In 2015, the Sexual Behaviours Clinic (SBC) at The Royal Ottawa Mental Health Centre received the Gold Award—the top award given by the American Psychiatric Association for “Best Academic Out-patient Clinical Research Program.” This was due in part to the fact that the SBC has led the way in revolutionizing approaches to change the manner in which sex offenders against children are assessed and treated. In the past 15 years the known hands-on re-offence rate of sex offenders treated in the SBC has fallen to virtually zero.
Unfortunately, much of what psychiatrists know about sex offenders is gleaned from popular public media outlets. News agencies report sex crimes on a daily basis, and so-called experts repeat the mantra: “Once a pedophile always a pedophile.” The truth is that popular media is about 30 years behind where the field is now. In this article I explain some of the realities about sex offenders and why psychiatrists should be more optimistic about their patients’ prognoses.
The first important point is that not all sex offenders have paraphilias and not all people with paraphilias commit sex offences. Most of what is reported in the news involves sex offenders who by definition are criminals. Until recently, most scientific studies of the paraphilias consisted of men who had committed sex crimes. This has biased what we know about the paraphilias in the same way that studies that only included people with schizophrenia who had committed violent crimes would create a biased and incorrect view of what most people with schizophrenia are like.
DSM-5 attempts to deal with this issue by creating a distinction between people with paraphilias and people with paraphilic disorders. So, for example, a person with sexual fantasies that involved wearing clothes of the opposite sex would not meet DSM-5 criteria for transvestic disorder unless their transvestic interests and behaviors caused distress or impairment. For paraphilic interests associated with illegal acts, the criteria can also be met simply by committing the criminal act. With one exception all the paraphilic disorders listed in DSM-5 can be designated “in full remission” if the person has not acted on the paraphilic interest and it has not caused distress after 5 years of opportunity.
The one exception is pedophilic disorder, which inexplicably does not have an “in full remission” designation. This is especially odd given that the DSM-5 states that the “course of pedophilic disorder may fluctuate, increase, or decrease with age” (page 699). For pedophilic disorder, it is as if DSM-5 were based on tabloid newspapers.
In fact, the primary evidence that the interest of people with pedophilia cannot change is the statement by John Money that paraphilias are “vandalized” love maps that once created cannot be changed.1 He published one book that consisted of several case studies of individuals who had sustained trauma (primarily medically induced iatrogenic trauma) and who subsequently developed paraphilic interests. However, he did not publish any follow-up data to show that the paraphilias did not undergo further change. So far as I know, no one has ever shown that paraphilic interests are immutable.
In contrast, multiple lines of evidence suggest that paraphilic interests do change. These include the fact that sex crime rates are dropping, the incidence of sex crimes decreases as people age, and the likelihood that a known high-risk sex offender will ever re-offend decreases the longer the offender does not commit a crime—as well as the self-report of men and women with paraphilic disorders.2
Dr. Fedoroff is Professor of Psychiatry at the University of Ottawa with cross-appointments to the Faculties of Criminology and the University of Ottawa Faculty of Law. He is Head of the Division of Forensic Psychiatry at the University of Ottawa. He is also Vice Chair of the Royal Ottawa Research Ethics Committee. He is Past-President of the Canadian Academy of Psychiatry and the Law. He is an appointed member of the Ontario Review Board. He was the first Director of Forensic Research Unit at the University of Ottawa Institute of Mental Health Research and Chair of the Sex Offender Committee of the American Academy of Psychiatry and the Law, where he is now a Counsellor. In 2014 the Royal College of Physicians and Surgeons honored him as “Specialist of the Year” in Ontario and Nunavut. He is Past-President of the International Academy of Sex Researchers. In 2015 the Sexual Behaviours Clinic, of which he is Director, was given the Gold Award, the highest honor of the American Psychiatric Association for an outpatient academic clinical research program. He reports no conflicts of interest concerning the subject matter of this article.
1. Money J, Lamacz M. Vandalized Lovemaps: Paraphilia Outcome of Seven Cases in Pediatric Sexology. Amherst, NY: Prometheus Books; 1989.
2. Fedoroff JP. Managing versus successfully treating paraphilic disorders: the paradigm is changing. In: Levine CB, Althof SE, eds. Handbook of Clinical Sexuality for Mental Health Professionals. New York: Taylor and Francis; 2016:345-361.
3. Muller K, Curry S, Ranger R, et al. Changes in sexual arousal as measured by penile plethysmography in men with pedophilic sexual interest. J Sex Med. 2014;11:1221-1229.
4. Murphy L, Bradford JB, Fedoroff JP. Paraphilia and paraphilic disorders. In: Gabbard GO, ed. Gabbards Treatments of Psychiatric Disorders. Washington, DC: American Psychiatric Publishing; 2008:669-694.