Minor-Attracted Persons: a Neglected Population
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Minor-attracted persons: A neglected population Such individuals who develop psychiatric symptoms deserve nonjudgmental treatment pproximately 1 in 5 Americans report childhood sex- ual abuse.1 While 50% to 65% of child sexual abuse Aoccurs in the absence of pedophilic interests and is thought to be driven by additional factors such as the avail- ability of an appropriate sexual partner,2,3 a substantial por- tion of childhood sexual abuse is perpetrated by individuals with pedophilia. However, many individuals with pedophilic interests never have sexual contact with a child or the penal sys- tem. This non-offending pedophile group reports a greater prevalence of psychiatric symptoms compared with the general population, but given the intense stigmatization of their preferences, they are largely psychiatrically under- PESKYMONKEY / ISTOCK recognized and underserved. This article focuses on the unique psychiatric needs of this neglected population. By Renée Sorrentino, MD understanding and addressing the treatment needs of these Clinical Assistant Professor patients, psychiatrists and other mental health clinicians can Harvard Medical School Boston, Massachusetts serve a pivotal role in decreasing stigma, promoting well- ness, and preventing sexual abuse. Janette Abramowitz, MD Assistant Professor of Psychiatry University of Hawaii John A. Burns School of Medicine Honolulu, Hawaii Understanding the terminology DSM-5 defines paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimula- tion or preparatory fondling with phenotypically normal, physiologically mature, consenting human partners.”4 The addition of the word “disorder” to the paraphilias Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products. Current Psychiatry doi: 10.12788/cp.0149 Vol. 20, No. 7 21 Table 1 Sexual attraction: Definition of terms Terminology Definition Comments Pedophilia Sexual attraction to Considered a psychiatric disorder if the prepubescent individuals individual has acted on the attraction and/or has experienced distress related to the interest Hebephilia Sexual attraction to pubescents Not considered a psychiatric disorder, constitutes Minor-attracted and adolescents illegal behavior if acted on persons Ephebophilia Sexual attraction to late Not considered a psychiatric disorder, constitutes adolescents illegal behavior if acted on Minor-attracted Sexual attraction to individuals May be a psychiatric disorder if pedophilia is with person under the legal age of consent acting on and/or distress Teleiophilia Sexual attraction to adults Commonly co-exists with minor attractions was introduced in DSM-5 to distinguish It is important to keep in mind that the Clinical Point between paraphilias that are not of clini- terms pedophilia and minor attraction are A minor-attracted cal concern and paraphilic disorders that not synonymous with childhood sexual cause distress or impairment to the indi- abuser or “child molester” because neither person may or may vidual, or whereby satisfaction entails term specifies whether the individual has not meet criteria personal harm or risk of harm to others. had sexual contact with a child or legal for pedophilia or As outlined in DSM-5, pedophilic disor- consequences. The terms offending/non- pedophilic disorder der refers to at least 6 months of recurrent, offending and acting/non-acting are used intense sexually arousing fantasies, sexual to specify the presence of sexual contact urges, or behaviors involving sexual activ- with a child, and do not convey any clini- ity with a prepubescent child.4 The indi- cal information. vidual has either acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal Prevalence data difficulty. Lastly, the individual must be The true prevalence of pedophilia and/ at least age 16 years and at least 5 years or attraction to minors is unknown, and older than the child. Sexual attrac- estimates vary considerably. In some stud- tion to peri- or postpubescent minors is ies, 1% to 4% of the general population not considered a psychiatric disorder, but were thought to have persistent attraction is illegal. to prepubescent children.5,6 In a commu- Coined by B4U-ACT (www.b4uact.org), nity sample of 8,718 German men, 4.1% the term minor-attracted person (MAP) reported sexual fantasies involving pre- refers to individuals with sexual attraction pubescent children, 3.2% reported sexual to individuals who are minors or below the offending against prepubescent children, legal age of consent. MAP is an umbrella and 0.1% reported a pedophilic sexual term that includes sexual attraction to pre- preference.5 In a study of 367 adult German pubescent individuals but also includes men surveyed from the community, 15.5% sexual attraction to peri- and postpubes- reported fantasies (9.5% daydream and cent individuals (Table 1). A MAP may 6.0% masturbation fantasies) involving or may not meet criteria for pedophilia prepubescent children.7 Discuss this article at or pedophilic disorder, based on the age www.facebook.com/ of their sexual interest and whether they MDedgePsychiatry have experienced distress or acted on the Stigmatization of minor-attracted attraction. Although many individuals persons with minor attraction identify with the Stigmatization is the process of forming term MAP, not all do. The term has been negative evaluations of an individual or critiqued for being too inclusive and con- groups of people based on limited charac- Current Psychiatry 22 July 2021 flating pedophilia with minor attractions. teristics.8,9 MAPs are a highly stigmatized group. This stigmatization can be profound, high rates of addiction, anxiety, depres- regardless of whether the MAP has had sex- sion, self-harm, self-hatred, and suicidal ual contact with a child. A public survey of thoughts and behaviors among MAPs.2 nearly 1,000 individuals showed that 39% The majority of posts regarding substance MDedge.com/psychiatry believed that non-acting MAPs should be use described such use as a means of disso- incarcerated, and 14% believed that they ciation. One post read, “…There are days I would be “better off dead.”10 Societal mis- cannot bear to be sober … I … drink myself conceptions of minor attraction are perva- into a coma.” Anxiety themes regarding sive and include10: the ability to have a meaningful relation- • MAP sexual orientation is a choice ship with an age-appropriate partner and • MAPs cannot resist their sexual urges concerns about being “outed” followed • all MAPs have offended, or inevitably by public persecution were prominent. will Posts regarding self-injurious and sui- • MAPs will not respond to therapy cidal behavior were common: “I want to • MAPs are fundamentally predatory kill myself so badly … I have to mutilate and immoral. myself as punishment for my attractions. In addition to societal stigma, internal- I wish myself dead. I don’t want to be Clinical Point ized stigma among MAPs has been docu- attracted to children; I despise myself for Many MAPs mented. Lievesley et al9 found that MAPs fantasizing about them.”2 who engaged in suppression of unwanted A study that analyzed a survey of 152 internalize the thought strategies had higher levels of MAPs sampled from websites such as societal stigma shame and guilt, low levels of hope, and Virtuous Pedophiles and others showed toward them, which a propensity to actively avoid children. >50% of respondents had strong feelings contributes to Similarly, Grady et al11 surveyed 293 MAPs of isolation and loneliness, nearly 30% their mental health and found prominent themes of viewing had extreme difficulty with concentration, themselves as “bad.” >40% had significant anger and frustration, burden and >30% were struggling with feelings of detachment.12 Notably, the respondents Psychiatric presentations include attributed these difficulties to their minor suicidal ideation attraction.12 Table 22,12-14 (page 24) summa- Many MAPs, including non-acting MAPs, rizes the findings of studies evaluating psy- internalize this societal stigma, which con- chiatric symptoms in MAPs. tributes to a significant mental health bur- den.12 A survey of 342 MAP actors and 223 MAP non-actors revealed that one-third Consider OCD, hypersexuality of both groups reported chronic suicidal It is important to be aware that an attraction ideation.13 In addition, online surveys to minors may be a symptom of obsessive- conducted by B4U-ACT and Virtuous compulsive disorder (OCD) or hypersexu- Pedophiles (www.virped.org)—both inter- ality.15 Pedophilia-themed OCD (POCD) is net-based organizations dedicated to sup- a manifestation of OCD in which the indi- porting non-acting MAPs—have provided vidual experiences shame, fear, and exces- similar results. In a 2011 B4U-ACT survey, sive worry related to sexual attraction to nearly one-half of participants reported sui- children. Typically, individuals with POCD cidal ideation due to their minor attraction, experience sexual thoughts of children as 32% had planned suicide attempts, and 13% ego-dystonic, whereas MAPs experi- had non-fatal suicide attempts. Notably, the ence such thoughts as ego-syntonic and age group with the most prevalent suicidal arousing.15 However, much like indi- ideation was age 14 to 16 years,14 which viduals with POCD, MAPs also experience makes minor attraction a prominent risk sexual thoughts of minors as distressing. factor