Pedophilia and DSM-5: The Importance of Clearly Defining the Nature of a Pedophilic Disorder
Fred S. Berlin, MD, PhD J Am Acad Psychiatry Law 42:404 –7, 2014 - EDITORIAL
Dr. Berlin is Associate Professor, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD. Address correspondence to: Fred S. Berlin, MD, 104 E. Biddle Street, Baltimore, MD 21202. E-mail: < firstname.lastname@example.org >.
Psychiatric terminology should convey information in as clear and unambiguous a manner as possible. In light of the associated stigma, that is especially so of the terms Pedophilia and Pedophilic Disorder. Although from a psychiatric perspective the term Pedophilia is intended to define a recognized clinical entity, in the collective consciousness of contemporary society, the term has become a demonizing pejorative.
Many in society are likely to equate Pedophilia with child molestation. They are not the same. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)[*1]
[*1] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association, 2013
may be contributing inadvertently to the misconception that they are the same, for the following three reasons:
First, DSM-5 states that an indicator of a Pedophilic Disorder would be that an individual has “acted on” his sexual urges (Ref. 1, p 697). “Acted on” could mean that he has actually molested a child. On the other hand, it could also mean that he has masturbated to pedophilic fantasies or that he has viewed child pornography.
The current criteria for diagnosing a Pedophilic Disorder place some persons who have never molested a child into the same diagnostic category as those who have done so. That could cause confusion, suggesting that the current definition of a Pedophilic Disorder may lack adequate diagnostic specificity. As a consequence, the distinction between being sexually attracted to children in some fashion (e.g., experiencing urges to view child pornography) and experiencing urges to act on that attraction with a child can easily be lost.
Second, at present, in discussing Pedophilia, DSM-5 makes reference to the term Pedophilic Sexual Orientation. Sexual Orientation is ordinarily used to designate the category, or categories, of persons whom a given individual finds to be sexually appealing. Those who are heterosexually oriented are sexually attracted to adults of the opposite sex; those who are homosexual, to adults of the same sex; men with a heterosexual pedophilic orientation, to prepubescent females; and men with a homosexual pedophilic orientation, to prepubescent boys.
In the face of significant criticism of its inclusion in the DSM-5, the American Psychiatric Association (APA) has stated its intention to remove the term Pedophilic Sexual Orientation from the diagnostic manual.[*2]
[*2] APA Statement on DSM-5 Text Error: pedophilic disorder text error to be corrected. Press release. Arlington, VA: American Psychiatric Association, October 31, 2013. Available at http://www.dsm5.org/Documents/13-67-DSM-Correction-103113.pdf. Accessed May 31, 2014 [*]
Removing that term in response to public criticism would be a mistake. Experiencing ongoing sexual attractions to prepubescent children is, in essence, a form of sexual orientation, and acknowledging that reality can help to distinguish the mental makeup that is inherent to Pedophilia, from acts of child sexual abuse.
Third, in discussing the nature of a Pedophilic Disorder, DSM-5 has done little to characterize the multitude of psychiatric burdens associated with the condition, burdens that are frequently present, even in the absence of any acts of child sexual abuse.
Viewing Child Pornography
Viewing child pornography should not be considered a useful diagnostic indicator of a Pedophilic Disorder. DSM-5 states that the “extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of a Pedophilic Disorder” (Ref. 1, p 698).
Any diagnosis simply constitutes a way of conveying information in shorthand. For example, when a diagnosis of Diabetes, Schizophrenia, or Anorexia Nervosa is made, that diagnosis conveys a great deal of useful information to a properly trained physician. For that reason, it is critical that the information conveyed not be misleading, particularly in a forensic setting. Under current circumstances, a diagnosis of Pedophilic Disorder can infer a risk of hands-on offending with children. If the diagnosis is made largely on the basis of the use of child pornography, the inference may be inaccurate, with potentially unwarranted negative consequences for the individual.
There are two ways of trying to determine whether those who have viewed child pornography pose a risk of hands-on offenses with children. One way is statistical, and the other clinical.
From both a clinical and an actuarial statistical perspective, an early retrospective study conducted at a Federal Civil Commitment Facility in Butner, North Carolina, inferred an association between accessing child pornography and hands-on sexual offending. [*3]
[*3] Bourke ML, Hernandez AE: The “Butner Study” redux: a report on the incidence of hands-on child victimization by child pornography offenders. J Fam Violence 24:183–91, 2009
From a purely statistical standpoint (all else being equal) individuals with no history of a hands-on sexual offense against a child, but who have accessed child pornography, are at low risk as a group of committing a hands-on sexual offense in the future. [*5]
From a forensic clinical perspective, as opposed to an actuarial perspective, it is important to be aware that when individuals are investigated by criminal justice authorities for having allegedly accessed child pornography, their computers and other electronic devices are routinely confiscated. That enables investigators to ascertain whether attempts have been made to enter chat rooms that cater to children and whether an electronic device has been used to try to entice a child.
In many instances, youngsters within the home of the suspect may have been questioned by child protective services and deemed not to have been abused. There may have been media publicity, with no children having come forward alleging sexual abuse.
These matters can and should be assessed when performing a forensic evaluation. Diagnosing a Pedophilic Disorder in the absence of credible forensic or clinical evidence of an attempt to engage a child sexually could mistakenly infer that such contacts with a child had occurred or that they were likely to occur. For that reason, one should not ordinarily diagnose a Pedophilic Disorder in the case of individuals who have viewed child pornography, but who have no known history of child molestation.
DSM-5 includes a diagnostic category labeled Other Specified Paraphilic Disorder. In the absence of evidence of any prior attempts to approach a child sexually and assuming that the criteria to diagnose a paraphilic disorder are present, one could achieve diagnostic specificity by making that diagnosis in the case of individuals who have viewed child pornography. The primary components of that diagnosis would be Pedophilia and Voyeurism, with the added specifier that pedophilic acts have been limited to the voyeuristic viewing of child pornography. Such a diagnosis would convey information in a clear and unambiguous fashion.
Clinically (as opposed to forensically), making distinctions between fantasies (e.g., voyeuristic fantasies) and real-life intentions is frequently not difficult. Many men in therapy have acknowledged feeling sexually aroused by images depicting rape, and some women have acknowledged being sexually aroused by fantasies of being raped. That does not mean that most such men are likely to become rapists or that most such women actually want to become rape victims. With the advent of the Internet, distinguishing between private fantasies and public intentions constitutes an ongoing forensic concern. Even though viewing sexualized images of children is illegal, privately viewing such images and fantasizing about them does not necessarily reflect a real-life intent or interest in being sexual with a child.
Pedophilia as a Sexual Orientation
DSM-5 did not err in referring to Pedophilia as a sexual orientation. In diagnosing any psychiatric disorder (including a Pedophilic Disorder), ordinarily the intent is to guide patient care, management, and research. In discussing the diagnostic features of individuals who are sexually attracted to prepubescent children, DSM-5 notes that some could be said to have a pedophilic sexual orientation.
The term sexual orientation ordinarily reflects an individual’s subjective awareness of the category (or categories) of persons toward whom he or she is erotically attracted. Clinically, there are individuals (many of whom are described as having Pedophilia) who report a subjective awareness of being erotically attracted (either exclusively or in part) toward a category of individuals comprised of prepubescent children. Many report experiencing those attractions as unchosen in a fashion that seems very much like an orientation. That such attractions are often unwanted does not alter their resemblance to an orientation.
In expressing its intent to remove the phrase Pedophilic Sexual Orientation from the DSM-5 discussion of Pedophilia, the APA press release stated in part
“APA stands firmly behind efforts to criminally prosecute those who sexually abuse and exploit children and adolescents. We also support continued efforts to develop treatments for those with a Pedophilic Disorder with the goal of preventing future acts of abuse.” [*2]
Without question, the protection of children should be a priority both for society and for the psychiatric profession. The APA statement says nothing about why persons diagnosed with a Pedophilic Disorder need or deserve treatment in their own right or about why (except for the disturbing consequences of acting upon pedophilic urges) Pedophilia should not be thought of as an orientation.
The APA was correct in supporting a criminal justice component to the serious matter of child sexual abuse. To the extent that pedophilic urges and fantasies cannot be either punished or legislated away, the APA was also correct in publically supporting the need for effective psychiatric treatment for individuals who have a Pedophilic Disorder. Publicly acknowledging Pedophilia as a sexual orientation that can be distinguished from a criminal mindset might also have been useful.
Distinguishing Psychiatric and Criminal Implications
DSM-5 does not adequately assist in distinguishing the psychiatric aspects of a Pedophilic Disorder from its potential criminal implications. Given the common misconception that Pedophilia is synonymous with child sexual abuse, DSM-5 has done little to define and characterize a Pedophilic Disorder as a psychiatric condition in its own right, independent of its potential criminal implications. DSM-5 has properly concluded that experiencing a recurrent sexual attraction toward children does not by itself constitute evidence of a disorder, unless those attractions also cause distress or some other significant difficulties. At the same time, experiencing pedophilic attractions can create a significant psychiatric burden and, in some cases, can make it very difficult to maintain full and consistent self-control.
In supporting the involuntary civil commitment and need for treatment of some individuals diagnosed with a Pedophilic Disorder, the United States Supreme Court used the presence of such a difficulty in self-control to justify civil commitment. [*7]
[*7] Kansas v. Hendricks, 521 U.S. 346, 1997
In fact, the decision went so far as to limit persons eligible for civil commitment to those who were “not able to control” their “sexual criminal acts.”
If the criminal justice system is acknowledging, as it seems to be, that having a Pedophilic Disorder can sometimes make it difficult to maintain proper self-control, why has the DSM failed to address that psychiatrically relevant question? The point here is not to argue that diagnostically related issues should be guided by legislative intent or by judicial decisions. It is simply to suggest that DSM-5 could have at least noted that some persons with a Pedophilic Disorder may need treatment, because it can sometimes be difficult to maintain consistent behavioral control without it.
Behaviors enacted by persons with a Pedophilic Disorder are energized by a powerful biological force (i.e., sex drive). [*8]
[*8] Berlin FS: Pedophilia: criminal mindset or mental disorder?—a conceptual review. Am J Forensic Psychiatry 32:3–26, 2011
Behaviors that are energized by powerful biological cravings (whether such cravings are for heroin, alcohol, or cocaine or for some unacceptable form of sexual activity) can be difficult to resist, sometimes necessitating psychiatric assistance. The psychiatric burden can be especially difficult for individuals who are sexually attracted exclusively to children, because, for good reason, society must prohibit them from having sexual contact with any and all members of the category of persons whom they find to be sexually appealing. Having to go through life under such circumstances can be both challenging and distressing.
Recently an organization called B4U-ACT conducted an anonymous Internet survey designed to obtain information from persons who feel sexually attracted to prepubescent children. [*9]
[*9] Available at < http://b4uact.org/science/survey/02.htm >. Accessed May 30, 2014
One hundred ninety-three individuals from a variety of countries and ranging in age from 15 to 70 responded to that survey. That survey found that
Clearly, this is a population in need of mental health care, and 40 percent of respondents had expressed an interest in receiving it.
Some survey respondents had made comments pertinent to appreciating the stress that can be associated with Pedophilia. For example, one stated:
“I’m a 15-year-old male... I’m not attracted to anyone my age or older anymore. I am only attracted to prepubescent girls. I feel like there is no hope for me to live, and some- times I feel like killing myself. . . . I know the idea of a psychologist and everything, but I can’t talk to anyone at this time because my parents would find out and get the wrong idea, and people would judge me and think I really want to hurt little kids.” [*9]Another said:
“I want to have sex with children all the time, but I cannot and will not because it will ruin that child’s life, and it will do the same for mine. I look at pictures all the time. That helps me to deal with my desires without actually going out and having sex with a young child.” [*9]Yet another stated:
“Parents will disown you, teachers will report you, friends will abandon you. People in my situation can’t discuss this without serious risk of persecution and/or harassment.” [*9]
Some of those wanting help may have mistakenly believed that mandatory reporting statutes would require that criminal justice authorities be notified, even if they had never approached a child sexually.”
In discussing the diagnostic features of a Pedophilic Disorder, DSM-5 states that
“the presence of multiple victims. . . is sufficient but not necessary for the diagnosis” (Ref. 1, p 698).
Once again, in emphasizing the possible (though certainly not inevitable) criminal implications of a Pedophilic Disorder, the DSM says little about why persons with this very stigmatized, and often misunderstood, condition need and deserve psychiatric help.
DSM-5 has placed insufficient emphasis on the psychiatric burdens of a Pedophilic Disorder that justify its inclusion in the DSM, even in the absence of any criminal misconduct. As a profession that bridges the gap between the scientific/medical communities and the criminal justice system, forensic psychiatry has both the opportunity and the obligation to further clarify these important matters.