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At the 2018 Annual Conference of the American Association of Sexuality Educators, Counselors, and Therapists (AASECT), Dr. Michael Seto presented a plenary talk titled “What Do We Know about Pedophilia?”. The talk mainly addressed characteristics of the attraction to children or young adolescents, but it also touched on issues related to assessment and treatment. As an organization dedicated to improving mental health services available to people with such attractions, B4U-ACT believes it is important to point out exemplary aspects of his talk, as well as those aspects that could have been improved. First a note about terminology: We use the term “minor-attracted people” (MAPs) to refer to this population, while recognizing its shortcomings (as pointed out by Dr. Seto), for reasons to be addressed later.

First, it is helpful to consider some context. For several decades, MAPs have felt stigmatized, “othered,” and even demonized by society, including the mental health community, due to language and descriptions that have suggested they were dangerous, devious, inscrutable, and fundamentally different from “normal” people. This has in part resulted from the fact that the substantial number of MAPs who do not engage sexually with children rarely come to the attention of authorities, clinicians, or the public. In fact, numerous studies have found that, in general, MAPs are not different in psychological make-up from the adult-attracted population, other than in the age of the people to whom they are attracted. In particular, they are no more prone to violence or aggression. Nevertheless, MAPs do suffer deeply from the stigma against them, but that very same stigma, together with a sense that the mental health system takes an adversarial stance toward them, prevent them from seeking assistance when needed. It is in this context that Dr. Seto’s influential talk was significant; it could either increase or reduce this perception by the extent to which it “othered” MAPs, by the terminology it used, and by the rationale it offered for treatment.

“Othering”

Fortunately, Dr. Seto abandoned false stereotypes commonly disseminated in the past that “othered” MAPs by claiming, for example, that their lives revolve around finding devious means for accessing and abusing large numbers of children. Instead, he emphasized the crucial distinction between attraction and behavior—noting that many MAPs do not behave sexually with children—and pointed out some of the similarities they share with the general population. For example, he acknowledged that, like people preferentially attracted to adults, they commonly feel emotional, not just sexual, attraction, that these feelings typically become apparent in puberty or adolescence, and that they can be conceptualized as constituting a sexual orientation. He estimated that up to 1.2 million American men may be preferentially attracted to prepubescent children (but did not mention how many additional may be attracted to pubescent children) and noted that they can be found in all walks of life. It was particularly encouraging when he noted similarities with LGBT people in terms of stigma, suggesting that knowledge about helping the latter can be applied to the former.

Along with these positive aspects of Dr. Seto’s talk, there were also some clarifications and improvements that could have been made. Things left unsaid and subtle interpretations can have a powerful effect on how stigmatized groups are perceived—effects that members of the majority don’t notice because it’s so much a part of common thinking, but to which members of the group in question are very sensitive. These omissions and interpretations are important to understand in the interest of reducing the stigma that prevents MAPs from getting their mental health needs met.

First, there were some relevant facts Dr. Seto could have mentioned that would have more completely counteracted inaccurate perceptions of difference. One is the evidence (such as Ray Blanchard’s work) that most men preferentially attracted to adults also feel some sexual attraction to young adolescents and prepubescent children, albeit at successively lesser intensities. This would have demonstrated that MAPs’ sexuality is not so bizarre and inscrutable as people believe. He could have also mentioned that hebephilia (attraction to younger adolescents) was rejected from inclusion in the DSM 5 by the DSM leaders at least partly on the grounds that attraction to young adolescents is not so unusual. Dr. Seto instead said that some people—it was unclear whether he meant researchers—reject the existence of hebephilia. However, the debate among leading researchers and clinicians has not been about whether hebephilia exists, but about whether it should be considered a disorder.

After noting that MAPs come from all walks of life and make up an estimated one percent of the male population, it would have been helpful to point out that this means that some of the clinicians and educators attending his talk, and possibly some of his own fellow researchers, are likely preferentially attracted to children. B4U-ACT volunteers personally know of six such practitioners—including a sex offender treatment provider—and one such psychological researcher. In addition, it is likely that many of those in the audience have children or other relatives who are attracted to children. Since the well-being of youth is of concern, it is also helpful to recognize that at a typical middle school or high school with a thousand students, Dr. Seto’s one percent male estimate means there are probably about five adolescent boys in the student body preferentially attracted to prepubescent children. By including these facts in his presentation, Dr. Seto could have helped to challenge the false us-vs.-them dichotomy.

In addition, there were some facts that Dr. Seto seemed to interpret in ways that can contribute to the perception of MAPs as fundamentally different, but that can instead be interpreted in less stigmatizing ways. For example, he referred to two “forms” of pedophilia: exclusive and non-exclusive, suggesting this is a peculiar characteristic of MAPs. In contrast, it is our experience that there is a spectrum of preference, similar to other spectra in sexuality, such as the heterosexuality-homosexuality spectrum. The reality is quite complicated, since people have varying amounts of attraction (along spectra) to different genders and ages (infant, prepubescent, pubescent, adolescent, adult, middle age, elderly, as Dr. Seto mentioned). Trying to fit people into a small number of neat categories without acknowledging this complexity can be unrealistic, misleading, and stigmatizing.

Dr. Seto also mentioned brain differences, using a diagram showing that the parts of the brain more commonly activated by the sight of attractive adults instead are activated by children in the brains of MAPs. However, this seems to show similarity rather than difference! It is analogous to the fact that gay men’s brains respond to men the same way straight men’s brains respond to women. Maybe Dr. Seto meant that these phenomena are similar, but that wasn’t clear since gay men’s brains weren’t mentioned.

Terminology

Terminology can reduce or increase stigma. The term “pedophilia” is especially problematic because it is almost universally understood as synonymous with child sexual abuse, even by clinicians and some researchers. Pedophiles and pedophilia are thoroughly reviled by all of society, including most mental health practitioners. It’s hard to imagine the term ever being rehabilitated; it seems similar to (but more extreme than) the terms “moron” and “idiot” in a previous century—originally precise clinical terms based on IQ, but eventually abandoned in favor of “mentally retarded person,” which then gave way to “person with intellectual disabilities,” when “retarded” itself acquired usage as an insult (though milder than “pedophile”). This is one of the reasons B4U-ACT uses the term “minor attracted person.”

However, Dr. Seto criticized the term “MAP” on two grounds: first that it is vague (it includes attraction to older adolescents, which is not considered clinically problematic), and second that it is a euphemism. He preferred the term “person with pedophilia or hebephilia.” His use of person-first language is to be commended, and his first criticism seems reasonable. But as already mentioned, “pedophilia” is problematic due to its stigmatizing connotations, and his second criticism is questionable. A euphemism is a word or phrase used in place of one that is unpleasant. Claiming that “MAP” is a euphemism can come across as saying that researchers need to be clear about how unpleasant and undesirable MAPs are. One would probably not want to criticize “intellectual disability” as a euphemism for “idiocy.”

Regardless of the term used, researchers who wish to reduce stigma could benefit from hearing from the stigmatized people themselves about the stigmatizing effects of a particular choice of terminology. At the minimum, if clinicians and researchers cannot give up the term “pedophilia,” they will be amenable to working with MAPs on an anti-stigma campaign to educate researchers, clinicians, and the public about the correct meaning of the term. B4U-ACT and other MAP organizations stand ready to begin such endeavors with Dr. Seto and other researchers.

Rationale for Treatment

MAPs who seek mental health services want to be treated like any other client and receive assistance to meet their needs, rather than to devise strategies to protect other people from them. Like other clients, most MAPs we have met do not have difficulty refraining from abusing children, but seek help dealing with the results of stigma and marginalization, such as self-hatred, depression, anxiety, suicidal feelings, lack of intimacy or sexual outlet, perceiving a need to live a double life, and feelings of alienation from society, friends, and family. In addition, like other clients, they may seek help dealing with issues unrelated to their attractions, but still want to be open about their sexuality.

Unfortunately, however, most research about MAPs and mental health services for them start from the assumption that MAPs constitute a serious risk to children, and that this should be the primary concern of researchers and clinicians. This assumption is the root of stigma. Therapists who put primary emphasis on preventing MAPs from offending are subordinating the psychological needs of their clients, sending the message that these needs are not as important as they would be for “normal” clients. MAPs sense they are being seen as risks or objects to be controlled rather than as people. This feels dehumanizing and adversarial, as if the therapist is an agent of law enforcement and social control rather than a helping professional. It is also discriminatory, since other clients are not treated this way. All of this, of course, intensifies rather than ameliorates stigma and mental health problems, alienating MAPs from the mental health system.

Compounding this, many MAPs are aware of the treatment methods that historically have been used coercively on sexual minorities as a result of such a social-control approach. These include being forced to self-identify as dangerous and incurably “deviant,” to submit to phallometry (a procedure often seen as degrading and stigmatizing, whereby a device is connected to the penis to measure erection while the person is subjected to sexual images or audio recordings), and to repeatedly undergo some kind of arousal reconditioning method such as aversion therapy or covert sensitization to associate fear or revulsion with their sexuality. MAPs are aware that similar methods have been used in modern times on MAPs, typically under coercion, including on young adolescents (one of whom attended a B4U-ACT workshop as a young adult), and have reportedly led to severe trauma and other psychiatric problems. MAPs may fear that researchers and therapists will approve of the use of such methods on them.

In light of this, it was encouraging when Dr. Seto recognized that many MAPs don’t abuse children, and that they face stigma similar to that faced by LGBT people. However, it was disheartening that most of the rest of his talk confirmed MAPs’ fears of social-control rather than wellness treatment rationales and methods.

First, Dr. Seto emphasized several times that his main goal was to prevent sexual abuse, and that this was the reason for treatment. No mention was made of the idea that MAPs’ mental health is important in its own right. He said he wanted to prevent children’s integrity from being violated by adults, but did not acknowledge how that integrity, in the case of young adolescents attracted to younger children (whom he acknowledged exist), has been violated by society’s revulsion for them, and by coercive treatment programs that have used shame, phallometry, and arousal reconditioning. This seemed like a double standard, compounding the perception that dehumanization of and discrimination toward MAPs is considered acceptable.

Emphasizing the social-control rationale is frequently defended by arguing that audiences (and funders) are not yet ready to see and treat MAPs the way they do other client populations, so can only be motivated by their desire to prevent CSA. However, this response accepts and reinforces discrimination, rather than confronting it, contrary to professional codes of ethics.

Second, at one point in his presentation, Dr. Seto showed a slide picturing a public webpage with hateful comments directed toward MAPs, such as “The only cure for pedophilia is a bullet in the head.” MAP attendees might expect such a slide to be given as an illustration of the horrific stigma they face, so it was a bit of a shock when Dr. Seto instead commented only that society responds to CSA after the fact, rather than trying to prevent it.

Third, Dr. Seto mentioned the German Project Dunkelfeld as an exemplary treatment program that should be adopted in other countries. While there are some laudable aspects to its implementation, the program makes clear its primary goal of preventing offending and its roots in traditional social-control-oriented American sex offender treatment. It makes little use of mainstream client-centered therapeutic and sexological knowledge and can be expected to intensify stigma and shame due to its dominant and recurring theme of MAP sexuality as inherently destructive. It should be noted that Project Dunkelfeld runs a similar program for children ages 12-17, again suggesting a double standard that children who are attracted to younger children should be subject to social-control treatment that ignores harm to their mental health.

Assessment

Also confirming MAPs’ fears of a social-control perspective, Dr. Seto mentioned phallometry as a useful assessment method. For reasons already mentioned, most MAPs perceive this procedure as a dehumanizing, unethical method used to force a diagnosis out of an unwilling client. In his talk, Dr. Seto noted that assessment of pedophilia is ideally based on an interview, but in a clinical or forensic setting, clients are not forthcoming, so phallometry must be used. He acknowledged the unpleasantness of the procedure, but not its history with LGBT people or its serious ethical ramifications, which can sound to MAPs like a whitewashing of its problematic nature.

In fact Dr. Seto seemed to approve of the adversarial use of phallometry. If the client is not forthcoming, does that not mean the client must be resisting diagnosis? This would be understandable, since in a forensic situation it could result in more severe punishment, and in a non-forensic situation, the stigma is so severe that the client may fear clinician revulsion, unethical treatment, or violation of confidentiality. Doesn’t that mean that the phallometry would be done against the client’s will? Is this ethical? Perhaps coerced diagnosis is routinely done in forensic settings with other disorders (if so, this needs to be clarified), but it’s especially unclear how it can be justified in a non-forensic setting.

Dr. Seto seemed to justify phallometry by saying that it predicts recidivism. Of course, “recidivism” is a law enforcement term, not a therapeutic one, again confirming a social-control rationale. In addition, even if phallometry has probabilistic predictive validity on groups of people, its use to predict an individual’s behavior calls to mind the ethically dubious concept of “pre-crime.” Even if there is some compelling ethical and therapeutic justification for phallometry, it has never been clarified to the MAP community. Without that, promotion of its continued use will intensify MAPs’ feelings of stigma and alienation from (and anger toward) the mental health profession, especially in light of alternatives.

What are these alternatives? Assuming that the helping professional’s primary objective is the well-being of their client (as specified in professional codes of ethics), it would seem most effective for the clinician to facilitate a trusting, therapeutic relationship so the client will be honest in a clinical interview. Not only that, many ethics codes state that the professional should advocate for the client; in this case, that would include protesting unjust social and legal factors that interfere with the therapeutic relationship by stigmatizing or punishing clients more severely on the basis of a mental health diagnosis.

Conclusion

Dr. Seto had an excellent opportunity to improve the knowledge and attitudes of sex educators and therapists regarding MAPs, and thereby reduce stigma and build MAPs’ trust in the profession. He took a small step toward this goal. He began dismantling the entrenched mythology that MAPs are fundamentally different from other people by abandoning explicit stereotypes and pointing out similarities between MAPs and the general population. Yet he could have done this even more effectively by noting some additional crucial facts, and by interpreting other facts more accurately. He could have acknowledged the stigmatizing nature of current terminology and committed to addressing the problem. To the extent that Dr. Seto’s talk was indicative of the direction the field is taking regarding MAPs, it suggests that researchers and clinicians are not yet fully aware of the ways they speak about MAPs that stigmatize them.

Commendably, Dr. Seto pointed out the stigma that adult and adolescent MAPs face, but he was not yet able to give up the traditional social-control paradigm in favor of one that sees MAPs as similar to other clients—valuable humans deserving of compassionate care that meets their needs. Dr. Seto, while encouraging his audience to reduce stigma, was embracing a paradigm that perpetuates that very stigma. He and other leaders, due to their influence in the field, could significantly build the trust of MAPs if they were to advocate a paradigm shift, turning away from the language, perspectives, concepts, and techniques of social control/law enforcement, toward therapeutic ones. This is probably their most important task, since the social-control paradigm is the fundamental source of the stigma they wish to eliminate.

The shortcomings pointed out here are not surprising, considering that Dr. Seto likely spoke without input from the people the talk was about. In general, it is helpful for researchers and practitioners to seek the perspectives of those they endeavor to study, treat, and speak about, particularly when they want to help them feel more comfortable working with them. There is a certain amount of wisdom in the slogan: “Nothing about us without us.”

I appreciate getting any feedback — whether praise or criticism — on my plenary and how it was perceived by the audience, especially from any persons that I’m directly talking about. It’s the best way for me to learn and grow as a researcher and educator.

I’d like to respond to some of the points, as part of a dialogue:

I appreciate the positive comments regarding my efforts to educate regarding the distinction between sexual attraction to children and sexual behavior involving children, introduce facts about sexual attraction to children, and discuss stigma.

I mentioned but did not sufficiently emphasize when discussing my criticism of the term MAPs that I think the term “child attracted persons” or CAPs would be more precise and more direct because many of the issues that I discussed are not pertinent to those individuals who are preferentially attracted to older adolescents. I understand the criticisms around the term pedophilia given the clinical, forensic, and public/social significance. At the same time, this is the term used in the most common mental health nosologies (DSM-5 and ICD-11) and I understood I was speaking to a primarily clinical audience who would be familiar with this term and would encounter it in their professional conduct.

I appreciate the criticism that I could have said more about the spectra of sexual attractions across age/maturity categories when discussing the DSM distinction between exclusive and nonexclusive forms. I also agree that I could have said more at many points in the talk, e.g., access to treatment by MAPs in its own right.

I had thought about explicitly stating the likely presence of some child attracted persons in the audience given there were hundreds of men in attendance (the 1% guesstimate applies only to men, the likely prevalence among women is much lower; we have no idea about the prevalence in non-binary individuals), but ironically, I held back because [it was] mentioned to me before my plenary that there were MAPs in attendance and I thought this might have made these individuals self-conscious. This to me is clearly an example of how consulting MAPs beforehand would have been helpful, to know if mentioning there were MAPs in attendance would have been perceived as acknowledgment or as “othering” (or perhaps both).

Regarding the slide showing the very hateful public comments, I know that I had included that slide with the very specific purpose of illustrating how powerful the public stigma is. I am sure that I made this point in showing the slide, noting how angry and frightened many people are when they hear about pedophilia, and I’m confident that my other point, that society tends to react after child sexual abuse has occurred, was made at a different point in my talk. I apologize if my point was not sufficiently clear because I would not have included the slide otherwise. My other regret about this slide is that I do not think I gave a specific or sufficiently clear trigger warning about the violence reflected in the screenshots of public posts, especially since I knew there were MAPs in attendance.

Regarding my “social control” perspective, I mentioned several times that my primary goal is the prevention of sexual offenses against children — so that it was clear to the audience that I spoke from my perspective as a clinical and forensic psychologist and researcher who has worked in the sexual offending prevention area for 20+ years. I am also interested in sexual attraction to children as its own topic, but I do not see myself as an advocate for MAPs, and my primary goal is not the mental health or well-being of MAPs, though I certainly wish for more human and compassionate treatment, as I explicitly mentioned in my talk. It is in this context that I discussed topics such as recidivism or phallometric testing of sexual arousal to children, not as something recommended for everyone but specifically for those individuals who have sexually offended against children, especially if they deny any sexual attraction to children. Yes, this is adversarial. To clarify, I would not agree with the phallometric testing of self-referred individuals who are seeking counseling or other help. After all, the person is coming forward with their concerns and “we” (clinical professionals) would not know about them otherwise. Indeed, I had hoped my talk would reduce barriers to treatment, hence my points about the emerging evidence regarding attitudes of therapists and barriers to treatment and what AASECT members could offer.

Michael
———————–
Michael Seto, Ph.D., C.Psych.
Director, Forensic Research Unit, The Royal’s Institute of Mental Health Research
Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group
Adjunct: University of Toronto, Ryerson University, Carleton University, University of Ottawa
Editor-in-Chief, Sexual Abuse (http://sax.sagepub.com)
Twitter: @MCSeto
https://ca.linkedin.com/in/mcseto

I’d like to thank Dr. Seto for his response. As I understand it, sexuality and mental health researchers who study particular populations generally do so for the purpose of understanding issues regarding their sexuality or mental health, for the ultimate purpose of enhancing their well-being. I’m not sure whether this would be called advocating for the population they’re studying, but regardless, I appreciate Dr. Seto’s honesty saying that unlike in other areas of research, the well-being of the population he studies is not his primary area of expertise or interest, nor was it the focus of his talk.

In this case, it would seem that the plenary’s title was confusing or misleading, since it seemed to suggest the topic was attraction to children in general, rather than about preventing abuse. These *are* two different things; the assumption that attraction to children equates to sexual danger to them is the root of the stigma and hatred directed toward child-attracted people (CAPs), including adolescents. Perhaps a better title for the plenary would have been something like “What We Know About Preventing Offending by People with Pedophilia.” As it was, it would be similar to a talk entitled “What We Know About Mental Illness” that neglected understanding mental illness for the sake of people with mental illness, and instead assumed and implied they were dangerous by primarily focusing on their risk to others. NAMI would rightly be upset about such a talk.

The problem was compounded by the fact that this was a plenary talk given by a leading researcher, so that it was much more widely attended than two other presentations about CAPs which reduced stigma by treating CAPs the way other people are treated and addressed broader mental health and sexuality issues.

Leading researchers, institutions, and organizations work to enhance mental health, prevent suicide, and protect people from institutional or societal abuse and hatred. However, they all tacitly exclude adolescents or adults attracted to children from these missions, sending a clear message that these people are not considered completely human. Imagine a 13- or 14-year old boy who realizes he’s attracted to prepubescent children, who knows he’s a “pedophile” (not unusual as Dr. Seto noted). Imagine his thoughts when he sees the following, published recently by a researcher: “Horror and disgust shouldn’t be our only response to pedophilia,” implying that horror and disgust for this boy are acceptable, even desirable, even though they are not enough.

Dr. Seto said his mission is to “prevent children’s integrity from being violated by adults,” but it appears there may be a double standard. It is not clear that he and similar researchers have the same concern for 13- and 14-year olds who are attracted to younger children and are therefore verbally and emotionally violated by adults (politicians, law enforcement officials, journalists, and even mental health professionals) who make derogatory or condemning public statements about “pedophiles.” Only when researchers publicly demonstrate the same concern for these children as they do for peer-attracted children–and publicly acknowledge their full humanity and dignity–will their concern for children seem genuine. Speakers with such inclusive messages at future conferences organized by AASECT and similar organizations would make a tremendous difference in the education of therapists and educators.

Sincerely,
Richard
Richard Kramer
Science & Education Director
B4U-ACT, Inc.
P.O. Box 1754
Westminster, MD  21158
www.b4uact.org