“Once a pedophile always a pedophile” is so 30 years ago. The author updates the realities about sex offenders and why psychiatrists should be more optimistic about their patients’ prognoses.
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST
Measuring Penile Tumescence
TABLE. Interventions for patients referred to the Sexual Behaviours Clinic
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
Treatment strategies from the SBC
Our group reported on a retrospective study of men who had phallometric testing on more than one occasion at least 6 months apart.3 Our study showed that some men with a diagnosis of pedophilia had changes on their phallometric test results. Not only did they show less penile tumescence in response to stimuli involving children, they also showed increased degrees of penile tumescence in response to stimuli involving adults. To date, there have been 4 published critiques of the article. The concern is that perhaps this additional evidence in support of the mutability of paraphilias might be caused by measurement error, regression to the mean, or clever faking by the test subjects. These, of course, are concerns to be raised about any un-replicated study.
Why all the fuss about this one, especially since the news appears to be good?
In my opinion, it is precisely because the news is good. None of the men treated in the SBC report changes in their chromosomal sex or gender identity. All men treated in the SBC report frequent changes in their sex drive. And virtually all men in the SBC report dramatic changes in their sexual interests from paraphilic to normophilic. Importantly, none report changes in their sexual orientation. These results are gratifying because they fit with the treatment goals of the clinic. So how do we achieve them?
We have recently reviewed treatment methods in several publications. The following is a condensed, highly abbreviated summary of the SBC approach.
1) Above all, champion consent. All sex crimes, with the exception of prostitution, involve violation of consent. Coercive treatment programs that “force” compliance or that appear to do so are doomed to failure. All SBC treatment is done on an out-patient basis, and patients are assured their attendance is voluntary.
2) Be optimistic. You have not only a right but an obligation to tell your patients that most sex offenders never re-offend; that all sexual behaviors are 100% voluntary; and that all available evidence indicates that paraphilic interests can be modified.
3) Remember, the agent of change is the patient. Do not tell patients you will “catch them” if they lie. The fact is you almost certainly won’t.
4) Remember, as a physician, you work for the patient. It is important to remember the evidence indicates that treatments that are not individualized are less effective. In the SBC, treatment options-and the risks and benefits of accepting the treatment and of rejecting it-are offered, and the patient is allowed to make an informed, voluntary, revocable consent.
Often, patients will elect a more invasive treatment than the standard protocol would suggest. For example, in a group session, one patient will mention how he finished his probation, got a job and a new apartment, and is looking forward to a date with a woman he met recently. The “new guy” will say, “I want to be on what he is on.” Frequently, the first patient will announce he is taking leuprolide, a gonadotropin- releasing hormone analog typically reserved on official protocols for the most serious of sex offenders in need of so-called “chemical castration.” In the SBC, we have found that allowing the patient to select the treatment is more effective and ethical than imposing it.
5) Paraphilic disorders thrive in isolation. People who are sexually aroused by committing sex crimes are prone to living dual lives or lives on the outskirts of society. This splitting of life from sex allows the individual to avoid taking responsibility for his criminal acts and from seeking or complying with treatment. The SBC works to reverse this trend by encouraging patients to consciously change their lifestyles.
Much of this work is done in group therapy in which patients at all stages of recovery and intellectual ability are welcomed. There is no requirement to recall or admit to past sex offences. All group members agree to keep what is said in group confidential, to be polite, to show up sober, and to disclose life-threatening thoughts so they can be dealt with immediately, and they agree that if a group member describes reportable harm to a child that it will be reported immediately. With these simple rules, patients quickly become willing participants, able to talk about life-long secrets while receiving advice, support, and encouragement to change.
6) Reporting is therapeutic. Many clinicians dread the day they will “be forced” to report a patient because he disclosed the fact that he sexually abused a child. Reporting laws vary from jurisdiction to jurisdiction, and clinicians should be familiar with the laws where they practice; don’t hesitate to consult with your malpractice issuance agent if you are uncertain about what to do.
However, many clinicians misunderstand the purpose of “reporting laws.” The laws are intended to protect clinicians from accusations of breaches of doctor-patient confidentiality, not to force them to do something. The fact is that all ethical physicians would want to seek immediate assistance for any child known to be in harm’s way. Reporting laws are unnecessary for that purpose. Some clinicians worry that by reporting, their relationship with the patient will be harmed, but this also is untrue. In the SBC, reporting laws are presented to the potential patient before he or she sees the doctor.
When a reportable situation becomes known, the importance of protecting the child is explained and the appropriate agency is called in the presence of the patient (in Ottawa, this is the Family and Children’s Aid Society [FCAS]). The issue of concern is disclosed, and the phone is handed to the patient to discuss with the FCAS worker. Typically, the patient makes a full disclosure. The process of taking action to help the child is highly therapeutic and puts the patient on the same side as the clinician, which is to ensure no further harm to any children occurs. The fact that the offender is the person reporting, that the child is no longer in danger, and that the offender is now in treatment all lead to better outcomes.
7) Assessment and treatment options for patients referred to the SBC are summarized in the Table. More complete summaries of the SBC approaches have recently been published, and clinicians should consult those and other recommendations.3,4 The SBC recommends adopting a scientific approach in which hypotheses are explicitly stated (and shared) with the patient, and they are tested and revised according to how successful the initial intervention was.
The SBC has recently received funding to begin a new project, which is to take what has been learned in the treatment of men and women who have committed sex crimes and apply it to people who have pedophilic interests before they have been charged. The hope is that earlier interventions will be even more successful and that future editions of the DSM will include “in full remission” designations for both pedophilia and pedophilic disorder.
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.