Mandatory Reporting: Child Sexual Exploitation Material

Child sexual exploitation material (CSEM) is one of the most frequent sexual crimes perpetrated online.¹ Despite the growing body of literature and statistics on this topic, clinicians lack clear guidance on how to proceed if a patient discloses they have viewed CSEM. Federal and state legislation mandate clinicians to report suspected child abuse or neglect, with legal penalties if not done so. However, guidelines for noncontact offenses, including viewing CSEM, may be unclear for clinicians. Clinicians should familiarize themselves with these laws to prevent criminal penalties for failing to report under state-mandated reporting legislation and ensure they are not violating patient confidentiality.

Case Example

“Jason,” a middle-aged man presents to his psychiatrist’s office for a follow-up appointment. During this appointment, he requests to speak with his psychiatrist about something sensitive. Jason discloses that he has been having unwanted sexual thoughts towards a female child. While he recognizes that acting on these desires is illegal and problematic, he is having difficulty controlling his urges. He denies any history of sexual contact with a minor. However, to prevent himself from seeking out a child, Jason tells his psychiatrist that he has been viewing child sexual exploitation material on the Dark Web. He asks his psychiatrist what they can do to help him with these urges, while the psychiatrist considers whether this disclosure warrants a mandated report.

Key Terms and Definitions

Child sexual exploitation material, as defined by Bloxsom et al, refers to the creation and/or distribution of sexual photos, videos, or live streaming content of children.² This material maybe produced, possessed, or distributed for sexual gratification or exploitation of minors. To be considered CSEM, the content in question must include (1) involvement of a child or adolescent, and (2) depiction of sexual acts or explicit sexual imagery.³ Sexual acts and imagery may include sexual abuse, rape, molestation, and/or exploitation.³ This includes any visual depiction (photos, videos, digital images) involving persons under the age of 18 years old, engaging in sexual activity or lewd exhibition of genitals or pubic area, grooming, and sextortion.¹ This can involve coercion of a minor to produce images or unlawful acquisition of CSEM by an adult without the minor’s knowledge.

Child sexual abuse material (CSAM) may be an additional term used clinically and in legal contexts. The Department of Homeland Security has differentiated and defined both CSEM and CSAM as 2 separate entities of child abuse. CSAM isused when there are visual depictions of sexually explicit conduct involving a person under 18 years old.⁴ CSEM includes the creation and distribution of CSAM, grooming, sextortion, and threats of self-harm.⁴ These terms are used differently in a legal context, and precise language is important. CSEM is the preferred terminology over “child pornography” because of the exact definition and the focus on victimization.^5,6

CSEM Background

A meta-analysis conducted by Henshaw et al⁷ identifies the unique motivations, characteristics, risks, and needs in offenders who exclusively view child sexual exploitation material.⁷ They identify 3 cohorts of offenders, including those who only view CSEM, contact-only sexual offenders, and dual offenders (those who engage in both CSEM and contact sexual offenses).⁷ CSEM exclusive offenders are a unique subcategory and the primary focus of this article. Henshaw et al identified elevated sexual preoccupation, attraction to children, and pedophilic fantasies among CSEM-only offenders, which are clinically relevant factors for risk assessment and targeted treatment.

A meta-analysis by Babchishin (2018) noted that a smaller percentage of CSEM-only offenders engage in contact sexual offenses. The remaining majority of offenders are typically CSEM-exclusive, meaning no prior history of or intention to pursue contact sexual offenses, rendering them “low-risk” offenders.⁸ Risk stratification of CSEM offenders will influence the clinical determination of treatment needed. Offenders with lower risk profiles (no history of contact sexual offenses) may benefit from interventions targeting affective and emotional regulation. In contrast, high-risk offenders may require the former in addition to treatment addressing pedophilic disorders and hypersexuality.⁸

Pedophilia, as defined by the DSM-5-TR, is characterized by at least 6 months of, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).⁹ An individual with pedophilic disorder has either acted on these urges or the sexual urges have caused marked distress/interpersonal difficulty.⁹ CSEM offenders with pedophilic interests are considered most at risk for cross-over from noncontact to contact offenses.⁸ Risk for a noncontact offender to commit a contact offense increases further if sexual preoccupation and antisocial tendencies are present.⁸

Hands-on vs Hands-off Offenders

Policies and processes for mandatory reporting exist for “hands-on” offenses, meaning any sexual offense of a minor involving physical contact.¹⁰ However, reporting protocols for CSEM viewing can be ambiguous for clinicians. It is important to note that urges to view CSEM or viewing CSEM itself is not a reportable offense, except in one state.¹¹ Clinicians should familiarize themselves with state laws, as these laws may vary from state to state. While there are federal criminal sanctions for online access to CSEM, clinicians are not obligated to report this behavior in most states.¹¹ The primary exception to this is the state of California, which classifies CSEM viewing as a reportable offense under mandated reporting responsibilities.

Clinician Responsibilities and Mandated Reporting Laws

While federal law requires states to have procedures for receiving and responding to allegations of abuse, individual state guidelines are dependent on local laws. The Child Abuse Prevention and Treatment Act (CAPTA) was federally created to require mandated reporting procedures in all states for allegations of abuse or neglect and to ensure children’s safety.⁵ Per CAPTA, federal law recognizes CSEM as a form of child abuse, and any person who knows or suspects a child is being abused/neglected may contact child protective services (CPS) or emergency services.¹² The level of evidence required to substantiate a report can vary from state to state (Table).

Although CSEM is characterized as a form of child abuse under CAPTA, there is a lack of agreement and uniformity on reporting laws amongst states. Berlin et al (2019) noted that the act of privately viewing CSEM does not appear to harm the victim directly.¹¹ In addition, there is minimal identifiable victim information in most cases of CSEM. Typically, government agencies will investigate and prosecute perpetrators who access CSEM online. Apart from California, the remainder of the states have not adopted their laws to include CSEM as a form of reportable child abuse. In all states, except California, clinicians are not obligated to report a patient viewing CSEM.

However, CSEM viewing becomes a reportable offense if a patient discloses an identifiable child they are creating CSEM of or engaging in sexual activities with.¹³ Ambiguous situations arise when a patient is sexually communicating online with an individual whose age and identity are unknown.

Special Consideration: California

In 2014, the California Supreme Court mandated clinicians to report patients who download, stream, and electronically access CSEM material under the Child Abuse and Neglect Reporting Act (CANRA).¹⁴ Under CANRA, clinicians are required to report to the local police the names, phone numbers, and addresses of any patient who has downloaded or streamed CSEM.¹⁴ This sparked a debate between the judicial system and local mental health providers who challenged these reporting laws.

Therapists and clinical psychologists filed a lawsuit in the California Court of Appeals (DON L. MATHEWS et al, Plaintiffs and Appellants, v KAMALA D. HARRIS, as Attorney General, Etc, et al, 2017) alleging that CARNA violates their patients’ right to privacy.¹⁵ Psychotherapists argued the reporting requirement would discourage individuals from seeking help for “porn addictions” and other sexual proclivities.¹⁴ The opinion summary of the court concluded, however, that the privacy interest of patients who communicate that they watch CSEM is not outweighed by the states’ interest in identifying and protecting sexually abused children.¹⁵ There is a continuing discussion on the benefits of criminal incarceration vs treatment and rehabilitation for these offenders. Psychologists and psychotherapists expressed concern that this policy may establish a precedent requiring clinicians to report behaviors the government deems “socially repugnant.”¹⁴

Reporting and Patient Privacy Laws

It is imperative to inform patients of the limits of confidentiality in the context of mandatory reporting initially, when meeting them, and then to remind them throughout the course of treatment. Both federal and state child abuse laws require a breach of confidentiality to protect the victim of abuse in the case of physical, emotional, or sexual harm to a child.¹⁶ These obligatory legislative requirements take precedence over privacy laws.

Clinicians must inform patients of their responsibility as mandated reporters, particularly when discussing sensitive topics. Once a report is made, only the minimum necessary information should be reported to the authorities.¹⁶ Documentation of the patients’ statements should be verbatim, with avoidance of subjective interpretations. Patients should be informed that law enforcement or child protective services may access health records after a report is filed.^5,16 Harm minimization can be achieved by both informing the authorities of reported child abuse and ensuring patients are informed throughout the reporting process. If a clinician is unsure if a patient’s disclosure meets the criteria for mandated reporting, consultation should be sought. This may include clinical consultation with a colleague and documentation of such a consultation. Clinicians may also consult with hospital risk management, child protection consultation teams, if available, or the institution's legal counsel in cases of ambiguity.⁵

Concluding Thoughts

This review of mandatory reporting laws for clinicians in the United States highlights a lack of uniformity and guidance between states regarding patients viewing CSEM. This has become an area of concern due to the increased dissemination of CSEM as the internet continues to expand. California is the only state to give explicit reporting guidance to psychiatrists and psychotherapists for CSEM offenders.The current literature suggests that CSEM-only viewers are at low risk of committing hands-on sexual offenses, and many have no identifiable victim.

The decision of what constitutes mandated reporting is a delicate balance between keeping children safe and providing treatment to individuals who pose a potential risk to children. Mandated reporting is just one strategy to protect children; treatment of high-risk sexual offenders is another. Psychiatrists who work with patients who view CSEM should be familiar with the legal mandates in the jurisdiction where they practice. These mandates should inform patient care. Reporting cases that do not meet the legal criteria for mandated reporting is a violation of our duty as physicians to respect patient privacy, avoid harm, and promote well-being.

Dr Gilani is a clinical resident in psychiatry at the Harvard South Shore/Veterans Affairs Boston Healthcare System.

Dr Sorrentino is a clinical assistant professor at Harvard Medical School.

References

1. Paquette S, Chopin J, Fortin F. Child sexual exploitation material offenders, one-size-fits-all for? Exploring tailored clinical dimensions based on cognitive and behavioural criminogenic factors. Crim Behav Ment Health. 2022;32(2):100-113.

2. Bloxsom G, McKibbin G, Humphreys C, et al. Five forms of coerced “self-produced” child sexual exploitation material: a critical interpretive synthesis. TraumaViolenceAbuse.2024;25(5):4230-4244.

3. 2023 National Strategy for Child Exploitation Prevention & Interdiction. US Department of Justice. Updated September 14, 2023. Accessed February 17, 2026. https://www.justice.gov/criminal-ceos/2023-national-strategy-child-exploitation-prevention-interdiction

4. Key Definitions - Know 2 Protect Campaign. US Department of Homeland Security. 2024. Accessed February 17, 2026. https://www.dhs.gov/know2protect/key-definitions

5. Greenbaum J, Kaplan D, Young J; Council on child abuse and neglect, council on immigrant child and family health. Exploitation, labor and sex trafficking of children and adolescents: health care needs of patients. Pediatrics. 2023;151(1):e2022060416.

6. Laird JJ, Klettke B, Hall K, Hallford D. Toward a global definition and understanding of child sexual exploitation: the development of a conceptual model. Trauma Violence Abuse. 2023;24(4):2243-2264.

7. Henshaw M, Ogloff JRP, Clough JA. Looking beyond the screen: a critical review of the literature on the online child pornography offender. Sex Abuse. 2017;29(5):416-445.

8. Babchishin KM, Merdian HL, Bartels RM, Perkins D. Child sexual exploitation materials offenders: a review. Eur Psychol. 2018;23(2):130-143.

9. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association; 2013.

10. Greenberg SRR, Firestone P, Bradford JM, Greenberg DM. Prediction of recidivismin exhibitionists: psychological, phallometric, and offense factors. Sex Abuse. 2002;14(4):329-347.

11. Berlin FS. Evaluating and reducing risk in online child pornography cases. J Am Acad Psychiatry Law. 2019;47(2):165-170.

12. Stoltzfus E. The Child Abuse Prevention and Treatment Act (CAPTA): Background, Programs, and Funding. Congressional Research Service; 2009:53.

13. Bourke ML, Hernandez AE. Butner Study Redux: a report of the incidence of hands-on child victimization by child pornography offenders. J Fam Violence. 2009;24(3):183-191.

14. Dolan M. Should psychotherapists be required to report patients who look at child porn? Los Angeles Times. December 8, 2019. Accessed February 17, 2026. https://www.latimes.com/california/story/2019-12-08/therapists-child-porn-court

15. Don L. Mathews et al., plaintiffs and appellants, v. Kamala D. Harris, as attorney general, etc., et al. The Court of Appeal of The State Of California. 2020.

16. Chung RJ, Lee JB, Hackell JM, Alderman EM; Committee on adolescence, committee on practice & ambulatory medicine. Confidentiality in the care of adolescents: technical report. Pediatrics. 2024;153(5):e2024066327.