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Pedophilia Is a Mental Health Issue. It's Still Not Treated as One

“This is a topic that scientists in the fields of mental health are not just uninterested in—it is actively repugnant."
August 24, 2020, 4:00pm

On the nights when the mental sexual images of children were most overwhelming, Joseph Parker took cold showers and baths, hoping the shock of freezing water would push his intrusive thoughts away. Other times, he would fixate on a picture of the Sri Lankan Buddhist monk Henepola Gunaratana, so that the monk's "wrinkly face" might replace the disturbing imagery in his head.

Parker, who is using a pseudonym to protect his identity, had known he was attracted to children since he was 17, but he didn't start having overpowering sexual urges until he was 24. (He's now 26.) These urges were the worst when he was falling asleep. "As soon as I tried to release myself from wakefulness, my mind would sink into the pool of sexual energy, and I would feel this horrible sense of joy and happiness towards children,” he said.

He read online about medications that could lower testosterone levels and, as a result, sex drive—a process sometimes referred to as "chemical castration." When he asked a psychiatrist for these drugs, he was given Risperidone, an antipsychotic, instead. He took that for about a year, then added on Sertraline, an antidepressant, but only found these drugs mildly helpful. He turned to the internet to get what he had wanted in the first place.

From a website based in Turkey that sells pharmaceuticals, he ordered cyproterone acetate, which lowers testosterone, along with the female hormone estradiol, and now takes the two medications together. The website that processes the sales is frequently shut down because of its illicit nature: "To my knowledge this is their third or fourth website change, at least, since I came upon them 14 months ago," he said.

Parker wishes it wasn't this hard for pedophiles to get sex-drive reducing medications. But for many pedophiles—and especially pedophiles who have not committed crimes—access to even talk therapy, let alone medication, can be difficult to come by, and the process is riddled with fears about being reported to legal authorities.

In the past several decades, researchers have arrived at new understandings about pedophilia, the sexual attraction to children. Pedophilia appears to be an in-born sexual preference, something a person does not choose and cannot change. A pedophile's attraction to children is consistent—not a phase—and they develop their attraction to children around the same time that other people develop sexual attractions.

While researchers' knowledge has been evolving, access to widespread, up-to-date healthcare hasn't kept up pace. Outside of the handful of researchers who provide therapy and medication to pedophiles, the barriers to finding an informed therapist or psychiatrist remain high. This has led to a hodgepodge of therapeutic approaches in the community, or people self-medicating, like Parker did. Many pedophiles are only directed towards treatment in the context of the criminal justice system, where in some states, chemical castration is used on sex offenders.

Yet importantly, researchers have established there's a distinction between pedophilia and child molestation, a difference between the attraction itself and the crime. “Most people hear these words and think that they're synonyms. They're not,” said James Cantor, a Canadian clinical psychologist and neuroscientist who studies pedophilia.

Only about half of child sex offenders are genuine pedophiles. The other half prefer adults sexually, and are abusing children because they’re available or easily manipulated. (Child porn offenders, on the other hand, are nearly always pedophiles because of the ready availability of adult porn alternatives.)

The goal of any modern, preventative treatment for pedophila should be to help people manage their sexual interests rather than try to change them, Cantor said. This can involve the voluntary use of hormone-reducing medication to control urges or therapy. Since pedophilia and sexual abuse are not synonymous, treatment for pedophilia is also not solely about preventing child sexual abuse—it’s about helping people with their overall mental health and well-being too. That’s a concept that may be hard to accept. It involves recognizing that people who are sexually attracted to children deserve to live healthy and meaningful lives.

Online support groups for non-offending pedophiles have only recently entered the public eye. The most well-known group, the Virtuous Pedophiles, was formed in 2012 as a safe place for pedophiles to discuss their struggles and commitment to not offend. Parker belongs to the Virtuous Pedophiles and is known to the community as Double22. Another organization, the Association for Sexual Abuse Prevention (ASAP) was formed by some members of the Virtuous Pedophiles, and they are currently ramping up their goal to create a platform to connect pedophiles to mental health professionals.

"In my opinion, they should not be seen as second class patients.”

In April of this year, the first randomized placebo-controlled study of a hormone-reducing drug for pedophilia took place in Sweden. Published in JAMA Psychiatry, it found that the drug reduced both high sexual desire and sexual attraction to children, and that the effects were noticeable within two weeks.

The study is the first to include people who self-identified as pedophiles and were seeking help of their own accord, not just people funneled from the criminal justice system. What’s even more remarkable about the study is that it included a placebo group—the first pedophilia study to do so. In an editorial about the study, Peer Briken, a professor of sex research at the University Medical Centre Hamburg-Eppendorf in Germany, wrote that it “marks a milestone in clinical sexual science and the field of forensic psychiatry.”

“I think one of the biggest problems is that people just don't understand this as a mental health issue,” said Fred Berlin, an associate professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. “Rightfully, people are concerned about protecting children. And so we just quickly stigmatize people who are attracted to children and often don't even see them as human beings with a problem who might be deserving of help.

"In my opinion, they should not be seen as second class patients.”

In 2014, journalist Luke Malone wrote an article about young people, some of them minors, who were discovering that they were attracted to children, and how they were coping with it. It was adapted as an episode of This American Life, one of several high-profile media pieces about pedophiles that explored the complicated existence of being born attracted to children—and how hard it is to get help.

When Adam, one of the young pedophiles in Malone’s story, admitted to a therapist what was wrong, “she just became extremely cold and harsh,” he told Malone. “She even, a few times, almost got to the level of shouting.” She ended up telling Adam’s mother.

“There is a huge reason [pedophiles] would avoid therapists and doctors—those people have an obligation to report them to police if they think children might be in danger in the future,” said Ethan Edwards, one of the co-founders of the Virtuous Pedophiles, who uses a pseudonym.“Especially if they are not specifically trained in the issue, and with the common belief that all pedophiles molest children sooner or later, it is very perilous for a pedophile to seek out a therapist.”


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Christoffer Rahm, a psychiatrist, researcher at the Karolinska Institute, and the senior author on the JAMA study from April, once worked at a clinic linked to a Swedish national helpline focused on sexuality, PrevenTell. Rahm ended up meeting some pedophiles who called in; one was a bus driver who brought children to school. The bus driver was struggling with his impulses and fantasies, but had not sexually offended in any way. Rahm looked for research to help determine the best treatment for his patient and found a gap in the literature: There were no rigorous comparisons of different medications, or recommendations about who might do best with therapy. (As far as we know, female pedophiles are rarer, and the research on treatment for them even more sparse.)

Cantor feels it's more than just a gap when it comes to pedophilia. “It is a black hole,” he said. “This is a topic that scientists in the fields of mental health are not just uninterested in—it is actively repugnant."

That’s what motivated Rahm to conduct his study. “If there are people seeking help for this, the best thing would be to manage it in a preventative phase before the damage is done,” he said. “Of course, society needs to say that any kind of abuse against a child is not okay. But it is counterproductive if these people can't even seek help with a professional.”

The medication Rahm studied is Degarelix, approved by the FDA in 2006 for treatment of advanced prostate cancer. This is the first time that it's been used off-label for pedophilia. It’s an injection that starts working right away and lasts for about three months. It works by shutting down signals from the brain to the body to produce testosterone.

In qualitative interviews Rahm’s team did during the study, they found that some of their participants experienced positive effects. “They described feeling an inner calm,” Rahm said. “They felt less pressure, that they had a better intimate life with their partners. Some described that the annoying thoughts around children disappeared so they can focus on other things. And many described that they had lost that enervating impulse to masturbate, and were able to see children as just human beings and not sexual symbols.” A majority of the participants in the group that got the active drug said that they would want to continue taking it.

Many of the therapies that have been used for pedophiles have not been validated this way, but deployed through forensic psychology and the criminal justice system. Though Berlin has prescribed hormone-reducing medications to countless patients, he feels that the legal system usually doesn’t collaborate with doctors and scientists who are studying the use of these drugs. “As a physician, I think that's completely inappropriate,” he said.

If someone goes to prison being sexually attracted to children, there’s nothing about prison that can get rid of that attraction, or enhance a person’s ability to resist temptation later on, Berlin said. It also leads to a mistrust of treatment, because of a history of involuntary use of chemical castration and aversion therapy—a therapy that associates negative cues with images of young children to dissuade future attraction.

“The idea that we can solve this simply through punishment and incarceration is very naive,” Berlin said.

Talk therapy should focus on managing a person's sexual interests, with an explicit acknowledgment that those interests will likely never change. In the past, therapy sometimes focused on searching for trauma, because of the belief that a history of abuse led someone to abuse. The truth is a bit more complicated. Having been sexually abused in your own childhood could be a factor in committing sexual abuse as an adult, but is not necessarily a factor in pedophilia.

“This is what I’ve heard over and over,” Cantor said. “They knew. They always knew it. All their past therapists were telling them to focus on trauma, what happened in their childhood. But their genuine experience of it was that they were born this way.”

“We need to move on to the next generation of research and quality development.”

Cantor said that once that basic framework of therapy changes from changing one’s sexuality to managing it, people adapt very quickly. It makes more sense to his patients, and they’re able to better commit. If a person has looked at child porn or committed sexual abuse in the past, a therapist would help them examine how and why their self-control broke down, and how to set up their life so that it doesn’t happen again—not how to stop being attracted to children.

For some people, this process could be paired with sex-drive reducing drugs. “Some people find they would rather live in that state than with those nagging sex drive that they can't express and can do anything to do anything about,” Cantor said.

Yet even in those states that have issued mandates for sex offenders to receive hormone-reducing drugs as punishment, it can be incredibly difficult for non-offending pedophiles who want it to get medication. “I get letters from people around the country all the time wanting access and they can't even get access to it,” Berlin said.

Rahm doesn’t advocate for medication to be used for every pedophile for life—his study explores whether this specific drug could help. He said a person may only want and need it for a few months. It could help a person through a difficult time, or be combined with the start of a behavioral therapy practice. “We need to move on to the next generation of research and quality development,” Rahm said. “We need to evaluate our treatments and to get evidence-based treatments out there so we know what we're doing.”

The word “castration” has a dark history, and dark connotations. It's often been wielded involuntarily: In Germany the number of involuntary castrations of sex offenders increased as a result of the Nazi German Act, with at least 2,800 sex offenders were castrated between 1934 and 1944. In the United States, Black men accused of raping or sexually assaulting white women could find themselves subject to castration. For reasons like these, Rahm is torn about calling Degarelix “chemical castration." While he thinks researchers and clinicians should accurately describe what the drug is doing and its side effects, he worries that referring to it as castration could scare people away, or disregard the consent and autonomy of patients who want it.

Rahm said that every person who participated in their study did so voluntarily, and was informed in detail about any possible side effects from taking Degarelix. They had the option to quit the study at any moment. He’s also currently running another placebo-controlled study on a non-pharmacological option: therapy geared specifically towards pedophiles that they can access anonymously, through the dark web.

The mere existence of Rahm's studies is important, outside of the details of the findings. Doing placebo-controlled studies on pedophilia was previously thought to be impossible, because of the ethical implications of not giving an active treatment to a group of people attracted to children.

In Briken’s editorial, he wrote that because the medication they used was fast-acting, and they allowed anyone with pedophilia into the study—not just those who were high-risk for offending—it helped make the placebo group ethically possible. Briken concluded that Rahm's study was “the most important contribution to the field of pharmacotherapy of pedophilic disorders since” the original study of hormone reducing drugs in 1998, and offers a starting point for a more comprehensive approach to pedophila treatment.

In Germany, Prevention Project Dunkelfeld, which offers therapy and medication, has 10 locations throughout Germany, and a person can get help while remaining completely anonymous.

The demand for their work is high: After a BBC documentary on the Dunkelfeld Institute aired, the Guardian reported that Dunkelfeld’s hotline was overwhelmed with calls from British pedophiles. “One British man was so desperate, he moved to Germany to be able to access a Dunkelfeld programme,” the Guardian wrote. “In an email exchange with the Guardian, the man, who wished to remain anonymous, wrote: 'So far, all I have ever received from the NHS is doors slammed in my face.'"

There's not as well-known a center for pedophiles in the U.S. to go to. Richard Kramer, the educational director at B4U-ACT, an online community for pedophiles, said he figured out he was attracted to pubescent boys in his 20s. (His attraction is to boys around the age of 12 or 13, which is technically called hebephilia.) “I was very ashamed about it and thought that I was seriously defective as a human being,” Kramer said, who is using a pseudonym. “I really wasn't able to find any information about it. I didn't want to go to the library for fear that people would see what I'm looking up.”

When he began reading information online, he said, everything he encountered was very negative. “It said that I would be a monster, I would have hundreds of victims, and that my entire life would be centered around an elaborate plot to deceive parents and to manipulate children into abusing them,” he said. “So I thought, well, this is what they think about me. I have no interest in seeing them and seeing a therapist.”

A big part of being successful in therapy is having the support of family and friends, something that pedophiles can lack. They often are going through difficult treatments alone, and are unable to talk about it to others. You can’t tell co-workers, or ask a boss for time off for your appointments. “You have two choices,” said Michael Seto, a forensic psychologist and sexologist at the University of Toronto. “You don't do it or you lie about it.”

When Kramer was ready to look for a therapist again, he didn’t really care what kind of approach they used, but was more concerned about whether they understood enough about pedophiles to not treat him like a criminal. His goals didn't involve a struggle to control his impulses, but to manage the shame and sense of isolation from others because he couldn’t be honest.

“We have to insist that people who have this orientation not act upon it,” Berlin said. “If we think about that, that can be quite a burden. It’s not surprising that some of these folks might be in need of mental health assistance, because of the effect of experiencing these attractions on their sense of self-esteem and self-worth.”

“Happy, mentally healthy people do not molest children.”

Some pedophiles are attracted to adults and children; some, only children. For those who are exclusively attracted to children and dedicated to non-offending, Kramer said, there needs to be a space for helping them grieve over not being able to have romantic and sexual relationships. “How do they deal with loneliness?” he said. There are other concerns, some almost mundane: How, for instance, do they deal with answering questions friends and co-workers ask about their personal lives? He’s had friends who asked him if he was gay, and he said he wasn’t sure how to answer.

“I'm not exactly gay, but I'm definitely not straight and I'm definitely not asexual,” he said. “How do you respond to that?”

Gary Gibson founded the ASAP as one potential solution to this problem. Through an involvement with the Association for the Treatment of Sexual Abusers (ATSA), Gibson has been curating a list of therapists to whom he can refer pedophiles. The list is now around 400 names long. ASAP primarily focuses on non-offending pedophiles, but they will also help people who have offended and want to stop. “People are just desperate out there,” Gibson said.

He has worked with pedophiles who were so desperate for help that they underwent physical castrations. One man traveled to Mexico to have the operation done; when he returned, he tried to find a doctor to supervise his recovery and medications. “I could not find a doctor who would take him on,” Gibson said. “They didn't want him in the office. I did find a therapist to work with him, and I kind of lost contact with him. I’m worried about what happened to him.”

Until recently ASAP has been handled almost entirely by Gibson, but ASAP is currently undergoing a significant expansion. It has increased its office and volunteer staff, is making a new, online database of mental healthcare providers, and creating a 24/7 helpline. Gibson said his dream is to get a multimillion dollar grant to create a mentor program for teenagers, aged 13 to 17, who are learning that they’re pedophiles. “I’ve applied three times,” he said. “Maybe the third time's the charm, because I’ve been denied twice.”

The goal is to help every non-offending person attracted to children find therapy if they want or need it, said Robert Hillman, a “lifelong virtuous (non-offending) pedophile,” and the new president of ASAP.  Hillman said that the mantra is: “All pedophiles are born non-offending,” and the aim is to help keep it that way. “Happy, mentally healthy people do not molest children," he said.

“People do the most desperate things when they feel the most desperate,” Cantor said. “A lot of what these groups and therapy provide is helping people lead a life that is worth protecting. When they have a life worth protecting, that’s when people get the energy and the willpower to control themselves, because they don’t want to risk the life that they have.”

What Hillman and Gibson want is the opportunity for any person attracted to children to chart their own path, and figure out what works best for them. That may include an experimentation with medication, and it may not. ASAP doesn’t control their therapists—they all operate independently, using different methods of treatment. They're not always successful. “One guy has committed suicide that I know of,” Gibson said said. “But I think that we have probably saved a few lives and saved many children from being abused.”

These support groups and therapy networks are providing a lifeline, but alone, they don't guarantee a consistency in treatment, nor fill the gaps in the scientific literature when it comes to which treatments might be best for a certain person. There might be certain hormone-reducing medications that are less risky or work better than others; certain pedophiles that fare better without drugs; certain therapeutic practices that are more helpful than others. Those answers aren't clear-cut.

As with all medications, some people have good experiences and others do not. Pedophiles can identify as “ego-dystonic” or “ego-syntonic.” Ego-syntonic people consider pedophilia as part of their identity, and can be okay with fantasizing and masturbating about children (though not with porn), while ego-dystonic people are not. It may be that treatment should be different with those who have different attitudes towards their attraction, even if members of both groups have the same commitment to not offend.

After about five weeks, Parker said that he felt better from the medication he had ordered online. “It was night and day," he said. "I can't tell you what a weight was lifted off of me, or a pressure from under me that was relieved. Whenever I think about it I just lay back in my chair and breathe a contented sigh, knowing that I won't suffer like that again. Both physical urges in my body and intrusive imagery in my mind have disappeared."

He doesn’t think that medication should be thought of only as a stop-gap to a person committing sexual abuse. “Offending was never a danger for me in the first place,” he said. He doesn’t take the medication to stop himself from molesting a child, but as a way to improve his quality of life.

When Max Weber, who helps run a peer-support website for pedophiles in Germany, realized his attraction to young girls in his early 20s, he said, he was terrified. “My picture of pedophilia at the time was the same wrong impression most parts of society have: that pedophiles were bound to offend,” he said.

Weber got treatment at Dunkelfeld, and said he views medication like a pair of eyeglasses. “You can put [them] on to help yourself focus on things that you want to change about your life.”

To Weber, pedophilia was like being surrounded by deep water; he had to struggle to stand on his toes to avoid drowning. “I needed all my strength to cope with it and don’t drown in my own fears and self-hate,” he said. “As a result sexual impulses felt very powerful since, when you are standing on your toes, even the slightest push could throw you over.”

He took medication for about nine months. During that time when his sexual feelings were repressed, he regained a foothold on his life, he said, and found that even without medication he is able to be around children without issue. “I now know that I am in charge, and no one can make me offend other than myself,” he said.

Two years ago, David, a 22 -year-old recent college graduate from New York and a volunteer for a peer-support group including pedophiles, desperately wanted to take hormone-altering medication. “I hated myself for having feelings about children, and I just wanted to be like everyone else," he said. "I was also going online and finding articles about how to raise libido, and doing the opposite of all of the advice I found. But I couldn’t find a therapist I felt safe coming out to.”

Since then, he said that support groups like Virtuous Pedophiles have helped him realize that being attracted to children is not something he chose, and he’s not tempted towards any illegal behaviors. “In the end, there was no need for me to go through such a treatment with dangerous side effects," he said.

Though he never ended up trying medication, David thinks his experience with peer support reveals something important. Medications can help reduce physical symptoms, he said, but the rest—the support, the isolation, the shame—all needs to be addressed outside of just taking a pill.

“I struggled with serious depression, anxiety, and self-hatred as a teenager starting to understand that I was a pedophile,” David said. “Becoming less isolated, having people to help when I was hurting, and being able to help others in the same way is what brought me back from that.”

Hillman was a patient of Berlin’s about 25 years ago. “I was on the brink of madness from the desires and from the shame and self-hatred and loathing,” he said. "It was crushing me and I was not going to survive it.” He took hormone-reducing medication with Berlin's help, and said that combined with therapy, it saved his life. “Since I was at that time and have always been non-offending, my anti-androgen therapy was not mandatory in any way and thus I started and stopped it several times, because of the affordability issues,” Hillman said. “But I can attest that the medication did reduce my thoughts and therefore some of my distress.”

Then he found the Virtuous Pedophiles group about one year ago, and the support he’s culled from the others there has given him a new gusto for life, without medication. “Now I am dedicated to living. And I am dedicated to making sure no one else has to waste their life just to be virtuous,” he said.

Hillman said that these narratives reveal how all pedophiles are different. “Some will benefit from meds and some will not,” he said. “Some are against medication, some are not.”

Rahm hopes to continue studying treatment options for pedophilia, in a rigorous way. In his view of a forthcoming modern pedophile treatment, each person would get an individual assessment and be offered an evidence-based treatment. It would work with helping a pedophile address both their personal feelings and concerns, and also their risk of offending.

“In my vision, some people need therapy, some need medication, some need both, and some won't have any effect on any of these. They need something else,” Rahm said. This is nothing novel or groundbreaking, he added. “I would just like to apply modern psychiatric thinking to this group.”

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