not chosen their sexuality, and who, unlike most of us, will never be able to live it out freely… We should differentiate between child sexual abuse and pedophilia.” (University of Würzburg, 2018) The talk was removed from TedX due to backlash: “After contacting the local TEDx organizer to understand why the talk had been taken down, we learned that the speaker herself requested it be removed from the internet because she had concerns about her own safety.” (TEDStaff, 2018)

Some psychiatrists who treat pedophiles are trying to change the public view. One study interviewed healthcare practitioners from the German Prevention Network “Don’t offend”. It stated “to destigmatize pedophilia and benefit the prevention of child sexual abuse, a fact box for journalists was developed based on practitioners’ expert knowledge.” (Stelzmann, 2020)

Pedophiles Have Increased Rates of Child Abuse

Studies have found that the earlier an individual becomes sexualized, the more likely they are to choose inappropriately young partners. This may be due to the emotions tied to a person’s first seuxal encounter, and wanting to go back and repeat that experience.

According to one study, “Twenty men with pedophilia, heterosexual type were compared with 24 demographically similar, healthy male control subjects on a questionnaire specifically designed to assess childhood sexual history in pedophiles. Sixty percent of pedophiles compared with 4% of control subjects reported adult sexual advances as a child. Seventy-five percent of pedophiles and 22% of control subjects reported a first sexual encounter before age 14 years. About 60% concordance was found between acts experienced as a child and perpetrated as an adult.

Finally, numerous inconsistencies throughout the questionnaire add preliminary support for the role of cognitive distortions with regard to childhood and adult sexual history.” (Cohen, 2002)

Treatment:

Medications 

The two main choices for medications are antiandrogens and SSRI’s. SSRI’s can decrease arousal and delay orgasm or even cause anorgasmia. This helps many patients by decreasing the reinforcement of sexual urges. Anti-androgens like medroxyprogesterone (Depo-Provera) and leuprolide are used to decrease circulating testosterone levels. The treatment goal is to decrease testosterone by circa 75% from baseline, to decrease sex drive while avoiding bone demineralization from testosterone elimination. Annual bone density scans should be done to monitor demineralization during treatment. Leuprolide comes in monthly, quarterly, and 6 month injections, which is beneficial for ease of treatment compliance. It is important to know that when beginning treatment, testosterone will increase for the first 2 weeks after the initial injection, as leuprolide is a GnRH analog. There may be an increase in sex drive and sex behavior that will then decline over time. Depo-Provera is used less often, as it poses a greater risk of causing hepatitis.

According to a recent study done in France, “Antiandrogens, and mostly GnRH analogues, significantly reduce the intensity and frequency of deviant sexual arousal and behavior, although informed consent is necessary in all cases. GnRH analogue treatment constitutes the most promising treatment for sex offenders at high risk of sexual violence, such as pedophiles or serial rapists. SSRIs remain an interesting option in adolescents, in patients with depressive or OCD disorders, or in mild paraphilias such as exhibitionism. Pharmacological interventions should be part of a more comprehensive treatment plan including psychotherapy and, in most cases, behavior therapy.” (Assumpção, 2012)

Psychiatry Pearls

Psychiatrists should characterize pedohpiles further if you have contact with them: are you looking at someone who is engaging in pedophilic behavior as part of a predatory pattern? Or is their pedophilic behavior due to another disorder, such as intoxication or mania? The latter group are much better treatment candidates, while the former will be much more difficult to treat and will be much more dangerous. 

Therapy 

For pedophiles who desire to abstain from illegal activities, there are support groups available similar to Alcoholics Anonymous. The dominant form of psychotherapy is modified CBT done on groups. Group therapy is more effective than individual therapy, as pedophiles are much better at calling each other out than therapists are. “The combination of psychotherapy and pharmacotherapy is associated with better efficacy compared with either treatment as monotherapy.” (Assumpção, 2012) Every therapist should become familiar with the resources in their area, such as support groups for different disorders.

Main Take Away Points:

• Despite being a topic of interest for millenia, we still do not understand much about how people become attracted sexually to the people they are attracted to.

• Pedphilic transgressions are an area of the law where things have not been dealt effectively with historically or today.

• Our society tends to sexualize very young individuals, which gives an unrealistic and permissive view of underage sex that reinforces the sexual desires of pedophiles.

• For pedohpilic disorder to be diagnosed, an individual must either (1) act on their sexual urges or (2) experience significant distress or interpersonal difficulty as a result of their urges or fantasies. Without these two criteria, a person may have a pedophilic sexual orientation but not pedophilic disorder according to the DSM V.

• People who desire to have sex with prepubertal individuals are psychologically much more abnormal and more likely to be compulsive and violent than those attracted to postpubertal minors.

• Penile plethysmography along with the Gene Abel image test is used to judge the pedophilic patient’s response to treatment.

• For “true predators” there is a high rate of comorbidity with other psychopathies, as psychopaths typically have a disregard for the welfare of others and will not be bothered by victimizing children. In contrast, pedophiles who are not psychopaths are often tortured by their sexual urges. 

• Studies have found that the earlier an individual becomes sexualized, the more likely they are to choose inappropriately young partners.

• Antiandrogens significantly reduce the intensity and frequency of deviant sexual arousal and behavior.

• SSRIs can be an option for medical treatment in adolescents, patients with depression or OCD, or in mild paraphilias like exhibitionism.

• Psychiatrists should characterize pedohpiles further if you have contact with them: are you looking at someone who is engaging in pedophilic behavior as part of a predatory pattern? Or is their pedophilic behavior due to another disorder, such as intoxication or mania?

• For pedophiles who desire to abstain from illegal activities, there are therapeutic support groups available that will increase the effectiveness of their treatment.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (5th ed.). American Psychiatric Publishing.

Assumpção, A. A., Garcia, F. D., Garcia, H. D., Bradford, J. M. W., & Thibaut, F. (2014). Pharmacologic Treatment of Paraphilias. Psychiatric Clinics of North America, 37(2), 173–181. https://doi.org/10.1016/j.psc.2014.03.002 

Cohen, Lisa J., Mcgeoch, Pamela G., Gans, Sniezynawatra S., Nikiforov, Konstantin, Cullen, Ken, & Galynker, Igor I. (2002). Childhood Sexual History Of 20 Male Pedophiles Vs. 24 Male Healthy Control Subjects. The Journal Of Nervous And Mental Disease, 190(11), 757–766. Https://Doi.Org/10.1097/00005053-200211000-00006

Dombert, B., Schmidt, A. F., Banse, R., Briken, P., Hoyer, J., Neutze, J., & Osterheider, M. (2015). How Common is Men’s Self-Reported Sexual Interest in Prepubescent Children? The Journal of Sex Research, 53(2), 214–223. https://doi.org/10.1080/00224499.2015.1020108 

Fletcher, J. M., & Schurer, S. (2017). Origins of Adulthood Personality: The Role of Adverse Childhood Experiences. The B.E. Journal of Economic Analysis & Policy, 17(2), 212. https://doi.org/10.1515/bejeap-2015-0212 

Gebhardt, W. (2020, June 17). The dark legacy of sexual liberation in Germany: DW: 17.06.2020. Retrieved September 14, 2020, from https://www.dw.com/en/germany-allowed-pedophiles-to-foster-children/a-53839291 

Goldenberg, R. (2020). Berlin authorities placed children with pedophiles for 30 years: DW: 15.06.2020. Retrieved September 14, 2020, from https://www.dw.com/en/berlin-authorities-placed-children-with-pedophiles-for-30-years/a-53814208

Hall, R. C. W., & Hall, R. C. W. (2007). A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues. Mayo Clinic Proceedings, 82(4), 457–471. https://doi.org/10.4065/82.4.457 

Müller, K., Curry, S., Ranger, R., Briken, P., Bradford, J., & Fedoroff, J. P. (2014). Changes in sexual arousal as measured by penile plethysmography in men with pedophilic sexual interest. The journal of sexual medicine, 11(5), 1221-1229. 

Seto, M. C., Cantor, J. M., & Blanchard, R. (2006). Child pornography offenses are a valid diagnostic indicator of pedophilia. Journal of abnormal psychology, 115(3), 610.

Seto, M. C., & Eke, A. W. (2005). The criminal histories and later offending of child pornography offenders. Sexual abuse: a journal of research and treatment, 17(2), 201-210.

Stelzmann, D., Jahnke, S., & Kuhle, L. F. (2020). Media Coverage of Pedophilia: Benefits and Risks from Healthcare Practitioners’ Point of View. International Journal of Environmental Research and Public Health, 17(16), 5739. https://doi.org/10.3390/ijerph17165739 

Stringini, M. (2020, September 2). New California bill would lower penalties for adults who have sexual relations with a minor. FOX 11 Los Angeles. https://www.foxla.com/news/new-california-bill-would-lower-penalties-for-adults-who-have-sexual-relations-with-a-minor 

TEDStaff. (2018, July 26). TEDx talk under review. TED Blog. https://blog.ted.com/tedx-talk-under-review/ 

University of Würzburg TedX Talk. (2018, May 5). “Why our perception of pedophilia has to change.” [Video]. TedX YouTube Channel. https://vimeo.com/275952699