HISTORY: REPEAT OFFENDER
Mr. V, age 68, was incarcerated for 13 years for two separate pedophilia convictions. During that time, he passed numerous rehabilitative courses. With several years left on his sentence, he was paroled on condition that he undergo a bilateral orchiectomy.
Eight months later, Mr. V complained to his primary care physician that he could not have sex with his girlfriend, even after taking 50 mg of sildenafil, which he had obtained from a friend. He requested testosterone injections to allow him to have intercourse. After consulting an endocrinologist, the physician ordered Mr. V to undergo a psychiatric assessment before receiving testosterone. He was referred to our outpatient clinic.
During our evaluation, Mr. V described both pedophilia incidents. In the first, he had fondled a 14-year-old girl who was a friend of his family. He pled guilty to a charge of inappropriate sexual contact with a minor and was sentenced to 3 years in a state prison for sex offenders.
Less than 2 years after he was paroled, Mr. V said, he fondled his 12-year-old granddaughter. He said his daughter “should have known better” than to leave him home alone with the child. Again he was convicted of illegal sexual relations with a minor and sentenced to 10 years at the state hospital for the criminally insane.
As Mr. V describes his past offenses, we begin feeling tremendously uneasy. Although forthcoming, he blandly denies responsibility for either incident. He acknowledges that society views his actions as wrong, but he never indicates that he believes them to be wrong. At times he tries to normalize his behavior, saying “What man would have acted differently?”
Mr. V is polite and appropriate and promises to abide by our recommendation, yet he sees no reason for us to deny his request and no connection between his criminal record and the nature of his crimes or the terms of his parole. His denial and lack of insight are typical of convicted pedophiles (Box 1).
The typical pedophile: male, middle-aged, and in denial
Most pedophiles are unemployed men ages 30 to 42.1 In one clinical study, 70% of convicted pedophiles reported fewer than 10 victims, and 23% reported 10 to 40 victims.1 Conte et al2 found that the average number of victims per offender may exceed 7.
Poor insight and denial are common among pedophiles. In one study that explored the relationship between denial of hostility and psychopathology, 37 of 82 patients denied the charges against them.3 The study’s authors state that their data “support the contention that alleged sex offenders’ self-reports and their scores on obvious-item hostility inventories are highly suspect and should not be accepted at face value.”
During evaluation, a sex offender who minimizes his psychopathology is less likely to admit to hostility, whereas those who exaggerate psychopathology usually acknowledge more hostility. In one study,3 no offenders who denied charges acknowledged psychopathology, but offenders who denied allegations admitted to less hostility than those who did acknowledge them.
The authors’ observations
Anyone evaluating Mr. V would be inclined to treat or dismiss him, or to suppress his or her feelings to avoid prejudice.
Treat or dismiss. As physicians, we are trained to “First, do no harm.” In this case, however, we must consider who could be harmed by treatment or dismissal.
“First, do no harm” is usually taken to mean “no harm to the patient” but could also be interpreted as “no harm to society.” Even if testosterone treatment did not physically harm Mr. V, activating his sex drive could endanger society by spurring him on to molest another child (Box 2). The treatment could also harm Mr. V by making it easier for him to violate parole.
Although failure to treat Mr. V’s sexual dysfunction would likely pose no harm to society, not assessing him might endanger society by clearing the path toward this treatment.
Pedophilia: A hidden epidemic
Avoiding prejudice. When facing an unpleasant task, people often tell themselves consciously or unconsciously that their reaction is wrong and that they must carry on.7 Our revulsion toward Mr. V prompted us to be dispassionate and objective, but suppressing our emotions altogether could have obscured potentially serious objections. At the same time, giving ascendancy to negative emotions without questioning them could harm the patient—or at least obscure an opportunity to do good. Sexual abuse of children and adolescents is common but underreported.4
The National Crime Victimization Survey estimates that 110,000 sexual assaults in 1996 involved victims ≤age 12, yet only one-third of these assaults were reported to police.5 Data from law enforcement agencies in 12 states indicate that 67% of victims who reported a sexual assault were age 6