Dear Alice,

For my entire adult life (the past four years), I have been sexually attracted to young girls. I think about being with one often when I masturbate, and have intense sexual fantasies involving 8 to 14 year old females. I have yet to act on my feelings, NOR DO I WANT TO! I know it is wrong to have sex with a minor; I know that it violates them and totally scars them emotionally for life. I know that a child can NEVER consent to sex. But... I still have these fantasies. I'm afraid to tell a therapist about this, but I know that's what I should do. Would a therapist tell the cops or something? I haven't broken any laws... but still, what would a doctor say or do? I want more than anything else to be normal, and have healthy relationships with women, but I'm so afraid of them. I feel as though I'm a moth, and adult women are fire... they may look nice, but if I get too close to them, they'll burn me. But little girls... they just seem more real. I have never had an intimate relationship with anyone in my life. I have never been on a date, never kissed, never even held hands. But then again, I've never asked a woman out either. I'm just so afraid of women. I think that might be why I like little girls. I guess what I want to know is... should I tell a shrink, or will that only make things worse?

Sincerely,

the reluctant pedophile

Dear the reluctant pedophile,

Given the nature of pedophilia or pedophilic thoughts, people may find it difficult to seek treatment in fear of being ostracized, assaulted, or even arrested. However, psychologists, psychiatrists, social workers, and other qualified mental health professionals and health care providers are required to keep conversations between themselves and their patients confidential; that is, unless their patients explicitly give their providers permission to disclose personal and sensitive information, or providers reasonably believe that their patients may pose a danger to themselves or others. Given that you haven’t acted on your feelings and have actively expressed intention to not do so, your situation doesn’t sound like one that a provider may turn over to law enforcement or anyone else. Additionally, not every person who experiences sexual interest in children are or will become child sex offenders — so it's possible for you to continue to not act on your fantasies and urges. However, to help you minimize these, you may find it helpful to speak with a trusted provider who might better understand your thoughts and feelings, potentially offer a diagnosis, and help you explore suitable treatment options.

Generally speaking, people who experience strong sexual interests in children may be living with pedophilic disorder (commonly called ‘pedophilia’), or pedophilia-themed obsessive-compulsive disorder (P-OCD). According to the Diagnostic and Statistical Manual (DSM-V), pedophilia involves an intense and persistent sexual interest in prepubescent children, which may include recurrent and intense sexually arousing fantasies, urges, or behaviors involving prepubescent children. Typically, pedophilic thoughts are ego-syntonic, meaning people find pleasure in these thoughts; as a result, they may seek out social situations with children. On the other hand, P-OCD involves excessive worries, fear, and distressing intrusive thoughts about being sexually attracted to and sexually violating children. These thoughts are ego-dystonic, meaning people with P-OCD are likely to feel scared, disgusted, anxious, and ashamed of their thoughts, and consequently minimize their social contact with children. There are different treatment options for each condition. Unfortunately, pedophilic disorder and P-OCD can occasionally be mistaken for one another, with up to 40 percent of P-OCD cases being misdiagnosed as pedophilic disorder.

So, what are the treatment options? It may help to keep in mind that the current understanding of treatment options for pedophilia is impeded by a limited understanding of the condition, and the experiences of people who have it. Most of what's known about pedophilia is based on people who’ve acted on their urges and committed an act of child sexual abuse. Very little is known about people with pedophilia who haven't acted on their sexual interests. Likewise, there’s minimal research on those who’ve acted on their urges in a “hands-off” approach (e.g., through using child pornography). That said, for people with pedophilic disorder, the two main treatment options include:

  • Cognitive behavioral therapy (CBT) seeks to understand and address people’s experiences (including sexual experiences) prior to their expressed sexual interest in children. In cases of pedophilia, CBT aims to build empathy for children, improve people's relationships with adult consenting partners, and decrease pleasure found in sexual fantasies and urges surrounding children. As such, they’re taught to replace sexualized coping strategies with healthy alternatives and develop a plan to prevent them from sexually abusing children. Unfortunately, current research on CBT shows mixed results, so it’s unclear if people who are treated are less likely to abuse children than people who are untreated.
  • Medications including hormonal treatments and selective serotonin reuptake inhibitors (SSRIs) are commonly used alongside CBT. Various hormonal treatments lower a person’s testosterone levels and reduce their sexual drive; however, it doesn’t change to whom or what that person is sexually attracted. Instead, it can temporarily reduce urges and compulsions towards children. Similarly, SSRIs may decrease a person’s sexual obsessions and lower the individual’s sex drive.

Unlike treatments for pedophilia, treatments for P-OCD don’t focus on reducing or eliminating sexual interests and urges towards children; rather, they seek to decrease the intensity and frequency of those obsessions by reducing the compulsions that reinforce these thoughts. Treatment options include:

  • Exposure and response prevention (Ex/RP) involves repeated therapy sessions in which clients gradually get used to the distress evoked by OCD-related stimuli without acting on their compulsions. Note that these ‘compulsions’ refer to behaviors those with OCD engage in to relieve their anxiety, and not the urges experienced by those with pedophilic disorder. Eventually, with enough exposure to the OCD-related stimuli and experience with preventing these compulsions, people with P-OCD may find their distress dissipating over time.
  • Psychoeducation which involves teaching people with P-OCD about the nature and prevalence of intrusive thoughts. People are reassured that they may openly discuss their intrusive thoughts in allocated safe environments, particularly where their therapy sessions occur.

With all of this in mind, you may find it helpful to talk with a mental health professional about your urges, and how you can reduce or eliminate them or any likelihood of acting on them. During your consultation or treatment course, your provider may start by asking you about related thoughts and experiences to better understand the root of your sexual interests. This may help them provide you with a diagnosis (if there is one) and help you explore treatment options and coping strategies. Additionally, it’s worth remembering that you can’t change everything overnight; these things take time, so it’s crucial that you be patient with yourself.

Take care,

Alice!

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