Pedophilia

Pedophilia is the most widely and intensely repudiated of the paraphilias. Pedophiles are men who erotically and romantically prefer children or young adolescents. They are grouped into categories depending on their erotic preferences for boys or girls and for very young, young, or pubertal children. Some pedophiles have highly age-and sex-specific tastes; others are less discriminating. Because the diagnosis of pedophilia requires that for a period of at least 6 months there are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children, the disorder should not be expected to be present in every person who is guilty of child molestation. Some intrafamilial child abuse occurs more quickly and results from combinations of deteriorated marriages, sexual deprivation, sociopathy, and substance abuse. Child molestation, whether paraphilic or not, is a crime, however. Child molesters show several patterns of erectile responses to visual stimulation in the laboratory. Some have their greatest arousal to children of a specific age, and others respond to both children and adults. Others respond with their greatest arousal to aggressive clues.

Treatment

The treatment of pedophilia involves four general approaches: evaluation only, psychotherapy, medications, and external controls. The psychiatrist is often called on to prescribe the approach.

Evaluation Only

Evaluation only is often selected when the psychiatrist concludes that the pedophilia is benign in terms of society, the patient will be resistant to the other approaches, and the patient does not suffer greatly in terms of social and vocational functioning in ways that might be improved. Often these patients are isolated men with private paraphilic sexual pleasures, such as having telephone sex with a masochistic scenario.

Psychotherapy

What constitutes psychotherapy for pedophilia heavily depends on the psychiatrist’s training rather than on strident declarations of treatment of choice. Little optimism exists that any form of therapy can permanently change the nature of a long-established paraphilic erotic script, even among teenage sex offenders. Individual psychodynamic psychotherapy can be highly useful in diminishing paraphilic intensifications and gradually teaching the patient better management techniques of the situations that have triggered exacerbations. Well-described cognitive-behavioral interventions exist for interrupting paraphilic arousal via pairing masturbatory excitement with either aversive imagery or aversive stimuli. Comprehensive behavioral treatment involves social skills training, assertiveness training, confrontations with the rationalizations that are used to minimize awareness of the victims of sexual crimes, and marital therapy.

The self-help movement has created 12-step programs for sexual addictions to which many individuals now belong. Group psychotherapy is offered by trained therapists as well. When the lives of paraphilic patients are appreciated in various therapies, the emotional pain of the patients is thought to be great; the sexual acting out is often perceived as a defense against recurrent unpleasant emotions from any source.

Medications

In the early 1980s, medroxyprogesterone acetate (Provera) was first used to treat those who were constantly masturbating, seeking out personally dangerous sexual outlets, or committing sex crimes. The weekly 400-to 600-mg injections often led to the men being able to work, study, or participate in activities that were previously beyond them because of concentration or attention difficulties. In the late 1980s, the use of oral medroxyprogesterone (20 to 80 mg/d) led to similar results: the drug enabled these men to leave their former state in which their sexual needs took priority over other life demands, and they did not have the weight gain, hypertension, muscle cramps, and gynecomastia as those on injections sometimes experienced. Although these results are among the most powerful effected by any psychopharmacological treatment, many psychiatrists cannot overcome their negative feelings about giving a “female” hormone to a man or working with patients who victimize others sexually.

Serotoninergic agents have been tried with some initial success with a small number of paraphilic patients. Although these studies are not as sophisticated methodologically as they should be, these drugs are in widespread use for compulsive sexual behaviors and sexual obsessions and are the source of the speculation that pedophilia may be an obsessive-compulsive spectrum disorder.

External Controls

Sexual advantage taking, whether it be by a paraphilic physician with his patients, or a pedophilic mentally retarded man in the neighborhood, or a grandfather who has abused several generations of his offspring and others, can often be stopped by making it impossible for these behaviors to remain unknown to most people in his life. The physician’s staff can be told, the neighbors can know, the family can meet to discuss the current crisis and review who has been abused over the years and plan never to allow the grandfather to be alone with any child forever in the future. The concept of external control is taken over by the judicial system when sex crimes are highly repugnant or heinous. The offender is removed from society for punishment and the protection of the public.

Treatment Summary

Psychiatrists need to be realistic about the limitations of various therapeutic ventures. Sexual acting out may readily continue during therapy beyond the awareness of the therapist. The more violent and destructive the paraphilic behavior to others, the less the psychiatrist should risk ambulatory treatment. Because pedophilia occurs in patients with other psychiatric conditions, the psychiatrist needs to remain vigilant that the treatment program is comprehensive and does not lose sight of the pedophilia just because the depressive or compulsive symptoms are improved. Pedophilia may be improved by the medications and psychotherapy, but the psychiatrist should expect that the intention disorder is the patient’s lasting vulnerability.

Rate this:

2.5

The nicest compliment that you can give me is to to subscribe to the Dental Blogging Newsletter. Thanks for visiting!