Psychotic and sexually deviant
During evaluation for psychotic symptoms, Mr. P, age 21, reveals that he has been viewing child pornography for 2 years, but has not acted on his fantasies. How would you treat him?
The relationship between viewing child pornography and pedophilia is unclear. Some child pornography viewers are pedophilic, others are sexually compulsive, and others are viewing out of curiosity and have no sexual deviance. Seto et al13 suggested that child pornography offenders show greater sexual arousal to children than to adults. Persistent child pornography use is a stronger diagnostic indicator of pedophilia than sexually offending against child victims.13 A clinician who learns that a patient is viewing child pornography should take a detailed sexual history, including a review of criteria for paraphilias. In addition, when appropriate, the clinician should perform a risk assessment to determine the patient’s risk of engaging in sexual offenses with children.
OUTCOME: Expert consultation
We start Mr. P on risperidone, 1 mg/d, to treat his paranoia and request a consultation with an expert in paraphilias to determine if Mr. P has a paraphilia and to discuss treatment options.
Mr. P’s initial diagnosis is psychotic disorder not otherwise specified. His viewing of child pornography and sexual interest in prepubescent individuals is not limited to his current mental status, and these interests persist in the absence of mood and psychotic states. Mr. P’s viewing of child pornography and sexual attraction to prepubescent girls meet the diagnostic criteria for pedophilia. During hospitalization, we educate Mr. P about his diagnoses and need for continued treatment. We refer him to a sexual disorders outpatient clinic, which continues to address his deviant sexual interests.
The authors’ observations
A meta-analysis indicates that a combination of pharmacologic and behavioral treatments coupled with close legal supervision seems to reduce the risk of repeated sexual offenses.14 Legal supervision is a general term to describe oversight of offenders in the community by supervisory boards, such as probation or parole, and tracking devices such as GPS. Currently, pedophilia treatment focuses on minimizing deviant sexual arousal through behavioral modification, cognitive-behavioral therapies, and testosterone-lowering medications, such as medroxyprogesterone or leuprolide. The decision to prescribe testosterone-lowering medication should be based on informed consent and the patient’s risk of dangerous sexual behaviors.
- Reijnen L, Bulten E, Nijman H. Demographic and personality characteristics of internet child pornography downloaders in comparison to other offenders. J Child Sex Abus. 2009;18(6):611-622.
- Hall RC, Hall RC. A profile of pedophilia: definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues. Mayo Clin Proc. 2007;82(4):457-471.
- Leuprolide • Eligard, Lupron
- Medroxyprogesterone • Cycrin, Provera
- Risperidone • Risperdal
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
