Summary

Group treatment programs for pedophiles are often designed for populations of convicted men in closed institutions with limited application to other populations. Treatment is usually focused on reducing the ‘deviant” sexual arousal and/or acquiring heterosocial skills and eventually establishing the ability to engage in adult heterosexual relationships. A six-week highly structured program is presented to five men in anon-residential setting. In addition to individual psychotherapy, group counseling is offered. Male pedophiles, arc trained to talk effectively about common problems surrounding man-boy relationships. Counseling is based on the notion that the emotional, erotic and sexual attraction to boys per se docs not need to be legitimized or modified. The attraction, however, can be a source of psychological and social problems that can
be handled by using a social support system. Social support for pedophile problems can be obtained from and in interaction with other pedophiles.

 Gertjan van Zessen is Clinical psychologist at Utrecht University and at the Netherlands Institute for Social-Sexological Research. Correspondence may be addressed to NISSO. Da Costakade 45, 3521 VS Utrecht, Thc Netherlands.
Thc author wishes to acknowledge the helpful assistance and comments of Theo Sandfort and Alex van Naerssen during the preparation of this manuscript.

 Introduction

 Treatment programs for pedophiles are almost entirely designed for particular populations: convicted men in penal or psychiatric institutions. Pedophiles and other sex offenders are treated within the same programs, and pedophiles are almost always treated as a homogeneous population. A man who forced a three-year-old girl to have sexual intercourse with [him] and another having a loving relationship with a boy of 14 receive the same treatment. The common problem with treatment programs in institutions is that it is
difficult to assess whether motivation to participate is internal, a real desire to change one's behavior, or external, a desire to leave the institution as quick as possible,

 Theory and treatment

Whethcr medically, psychoanalytically, or behaviorally orientated, all programs share the presumption that a sexual attraction to children is undesirable and requires modification.

In the medical review, pedophile behavior is the result of an excessively high sexual drive. Medical therapies  for sex offenders, including castration and administration of hormones and drugs, have raised various ethical questions., Irreversible interventions, such as castration, seem to be effective from a criminological point of view; Stürüp reports a recidivism rate of 2.2% on a total of 3,186 sex offenders (Stürüp, 1968).

In an overview of treatment programs, Crawford (1981)concludes that two other approaches, psychoanalysis and individual (insight-orientated) psychotherapy, not used in conjunction with other forms of psychotherapy, are of little value in the treatment of pedophiles.

The majority of the reported studies have roots in behavior therapy. The early behavioral approaches were aimed at reducing the  deviant sexual arousal by aversion therapy (Quinsey et al., 1976). The attraction to children is viewed as purely sexual (Howells,
1979). In its simplest form, the child is the stimulus that elicits sexual excitement in the adult (Quinsey ct al., 1975). All other motivations and meanings of pedophile attraction arc ignored.

In later studies it is recognized that, in addition to reducing pedophile arousal, attention should be given to establishing new sexual ant! social relationships. Treatment is aimed at conversion and at enlarging the pedophile's heterosocial and heterosexual skills 
(Crawford and Allen, 1979; Hayes et al., 1983; Travin et al., 1985; Segal and Marshall, 1985). There is little empirical evidence, however, indicating exactly what skills are deficient (Harlow, 1974).

 Treatment is always aimed at reducing pedosexual arousal and establishing adult, heterosexual arousal patterns (conversion). It is considered crucial for therapeutic success to teach sufficient social skills to implement new arousal (Herman and Prewett, 1974). Social skills training does not include enlarging the client's autonomy but assures that the pedophile attraction remains reduced. The meaning of the pedophile attraction for the individual is not taken into account and no difference is made between abuse and other
interactions. Little or no attention is given to the question of whether or not the meaning and function of pedophile attraction can be replaced by a different meaning and function associated with heterosexual attraction. In an overview of the literature concerning
homosexual conversion therapies, James (1978) concluded that the majority of studies were unsuccessful in changing sexual orientation. It is likely that the same holds for pedophile conversion therapy.

 Counseling in a non-residential setting

Counseling pedophiles at the Department of Clinical Psychology at the Utrecht University differs in two crucial ways from the programs described above.

Firstly, only non-residential client are seen. Most males are 25 to 50 years old, with a predominant or exclusive preference for boys between the ages of 9 and 16. These
men are non-violent in their contacts with boys and show no severe psychopathology. This non-violence is one of the main differences between these non-residential clients and pedophiles in institutions, where a mixture of sexual behavior and aggression is more common.

Secondly, therapy is not aimed at conversion. Treatment is not aimed at reducing sexual and emotional attraction to boys, nor at establishing heterosexual orientation, nor in enlarging heterosocial skills. Conversion to a satisfying heterosexual orientation,
however, is not considered to be entirely impossible. Although James (1978) and Sengers (1969) claim that prognosis for conversion is poor, Masters and Johnson ( 1979)) report a few successful conversions with male homosexuals. They suggest that (homosexual) conversion may be possible when the client is relatively young, strongly motivated, and not exclusive1y attracted to men. As virtually no pedophile client fulfills these conditions, no attempts at conversion are made at the Utrecht Institute .

Instead, the structure and function of pedophile desire is assessed in the total sexual orientation (van Naerssen, 1986). As part of the assessment procedure, an extensive life history is taken, including a chronological account of the psychosexual (hetero-, homo­ and pedosexual) development. Individual counseling and treatment start with an analysis of this biographical material in relation to present problems. On the whole these problems are divided into two categories: problems concerning the erotic and sexual attraction, and problems in the realization of these desires in interactions with others.

Individual therapy is consequently divided into two phases: identity­ and realization-therapy. In the first phase, the focus is on sexual identity: on the man's sexual and erotic desires and the cognitive framework available to structure these. The cognitions concerning the sexual identity and the sexual self are often diffuse, associated with feelings of guilt and insecurity and valued negatively. In this phase of therapy, the meaning of the desires is explored and discussed. The therapist helps to focus on the desires and to positively change the self-image.

The second phase focuses on problems concerning realization of desires and on the problems concerning interactions and relationships with boys, and problems arising from the forbidden nature of these relationships. The focus in realization therapy is on the way the desires are expressed in interactions with others.

The identity­ and realization-phases are not mutually exclusive but represent different areas of concern. As therapy proceeds, attention shifts from intra­ to inter-individual issues. When emphasis on the later increases, the problems discussed change from an individual to a social and communal level.

 Talking in groups about man-boy relationships

The attraction to children can be the source of psychosocial problems, because it serves no social function, is illegal and considered immoral. No one is brought up to be a pedophile and there are no visible models to follow in coping with problems. The social framework for intergeneration relationships is lacking. One important Implication is that the necessary social support for pedophile issues can only be obtained in a very limited circle, mainly among other pedophiles, Social support systems are considered important in the coping process. Because the possibility of obtaining social support is scarce, it is desirable to make optimal use of the few available support systems. Social support can be found among other pedophiles in organized settings (self-help or emancipation groups, often with a strong ideological background) or in informal situations (circles or networks of "colleagues"). Must clients are involved in one or more pedophile circles. An effective way to communicate about problems is necessary. That this communication is often reported to be unsatisfactory is partly due to the nature of these circles, where status is mainly determined by the number of partners a man has, as boys willing to engage in man-boy relationships are scarce. Interactions are often characterized by jealousy and bragging about scoring. The model for group counseling presented here is aimed at improving these interactions.

In addition to individual psychotherapy, small groups (five to eight members) can form to improve communication on common pedophile topics. Successful participation in such a group increases the capacity to solve problems in the man's own support systems. The main goal, therefore, is defined as enlarging autonomy. Men in advanced stages of individual therapy are likely participants in group sessions. They should be in realization-therapy and beyond identity-therapy, since the problems discussed are, by definition, problems concerning interactions with others.

Two male counselors, familiar with pedophile lifestyles and the problems frequently occurring in individual therapy, suggest topics of conversation and exercises. They structure the sessions and offer methods for the systematic analysis of problems.

Examples of general pedophile problems are: coming out: how much self-disclosure to whom? Interactions with boys and sexual relationships. Interactions with boy's parents and own neighbourhood. Interactions with other pedophiles and with the police. Growing older .

Each session deals with one or two of these themes. An inventory of prior experiences and solutions is made, discussing the advantages and disadvantages of these solutions and drawing conclusions. Which subject of conversation is chosen is not as important as the way it is discussed. Basic techniques, improving interaction (attentive listening, giving and receiving feedback, etcetera) are stimulated. The objective is to enable men to make optimal use or the experience available in the group, and to look at their own problems as part of an experience they can share with others.

Exercises include role playing and short writing exercises as for example, "Consider your last significant relationship with a boy. How would you describe yourself, as seen through his eyes?" Effects of participation are twofold: Firstly. participants profit from practical solutions they learn from each other, secondly. functioning in their own social circles improves.

This group counseling mode1 was tested in 1986 in a pilot-series of 6 three-hour sessions. Two male counselors presided over five men who were involved in individual therapy. The sessions were highly structured. A detailed script was made beforehand containing the abovementioned topics and exercises. Topics could be modified according to wishes of the men.

 Subjects

The mean age of this group was 40, outranged from 36 to 45. Four of the five men had little education and were living on welfare. They considered themselves exclusively pedophile, although all of them had had hetero­ and homosexual adult relationships. They strived for affectionate and erotic relationships with pubescent boys around the ages of 10 to 15. These four men had realization problems. The fifth man! had recently engaged in therapy. He was well educated, married and thought of himself as bisexual. His problem was, more than with the other men, in the sexual-identity phase. The overall ability of this group to function on an abstract level is categorized as low.

 Results

No measures to assess effectiveness of communication were taken so no pre- and posttest measures can be presented.  Subjective judgment of the counselors was that the communication improved during the sessions: the men listened more attentively to each other, feedback was more frequently given and asked for and self-disclosure grew. Systematically presented schemas to analyze problems (i.e., making inventories of both negative and positive aspects, discussing benefits and disadvantages and drawing conclusions) were quickly adopted and led to an objective, rather than a subjective approach to problems. Participants preferred practical problems (e.g., interaction with parents of boys) over abstract topics (e.g., pedophilia as a social phenomenon). Nevertheless, fairly abstract levels of analysis could be handled, for instance, when certain techniques from rational emotive therapy were presented. Often, encouragement in defining problems by their[ positive as well as their negative aspects (positive relabeling) was enough to create a new and more hopeful perspective. For instance, glowing older can be defined by a growing age-gap between man and boy, and also by the increased skills to interact with boys. The feeling of both participants and counselors was that the sessions were too few to efficiently explore the relevant themes.

 Conclusions and discussion

As with many social skill programs, changes in social functioning, especially outside of group settings, are hard to assess. Without these measures, conclusions regarding improvements in functioning outside the group sessions cannot be made. Although limited by the number of participants and sessions, positive changes in interaction snd analysis during the sessions were observed and reported by participants.

Participating in a group like the one described here may form a useful addition to individual psychotherapy. Because of its limited scope, the proposed model of group counseling can not replace individual psychotherapy. This is especially true when sexual identity is the focus of treatment. For example, suppose a client enter therapy stating that he is a pedophile, afraid to engage in sexual or emotional relationships with pubescent boys. Therapy starts with an exploration of his sexual identity: what exactly are his sexual desires, how are they structured. which feelings and cognitions arc they associated with? Earlier experiences and the function of the desires in the total sexual orientation are assessed. This phase of therapy is emotional, personal, and confronting, and  deserves the therapist's full attention. Furthermore, it may well be possible that the problems concern sexual orientation in general and not only pedophile attraction. The selflabeling "I am a pedophile" may then function as all important stabilizing factor in the total personality structure, and prevent an effective approach of personal problems. Participation in a group entirely focused on pedophile realization-problems may prove counterproductive.

However, for men who arc in the therapeutic phase of dealing with realization-problems, participation call provide a different perspective, enabling them to profit more effectively from their own social support systems, reducing their dependency on therapy. Participation of well adjusted pedophiles not involved in psychotherapy is possible. This might even increase overall effectiveness, since they can function as role models.

Goals are defined in terms of enlarging the autonomy of the men and not, as in regular treatment programs described earlier, in terms of regulating socially unacceptable or illegal behavior. Sexual contacts with boys 15 years old and under are illegal in The Netherlands. The age of consent is 16. There is no law in The Netherlands forcing therapists or counselors to report sexual acts with minors to the authorities. A therapist cannot be considered an accessory to a criminal act by accepting the sexual relationships of his client and choosing not to try to reduce the pedophile attraction or behavior .

Virtually no client enters therapy requesting to be set free from his attraction to boys. In the rare case where reduction in attraction to boys is requested, the man is told that the prognosis for successful conversion through psychotherapy is considered very poor.

These men strive for enduring, affectionate and erotical friendships with boys; they have no interest in forced or violent sexual contacts. When a boy is very young (12 years old and under) or emotionally unstable, the counselor can suggest that the man reconsiders the relationships thoroughly, especially its sexual aspects. A non-sexual relationship with a boy, regardless of his age, is not illegal. However, when partners voluntarily enter into a relationship or sexual contact, there is no need for the therapist to condemn or interfere.

Postscript

This contribution was conceived in late 1986. Since that time considerable changes regarding the attitude towards relationships between adults and children have taken place within Dutch society. These changes have affected the present problem of male pedophiles. This has led to adoptions of the model described here. The emphasis of the counseling process has shifted from optimizing social support towards the exploration of psychological function of pedophile attraction and behavior.

References

Barlow, D.H., (1974)
The treatment of sexual deviation: Towards a comprehensive behavioral approach. In K.S. Calhoun, H.E. Adams & K.M. Mitchell (Eds), Innovative Treatment Methods in Psychopathologt (121-148). New York: Wiley

Crawford, D.A. & J.V. Allen (1979)
A social skill training programme with sex offenders. In M.Cook & G. Wilson (Eds), Love and attraction (527-536). Oxford: Pergamon Press

Crawford, D.A. (1981)
Treatment approaches with pedophiles. In M. Cook & K. Howells (Eds), Adult Sexual Interest in Children (181-217). London: Academic Press.

Hayes, S.C., K.G. Brownell & D.H. Barlow (1983)
Heterosocial skills training and covert sesitization in sexual deviant. Behavior Research and Therapy, 21, 383-392.

Herman, S.H. & M. Prewett (1974)
An experimental analysis of feedback to increase sexual arouse in a case of homo- and heterosexual impotence: A preliminary report. Journal of Behavioral Therapy and Experimental Psychiatry, 5, 271-274

Howells, K. (1979)
Some meanings of children for pedophiles. In M. Cook & G. Wilson (Eds), Love and attraction (519-526). Oxford: Pergamon Press.

James, E.C. (1978)
Treatment of Homosexuality: A reanalysis and Synthesis of Outcome Studies. Bringham Young University.

Masters, W.H. & V.E. Johnson (1979)
Homosexuality in Perspective. Boston: Little Brown and Company.

Naerssen, A.X. van (1986)
Pedofilie en hulpverlening. In M. Moors-Mommers (Ed), Handboek Seksuele Hulpverlening. Deventer: Van Loghum Slaterus.

Quinsey, V.L., C.M. Steinman, S.G. Bergerson & T.F. Holmes (1975)
Penile circumference, skin conductance and ranking responses of child molesters and "normals" to sexual and non-sexual visual stimuli. Behavior Therapy, 6, 213-219

Quinsey, V.L., S.G. bergerson & C.M. Steinman (1976)
Changes in physiological and verbal responses of child molesters during aversion therapy. Canadian Journal of Behavioral Sciences, 8, 202-212

Segal, Z.V. & W.L. Marshall (1985)
Heterosexual social skills in a population of rapists and child molesters. Journal of Consulting and Clinical Psychology, 53, 55-63

Sengers, W. (1969)
Homosexualiteit als klacht. Bussum: Paul Brand

Stürüp, G.K. (1968)
Treatment of Sexual Offenders in Herstedvester, Danmark. Copenhagen: Munksgaard

Travin, S., H. Bluestone, E. Coleman & J. Melella (1985)
Pedophilia: An update on theory and practice. Psychiatric Quarterly, 57, 89-103.