Tuesday 24 October 2017

Targeting Paedophilia... the last taboo

Dr Patricia Casey
Dr Patricia Casey

Patricia Casey

Paedophilia is defined as a sexual attraction to children under the age of 12. It has traditionally been regarded as a psychiatric disorder and continues to be, but increasingly, researchers and psychiatrists, particularly in the US, distinguish between those who don't act on their fantasies and those who do.

The American Psychiatric Association, which attempted to incorporate this distinction in their Diagnostic Manual by identifying one as an orientation and the other as a disorder, had to rescind this decision in 2013 after a backlash from those fearing that the way was being paved towards ultimately accepting all pedophilic attraction and behaviour as an orientation like homosexuality or heterosexuality.

The APA responded by saying that it supports the criminalisation of those who molest and exploit children while supporting developments in treatment for those with non-offending paedophilic disorder. In other words, it is saying that not all paedophiles are sexual offenders.

The composer Benjamin Britten is one such person who was reportedly attracted to boys but never engaged in sexual activity with them. However, the public does not make this distinction and for them, paedophilia is synonymous with the abuse of children. The images of Catholic priests and of high-profile media stars denying any untoward sexual activities reinforce this.

Damien McGuinness presented a fascinating, but disturbing, documentary on BBC Radio 4 on July 13. It discussed a project in Germany that offers treatment to paedophiles without reporting them to the police. There is acceptance there that there are some who loath the attraction they feel for children and have never offended. It is hoped that treatment can enable them to avoid this.

The comment of one interviewee resonated when he said: "A treatment like this can prevent the first offence. Criminalisation - if it works very, very well, and it usually doesn't - can only prevent the second offence."

The Dunkelfeld Prevention Project, operating at 11 centres across Germany, provides the intervention free for one year. Therapy is available for those who request it, in the knowledge that they will not be reported to the police for having this attraction. Since its launch in 2005, over 4,500 patients, mostly men, have entered therapy.

The treatment is a form of cognitive behavioural therapy (CBT), which analyses past sexual behaviour and feelings and develops strategies to avoid potentially abusive situations in the future. Some practical advice is very simple, such as never being alone with a child.

Other more complex approaches involve changing attitudes. For example, helping the patient to grasp that sexual contact with children can never be consensual.

A controversial aspect of the programme is that it is also available to past unidentified offenders who say they do not want to reoffend. In Ireland, such a person would have to be reported to the gardai, but in Germany, according to Dr Anna Konrad, a psychologist specialising in the treatment of paedophiles, there is no obligation to report past abuse and doctors are prohibited by law from violating the principle of doctor-patient confidentiality.

She is adamant that "this is not a grey area" since the aim of this approach is child protection above all else. She argues that the requirement in other countries to report past offences makes it very difficult for such people to come forward for treatment and that this would also compromise the exploration of these people's past sexual behaviour in therapy.

Germany now also supports an initiative called the "Step Out of the Shadows Project" to encourage non-offending paedophiles to seek treatment, and is running a national advertising campaign.

"I always knew I was different and what others thought about people like me," say masked men in a TV ad - one dressed as a doctor, another as a workman, another as a student.

"No-one is guilty because of their sexual inclination - but everyone is responsible for their behaviour," says the final young man as he takes the mask off, adding: "I don't want to become an offender."

Another ad says: "Do you love children more than you'd like to? There is help."

According to colleagues of mine in Germany, such advertisements are no longer controversial there.

Some aspects of the German's approach seem appropriate, particularly for those who have never offended. Yet, it is troubling that those who have offended in the past are not reported to the police.

How can the therapist know if a person with paedophilic attraction is being truthful about their offending history? It is also disquieting that potential offenders are in contact with each other with the possibility of these well-meaning groups becoming a recruiting ground for paedophile rings.

The German project published data on its results in the Journal of Sexual Medicine in February this year. Using self-reports, it found in the group, as a whole (offenders and non-offenders), that compared to a waiting-list control group, the therapy group had better self-regulation and better emotional control. Among a subgroup of former offenders, one-fifth were still engaging in abuse and most were still using child pornography.

It is difficult to forecast how these mixed results influence the direction of this project. They suggest that the non-offenders are more likely to benefit, while the impact on offenders seems unimpressive. Of course, more data will emerge over time.

I have mixed feelings about this approach. I have seen patients in the past who had an attraction to children, but didn't act on it, and it would be immensely helpful if there was a treatment that would prevent progression to offending.

On the other hand, public advertisements on television may yet be too overt for such a sensitive area and time may show that they worsened rather than improved the situation because of the destigmatisation of this remaining taboo.

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