Changes in Sexual Arousal as Measured by Penile Plethysmography in Men with Pedophilic Sexual Interest

Perspective: Clinical care of pedophilic individuals in Zurich, Switzerland

Individuals with pedophilia are considered to have an elevated risk for child sexual abuse (CSA). Nevertheless, it is assumed that pedophilic sexual impulses can be controlled from acting out. To prevent CSA an outpatient treatment facility for people with pedophilia was founded in Zurich, Switzerland in 2021. The program focuses on the prevention of CSA and improvement of quality of life, incorporating empirically validated treatment principles, such as the Risk-Need-Responsivity (RNR) model and the Good Lives Model (GLM). Within the initial 24-month 142 individuals sought help, 46 individuals (mean age 36.0 ± 12.4 years) completed the assessment phase, two-thirds suffered from psychiatric comorbidities, and 67.4% reported sexual delinquency. The high drop-out rate was predominantly due to ongoing criminal proceedings, or other mental health conditions. Overall patients at this facility generally sought treatment voluntarily, leading to good treatment adherence, with severe self-harm being more prevalent than acute danger to others. A treatment approach focused solely on pedophilia is considered insufficient; psychiatric and psychosocial factors must also be addressed.

"Not Offending Is Easy. The Double Life, the Secrets, the Loneliness Are the Hardest Parts I Needed Help with": Understanding the Treatment Needs of People with Attractions to Children

People with sexual attractions to children are often subject to heavy stigmatization, and several studies have started to look at how this affects their mental health. This is likely due to a conflation with offending and sexual risk within society, which translates into academic work on the topic. In this context, little is known about how the experiences of non-offending individuals with attractions to children inform their treatment needs in non-forensic contexts. We conducted anonymous semi-structured interviews with large sample of 31 non-offending adult men who are attracted to children, recruited through online forums. The results focus on two superordinate themes central to interpersonal and intrapersonal experiences, and the effects of these on both everyday functioning ("Living with a sexual interest in children"), and perceived treatment needs ("Establishing treatment targets"). These findings hold significance for the effective design and delivery of both preventative and healthcare-related support services, particularly in relation to early intervention and assisting this population in living full lives with their sexual attractions.

Perspectives, Treatment Goals, and Approaches of Prevention-Specialist Mental Health Professionals in Working With Clients Attracted to Children

The provision of effective mental health services to individuals attracted to children is rapidly expanding. However, these services have not yet been integrated into general mental healthcare systems and are mainly offered by organizations that predominantly provide services to child sexual abuse perpetrators. Little is known about the perspective, treatment goals, and approaches employed by prevention-specialist mental health professionals when working with clients attracted to children. To address this gap, we used purposive sampling to recruit 10 practitioners who had experience of working in prevention settings with clients attracted to children. After conducting semi-structured interviews and analyzing data through interpretative phenomenological analysis, we identified three main themes and four subthemes within the data. While most participants believed that attraction to minors is unmodifiable or doubted the possibility of modifiability, this belief did not necessarily manifest in their practice. Participants stressed the importance of finding safe alternatives for clients and highlighted the significance of accessing evidence-based information on alternative sexual outlets, such as sex dolls. One overarching theme that emerged across all themes and within participants' accounts was the concern of escalation, indicating a fear that pedophilic fantasies or alternative sexual outlets such as sex dolls could potentially lead to sexual offenses. The findings shed light on the approach of prevention-specialist mental health professionals in working with clients attracted to children and may be used to inform future intervention plans to facilitate service provision to this population.

Atypical Sexual Interests in Compulsive Sexual Behavior: Results From a Phallometric Study

The link between Compulsive Sexual Behavior (CSB) and atypical sexual interests is elusive. This study aimed to provide preliminary insights into the relationship between both aspects. The study sample comprised 61 self-identified straight men. CSB was measured through a composite self-report index assessing symptoms of CSB, whereas sexual interests -atypical and normophilic- were assessed objectively through penile plethysmography. The CSB index had small, non-significant correlation with greater sexual response to different sexual stimuli (r_{general sexual responsiveness}=.127 [95% CI: -.137, .384]). In terms of overall sexual interest, increased scores on the CSB index had small, non-significant correlation with a higher preference for younger sexual stimuli (r = -.098 [95% CI: -.499, .215]) and persuasive sex (r = .10 [95% CI: -.168, .316]). Finally, CSB had a moderate correlation with sexual response when presented with stimuli depicting "female toddler coercive" (r = .27 [95% CI: -.083, .544]). We conclude that our findings do not support the hypotheses that CSB is significantly related to an increased arousability across sexual stimuli. The study findings also suggest that CSB may be, to a small degree, predisposed to experience sexual attraction toward children. Given the preliminary nature of the study, these conclusions warrant further research. Alternative explanations for the study findings related to the particular components of CSB that may be related to typical and atypical sexual interests are also considered.

Primary Health Professionals' Beliefs, Experiences, and Willingness to Treat Minor-Attracted Persons

There is a desire and need among minor-attracted persons (MAPs) to access support within the community, and this often begins with an approach to healthcare providers working in general medical/mental health settings. However, little is known about the experiences of these non-specialist professionals in relation to their beliefs, knowledge, and decision-making processes when working with patients who disclose sexual attractions to children. Using an online survey, this study explored the knowledge, comfort, competence, and treatment willingness of 220 non-specialist healthcare providers when faced with patients who disclose sexual attractions to children. We investigated how often such disclosures were made, clinician stigma, treatment priorities, and professionals' willingness to report MAPs to external agencies because of their sexual attractions. Some key differences were found when comparing primary medical vs. mental health professionals, including increased likelihood to view MAPs as dangerous, unable to control behaviors and that sexual attractions are an avoidable choice, in the former group. Both groups prioritized mental health treatment targets above controlling attractions and living with stigmatized attractions, although controlling or changing attractions were still relatively high priorities. Results indicated a need for further training, focusing on increasing comfort around working with MAPs, as this was associated with a greater willingness to work with this group. We identify current gaps in service provision for MAPs seeking professional support and discuss recommendations for professional training.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Use of penile plethysmography in the court: A review of practices in Canada, the United Kingdom and the United States

Penile plethysmography (PPG) is an objective measure of male sexual arousal in response to the presentation of a series of erotic and neutral stimuli. This measure is now widely recognized as the most reliable means of objectively measuring male sexual arousal to specific stimuli. Many clinicians and researchers consider PPG to be a vital contribution to the assessment and treatment of adult men with paraphilic interests and men who have committed sex crimes. PPG contributes to the clinical assessment of paraphilic interests, appraisal of risk of recidivism, and provides an objective measurement of changes in sexual arousal in response to treatment. There is strong support for the utility of PPG within clinical and legal contexts. This article addresses ways in which PPG has been utilized in the courts as part of expert clinical opinion. History of its use, details regarding admissibility in court, and case law are explored within the legal systems of Canada, the UK and the USA. Support for the inclusion of PPG as expert evidence is provided and judicial misunderstandings on the rationale for PPG use and its clinical utility in forensic assessments are discussed.

Stimuli used in the measurement of problematic sexual interests

Penile plethysmography (PPG) is the primary physiologic assessment method used to gauge sexual responses in adult men. Depending on the country or jurisdiction of assessment, stimuli used to elicit arousal can include videos, still images, and audio materials. It can depict a variety consenting and non-consenting sexual scenarios as well as neutral, non-sexual scenarios. Models in visual stimuli can be clothed, semi-clothed, or nude. Variation in stimuli modality and the type of sexual interest being tested can have a large impact on PPG outcomes. This paper reviews research on types of PPG stimuli, the different sexual interests being assessed, reliability and validity, and the impact of anonymizing models depicted in assessment materials. Innovations in stimuli development in three labs located in Canada, the United States, and the Czech Republic are also discussed. The work done in these three labs and the broader range of research on assessment stimuli are presented to highlight the need for a unified, multi-site, standardized approach to assess problematic sexual interests and their change in response to treatment.

Taxometric Analysis of the Latent Structure of Pedophilic Interest

The present study examined the latent structure of pedophilic interest. Using data from phallometric tests for pedophilic interest across four samples of offenders (ns = 805, 632, 531, 261), taxometric analyses were conducted to identify whether pedophilic interest is best characterized as taxonic or dimensional. Across the samples, the majority of analyses supported taxonic latent structure in pedophilic interest. Visual inspection of taxometric curves indicated trichotomous latent structure (i.e., three-ordered classes) may characterize pedophilic interest in these samples. In a second step of taxometric analysis, the results supported trichotomous latent structure, indicating the presence of a complement taxon and two pedophilic taxa. In comparison with the complement taxon, the men in the first pedophilic taxon were non-exclusively pedophilic and had similar rates of sexual recidivism and sexual compulsivity. The men in the second pedophilic taxon were exclusively pedophilic, had more child victims and total victims, sexually re-offended at a higher rate, and were more sexually compulsive. The finding of trichotomous latent structure in pedophilic interest is both consistent and inconsistent with previous taxometric studies and has implications for research, assessment, and treatment of pedophilic interest.

"It's Not Something I Chose You Know": Making Sense of Pedophiles' Sexual Interest in Children and the Impact on Their Psychosexual Identity

Sexual interest in children is one of the most strongly predictive of the known risk factors for sexual reconviction. It is an important aspect of risk assessment to identify the presence of such interest, and an important task for treatment providers to address such a sexual interest where it is present. It has been argued that understanding pedophiles' deviant sexual interest in children can enhance risk assessment, management, and treatment planning. This research study aims to explore the phenomenology of deviant sexual interest in children, the impact it has on pedophilic offenders' identities, and their views on the treatability of that interest. The study used semistructured interviews and repertory grids to make sense of participants' experiences. The results revealed three superordinate themes: "'living' with a deviant sexual interest," "relational sexual self," and "possible and feared sexual self." The analysis unpacks these themes and repertory grid analysis is used to explore a subset of participants' identities in more detail. The results reveal that there needs to be an acceptance from both client and therapist that their sexual interest in children may never go away. Through this acceptance, clients could work on enhancing sexual self-regulation, recognizing their triggers, and so managing their sexual thoughts, feelings, and behavior. Implications for treatment are also discussed.

Diagnostic Issues in the Paraphilias

PURPOSE OF REVIEW

To examine the empirical bases underlying the diagnoses of the paraphilias. We address issues concerning the reliability of these diagnoses and their implications for etiology, treatment, and prognosis.

RECENT FINDINGS

Research on these issues with the paraphilias is quite limited except for those paraphilics whose interests lead them to sexually offend. Even among these clients, research has, for the most part, failed to distinguish those who meet criteria for a paraphilia from those who do not, thereby limiting the possibility of drawing firm conclusions regarding the value of a paraphilic diagnosis. Speculations regarding the etiology of the paraphilias are for the most part limited to those who sexually offend and these theories do not distinguish those who do, or do not, meet paraphilic criteria. Treatment of sex offenders, when effective, appears to have the same impact regardless of whether or not clients meet criteria for a paraphilia. In terms of prognosis, it was only among untreated child molesters that a paraphilic diagnosis (in this case "pedophilia") predicted long-term outcome. In the face of these problems, we suggest a dimensional approach to diagnoses may represent an improvement over the current categorical model.

Keep Faith in Yourself! A Pilot Study on the Relevance of Specific Self-Efficacy for Modifying Sexual Interest in Children Among Men With a Risk to Sexually Abuse Children

Among 26 pedophilic/hebephilic men, we investigated (1) the relationship between "specific self-efficacy for modifying a sexual interest in children" (SSIC) and actual sexual interest in children and (2) whether changes in SSIC are associated with changes in sexual interest in children. Results showed that the more clients believe they are able to influence their sexual interest in children, the less strong they perceive their sexual interest in children to be. Furthermore, an increase in SSIC is associated with a decrease in sexual interest in children. We suggest avoiding generalized statements about the immutability of sexual interest in children.

Inhibiting Sexual Arousal to Children: Correlates and Its Influence on the Validity of Penile Plethysmography

The current study examined the extent to which 1136 men were able to inhibit their sexual arousal on a phallometric assessment, when instructed to do so. Although the observed changes between the two conditions (i.e., Normal and Suppression) were small to moderate in magnitude, the change was not more than what would be expected by measurement error for most participants (e.g., 83% of pedophilic sex offenders against children did not successfully inhibit their sexual arousal in the Suppression condition). There were very few variables that were associated with the ability to suppress. Higher Pedophilia Index scores in the Suppression condition predicted a greater likelihood of sexual recidivism among sex offenders (hazard ratio = 1.17, 95% CI [1.04, 1.32]), but the ability to suppress sexual arousal was not found to predict sexual recidivism. The current study highlights the importance of accounting for measurement error and found that, when doing so, most sex offenders against children are unable to successfully inhibit their sexual arousal to children when instructed to do so, and that the ability to suppress sexual arousal is not associated with recidivism.

The Puzzle of Male Chronophilias

In this article, I return to the idea that pedophilia, a sexual interest in prepubescent children, can be considered a sexual orientation for age, in conjunction with the much more widely acknowledged and discussed sexual orientation for gender. Here, I broaden the scope to consider other chronophilias, referring to paraphilias for age/maturity categories other than young sexually mature adults. The puzzle of chronophilias includes questions about etiology and course, how chronophilias are related to each other, and what they can tell us about how human (male) sexuality is organized. In this article, I briefly review research on nepiophilia (infant/toddlers), pedophilia (prepubescent children), hebephilia (pubescent children), ephebophilia (postpubescent, sexually maturing adolescents), teleiophilia (young sexually mature adults, typically 20s and 30s), mesophilia (middle-aged adults, typically 40s and 50s), and gerontophilia (elderly adults, typically 60s and older) in the context of a multidimensional sexual orientations framework. Relevant research, limitations, and testable hypotheses for future work are identified.

Regression to the Mean Mimicking Changes in Sexual Arousal to Child Stimuli in Pedophiles

The sexual preference for prepubertal children (pedophilia) is generally assumed to be a lifelong condition. Müller et al. (2014) challenged the notion that pedophilia was stable. Using data from phallometric testing, they found that almost half of 40 adult pedophilic men did not show a corresponding arousal pattern at retest. Critics pointed out that regression to the mean and measurement error might account for these results. Müller et al. contested these explanations. The present study shows that regression to the mean in combination with low reliability does indeed provide an exhaustive explanation for the results. Using a statistical model and an estimate of the retest correlation derived from the data, the relative frequency of cases with an allegedly non-pedophilic arousal pattern was shown to be consistent with chance expectation. A bootstrap simulation showed that this outcome was to be expected under a wide range of retest correlations. A re-analysis of the original data from the study by Müller et al. corroborated the assumption of considerable measurement error. Therefore, the original data do not challenge the view that pedophilic sexual preference is stable.

Understanding Online Child Sexual Exploitation Offenses

In the past three decades, there has been an exponential increase in the worldwide availability of Internet access and devices that are able to access online materials. This literature review investigated whether increased accessibility of Internet child pornography (CP) increases the risk of in-person child sexual exploitation. The current review found little to no evidence that availability of the Internet has increased the worldwide incidence or prevalence of in-person child sexual abuse. In fact, during the time period in which the Internet has flourished, international crime statistics have shown a steady decrease of in-person child sexual abuse. The only exception to this trend is an increase in Internet child pornography or luring offenses (e.g., Stats Can, 2014), which involves child abuse by definition. This article reviews the impact of the Internet on child sexual abuse. It also reviews the characteristics of online CP offenders. Treatment of these offenders and prevention of such offenses is also discussed.

Stability of Self-Reported Arousal to Sexual Fantasies Involving Children in a Clinical Sample of Pedophiles and Hebephiles

In forensic research, there is a controversial discussion concerning the changeability or stability of pedophilia. Seto (2012) conceptualized pedophilia as a sexual age orientation characterized by an early onset, correlations with sexual and romantic behavior, and stability over time. However, empirical data are sparse and are mostly based on samples of detected offenders. The present study examined self-reported arousal to sexual fantasies involving children in a clinical sample of pedo-/hebephiles. In Study 1, retrospective self-reports on the age of onset and duration of sexual interest in minors were examined. In Study 2, the stability and variability of self-reported arousal to sexual fantasies involving children were evaluated prospectively. Non-prosecuted self-identifying pedo-/hebephilic men seeking professional help were recruited within the Berlin Prevention Project Dunkelfeld. Between 2005 and 2013, 494 participants completed the intake assessment. Self-reported data were collected via questionnaire focusing on sexual arousal to fantasies during masturbation involving prepubescent and/or early pubescent minors. Subsequent assessments of sexual arousal were obtained for 121 of the participants. The average time between the first and last assessment was approximately 29 months. Spearman's correlation coefficients examined the between-group rank-order and Wilcoxon signed-rank tests examined the within-individual mean-level stability. The majority of subjects reported an early onset of their pedo-/hebephilic sexual arousal. The rank-order stability was medium to high. Over the investigated period, the majority of subjects showed no or only minimal decrease or increase of self-reported sexual arousal. These results suggested that sexual arousal to fantasies involving prepubescent and/or early pubescent children is stable. Furthermore, the results support the conceptualization of pedo-/hebephilia as a sexual age orientation in men.

Standardization of Penile Plethysmography Testing in Assessment of Problematic Sexual Interests

Penile plethysmography (PPG) is an objective measure of sexual arousal for men, commonly used to assess sexual arousal to both abnormal (i.e., paraphilic) and normal stimuli. While PPG has become a standard measure in the assessment and treatment of male sex offenders and men with paraphilic interests in both Canada and the United States, there is a lack of standardization of stimulus sets and interpretation of results between sites. The current article critically reviews the current state of the art while highlighting clinical and research efforts that may be undertaken in an attempt to reduce issues arising from lack of standardization across sites. Types and themes of stimulus sets, assessment apparatuses, laboratory preparation, and testing procedures are discussed. The continued development of standardized testing protocol and procedures across multiple international sites continues to be encouraged to promote unified PPG administration and interpretation, thus further enhancing the practical utility of the measurements and decreasing inter-rater discrepancies and error.

Assessment of problematic sexual interests with the penile plethysmograph: an overview of assessment laboratories

Phallometric testing, or penile plethysmography (PPG), is an objective measure of sexual arousal for males. While extensive research on the reliability and validity of PPG has promoted its reputation as the "gold standard" of objective measurement of sexual arousal, there is a lack of standardization of stimulus sets and interpretation of results between sites. This article describes the laboratory protocol employed for PPG at the Royal Ottawa Mental Health Centre's Sexual Behaviours Clinic (SBC) in Ottawa, Ontario, as well as those used by the Sexual Behaviors Clinic and Lab (SBCL) in the Community and Public Safety Psychiatry Division (CPSPD) of the Department of Psychiatry and Behavioral Sciences at Medical University of South Carolina (MUSC) in Charleston, South Carolina. The need for standardization in both testing protocol and stimuli use across sites are highlighted.

Assessment of female sexual arousal in forensic populations

Sexual offenses cause significant harm to victims, their families, and society as a whole and thus are an important social concern. While it is commonly assumed that sexual offenses are committed solely by males, research has shown that approximately 5 % of sex crimes in the USA and Canada are committed by females. Penile plethysmography (PPG) is a method to measure male genital arousal, which is commonly used in the assessment and treatment of male sex offenders and men with paraphilic sexual interests. Similarly, vaginal photoplethysmography (VPP) is a test to measure female genital arousal and is commonly used to assess female sexual dysfunctions. Although VPP is currently the most validated method to measure genital arousal in women, its use with female sex offenders or females with paraphilic sexual interests has been almost nonexistent. One explanation for this is that some research has suggested that female genital arousal may not be category-specific, meaning that women will respond to any sexual cues, not just those involving their preferred sexual interests. However, not all research supports this finding. Due to the potential benefits of using VPP in the assessment and treatment of female sex offenders or females with paraphilic sexual interests, it is important that further research be done before dismissing the use of VPP in forensic populations. The purpose of this article is to review the current research on VPP and its applicability to female sex offenders and females with paraphilic sexual interests.