The Pedophilia and Orientation Debate and Its Implications for Forensic Psychiatry

Definitions for Orientation

Perhaps the most comprehensive review of the evidence potentially in favor of the idea that pedophilia is an orientation is embedded in a fifty-page treatise on the subject of “sexual orientation.”⁸ These authors define sexual orientation as “attraction to members of the same sex, both sexes, or the other sex” (Ref. 8, p 48). They acknowledge multiple hypotheses for the determinants of orientation including “… hormonal, genetic, social environmental, and nonsocial environmental influences” (Ref. 8, p 45). In addition, they report that “behavior, attraction, identity and arousal …tend to go together,” but “not always” (Ref. 8, p 48). Further, they claim “…there is no evidence to suggest that individuals can consciously alter their genital arousal to fit a certain identity label” (Ref. 8, p 54). This idea is surprising based on examples such as sex workers, or gay men who engage in sexual relations with women, or lesbians who engage in sexual intercourse with men. In fact, one of the explanations for the dearth of research involving lesbian women is that it is so difficult to find women who identify as lesbian and who never have had at least one sexual encounter with a man. The field of sexology now accepts the concept of “sexual fluidity” in women to the extent of hypothesizing that “romantic love and sexual desire rely on different motivational systems” (Ref. 8, p 56, citing Diamond⁹). Nevertheless, the broad definition of orientation proposed in this article has the potential to support a paradigm that conceptualizes pedophilia as an orientation which is as undeserving of treatment as homosexuality.

Homosexuality and Paraphilias

Pedophilia (persistent sexual interest in children) is a paraphilia. Cantor argues it is reasonable to deem homosexuality a paraphilia if there are enough “…correlates and associated features of homosexuality with those of the acknowledged paraphilias” (Ref. 10, p. 238). In contrast to Bailey and colleagues,⁸ Cantor chose to define “homosexuality” as “predominant sexual interest in persons of the same sex [including] interest in adults and children of the same sex” (Ref. 10, p 238). Cantor reviews similarities between people who identify as homosexual and people with paraphilic interests. He compares the two groups on several factors: onset and course (he claims these factors are similar); fraternal birth order (gay men, on average, have more older brothers), short height (mixed results), non-right-handedness (more for gay men), decreased intelligence (more for pedohebephilic men), and what he refers to as “neuroanatomic studies” (e.g., structural MRI, de-monstrating “non-overlapping sets of anatomy”). Cantor acknowledges that correlation does not prove causation but nonetheless argues that the failure to find similar correlations between homosexual orientation and paraphilic interests suggests “…the existing data seem more consistent with the conclusion that homosexuality is a characteristic distinct from the paraphilias” (Ref. 10, p. 244).

Cantor's approach to the question is unique. He compares items correlated with paraphilias and items correlated with homosexuality and decides that because there are few if any common published correlations, they most likely are different. This is like observing that because black cats are more often associated with superstitious anxieties than white cats, they likely are different things. Or conversely, comparing a cat with a rock and deciding that because they both fall to the ground at the same rate if dropped, they likely are the same thing. This is treacherous reasoning. It is important to remember that even if homosexuality, however it is defined, were shown to correlate with pedophilia, it would not mean one causes the other, or that they are the same. For example, height correlates with weight, but height and weight are clearly not the same thing and one does not cause the other. Ironically, the main item that Cantor claims to be similar between homosexuality and the paraphilias, namely their onset and course, is arguably not true. Most people are aware of their gender and orientation before they become aware of their sexual interests, and Cantor's claim that paraphilias are immutable has been debated elsewhere.^10,11,12

Pedophilia and Sexual Age Orientation

Seto¹³ provides a third strategy in favor of the idea that pedophilia is an orientation. He argues that in the same way that homosexuality can be defined as a sexual orientation for gender, pedophilia can be defined as a sexual orientation for age. In Seto's article, sexual orientation is defined as “a stable tendency to preferentially orient – in terms of attention, interest, attraction, and genital arousal - to particular classes of sexual stimuli” (Ref. 13, p 3). Some ideas presented in Seto's paper have been debated¹⁴ and clarified,¹⁵ and Seto has acknowledged that, although longer term studies have not been done, “Gender and age orientations may operate differently from each other…” (Ref. 15, p 2176). Arguably, the contention that the paraphilia pedophilia is like the orientation homosexuality confuses sexual interest (pedophilia) with affection (orientation). (See below.)

Another Perspective

Each of the papers briefly reviewed above provides a unique definition for orientation. Importantly, the definitions blur concepts such as attention, arousal, identity, and behavior(s) with the sine qua non of the paraphilias, which is unconventional sexual interest. This is analogous to a classification of pneumonias that ignores the difference between pneumonias caused by viruses and pneumonias caused by bacteria. Not only is this approach of blending conditions less accurate in terms of classification, but it also may lead to mistakes in treatment as well as false conclusions about what is treatable.

Rather than equating pedophilia with homosexuality, one proposal is to distinguish between known aspects of sexuality. I have recommended considering five distinct aspects of sexuality that have different levels of mutability.¹⁶

Concerns Arising

There are several problems that arise from accepting the definition of pedophilia as an orientation. Referring to pedophilia (which is defined solely on the basis of sexual interest in children) as an orientation (which is defined on the basis of gender of affection) confuses what is pathologic about the condition of pedophilia. It is not that the person feels affection toward children; it is that the person is sexually aroused by children.

Correctly, modern understanding of the variations in orientation does not imply pathology. There is a growing consensus that variations in orientation should not be “treated” or modified (see, for example, negative discussions about so-called “restorative therapy”¹⁸). When the view that variations in orientation should not be treated is applied to pedophilia, the result is a failure to offer potentially beneficial treatment to people with pedophilia.

Given these understandings of what is considered to be a disorder, orientation, especially in men, has become identified as not only immutable, but also undeserving of treatment. Because they equate pedophilia with orientation, commentators who claim that pedophilia is an untreatable condition often resort to arguments more applicable to homosexuality. Patients often subscribe to the same confusion of concepts. It is common for a man with pedophilia who has been convicted of sex with boys to think that his treatment will involve changing his orientation. Most are relieved and surprised when they learn that treatment of pedophilia involves changing their sexual interest from children to adults (male or female) with no expectation of changing their orientation. When they hear this, some cry.

Words Do Make a Difference

The researchers who claim that pedophilia is untreatable all cling to the “lovemaps” paradigm originally proposed by John Money,¹⁹ which combined gender, orientation, and interest, based on now debunked theories of human imprinting and the impossibility of neural plasticity. No one has ever published survival cures supporting their claims of 100 percent failure rates in the treatment of people with pedophilia. Perhaps it is time to change the paradigm and consider pedophilia not as an orientation but as a disorder of sexual interest which is as modifiable as other interests. For more on these arguments, please see Fedoroff.¹⁶

Readers may wonder how this discussion of pedophilia applies to their practice of forensic psychiatry. Consider the following final set of arguments.

The debate between the researchers reviewed in this essay has been both collegial and productive. All proponents of the alternative views expressed in this article are scientific colleagues who have agreed to collaborate on research to test our divergent hypotheses. In forensic psychiatry, which by its nature tends to veer toward the legal method of oppositional reasoning, it is important to remember the ultimate aim of parsimoniously explaining existing data and accurately predicting new data, not clinging to a paradigm just because it is the prevailing one. If the facts you are trying to explain do not make sense, consider whether there may be another way to look at things.

Paradigms help us to explain known observations and make accurate predictions. They also can blind us to new perspectives and data that may be better. Often, a new perspective or paradigm changes the valence of facts and reveals data that previously were overlooked or discounted.

Contrary to prevailing views, it is permissible to entertain competing paradigms. Quantum physics is based on the realization that light can be both a particle and a wave. Similarly, there may be times when it makes sense to combine sexual interest and orientation into sexual orientation, as long as it is remembered they are two different things that do not always go together. It is acceptable to offer more than one explanation or to admit one paradigm does not make sense.

Readers may have noted that proponents of the idea that pedophilia is an orientation always use “identity-first” terminology instead of “people-first” terminology. Patients in the Royal's Sexual Behaviours Clinic groups are always reminded not to think or refer to themselves as “pedophiles,” as that is an identity they will change. In progress notes, to remind the reader of the fact that these are people with a condition for which treatment is being received, they are referred to as “people with pedophilia,” instead of “pedophiles.” It is a treatment aim that people with pedophilia will cease having sexual interests in children. When their interests change to adults, they will no longer have pedophilia. This approach is important both to patients and the treatment team and arguably applicable to all of our patients in whichever branch of forensic psychiatry we work. The use of person-first terminology is vital when forensic psychiatrists treat patients, testify in court, teach, and, especially, make public media presentations. It does make a difference.