“I Could Never Work With Those People . . . ”: Secondary Prevention of Child Sexual Abuse Via a Brief Training for Therapists About Pedophilia

Abstract

Sexual abuse prevention efforts should ideally include counseling for people who have attractions to children before they offend. Due to a variety of factors, many therapists do not wish to work with this population. The aim of this pilot project was to create, implement, and evaluate a short training workshop to help prepare clinical therapists (n = 94) to respond ethically and effectively to individuals seeking counseling for pedophilic interests. Data were collected at four different clinical-therapy professional conferences over the course of 14 months. The pretest/posttest design asked questions about six specific areas of knowledge related to pedophilia, mandatory reporting, treatment needs, and goals for this difficult-to-reach population. In addition, six questions were asked about attitudes toward working with minor-attracted persons and capacity to build a therapeutic relationship. Some significant changes were detected in knowledge and attitudes about clients with pedophilia after receiving training about the topic, indicating increased willingness to work with this population and improved feelings of competence in providing services. Implications for prevention are discussed.

Keywords

sexual abuse child abuse prevention sexual assault prevention of child abuse

Child sexual abuse (CSA) prevention efforts should ideally include access to services for people with attractions to children before they offend. Unfortunately, individuals with minor-attraction rarely receive services until after an arrest and conviction for CSA (tertiary prevention). In a public health model, primary prevention efforts generally involve universal precautions, while secondary prevention is typically described as an intervention targeting a group at risk for a particular problem (German et al., 2001; Kaufman, 2006; McMahon, 2000). Research indicates that when people concerned about sexual interest in children do seek help, they often encounter therapists who are judgmental or lack knowledge, which discourages them from engaging in preventive therapy (Buckman, Ruzicka, & Shields, 2016; Levenson, Willis, & Vicencio, 2017; Piché, Mathesius, Lussier, & Schweighofer, 2016). As a result, they may experience isolation, hopelessness, and increased risk for abusing children (B4UAct, 2011a). Therefore, from a secondary prevention perspective, it is imperative that people at risk to abuse have access to competent, ethical, and empathic treatment. Many clinicians, however, do not wish to work with individuals with pedophilia, due to revulsion, fear of liability, or a belief that such clients cannot benefit from therapy (Jahnke, Philipp, & Hoyer, 2015). If these individuals cannot access proper counseling services, an opportunity to prevent CSA may be lost.

To reduce CSA in our communities, it is essential that researchers and practitioners offer innovative strategies for prevention. One possible method is to work with individuals who self-identify as pedophilic or minor-attracted persons (MAPs) before they act on their attractions. However, MAPs face a great deal of discrimination and stigma, potentially interfering with help-seeking intentions and behaviors (Harper, Bartels, & Hogue, 2016; Houtepen, Sijtsema, & Bogaerts, 2016; Imhoff, 2015; Jahnke, 2018; Jahnke, Imhoff, & Hoyer, 2015; Jahnke, Philipp, & Hoyer, 2015; Wurtele, Simons, & Parker, 2018). Consequentially, most MAPs choose not to discuss their sexual interests with others, including professionals. This leads to help-avoidance, placing them at increased risk for both psychological distress and for acting on their attractions (B4UAct, 2011a; Freimond, 2013; Jahnke, 2018; Lasher & Stinson, 2017; Pattyn, Verhaeghe, Sercu, & Bracke, 2014).

This pilot study was aimed at altering the knowledge and attitudes of mental health professionals to increase the pool of competent practitioners willing to provide counseling services to MAPs. Though potentially controversial, these ideas represent a new frontier in the prevention of CSA. By building upon the literature informing our understanding of stigma, help-seeking and minor-attraction, we propose and test a novel approach to CSA prevention through training and education of mental health professionals.

Minor-Attracted Persons

The term “minor-attracted person” is the language preferred by people who find themselves to have sexual interest in children or adolescents (B4UAct, 2018), and is used here as an alternative to diagnostic or legal labels. It is important to make the distinction between sexual interests and sexual behavior (Bailey & Hsu, 2017), and to differentiate a legal designation (“sex offender”) from a clinical or diagnostic classification (“pedophile”). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) provides two categories to conceptualize the presentation of people with attractions to children: (a) pedophilia (intense and persistent sexual interest in prepubescent children) and (b) pedophilic disorder, which requires fantasies, urges, or behaviors involving sexual activity that persist beyond 6 months and cause marked distress, interpersonal difficulty, or harm (or risk of harm) to others (APA, 2013; Merrick, 2016). MAPs might fall into either or neither category based on the severity of the distress they experience or behaviors in which they engage. Not all individuals who have committed sexual offenses (ISOs) against minors meet criteria for the disorder of pedophilia, and not all people with pedophilia have sexually abused a child. Importantly, some MAPs refer to themselves as “virtuous pedophiles” (www.virped.com) and are committed to avoid acting on their sexual preference because they understand the many reasons why sexual abuse is harmful to youngsters (Mitchell & Galupo, 2016). Though not part of the official diagnostic taxonomy, the term “pedohebephilic” is used by some researchers and practitioners to describe sexual preference for prepubescent children and/or pubescent teens (Bailey, Hsu, & Bernhard, 2016; Kramer, 2011; Seto, 2017). Furthermore, some people are preferentially attracted to postpubescent teens (“barely legal”). We use the term MAP for simplification and to capture the complex spectrum of people who might seek services for sexual interest in children and adolescents. And, even though the terminology was developed and is preferred by people with minor-attraction, we acknowledge that it is not entirely consistent with current initiatives to use person-first language.

Most studies about pedophilia have involved forensic clients receiving treatment after a conviction for sexual abuse, but a body of research is emerging to inform our understanding of nonoffending MAPs. Researchers estimate that up to 4% to 5% of the adult male population may have some sort of sexual interest in minors, ranging from sexual thoughts or fantasies to actual sexual contact with a youngster below age 18 (Ahlers et al., 2011; Dombert et al., 2016; Seto, 2008). The majority of MAPs report that they first noticed their atypical sexual preferences during adolescence, but over time, as they got older, the focus of their attractions did not change (Buckman et al., 2016; Levenson et al., 2017; Seto, 2012). Efforts to understand the spectrum of sexuality for persons self-identified as MAPs reveal that variation exists; some MAPs report an exclusive attraction to minors (not attracted to adults at all), while others have satisfactory sexual relationships with adults, and still others report sexual interest in adults of one gender and minors of the other (Bailey et al., 2016).

Help-Seeking Experiences

Help-seeking involves self-assessment of physical or mental health symptoms and the decision-making process prompting someone to access care (Mechanic, 1975, 1982). Help-seeking is conceptualized as a form of adaptive coping (Rickwood & Thomas, 2012). First, a person must go through a cognitive process of awareness, interpretation, and appraisal of symptoms and then determine whether intervention is necessary and desired (Scott, Walter, Webster, Sutton, & Emery, 2013). Stigmatized populations expect to encounter stereotyping or discrimination and tend to internalize negative societal narratives, predisposing them to psychological stress; these same conditions ironically deter them from formal and informal help-seeking to relieve that distress (Pattyn et al., 2014). Minority stress theory describes this phenomenon, which has been applied to sexual minorities such as lesbian, gay, and transgender persons (Meyer, 2003). Though controversial, some scholars have proposed that chronophilia (attraction to a particular age range) should be considered a type of sexual orientation (Bailey & Hsu, 2017; Cantor & McPhail, 2016; Seto, 2017; Walker & Panfil, 2017).

The stress and stigma of minor-attraction is not surprising, given public opinions about people with pedophilic interest. Survey participants believe that MAPs are disgusting, dangerous, and immoral, which results in public fear and anger, and many respondents endorsed that MAPs would be “better off dead” even if they had not sexually molested a child (Jahnke, 2018; Jahnke, Philipp, et al., 2015). Others described people with pedophilia as pathetic, perverted, and making a lifestyle choice, denying that pedophilia is a mental illness and opining “hang them . . . they don’t get better” (Richards, 2018, p. 842). These societal responses are adopted by MAPs, infusing psychologically damaging beliefs into their own identity (Blagden, Mann, Webster, Lee, & Williams, 2017). Unfortunately, these stigmatizations extend to the views of psychotherapists (Jahnke, Philipp, & Hoyer, 2015)

When questioned about experiences with mental health professionals, MAPs report encountering contempt, disdain, breaches of confidentiality, lack of empathy, and lack of knowledge. Therapists sometimes reacted in ways that contributed to their shame by refusing to work with them, insinuating that they cannot be helped, or focusing exclusively on risk-related issues that precluded a holistic, collaborative, client-centered therapy approach (B4UAct, 2011a; Buckman et al., 2016; Houtepen et al., 2016; Levenson & Grady, 2018; Levenson et al., 2017). When seeking help, MAPs faced profound stigma and discrimination and practitioners often exacerbated their isolation and hopelessness rather than offering relief. Unable to find help, 3% to 4% of MAPs reported that they later acted upon their attractions and were convicted of a sexual crime (B4UAct, 2011a). Therefore, it is critical that sexual abuse prevention efforts include educating professionals about the mental health needs of MAPs, striving to alter stereotypical perceptions, reduce judgment, and improve ethical, competent, compassionate responses to this population (Jahnke, 2018; Jahnke, Philipp, et al., 2015).

Reluctance of Mental Health Providers

The adverse experiences described by MAPs are unsurprising, given that mental health providers report many reasons for their reluctance. Therapists may feel unprepared to work with MAPs due to a lack of knowledge about pedophilia as well as assumptions of dangerousness (Lasher & Stinson, 2017). MAPs are often viewed as sexually compulsive or antisocial, and perceived to be unamenable to treatment; counselors avoid working with these clients due to negative countertransference, belief that therapy will be ineffective, and concerns about liability (Jahnke & Hoyer, 2013; Jahnke, Philipp, & Hoyer, 2015; Stiels-Glenn, 2010). These challenges can interfere with engagement and make it difficult to maintain the nonjudgmental client-centered objectivity required for a positive therapeutic alliance (Jahnke, 2018; Jahnke & Hoyer, 2013; Stiels-Glenn, 2010).

In one study, 95% of psychotherapists surveyed said that they would refuse to work with pedophiles (Stiels-Glenn, 2010). A majority (65%) of therapists believed that they had poor or insufficient knowledge about minor-attraction, and 38% endorsed a negative attitude toward people with pedophilia (Jahnke, Imhoff, & Hoyer, 2015). Given these views, some scholars have argued that a critical step in preventing sexual abuse is to help psychotherapists alter their attitudes toward individuals at risk for harming children, so they can receive help prior to offending (Cantor & McPhail, 2016; Harper et al., 2016; Houtepen et al., 2016; Jahnke, 2018; Jahnke & Hoyer, 2013).

Altering Attitudes and Bias

Although there is clearly a need for interventions to reduce bias among therapists, few programs have been developed to investigate efforts to do so. In one of the only available studies aimed at addressing professional attitudes about MAPs, Jahnke and colleagues (2015) provided psychotherapists-in-training with a 10-min educational program and compared their postintervention and preintervention scores. These scores were also compared with those in a control group who received general violence-related information. The posttests revealed that the intervention group members were more empathic toward MAPs than the control group. However, the intervention did not increase actual willingness to work with people with pedophilia in clinical practice (Jahnke, Philipp, & Hoyer, 2015).

Professionals who work with those convicted of sex crimes seem to hold less negative attitudes and have more confidence in treatment effectiveness compared with other professionals (Fortney, Baker, & Levenson, 2009). In a study comparing 60 professionals and 71 teachers, those who had worked with ISOs had significantly fewer negative attitudes and were less likely to endorse stereotypes, while less knowledge about sexual abuse led to more stereotyping (Sanghara & Wilson, 2006). Similarly, in a study in a forensic setting, staff had more positive attitudes than students, suggesting that time spent interacting with MAPs can humanize them and alter perceptions (Ferguson & Ireland, 2006).

Interventions to reduce stigma in other populations have used educational programming to improve factual knowledge and increase tolerant attitudes (Üçok et al., 2006). However, exposure to information alone may not reduce prejudice (Sherif, Harvey, White, Hood, & Sherif, 1988). Interfacing with unfamiliar groups seems to be an important ingredient for contradicting negative expectations and fostering acceptance (Wright, Aron, McLaughlin-Volpe, & Ropp, 1997). Programs combining education and interaction with people from stigmatized groups tend to be more successful in altering harsh perceptions (Altindag, Yanki, ÜÇok, Alptekin, & Oskan, 2006; Chung, 2005; Jones et al., 1984; Scheyett & Kim, 2004). However, more research is needed to explore ways to reduce stigmatizing responses among service providers who may be contacted by MAPs.

Current Study

This pilot project involved the creation, implementation, and evaluation of a training program to prepare clinical therapists to respond more effectively to nonoffending individuals who seek counseling services for pedophilic interests. The aim of the study was to use a pretest/posttest design to determine whether significant differences were detected in knowledge and attitudes about working with people with pedophilia after receiving training about the topic. The exploratory pilot study was guided by the following research questions:

Research Question 1: Does an educational intervention program about MAPs alter knowledge or attitudes among therapists?

Research Question 2: Does an educational intervention program about MAPs change therapists’ confidence in their ability to work effectively with MAPs?

Research Question 3: Are there within- and between-group differences in attitudes and confidence between therapists who have experience working with ISOs compared with general practitioners?

Method

Recruitment and Sample

The aim of this pilot project was to create, implement, and evaluate a training program to help prepare therapists (n = 94) to respond ethically and effectively when individuals seek counseling services for pedophilic interests before child abuse has occurred. Participants included mental health professionals who signed up for a conference workshop session titled “Beyond the Ick Factor: Counseling Nonoffending Minor-Attracted Persons,” facilitated by the lead author of the study. The workshop was presented at four professional conferences over a period of 14 months, targeting two groups of social workers, and two interdisciplinary groups of counselors who specifically work with ISOs. Though the material and learning objectives were the same for all conferences, two sessions allotted 90 min for the workshop and two sessions allotted 3 hours. The training was offered at the National Association of Social Workers-Florida Chapter (NASW-FL) annual conference in Orlando in June 2016 (3 hr), and at the National Organization of Forensic Social Work conference in Boston in July 2017 (90 min). The workshop was also presented at two regional chapter conferences of the Association for the Treatment of Sexual Abusers (ATSA). These were both held in April 2017, one at the Florida chapter conference (90 min), and the other at the Massachusetts conference (3 hr), which draws treatment professionals who work with ISOs from the New England region.

The sample consisted of 94 individuals (70% female, 30% male) with a mean age of 52 (see Table 1). Most were currently married, and 85% identified as White. The majority (86%) held a graduate degree, and more than half were seasoned professionals with over 10 years of postdegree professional counseling experience. About two thirds (67%) of the surveys were collected at the regional ATSA conferences, while 33% were collected at the social work conferences.

Table 1.

Demographics.

Item	%	M (SD)
Currently providing services to a MAP	45
Age		52 (14.4)
Gender
Male	30
Female	70
Marital status
Never	28
Currently married	52
Divorced or separated	17
Widowed	2
Race
White	85
Minority	14
Education
Bachelors	11
Masters	65
PhD	21
No degree	3
Years of postdegree counseling experience
<1 year	20
1-3 years	13
3-5 years	3
5-10 years	11
>10 years	53
Conference type
Social work	n = 31 (33%)
Treatment of sexual abusers	n = 63 (67%)

Note. MAP = Minor-attracted person.

Data Collection

The lead author created the training protocol, which clarified the DSM-5 criteria for Pedophilic Disorder, discussed issues related to mandatory reporting, and offered a framework for providing ethical clinical services to nonoffending MAPs. Content of the training also included engagement in a positive therapeutic alliance, affirmative cognitive-behavioral strategies, and dealing with countertransference. A video clip and audio clip were used in the trainings to depict and humanize the experiences of MAPs. Readers can email the authors to obtain conference brochure descriptions and learning objectives.

A pretest/posttest method was used to evaluate the effectiveness of the program on influencing changes in attitudes and knowledge. All workshop attendees were invited to participate in the study when they arrived at the workshop. They were presented with the pretest along with informed consent information. Due to the fluidity of attendance patterns at the workshops, it is impossible to know what percentage of participants opted to complete the pretest/posttest materials but by observation, it seemed that nearly everyone filled out the pretest and a few exited at the end without completing the posttest. The survey was anonymous and confidential, and no names were collected. Surveys were placed into a box after completion of the training. The pretest and posttest were copied on different colored paper to easily tell them apart. This study was approved by the lead author’s university institutional review board (IRB).

Measure

The pretest/posttest survey was developed by the lead author and was designed to measure pretraining and posttraining knowledge and attitude levels. The survey contained 13 total items which can be seen in Table 2. Items 1 to 6 measured six specific areas of knowledge about pedophilia, mandatory reporting, treatment needs, and goals for this difficult to reach population. Items 7 to 12 measured attitudes about working with MAPs including empathy, therapist belief in one’s own capacity to provide effective services, and ability to build a therapeutic relationship. Question 13 was a general question about the participant’s confidence in being able to provide effective counseling for MAPs. Participants were asked to endorse their answers in a Likert-type scale with the instructions: “Please rate the questions using a scale of 0 - 3, with 0 being not true at all and 3 being very true (circle the number that best applies to you).” The pretest data collection also contained questions about demographics and general clinical practice experience.

Table 2.

Pretest–Posttest Mean Differences.

Item	Pretest/Posttest	n	M Rating	SD	SE M
1. Mandatory reporting laws typically require counselors to report a suspicion that a child is being abused, and this would include reporting a self-described MAP who seeks counseling. (-)	Pre	90	1.07	1.234	0.130
	Post	94	.64*	1.025	0.106
2. The primary goal for a MAP in counseling would be to learn skills to manage their sexual attractions to children. (-)	Pre	90	2.39	0.831	0.088
	Post	93	1.41***	1.086	0.113
3. The primary goal for a MAP in counseling is to decrease shame, stigma, isolation, and improve self esteem.	Pre	91	2.55	0.734	0.077
	Post	94	2.77*	0.612	0.063
4. I am familiar with all the DSM-5 criteria for Pedophilia and how it is distinguished from Pedophilic Disorder.	Pre	91	1.95	1.109	0.116
	Post	94	2.39**	0.883	0.091
5. Someone with attractions to minors will always present a risk to sexually abuse children. (-)	Pre	93	1.29	1.089	0.113
	Post	93	0.95*	0.913	0.095
6. Someone with attractions to minors is unlikely to benefit from counseling services. (-)	Pre	92	0.38	0.888	0.093
	Post	94	0.45	0.887	0.092
7. I would be able to provide a MAP with the same level of empathy and compassion as I would with other clients.	Pre	93	2.45	0.879	0.091
	Post	94	2.59	0.754	0.078
8. I would be able to provide a MAP with the same level of respect and nonjudgmental responding as I would with other clients.	Pre	92	2.63	0.737	0.077
	Post	94	2.61	0.722	0.074
9. I would be able to work effectively with a MAP.	Pre	93	2.09	1.018	0.106
9. I would be able to work effectively with a MAP.	Post	94	2.22	0.735	0.076
10. I think that my primary objective of counseling MAPs would be to prevent child abuse.	Pre	92	1.99	0.989	0.103
	Post	94	1.49**	1.024	0.106
11. I would be able to develop a strong therapeutic alliance with a minor-attracted client, similar to the alliance I form with other clients.	Pre	92	2.48	0.818	0.085
	Post	94	2.60	0.677	0.070
12. I think I would be likely to have some negative feelings about a minor-attracted client. (-)	Pre	93	1.22	0.987	0.102
	Post	94	1.06	0.993	0.102
13. I am confident in my ability to provide effective counseling to MAPs.	Pre	89	1.89	0.959	0.102
	Post	91	2.21*	0.723	0.076

Note. Items used a rating scale of 0 to 3, with 0 being not true at all and 3 being very true (circle the number that best applies to you). Items marked (-) were expected to show a decrease in ratings after training. MAP = minor-attracted person; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

p < .05. **p < .01. ***p < .001.

Analytic Strategy

First, pretest–posttest mean scores on each item, total score, and subscales were compared for the entire sample using independent sample t tests. Next, within-group changes were compared for each item by participant group (ATSA and social workers). Finally, between-group mean changes in total scores were compared by conference type and length of training using one-way analysis of variance (ANOVA).

Results

First, pretest and posttest mean scores on each item were compared for the entire sample using independent sample t tests (see Table 2). Items 1, 2, 5, 6, and 12 are marked (-) because they were expected to show a decrease in ratings after training. All rating changes were in the expected direction, except Items 6 (not significant) and 10.

Overall, significant changes were found in items related to knowledge about mandatory reporting, goals for MAPs in counseling, DSM-5 criteria for Pedophilia, and risk for abuse. Attitude changes were, for the most part, not significant, with the exception of Item 10, which showed a change in the unexpected direction.

Within-group changes were tested to see whether differences existed between social workers and ATSA professionals (see Table 3). Social workers showed significant changes in knowledge items related to therapy goals and DSM-5 diagnostic criteria, and in attitude items related to perceived effectiveness and confidence in providing services to MAPs. ATSA participants showed significant increases on knowledge items related to mandated reporting and therapy goals, and in attitude items related to primary objectives of counseling for MAPs.

Table 3.

Within-Group Changes—ATSA Versus SW.

Item	Within-Group Changes
Item	SW	Significance	ATSA	Significance
1. Mandatory reporting laws typically require counselors to report a suspicion that a child is being abused, and this would include reporting a self-described MAP who seeks counseling.	−0.403	ns	−.444	*
2. The primary goal for a MAP in counseling would be to learn skills to manage their sexual attractions to children.	−1.17	***	−.878	***
3. The primary goal for a MAP in counseling is to decrease shame, stigma, isolation, and improve self-esteem.	+0.310	ns	+.171	ns
4. I am familiar with all the DSM-5 criteria for Pedophilia and how it is distinguished from Pedophilic Disorder.	+0.897	**	+.228	ns
5. Someone with attractions to minors will always present a risk to sexually abuse children.	−0.355	ns	−.339	ns
6. Someone with attractions to minors is unlikely to benefit from counseling services.	+0.323	ns	−.060	ns
7. I would be able to provide a MAP with the same level of empathy and compassion as I would with other clients.	+0.290	ns	+.054	ns
8. I would be able to provide a MAP with the same level of respect and nonjudgmental responding as I would with other clients.	+0.147	ns	−.107	ns
9. I would be able to work effectively with a MAP.	+0.548	*	−.069	ns
10. I think that my primary objective of counseling MAPs would be to prevent child abuse.	−0.194	ns	−.659	***
11. I would be able to develop a strong therapeutic alliance with a minor-attracted client, similar to the alliance I form with other clients.	+0.186	ns	+.086	ns
12. I think I would be likely to have some negative feelings about a minor-attracted client.	−0.290	ns	+.083	ns
13. I am confident in my ability to provide effective counseling to MAPs.	+0.599	**	+.170	ns

Note. Items used a rating scale of 0 to 3, with 0 being not true at all and 3 being very true (circle the number that best applies to you). ATSA = Association for the Treatment of Sexual Abusers; SW = social worker; MAP = minor-attracted person; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

p < .05. **p < .01. ***p < .001.

Items 1, 2, 5, 6, and 12 were then reverse-scored and a full-scale score (possible range 0-36) was calculated. The posttest mean score increased nearly 3 points and reflected a significant positive change (see Table 4). There were no significant between-group differences dependent on conference type (ATSA vs. Social Work), F(1, 186) = .010, p = .919, or length of training (90 min vs. 180 min), F(1, 186) = .508, p = .477, as determined by one-way ANOVA.

Table 4.

Pretest and Posttest Scores, Full Scale, and Subscales.

	Pretest/Posttest	n	M Score	SD	SE	t	df	Significance
Full scale	Pre	83	26.8	5.76524	.63,282
Full scale	Post	90	29.7	4.79738	.50,569	−3.557	171	.000
Knowledge Items 1-6	Pre	87	11.5	2.62312	.28,123
Knowledge Items 1-6	Post	93	13.7	3.30317	.34,252	−5.008	178	.000
Attitude Items 7-12	Pre	90	13.4	3.63991	.38,368
Attitude Items 7-12	Post	94	13.4	3.08503	.31,820	−.118	182	.907

Subscale scores were calculated for items related to knowledge (Items 1-6; possible range 0-18) and attitudes (Items 7-12; possible range 0-18). A significant increase in knowledge was found, but attitudinal change was not statistically significant.

A classification item asked “are you currently providing counseling to any MAP(s)?” and pre/post full scores were compared for the two groups (yes or no). As expected, there were significant differences between the groups, with a more substantial change in the mean full score of posttests for those who were not seeing MAPs (increase from 24.36 to 28.52) compared with those who are already working with MAPs (increase from 29.55 to 30.83), t(86) = 2.289, p = .025, confirming our expectation that those who have worked with ISOs or MAPs will experience fewer significant changes post intervention. Item 13 asked “on a scale of 0-3, with 0 = not at all and 3 = very, how confident are you in your ability to provide effective counseling to MAPs?” and was analyzed for pre/post differences across the whole sample. Small but statistically significant positive changes (+.321) were found in participants’ confidence in their ability to provide effective counseling for MAPs, t(178) = 2.541, p = .012.

Discussion

Summary of Findings

Some significant differences were detected in knowledge and attitudes about MAPs after mental health professionals received training, suggesting that a brief intervention can increase knowledge about this population and foster an improved sense of competence in providing services. Differences were not found depending on the length of the training or the type of conference at which the training took place.

More change was found in knowledge items than in attitude items, which was somewhat surprising. The type of knowledge change differed for those more or less familiar with MAPs, with social workers showing more changes in knowledge related to therapy goals and DSM-5 diagnostic criteria, and ATSA participants showing greater increases on knowledge items related to mandated reporting. This finding perhaps suggests that ATSA members might be more knowledgeable about pedophilic interests due to their work with ISOs. However, due to their experience with offenders, ATSA members may be more inclined to “err on the side of caution” when assessing whether material disclosed in therapy sessions requires a mandatory report.

Attitudes were not especially negative to begin with (most mean attitude items were between 2 and 3) and did not show many significant changes. This might be due to the recruitment strategy and types of participants. For instance, ATSA members who have counseled people convicted of sex offenses against children would be expected to be more comfortable working with such clients, as might social workers attending a conference with an emphasis on human rights and social justice. In addition, the participants self-selected to attend this training, which may indicate that they are more open to and interested in this population.

One surprising finding was the observed reduction in belief that the “primary objective of counseling MAPs would be to prevent child abuse.” In retrospect, the question was ambiguous. The finding might be attributed to material in the training suggesting that not all MAPs are at risk to abuse, and that a client-centered focus on MAP well-being is important. While this point is important for professionals to hear so that stereotypical assumptions can be reduced, trainings should also explicitly clarify that appraisal of risk and safety planning should not be ignored. However, prevention and well-being are not mutually exclusive; in fact they are both desirable outcomes, because perpetuating secrecy, stigma, and fear can increase risk for self-destructive or abusive behavior (B4UAct, 2018). What is important for clinicians to understand is that assessments should be collaborative and client-centered, providing a safe therapeutic environment for MAPs to honestly disclose their thoughts and feelings so that when applicable, risk can be assessed and addressed in an ethical, relevant, and compassionate manner.

Mental health professionals who encounter MAPs in clinical practice should understand the dual importance of prevention and client well-being. Many MAPs report that their attraction to minors is a significant cause of emotional distress. As a result, they report impairment in psychosocial well-being including fear and anxiety, depression, hopelessness, substance abuse, and alienation (Beier, 2016; Houtepen et al., 2016; Jahnke, 2018; Lasher & Stinson, 2017; Levenson & Grady, 2018). These struggles can be quite severe; suicidality is common among MAPs (B4UAct, 2011b), and in one study, 23% of those surveyed reported at least one suicide attempt (Levenson & Grady, 2018). In a recent qualitative study, MAPs described well-being issues as often overlooked by professionals who attend primarily to concerns about risk and have a bias that sexuality should be the focus of therapy (Grady, Levenson, Mesias, Kavanagh, & Charles, 2018). MAPs have noted that they wished therapists would also help them cope with being part of a stigmatized group and to build more acceptance of self (not abuse behavior), leading toward a safe, healthy, productive life (Grady et al., 2018).

Implications for Prevention

In a public health model, primary prevention of a social problem incorporates universal precautions, secondary prevention targets interventions toward high-risk groups, and tertiary prevention intervenes after a problem emerges, designed to prevent recurrence (German et al., 2001; Kaufman, 2006; McMahon, 2000). Most efforts aimed at reducing CSA perpetration fall into the category of tertiary prevention, usually in the form of mandated sex-offending treatment and risk management after a conviction. Few programs exist to identify those at risk for offending and prevent CSA using a public health model (Levine & Dandamudi, 2016). However, some secondary prevention models exist, with indications of effectiveness. For instance, the Dunkelfeld Project in Germany used public service announcements to advertise treatment for people concerned about their attraction to children, and outcomes showed some reductions in emotional deficits, offense-tolerant cognitions, and risk-related behaviors, along with some reported improvements in sexual self-regulation (Beier et al., 2009; Beier et al., 2015; Beier et al., 2016). Likewise, a survey of callers to a Stop it now! helpline in Europe revealed a number of positive risk-reducing and desistence-promoting effects from the advice and information given to them by hotline workers (Horn et al., 2015).

Attention is now being paid to the importance of CSA prevention through provision of services to MAPs, a hidden population dissuaded from seeking help by fear, shame, and stigma. By helping psychotherapists to gain clinical understanding and develop more positive attitudes toward this population, individuals at risk for harming children might be better able to receive help prior to offending (Cantor & McPhail, 2016; Harper et al., 2016; Houtepen et al., 2016; Jahnke, 2018; Jahnke & Hoyer, 2013). Though it may be unrealistic to expect all therapists to become fully equipped to counsel this population, exposure to information can challenge common assumptions and negative judgments about MAPs. This can, in turn, help to avert negative help-seeking experiences that discourage MAPs from seeking preventive care.

Applying a social psychological theory of prejudice and stereotyping can inform our understanding of how to change professional attitudes about MAPs. With other types of social prejudice, it is known that ignorance about a particular group invites stereotyping, while information and personal experience with a marginalized group can diminish typecasting, labeling, and prejudice (Allport, 1954; Gaertner et al., 1991). Stereotypes can emerge out of an internal dialogue used to manage expectations of those who are unfamiliar, and they can also develop from publicly available misinformation (Sherif et al., 1988). MAPs may seem, based on media presentations, to be untrustworthy, untreatable, and unmotivated to resist harming children. Challenging these assumptions through training can help therapists feel more prepared and willing to counsel nonoffending MAPs, enhancing prevention of CSA.

As we envision prevention programs for MAPs, we must also begin to have a more thoughtful dialogue in the United States about the dilemma of mandatory reporting laws. Clearly such laws are intended to protect children from harm by reporting unlawful sexual behavior and plans for such behavior. However, MAPs have described instances where breaches of confidentiality have occurred even when the client disclosed only thoughts or feelings about children but not actions or intentions (B4UAct, 2017; Buckman et al., 2016; Houtepen et al., 2016; Levenson et al., 2017; Piché et al., 2016). Concerns about privacy create a formidable barrier to help-seeking prior to offending. In a few states, mental health professionals are now required to report viewing of online child pornography, or sexual thoughts and fantasies of children, even without a contact victim. Professional counseling interest groups have lobbied against these new laws, arguing that they contradict traditional ethical commitments to privileged communications that allow breaches only in cases where an identifiable person is at imminent threat of harm (Clark-Flory, 2016). Similar quandaries have been debated in the context of other types of preventive care; for instance, substance-using women may avoid prenatal services due to fear of punitive consequences, creating a different set of risks for infant health (Stone, 2015). Though mandatory reporting statutes were passed to protect children, they have a paradoxical effect if they deter potential abusers from seeking preventive therapies (Beier, 2016; Jahnke, 2018; Lasher & Stinson, 2017).

Attention to Diversity

Abusing children is a choice, but minor-attraction is not. For some people, it is akin to a sexual orientation and therefore should be discussed in the context of theories and practices pertaining to sexual minorities (Jahnke, 2018; Seto, 2017; Walker & Panfil, 2017). Mental health professionals should be committed to providing access to client-centered and compassionate care for all who seek it. Counseling services for MAPs are valuable not only as a means to prevent CSA but also to promote emotional well-being and relief from the distress caused by minor-attraction (Beier, 2016; Houtepen et al., 2016). From a human rights and social justice perspective, people should not be afraid to access services because they belong to a stigmatized group. Many MAPs are motivated to maintain an emotionally healthy and nonvictimizing lifestyle, and we encourage advocacy for access to mental health treatment for those who wish to enhance their well-being or prevent themselves from harming children. Help-seeking can also be impacted by privilege and marginalization, affecting the ability to access support or pay for care.

Limitations

The results of this study need to be considered in the context of its limitations. First, there was no control group, and thus it is impossible to determine causality in any of the changes identified after the training. Second, individuals who participated in the study all self-selected to attend the training and complete the surveys. Those who chose to attend this workshop may be more open to learning about MAPs and amenable to changing beliefs or attitudes. Future research should test similar training interventions with subjects who may be less likely to seek them out on their own. For instance, desensitization about minor-attraction might show different effects with clinical graduate students in general courses such as Abnormal Psychology, Psychopathology, Human Sexuality, or Human Development. Third, the survey responses were self-reported immediately following the training with no follow-up assessing the stability of changes over time. Finally, while the survey did ask about confidence in the ability to work with MAPs, the study was unable to determine whether any detected changes translated into measurable clinical action. In other words, the study could not measure whether therapists altered their practice in any way after completion of the training. Future research should include other indicators to concretely measure implementation of skills, and perhaps collect follow-up data to determine whether knowledge or attitude changes are sustained over time.

As researchers, we sometimes see methodological design flaws only in retrospect, and we try to learn from them. We made the decision to keep our instrument very short, given the circumstances of the data collection (i.e., conference attendees who were paying for workshops, so we did not want to take too much time away from the learning). As a result, the pre- and postsurveys limited the types of analyses and group comparisons that could be conducted. Improvements in the questionnaire could have been made by including supplemental items such as those from Jahnke, Philipp, and Hoyer (2015), which provided a much more comprehensive array of questions related to beliefs and attitudes about MAPs. As well, it would have been interesting to use open-ended prompts to elicit narrative qualitative responses that could be analyzed thematically. These ideas serve as recommendations for future research.

Conclusion

Those who belong to groups with higher levels of perceived stigma internalize damaging self-narratives and resist help-seeking due to expectations that they will encounter judgmental attitudes (Pattyn et al., 2014). Many surveys of MAPs suggest that negative experiences with counselors are not uncommon and include breaches of confidentiality, lack of empathy, and a focus on risk to the exclusion of client well-being (B4UAct, 2011a; Houtepen et al., 2016; Levenson et al., 2017; Van Horn et al., 2015). Consequently, some MAPs who wish to understand their own sexuality and avoid harming children are unwilling to speak openly with a professional. This can result in an exacerbation of mental health symptoms, maladaptive coping, and risk for acting on sexual interest in children (B4UAct, 2011a). Educational training programs to provide knowledge and information about minor-attraction offer a promising new strategy to improve ethical and effective care in the service of CSA prevention.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Jill S. Levenson is a professor of Social Work at Barry University in Miami, FL and a licensed clinical social worker specializing in sexual abuse perpetration.

Melissa D. Grady is an associate professor of Social Work at The Catholic University of America in Washington, DC and a licensed clinical social worker specializing in sexual abuse perpetration.

References

Ahlers

C. J.

Schaefer

G. A.

Mundt

I. A.

Roll

Englert

Willich

S. N.

Beier

K. M.

(2011). How unusual are the contents of paraphilias? Paraphilia-associated sexual arousal patterns in a community-based sample of men. The Journal of Sexual Medicine, 8, 1362-1370. doi:10.1111/j.1743-6109.2009.01597.x

Allport

G. W.

(1954). The nature of prejudice. Cambridge, MA: Addison-Wesley.

Altindag

Yanik

Üçok

Alptekin

Ozkan

(2006). Effects of an antistigma program on medical students’ attitudes towards people with schizophrenia. Psychiatry and Clinical Neurosciences, 60(3), 283-288.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

B4UAct. (2011a). Mental health care and professional literature survey results. Retrieved from http://www.b4uact.org/research/survey-results/spring-2011-survey/

B4UAct. (2011b). Youth, suicidality, and seeking care. Retrieved from http://www.b4uact.org/research/survey-results/youth-suicidality-and-seeking-care/

B4UAct. (2017). Principles and perspectives of practice. Retrieved from http://www.b4uact.org/about-us/principles-and-perspectives-of-practice/

B4UAct. (2018). Retrieved from http://www.b4uact.org/know-the-facts/faq/

Bailey

J. M.

Hsu

K. J.

(2017). Orienting basic research on chronophilias. Archives of Sexual Behavior, 46, 23-26. doi:10.1007/s10508-016-0885-1

10.

Bailey

J. M.

Hsu

K. J.

Bernhard

P. A.

(2016). An Internet study of men sexually attracted to children: Sexual attraction patterns. Journal of Abnormal Psychology, 125, 976-988.

11.

Beier

K. M.

(2016). Proactive strategies to prevent child sexual abuse and the use of child abuse images: Experiences from the German Dunkelfeld project. In Kury

Redo

Shea

(Eds.), Women and children as victims and offenders: Background, prevention, reintegration: Suggestions for succeeding generations (Vol. 2, pp. 499-524). Cham, Switzerland: Springer.

12.

Beier

K. M.

Ahlers

C. J.

Goecker

Neutze

Mundt

I. A.

Hupp

Schaefer

G. A.

(2009). Can pedophiles be reached for primary prevention of child sexual abuse? First results of the Berlin Prevention Project Dunkelfeld (PPD). The Journal of Forensic Psychiatry & Psychology, 20, 851-867.

13.

Beier

K. M.

Grundmann

Kuhle

L. F.

Scherner

Konrad

Amelung

(2015). The German Dunkelfeld project: A pilot study to prevent child sexual abuse and the use of child abusive images. Journal of Sexual Medicine, 12, 529-542. doi:10.1111/jsm.12785

14.

Beier

K. M.

Oezdemir

U. C.

Schlinzig

Groll

Hupp

Hellenschmidt

(2016). “Just dreaming of them”: The Berlin Project for Primary Prevention of Child Sexual Abuse by Juveniles (PPJ). Child Abuse & Neglect, 52, 1-10. doi:10.1016/j.chiabu.2015.12.009

15.

Blagden

N. J.

Mann

Webster

Lee

Williams

(2017). “It’s not something I chose you know”: Making sense of pedophiles’ sexual interest in children and the impact on their psychosexual identity. Sexual Abuse, 30, 728-754. doi:10.1177/1079063217697132

16.

Buckman

Ruzicka

Shields

R. T.

(2016). Help wanted: Lessons on prevention from non-offending young adult pedophiles. ATSA Forum Newsletter, 28(2), 9-11.

17.

Cantor

J. M.

McPhail

I. V.

(2016). Non-offending pedophiles. Current Sexual Health Reports, 8, 121-128.

18.

Chung

K. F.

(2005). Changing the attitudes of Hong Kong medical students toward people with mental illness. The Journal of Nervous and Mental Disease, 193(11), 766-768.

19.

Clark-Flory

(2016, May 23). Pedophiles put therapists in an ethical catch-22. Vocativ. Retrieved from http://www.vocativ.com/315929/pedophiles-seeking-help-put-therapists-in-ethical-catch-22/

20.

Dombert

Schmidt

A. F.

Banse

Briken

Hoyer

Neutze

Osterheider

(2016). How common is men’s self-reported sexual interest in prepubescent children? The Journal of Sex Research, 53, 214-223. doi:10.1080/00224499.2015.1020108

21.

Ferguson

Ireland

C. A.

(2006). Attitudes towards sex offenders and the influence of offence type: A comparison of staff working in a forensic setting and students. British Journal of Forensic Practice, 8(2), 10-20.

22.

Fortney

Baker

J. N.

Levenson

J. S.

(2009). A look in the mirror: Sexual abuse professionals’ perceptions about sex offenders. Victims and Offenders, 4, 1-16.

23.

Freimond

C. M.

(2013). Navigating the stigma of pedophilia: The experiences of nine minor-attracted men in Canada. Arts & Social Sciences: Department of Sociology and Anthropology. Retrieved from https://summit.sfu.ca/item/13798

24.

Gaertner

S. L.

Dovidio

J. F.

Rust

M. C.

Nier

J. A.

Banker

B. S.

Ward

C. M.

. . . Houlette

(1991). Reducing intergroup bias: Elements of intergroup cooperation. Journal of Personality and Social Psychology, 76, 388-402.

25.

German

R. R.

Lee

Horan

Milstein

Pertowski

Waller

(2001). Updated guidelines for evaluating public health surveillance systems. MMWR Recommendations and Reports, 50, 1-35.

26.

Grady

M. D.

Levenson

J. S.

Mesias

Kavanagh

Charles

(2018). “I can’t talk about that”: Stigma and fear as barriers to preventive services for minor-attracted persons. Stigma and Health. Advance online publication. doi:10.1037/sah0000154

27.

Harper

C. A.

Bartels

R. M.

Hogue

T. E.

(2016). Reducing stigma and punitive attitudes toward pedophiles through narrative humanization. Sexual Abuse, 30(5), 533-555. doi:10.1177/1079063216681561

28.

Horn

J. V.

Eisenberg

Nicholls

C. M.

Mulder

Webster

Paskell

. . . Jago

(2015). Stop it now! A pilot study into the limits and benefits of a free helpline preventing child sexual abuse. Journal of Child Sexual Abuse, 24, 853-872. doi:10.1080/10538712.2015.1088914

29.

Houtepen

Sijtsema

J. J.

Bogaerts

(2016). Being sexually attracted to minors: Sexual development, coping with forbidden feelings, and relieving sexual arousal in self-identified pedophiles. Journal of Sex & Marital Therapy, 42, 48-69.

30.

Imhoff

(2015). Punitive attitudes against pedophiles or persons with sexual interest in children: Does the label matter? Archives of Sexual Behavior, 44(1), 35-44.

31.

Jahnke

. (2018). The stigma of pedophilia. European Psychologist, 23, 144-153. doi:10.1027/1016-9040/a000325

32.

Jahnke

Hoyer

(2013). Stigmatization of people with pedophilia: A blind spot in stigma research. International Journal of Sexual Health, 25, 169-184.

33.

Jahnke

Imhoff

Hoyer

(2015). Stigmatization of people with pedophilia: Two comparative surveys. Archives of Sexual Behavior, 44, 21-34.

34.

Jahnke

Philipp

Hoyer

(2015). Stigmatizing attitudes towards people with pedophilia and their malleability among psychotherapists in training. Child Abuse & Neglect, 40, 93-102.

35.

Jones

E. E.

Farina

Hastorg

A. H.

Markus

Miller

D. T.

Scott

R. A.

(1984). Social stigma: The psychology of marked relationships. New York, NY: Freeman.

36.

Kaufman

(2006). Promoting the prevention of sexual violence: Strategic use of prevention theories and models. ATSA Forum, 18(3), 14-23.

37.

Kramer

(2011). APA guidelines ignored in development of diagnostic criteria for pedohebephilia. Archives of Sexual Behavior, 40, 233-235. doi:10.1007/s10508-010-9683-3

38.

Lasher

M. P.

Stinson

J. D.

(2017). Adults with pedophilic interests in the United States: Current practices and suggestions for future policy and research. Archives of Sexual Behavior, 46, 659-670. doi:10.1007/s10508-016-0822-3

39.

Levenson

J. S.

Grady

M. D.

(2018). Preventing sexual abuse: Perspectives of minor-attracted persons about seeking help. Sexual Abuse. Advance online publication. doi:10.1177/1079063218797713

40.

Levenson

J. S.

Willis

G. M.

Vicencio

C. P.

(2017). Obstacles to help-seeking for sexual offenders: Implications for prevention of sexual abuse. Journal of Child Sexual Abuse, 26, 99-120. doi:10.1080/10538712.2016.1276116

41.

Levine

J. A.

Dandamudi

(2016). Prevention of child sexual abuse by targeting pre-offenders before first offense. Journal of Child Sexual Abuse, 25, 719-737. doi:10.1080/10538712.2016.1208703

42.

McMahon

P. M.

(2000). The public health approach to the prevention of sexual violence. Sexual Abuse: A Journal of Research & Treatment, 12, 27-36.

43.

Mechanic

(1975). Sociocultural and socio-psychological factors affecting personal responses to psychological disorder. Journal of Health and Social Behavior, 16, 393-404.

44.

Mechanic

(1982). Symptoms, illness behavior, and help-seeking (Vol. 3). New York, NY: Prodist.

45.

Merrick

W. A.

(2016). Changes in DSM-5 diagnostic criteria for paraphilic disorders. Archives of Sexual Behavior, 45, 2173-2179.

46.

Meyer

I. H.

(2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697.

47.

Mitchell

R. C.

Galupo

M. P.

(2018). The role of forensic factors and potential harm to the child in the decision not to act among men sexually attracted to children. Journal of Interpersonal Violence, 33(14), 2159-2179. doi:10.1177/0886260515624211

48.

Pattyn

Verhaeghe

Sercu

Bracke

(2014). Public stigma and self-stigma: Differential association with attitudes toward formal and informal help seeking. Psychiatric Services, 65, 232-238. doi:10.1176/appi.ps.201200561

49.

Piché

Mathesius

Lussier

Schweighofer

(2016). Preventative services for sexual offenders. Sexual Abuse: Journal of Research and Treatment, 30, 63-81. doi:10.1177/1079063216630749

50.

Richards

(2018). Born this way? A qualitative examination of public perceptions of the causes of pedophilia and sexual offending against children. Deviant Behavior, 39, 835-851.

51.

Rickwood

Thomas

(2012). Conceptual measurement framework for help-seeking for mental health problems. Psychology Research and Behavior Management, 5, 173-183.

52.

Sanghara

K. K.

Wilson

J. C.

(2006). Stereotypes and attitudes about child sexual abusers: A comparison of experienced and inexperienced professionals in sex offender treatment. Legal and Criminological Psychology, 11, 229-244.

53.

Scheyett

Kim

(2004). Can we talk? Using facilitated dialogue to positively change student attitudes towards persons with mental illness. Journal of Teaching in Social Work, 24(1-2), 39-54.

54.

Scott

Walter

Webster

Sutton

Emery

(2013). The model of pathways to treatment: Conceptualization and integration with existing theory. British Journal of Health Psychology, 18, 45-65.

55.

Seto

M. C.

(2008). Pedophilia and sexual offending against children: Theory, assessment, and intervention. Washington, DC: American Psychological Association.

56.

Seto

M. C.

(2012). Is pedophilia a sexual orientation? Archives of Sexual Behavior, 41(1), 231-236.

57.

Seto

M. C.

(2017). The puzzle of male chronophilias. Archives of Sexual Behavior, 46, 3-22. doi:10.1007/s10508-016-0799-y

58.

Sherif

Harvey

O. J.

White

B. J.

Hood

W. R.

Sherif

C. W.

(1988). The Robbers Cave experiment: Intergroup conflict and cooperation. Middletown, CT: Wesleyan University Press.

59.

Stiels-Glenn

(2010). The availability of outpatient psychotherapy for paedophiles in Germany. Recht & Psychiatrie, 28, 74-80.

60.

Stone

(2015). Pregnant women and substance use: Fear, stigma, and barriers to care. Health & Justice, 3, 2. doi:10.1186/s40352-015-0015-5

61.

Üçok

Soygür

Atakli

Kuşcu

Sartorius

Duman

Z. Ç.

. . . ErkoÇ

. (2006). The impact of antistigma education on the attitudes of general practitioners regarding schizophrenia. Psychiatry and Clinical Neurosciences, 60(4), 439-443.

62.

Van Horn

Eisenberg

Nicholls

C. M.

Mulder

Webster

Paskell

. . . Jago

. (2015). Stop it now! A pilot study into the limits and benefits of a free helpline preventing child sexual abuse. Journal of Child Sexual Abuse, 24, 853-872.

63.

Walker

Panfil

V. R.

(2017). Minor attraction: A queer criminological issue. Critical Criminology, 25, 37-53.

64.

Wright

S. C.

Aron

McLaughlin-Volpe

Ropp

S. A.

(1997). The extended contact effect: Knowledge of cross-group friendships and prejudice. Journal of Personality and Social Psychology, 73, 73-90.

65.

Wurtele

S. K.

Simons

D. A.

Parker

L. J.

(2018). Understanding men’s self-reported sexual interest in children. Archives of Sexual Behavior, 47(8), 2255-2264. doi:10.1007/s10508-018-1173-z