Richard Kramer*

The DSM and the Stigmatization of People
who Are Attracted to Minors

Original lecture from the symposium
Pedophilia, Minor-Attracted Persons,
and the DSM: Issues and Controversies;
Wednesday, August 17, 2011, Baltimore, Maryland;
B4U-ACT, Inc., Westminster, MD, http://www.b4uact.org
Reproduced here by permission of the author.

*) Director of Operations, B4U-ACT, Inc., Westminster, MD

Fear of stigma discourages individuals from getting the help they need. More tragically, it deprives people of their dignity and interferes with their full participation in society.

—  Center to Address Discrimination and Stigma,
U.S. Department of Health and Human Services

The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides the mental health professions’ official description of people who are sexually and emotionally attracted to children or young adolescents. Although many “minor-attracted people” (MAPs) may not meet DSM diagnostic criteria for pedophilia, the only description of the attraction to minors found in the dominant professional literature is that devoted to pedophilia. This literature frequently repeats the description found in the DSM (e.g., Hall & Hall, 2007; Pessimism about Pedophilia, 2010) and influences professional beliefs and practices. Therefore, the DSM has a profound influence on the accuracy of the professional literature and on the extent to which MAPs are stigmatized by it, which in turn affect their willingness to seek mental health services.

In this paper, I analyze the DSM-IV-TR (American Psychiatric Association, 2000) and proposed DSM-5 (American Psychiatric Association, 2011) entries for pedophilia for accuracy and potential sources of stigma. First, I will briefly describe characteristics of people who are attracted to minors based on non-forensic research and present survey results regarding their feelings of stigma and reluctance to seek mental health services. Then I will analyze DSM documents for their accuracy and potential to stigmatize. After this, I will use survey results to demonstrate the extent to which MAPs actually feel stigmatized by the DSM and related literature, and how this contributes to their reluctance to seek mental health services. Finally, I will propose guidelines for revising the DSM so that it will serve its professed purpose of helping practitioners identify the needs of their clients.

Characteristics of people who are attracted to children or adolescents

To understand the stigmatizing potential of the DSM, it is helpful to examine relevant findings about the characteristics and behavior of MAPs from non-forensic literature. Forensic research suffers from two shortcomings: it is based on extremely unrepresentative samples—people who have been charged or convicted of crimes—and it starts from criminological assumptions, which bias its results. Thus, by non-forensic research, I mean research that not only uses samples of MAPs in the general population, but also does not start from inaccurate assumptions of pathology or criminality. Although such research is essential for understanding MAPs, it is rare and difficult to conduct today (e.g., see Goode, 2010, pp. 43-56). However, a few helpful studies were conducted 20 to 30 years ago.

Possibly the most important finding from non-forensic literature is that sizable numbers of MAPs may refrain from sexual interaction with children (Hall, Hirschman, & Oliver, 1995; Okami & Goldberg, 1992). They often do so due to the child’s desires and/or the adult’s knowledge of the risk sexual activity poses (Okami & Goldberg, 1992; Sandfort, 1987; Wilson & Cox, 1983).

Another important finding from non-forensic literature (and even some forensic literature) is that the attraction to minors is similar to the attraction to adults in some important ways. It typically involves feelings of affection and being in love (Blanchard, 2009; Howells, 1981; Ingram, 1981; Li, 1990; Sandfort, 1987; Wilson & Cox, 1983). For example, in his study of 27 minor-attracted men in the general population, Li (1990) noted that the majority stressed the importance of affection and emotional closeness in their feelings toward children. Li wrote that that their interaction with children is “comparable to that which obtains in the socially acceptable forms of heterosexual courtship …” (p. 139). Wilson & Cox (1983) found in their study of 77 MAPs that the qualities they found attractive in children were the same as those that form the basis for attraction between adults, and that their sexual fantasies had much in common with those of men attracted to adults. They concluded that “the sexual preferences of the paedophile are not so far removed from those of the normal man as they might at first appear (pp. 100-101).

In addition, the psychological functioning of MAPs in the general population may be similar to those of people attracted to adults, except possibly for those aspects affected by society’s negative reactions to them. Wilson & Cox (1983) found in their sample that the “majority showed no sign of clinically significant psychopathy or thought disorder. The majority of paedophiles … seem to be gentle and rational” (p. 122). Similarly, in their review of non-forensic research on pedophiles, Okami & Goldberg (1992) concluded that “little clinically significant pathology was found” (p. 297).

Feelings of stigma and reluctance to seek services

An online survey conducted by B4U-ACT in the spring of 2011 (B4U-ACT, 2011) showed that MAPs experience intense feelings of stigma at an early age, making them reluctant to seek mental health services when they are aware they need them. A total of 193 respondents ranging in age from under 18 to over 70 participated in this survey. About half (48%) were in the United States, and most of the rest were in Germany (10%), Canada (8%), the Netherlands (8%), and the U.K. (7%).

Feelings of attraction to younger children and the need to hide these feelings occurred early in the lives of respondents. The median reported age at which they were first preferentially attracted to children younger than themselves was 13 (n = 192), and the reported median age at which they first became aware of their feelings was 16. Two-thirds (66%) were under age 18 at first awareness. Respondents made comments such as:

•    “At the age of 13, I didn't really feel there was anyone I could talk to about my attraction to minors or the difficulty I experienced living with the attraction.”

•    “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.”

A significant number of respondents had considered suicide, often while still teenagers, but most felt unable to talk to anyone about their suicidal thoughts or reasons for them. Out of the 171 respondents who answered the questions about suicide, 46% had seriously considered it, 32% had planned a method for carrying it out, and 13% had attempted it. The median age at which they first considered suicide was 19, and 41% were under 18 when they did so. Two-thirds (67%) of respondents with suicidal thoughts felt unable to talk to another person about them. One respondent wrote, “You can't talk to anybody … The shame of committing suicide, or even of having attempted it, is far less than the shame of having attractions society deems inappropriate.” Some teens post at online mental health forums about this. One recently posted:

I'm a 15 year old male … I'm not attracted to anyone my age or older anymore. I'm only attracted to pre pubescent girls … i feel like there is no hope for me to live and sometimes 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 will judge me and think i really want to hurt little kids …

Most people in the survey affirmed that MAPs could benefit from mental health services, but they did not seek services due to fear that professionals would misunderstand, mistreat, and/or report them. Over 80% agreed with the statement, “Sometimes minor-attracted people could benefit from mental health services for reasons related to their attraction other than changing these attractions” but only 30% agreed that “I would seek help from a mental health professional if needed for an issue related to my attraction to minors” (n = 175). Forty percent said that they had actually wanted mental health care for reason related to their attraction to minors, but did not receive it (n = 159). Reasons for their reluctance to seek services included perceptions that their feelings would be misunderstood (85%), that they would be treated disrespectfully (54%; 28% were uncertain), judgmentally (63%; 26% were uncertain), or unethically (46%; 33% were uncertain), or that professionals would not maintain confidentiality about their feelings (51%; 25% were uncertain).

In light of this data and the potential of the DSM to influence professional perceptions of MAPs, I now examine the ways in which the DSM may contribute to stigma and MAPs’ reluctance to seek professional assistance.

Stigmatic aspects of the DSM

Documents related to the DSM-IV-TR and the proposed DSM-5 entry for pedophilia contain implicit assumptions and interpretations that contradict the findings of the non-forensic literature, and that have the potential to significantly stigmatize MAPs.[1]

First, the DSM-IV-TR assumes and implies that all or most people attracted to children or young adolescents engage in sexual behavior with them. Although the DSM-IV-TR accompanying text cursorily allows the existence of those who do not, it goes on to provide a long list of illegal or manipulative acts without ever describing those who do not engage in them. The implication that such behavior is typical is seen in the use of the term “pedophilia” to refer not to the attraction to children, but to sex offenses, as the text drifts into criminological language rather than psychological description. For example, the authors write of “Pedophilia involving male victims” and “the recidivism rate for individuals with Pedophilia.” Such statements are meaningless if pedophilia refers to attractions rather than behavior. Similarly, the literature review supporting the proposed DSM-5 diagnostic criteria (Blanchard, 2010) cites only three non-forensic studies of MAPs, but more than 30 forensic articles.

The DSM-IV-TR accompanying text also perpetuates the belief that people who are attracted to children or adolescents are violent or aggressive, a stereotype that has been thoroughly debunked (Bradford et al., 1988; Constantine, 1981; Crawford, 1981; Feierman, 1990a; Hall, 1996; Howells, 1981; Ingram, 1981; Okami & Goldberg, 1992; Virkkunen, 1981; West, 1998; West & Woodhouse, 1990; Wilson & Cox, 1982). The text misleadingly claims that people with pedophilia “use varying degrees of force” and that in some cases “the disorder is associated with Sexual Sadism.” Such statements could of course be said about people who are attracted to adults; there is simply no research suggesting that aggression is more common among MAPs in the general population than among those who are attracted to adults.

Another problematic implication of the DSM is that the attraction to children or adolescents is qualitatively different from the attraction to adults. The DSM-IV-TR accompanying text makes no mention of the non-sexual feelings that accompany sexual attraction, providing instead only a lengthy list of alleged sexual behaviors. Similarly, the proposed DSM-5 diagnostic criteria refer only to sexual feelings and behaviors. The reader may be left with the misleading impression that sexual attraction to children is devoid of any feelings of love or concern and therefore something alien and incomprehensible.

The accompanying text also presents the reader with questionable interpretations of the motives of MAPs who interact with children. It suggests that any behavior that seems caring should instead be interpreted as malicious in intent. No studies have established that this is typically the intent of MAPs in the general population, and there is no consideration of the alternative possibility that MAPs may be attentive to children’s needs because they care about them in a way similar to that of people attracted to adults (Ingram, 1981; Li, 1990; Sandfort, 1987; Wilson & Cox, 1983). In this way, the text characterizes MAPs as incapable of caring about children and therefore fundamentally different and incomprehensible.

Even if unintentionally, the DSM documents may give clinicians and MAPs the impression that the appropriate mental health response is adversarial and focused on social-control rather than therapeutic. This is because the predominant focus on offenders defines MAPs solely as criminals of the kind most feared and reviled by society. The literature review supporting the proposed DSM-5 diagnostic criteria (Blanchard, 2010) contains no mention of the important findings of the non-forensic literature described earlier. Instead, it identifies illegal behaviors as virtually the only symptoms used for diagnosis. There is no discussion of the diagnostic use or reliability of the single non-criminological criterion (clinically significant distress) as there is for the criminological criteria (sex offenses). In fact, a new criminological criterion has been added to the current proposal—use of child pornography—and another has been suggested for future DSM revisions—online sexual chatting with a police officer posing as a child. No non-criminological criteria, such as feelings of emotional or romantic attraction, have ever been proposed.[2]

There are additional features of the literature review that may encourage an adversarial, social control stance by the clinician. The review seems to take for granted that the patient will lie about his sexuality and that the clinician’s role is to diagnose him against his will. The article can be interpreted to say that the author has used phallometry (placement of a sensor around the penis to measure erection during the presentation of sexual stimuli) for this very purpose. Additionally, the rationales for adding hebephilia to the DSM-5 include the fact that many men are arrested for sex with adolescents and that the basis for civil commitment should be strengthened.

Effects of the DSM on the professional literature

Professional literature about the attraction to children may follow the DSM’s lead and propagate similar inaccurate and potentially stigmatizing assumptions. For example, a recent article published for clinicians in the Harvard Mental Health Letter (Pessimism about Pedophilia, 2010) repeats a list of behaviors similar to those in the DSM-IV-TR, suggesting that they are typical of MAPs. Similarly, the Association for the Treatment of Sexual Abuser’s fact sheet on adult sex offenders (Association for the Treatment of Sexual Abusers, 2001) provides a similar list of behaviors and claims that “virtually all pedophiles are child molesters” and that “[t]heir offenses are usually predatory.”

Such literature provides little to no guidance for addressing the psychological needs of MAPs. In a survey conducted in the summer of 2011 by B4U-ACT[3], MAPs who wanted mental health services but did not seek them identified the reasons for wanting them, as shown in Table 1.

Table 1. Reasons identified by MAPs for wanting mental health services (n = 62).

The professional literature appears to ignore the most pressing needs identified by MAPs, generally addressing only goals 6 and 8. It is virtually impossible for MAPs to find literature suggesting that professionals recognize the difficulties they face in developing positive outlooks, relationships, and self-concepts within a society that reviles their feelings of emotional and sexual attraction or that professionals acknowledge the feelings of hopelessness and suicidal thoughts experienced by MAPs, including young adolescents. The Pessimism about Pedophilia article mentioned only law enforcement approaches and methods to control sexual thoughts and behavior. While small numbers of MAPs may have difficulty with self-control, the majority have different and much broader mental health needs. Professional writing may suggest to the MAP a dismissal of these needs, decreasing significantly the willingness of MAPs to seek mental health services when needed.

Reactions of MAPs to the DSM and professional literature

Are MAPs actually stigmatized by the DSM and professional writing about pedophilia? More findings from the summer 2011 survey address these questions. The survey asked respondents to read and react to excerpts from three documents: the DSM-IV-TR accompanying text,[4] the literature review supporting the DSM-5 (Blanchard, 2010), and Pessimism about Pedophilia (2010). For comparison purposes, respondents were also asked to react to an excerpt from the non-forensic study conducted by Wilson & Cox (1983).

The vast majority (72-89%) of MAPs responding to the survey questions (79 or 80 people, depending on the question) felt that the DSM-IV-TR accompanying text was inaccurate but reflected the understanding of the typical professional, and that it contributed to a professional view that discouraged them from seeking mental health services (see Table 2). They said it did not encourage professionals to focus on their psychological well-being but instead contributed to adversarial therapist-client relationships and unethical practices by professionals. Responses to the excerpt from Pessimism about Pedophilia were very similar, with 69-72 people responding. Comments showed that several felt the articles were dehumanizing and promoted social control rather than therapeutic goals.

Reactions to the DSM-5 literature review (Blanchard, 2010) were in the same direction (with 69-71 respondents), although not quite as strong. A majority (66%) disagreed with the statement that the author’s recommendations would encourage professionals to focus on the patients’ psychological well-being, and 60% agreed that the recommendations would contribute to adversarial professional-client relationships. Almost half (49%) thought they would encourage unethical treatment (34% were uncertain or neutral), and 60% thought the author accepted the use of phallometry against the patient’s will. A large majority (80%) disagreed with the statement, “The recommendations of this article encourage me to seek help from a mental health professional.” Again, respondents’ comments expressed suspicion of a social control agenda:

•    “Isn't the goal of therapy for the person to feel comfortable enough to open up to the therapist about his/her attractions rather than using what amounts to a sexual lie detector?”

•    “[The article] dehumanizes the pedophile. The phallometric test in this instance is unethical and morally reprehensible. The study is meant to prove something, not to help anyone …”

•    “The article is … buying into the idea that MAPs should be punished as harshly as possible.”

It is instructive to compare these findings with responses to the non-forensic Wilson & Cox excerpt. Survey respondents reacted to this passage in a way that was almost exactly opposite to their reactions to the other three excerpts. Out of 75-78 respondents, the majority (65-74%) felt that the passage was accurate and expressed a desire to understand MAPs, that it encouraged professionals to focus on their psychological well-being, that it did not contribute to adversarial relationships or unethical practices, and that they “would seek help from a professional who believed information like this.” Some respondents said that they could recognize themselves in the description given in the excerpt. One respondent wrote, “A positive feature of the text is the way it seeks to remove the 'them verses us' world view” and another said, “[T]he attitude represented here would be a non-negotiable factor if I ever felt a need for professional help.”

Table 2. Respondents’ Agreement with Statements About
Two Pieces of Professional Writing About Pedophilia

Revising the DSM

One respondent wrote that the DSM-IV-TR accompanying text expresses a “view that is unable to allow both the therapist and the client to work towards a positive outcome.” If MAPs perceive the DSM as portraying them as so fundamentally different from other people, so incomprehensible, and so dangerous that containment and control are the only possible responses, then it is unlikely they would ever believe that professionals would address their needs and help them develop fulfilling lives that contribute positively to their communities and society.

However, non-forensic research demonstrates that the DSM portrayal of MAPs is not the result of objective research, and that the alienation of MAPs from the mental health system is not inevitable. If the DSM’s purpose is to help clinicians identify and understand the mental health needs of MAPs, it seems prudent for those responsible for the DSM-5 entry on pedophilia to heed the American Psychiatric Association’s exhortations regarding the DSM revision process:

•    “[A]ll recommendations should be guided by research evidence” from “diverse perspectives, disciplines, and areas of expertise” (American Psychiatric Association, 2010a and 2011). Non-forensic research free from assumptions and interpretations that are unwarranted or based primarily on forensic data is needed. A narrow focus on sex offenders is inadequate.

•    The DSM should clearly “reflect the needs of our patients” (American Psychiatric Association, 2010b) rather than appear to focus on social control. It must take into account the impact of stigma and the life problems MAPs face.

•    Patient and family groups should be involved in the revision process (American Psychiatric Association, 2010a). MAPs in the general population and their families have invaluable first-hand knowledge regarding the nature of attraction to children and adolescents, their own feelings and motives, the effects of stigma, their own mental health needs, and the problems they must negotiate living in society.

Revising the DSM in a productive way will require a change in the authors’ perception of MAPs from seeing them solely as offenders or potential offenders to seeing them as humans with needs and motives that are similar to those of other humans. It is B4U-ACT’s experience that this change requires face-to-face meetings.

Unless this happens, many MAPs will likely doubt the DSM’s credibility and perhaps that of the mental health profession and will likely avoid mental health services from clinicians who take the DSM seriously. MAPs will remain in hiding, with no support for living law-abiding lives. Both adolescents and adults will continue to experience depression, engage in self-harming behavior, and seriously contemplate or attempt suicide. This outcome is unsatisfactory for children, for minor-attracted people, and for society.

References

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