Nothing more than feelings?
A psychiatrist becomes morally outraged while hearing a convicted pedophile’s story. How can the therapist confront his emotions without compromising the evaluation?
When treating patients such as Mr. V, we must not dismiss our feelings—however uncomfortable or unprofessional they might seem—so that we can manage them appropriately. Don’t be ashamed of your feelings—or at least be aware of your shame.
In such cases, these important steps can minimize the risk of compromising treatment or assessment:
- Be aware of your feelings. Reflecting on countertransference after the session, either alone or with other therapists, can help you recognize your feelings.
- Seek peer supervision when evaluating a patient such as Mr. V to help identify potential “blind spots.”
- Be aware of your limitations. Hubris is among a therapist’s most serious potential pitfalls. We all have strengths and weaknesses and should be mindful of them.
The authors’ observations
We took a passive-neutral stance. Sitting with Mr. V without deciding a course of action gave us time to assess our own reactions and limitations and how they might influence our actions.
CONSULTATION: OTHER OPINIONS
The examining psychiatrist (a psychiatric resident) sought advice from an experienced geriatric psychiatrist, a neuropsychologist, and other residents. We discussed our countertransference toward Mr. V and provided mutual supervision. We then acknowledged that none of us had expertise in treating pedophiles and that treating an unfamiliar mental condition would be unethical.
The authors’ observations
In requesting other opinions, we also weighed these important questions:
Is Mr. V violating parole by requesting testosterone injections and taking (unprescribed) sildenafil? We felt we could not rightfully answer this question, since our expertise in the standard of care for patients such as Mr. V was insufficient and any recommendation would be ill-informed.
Sildenafil use is fairly common among convicted sex offenders, as evidenced by the recent controversy over Medicaid providing the drug to this group (see Related resources).
Assuming the testosterone injections promote intercourse, would they increase Mr. V’s arousal? Hall found that offenders who can voluntarily and completely inhibit sexual arousal are less deviant when not attempting to inhibit arousal than are those who cannot completely inhibit arousal.8
Hall, however, urges clinicians to consider variables that influence sexual response before determining how arousal affects an offender’s behavior. With no objective measure of sexual arousal, it is unclear whether increasing Mr. V’s testosterone would heighten it—and his potential threat to society.
The Abel Assessment of Sexual Interest was devised to determine sexual pathology, but evidence suggests this test is clinically unreliable.
Would enhancing Mr. V’s arousal increase his risk of recidivism? Although some studies have found that castration decreases a sex offender’s sexual activity, evidence suggests that sexual responsiveness after castration varies considerably. Heim found that:
- 31% of castrates could still have intercourse
- rapists are more sexually active than pedophiles after castration
- men ages 46 to 59 experience a greater reduction in sexual behavior than do men age 9
What standard of care applies to Mr. V? Treating pedophilia is difficult and poorly understood. Psychotherapy is considered an adjunct to medication or surgery. Surgical interventions are akin to punishment, whereas medications—well-studied and often augmented with psychotherapy—are associated with high recidivism rates.11,14
Surgery. Orchiectomy is by far the most common surgical intervention. Experimental procedures have targeted stereotaxic ablation of specific parts of the brain, usually the hypothalamus or amygdala, but these techniques have not been adequately studied in humans.11 Even so, testosterone therapy can restore sexual function after castration.10
Medications. Antiandrogens such as medroxy-progesterone acetate (MPA) inhibit intracellular uptake of androgens (such as testosterone) by blocking their binding to the receptor.12 MPA is most frequently used in the United States.
Long-acting analogs of gonadotropin-releasing hormone (GnRH), such as leuprolide, nafarelin, goserelin, and triptorelin, have shown efficacy in early studies.12 These agents down-regulate gonadotroph cells, inducing severe but reversible hypogonadism with few other side effects.
Although decreased libido is a common side effect of selective serotonin reuptake inhibitors (SSRIs), use of these agents to reduce sex drive in convicted pedophiles has not been studied. Because onset of decreased libido with SSRI use is unpredictable, we cannot recommend their use to reduce sex drive in convicted offenders.
Psychotherapy. Power14 nicely outlines the elements of psychotherapy for pedophilia:
- explanation and education
- manipulating the environment
- suggestion, including hypnosis and persuasion
- superficial analysis
- deep-transference analysis
- sublimation.
