Psychiatric Times.
No. 6
Special Report
Psychopathology and Personality Traits of Pedophiles
By Lisa J. Cohen, PhD and Igor Galynker, MD, PhD |
June 8, 2009
Dr Cohen is associate professor of clinical psychiatry and Dr Galynker is professor of clinical psychiatry and associate chairman for research in the department of psychiatry at Beth Israel Medical Center/Albert Einstein College of Medicine in New York. Dr Cohen reports that she has received a research grant from Bristol-Myers Squibb. Dr Galynker reports that he has no conflicts of interest concerning the subject matter of this article.
Treatment
Although, pedophilia is commonly seen as treatment-resistant, much research suggests this is not the case. Maletzky and colleagues7 reported a treatment failure rate of only 9% over a 20-year period with pedophiles in comprehensive and (frequently) court-mandated treatment. Nonetheless, given the severe consequences of any relapse and the possibility of relapse even decades after the original assessment, clinicians who encounter a patient with pedophilic tendencies would be well advised to consult with a specialist in sexual disorders or even refer the patient to a specialty clinic. Unfortunately, there are far fewer specialty centers than are needed. The Association for the Treatment of Sex Abusers (ATSA) (www.atsa.com), however, can be a useful resource.
Treatment of pedophilia is most effective when it is multimodal, long-term, and perhaps court mandated.7 Cognitive-behavioral treatments have been used to reduce pedophilic sex drive, to increase age-appropriate sexual and affiliative behavior, and to strengthen inhibition of pedophilic behavior. Associative conditioning techniques such as covert sensitization and aversive conditioning, as well as plethysmographic biofeedback and masturbatory satiation are used to reduce pedophilic arousal.5,7,29
With plethysmographic feedback, pedophilic patients can be provided with objective evidence of their sexual arousal patterns and of the effectiveness of any intervention to reduce pedophilic arousal. This can help cut through the denial and minimization that is such a problem with this population. More recent approaches have emphasized a relapse-prevention model, based on an addiction model of pedophilia.5 Training in interpersonal skills, assertiveness, and empathy are also used in order to enhance relationships with adults.
Finally, confrontation of denial, particularly in group format; cognitive restructuring of cognitive distortions; and training in empathy for victims are all used to strengthen inhibition of pedophilic behavior.3 Given the high rate of childhood abuse in pedophiles’ own histories, exploration of their own abuse and its relationship to their adult pedophilic behavior is also warranted.
In cases in which the risk of recidivism is high and danger to the public is of considerable concern, anti-androgen or other hormonal treatments may be indicated.29,30 The anti-androgen agent cyproterone(Drug information on cyproterone) acetate is widely used in Europe and Canada but is not available in the United States. Hormonal agents such as medroxyprogesterone(Drug information on medroxyprogesterone) and luteinizing hormone-releasing hormone (LHRH) analogues are also used. LHRH analogues, such as leuprolide, triptorelin(Drug information on triptorelin), and goserelin(Drug information on goserelin), are long-acting and can be given via injection.5,29,31 Because these treatments reduce global and not just pedophilic sex drive, treatment adherence may pose a serious problem and may depend on external pressures, such as court-mandated treatment.
SSRIs such as fluvoxamine(Drug information on fluvoxamine), fluoxetine(Drug information on fluoxetine) and sertraline(Drug information on sertraline) have also been used to treat pedophiles. With a more favorable adverse-effect profile than anti-androgens, treatment adherence with SSRIs may be less of an issue. A few studies have shown some efficacy.29,31 It is unclear, however, whether these work through reducing depression, reducing compulsive behavior, or reducing general sexual function.
Conclusion
Because of the many legal and ethical complications involved, some clinicians may choose not to treat individuals with pedophilia. It is nonetheless important for all clinicians to be familiar with the basic literature on pedophilia because these patients do present in a wide range of clinical settings. Moreover, given the high incidence of childhood sexual abuse and its pernicious, long-lasting effects, high-quality research, assessment, and treatment of pedophilia are of great public importance. Luckily, current techniques are promising. With better public support, there is opportunity for significant advances in the treatment and prevention of this disabling and destructive disorder.
Also in this Special Report
Drugs Mentioned in This Article
Cyproterone (Cyprostat)
Fluoxetine (Prozac, Sarafem, Symbyax)
Fluvoxamine (Luvox)
Goserelin (Zoladex)
Leuprolide (Lupron, others)
Medroxyprogesterone (Depo-Provera)
Sertraline (Zoloft)
Triptorelin (Trelstar)
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Evidence-Based References
Cohen LJ, Grebchenko YF, Steinfeld M, et al. Comparison
of personality traits in pedophiles, abstinent opiate
addicts, and healthy controls: considering pedophilia
as an addictive behavior. J Nerv Ment Dis.
2008;196:829-837.
Maletzky BM. Factors associated with success and
failure in the behavioral and cognitive treatment of
sexual offenders. Ann Sex Res. 1993;6:241-258.
