There is a growing concern regarding those who view and download child pornography. Clinicians who specialize in the treatment of sexually compulsive behavior/sex addiction are often challenged when confronted with a client who has accessed child pornography, downloaded images and/or chatted with teenagers. It is clear that the possession of child pornography is illegal and having sexual chat with a minor is very serious. Those who treat sex offenders are often baffled as to how to use the existing actuarial tools to assess risk, or whether any of them are even appropriate with this population.
There are important points regarding risk that need to be taken into account when a patient discloses their behaviors or the patient’s partner presents with the complaint that their spouse/partner has been looking at child pornography. Before even determining the risk, a thorough psychosexual assessment needs to be performed including a history of the current behavior, past behaviors, and a comprehensive sexual history. In addition, a complete psychosocial evaluation needs to be undertaken. Of significant importance is the assessment and diagnoses of the presence of any Axis I and Axis II disorders. Leaving out any portion of this comprehensive assessment will not provide the clinician with the correct information to determine risk.
Of particular controversy is the question: Is the person looking at pornography, but more specifically child pornography, a manifestation of an increase in sexually addictive behaviors and/or a particular preference or arousal template (Carnes, 2005) suggestive of a serious deviant arousal pattern? There is a lot of controversy about this in the field and one clinician’s opinion may be very different than another’s. There is no definitive answer to this question and the skilled clinician must use all the available resources to determine what is really going on. It is essential to know what the definition of child pornography is and no matter what the underlying reason the person engaging in the behavior needs to understand the legal ramifications of their behaviors.
When determining if the images are pornographic the following reference could be used. U.S. vs. Jacob Dost (U. S. 10th Circuit Court of Appeals vs. Dost (1978) identified six factors to determine whether a visual depiction of a minor could be considered pornographic and potentially illegal.
Those factors defining “child pornography” are:
1. Is the focal point of the image on the child’s genitalia or pubic area?
2. Is the setting sexually suggestive or a place or pose generally associated
3. Is the child depicted in a pose or attire that is not age appropriate?
4. Is the child fully or partially clothed or nude?
5. Is the image suggestive of coyness or a willingness to engage in sexual
6. Is the image intended or designed to elicit sexual response in the viewer?
Some additional factors in assessing risk should be:
1. The nature of any collection of images
2. The nature of the collecting behavior, and
3. The amount of Internet access and amount of computer use.
4. Knowledge of previous history of allegations or past contact offenses and access to children.
Other issues that should be looked at include:
• How images are stored?
• Are they categorized?
• Do they have series of pictures?
• Are they on a peer-to-peer network?
• Have they downloaded any programs to access IRC (Internet Related Chat)?
• Do the images represent a particular fetish, etc.?
• Are the files encrypted?
• Is there an indication of sharing of files?
• Is there any communication with others that have similar interests?
His looking at images and his other sexual behaviors that had become compulsive, had to stop.
Peggy called my office and subsequently came in with Sam, her husband of 11 years. They have two children under the age of six.
Consider Peggy’s story:
I walked up the stairs at 2 a.m. wondering if my husband fell asleep in the television room again. What I saw changed me forever. There he was hunched over the desktop computer right outside my sleeping children’s bedroom doors looking at pornography. My heart fell into my stomach. My first organized thought was “What is wrong with me?” During our marriage, I was the one who complained about not having enough sex. I was the sex instigator and he almost always turned me down. So there I stood, feeling as if I was not doing something right. Over time, I got numb to him and the way he was acting out. My thoughts were: “Well it is not like he beats me and the kids, he is not addicted to drugs and/or alcohol, and he is not cheating on me. In fact, he makes good money and great financial decisions for our family, and he loves the kids and I very much. Plus men look at porn, right?” He continued this behavior for years. I finally decided that, after discovering a few e-mails from a lady I did not know, he was indeed having an affair. I downloaded software on the laptop computer he used most that would track every move he made. When I checked the account that was tracking him, I was sickened about what I discovered. Not only were there e-mails from that lady, but the amount of pornography he was looking at was out of control. Although the amount of porn blew me away, it was what kind that made me sick: child porn. My husband of 11 years, father of 2, and professional in the working world was looking at under age porn, illegal porn. I felt ashamed, scared, disappointed, depressed, but most of all, frightened for my kids and my friend’s kids. How could I have not known?
I immediately called a sex addiction therapist who also specialized in sex offending behaviors and a certified sex therapist. We started a Recovery Plan as soon as we could, and my husband was diagnosed with a Paraphilic Disorder. He spent hours in therapy and attending group meetings. I too went to individual therapy and group therapy. The first month after his diagnosis was very hard. I was very depressed, and my children were not getting the mom they were used to. I was tired and lazy and could not find joy in anything. The house was a mess and for the first time I could care less. The few times I had a night out without the kids, I got so drunk with my friends that I blacked out. Thankfully, I pulled myself out of the hole with the help of therapy and good friends. I am sad because I have lost the family I thought I had and the marriage I thought I had. In reality, I never had either. Now I need to decide of the marriage and family I do have are worth holding on to or letting go. What is the best for my children? Me? Are my kids at risk? Will they ever be? Can I trust this person who I married?
Do I even know him? Only time and a good recovery program will give me the answers to my questions.
After disclosure, it was revealed that Sam had a past history of sexual and emotional affairs while being married and sexual relations with his wife were limited. After taking a detailed history it was discovered that his use of pornography began in his early teens. His particular fetish exacerbated his interest in pornography and it continued to escalate to viewing child porn, pictures of young teens as well as adults. The images of the teens, both male and female were of the age he was when he developed his particular arousal patterns. As a pubescent teen he was curious about his peer’s development and would often try to sneak looks to see if they had developed pubic hair. He became obsessed with this and developed his particular arousal template. He began puberty late and his early teen years were characterized by self doubt when viewing his peers in the locker room. He began viewing adult pornography at age 10 when he found a film in his father’s closet. The film was about incestuous relationships, and he continued viewing this film and began masturbating every day until currently. He was particularly confused by the “overly moral” and strict environment he was brought up in and then finding the film and also seeing his parents watch the film. He also denies any wishes to have contact with any children, but he realized that his pornography use, his inability to connect emotionally with his wife and his infidelity had escalated to the point where he realized this could no longer continue. Sam wanted help but was undecided if he wanted to stop his fetish. The legal ramifications of his behavior were made very clear to him and any continued looking at illegal images had to stop. Safeguards were then put into place and he understood what would happen if he was unable to follow the treatment plan His looking at images and his other sexual behaviors that had become compulsive, had to stop.
One might ask, “Do consumers of on-line child pornography pose a risk for handson sex offenses?” In one study (Endrass et al. 2009), 231 men who had been charged with consumption of illegal pornography were assessed. In brief, consuming child pornography, at least for those who had not committed a hands-on offense, the prognosis for not committing hands-on sex offenses was favorable.
Both sexual compulsives and sex offenders report a loss of control and life consequences.
Pedophilia is defined as a persistent sexual interest in prepubescent children. For a clinical diagnosis of pedophilia, a person will have had:
a) recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children for a period of at least 6 months. Moreover, the person has acted out on these sexual urges, or
b) The sexual urges or fantasies cause marked distress or interpersonal difficulty. The person is at least 16 years old and at least 5 years older than the child or children. Diagnostic Statistical Manual of Mental Disorders IV-R (2004)
Clinicians rely on several different sources when considering the diagnosis of pedophilia, including self-report, a history of sexual behavior involving children and a psychophysiological assessment. All of these sources have limitations and individuals will tend to deny pedophilic interests for fear of being reported and getting caught up in the legal system. Having an interest, thoughts, or fantasies are very different than acting them out. An individual’s history of past sexual offenses in terms of the number, age, gender and relatedness of child victims is informative but only approximate the person’s interest because it is limited to known victims. Seto & Lalumiere (2001) indicate this diagnosis suggests that the person must suffer internal conflict or social consequences. Only a small percentage of sex offenders meet these criteria for pedophilia.
A pedophile often starts offending at an early age and can have a large number of victims that are not family related. The pedophile is usually driven to offend and has hands on victims. All too often the term “pedophile” is used incorrectly and is very often misunderstood. Most of the time, but not always, the interest of the sex addict’s focus is on much older children who are past puberty and have sexual characteristics that are more developed.
There are similarities and differences between sex offenders and sex addicts. Not all sex offenders are sex addicts and all sex addicts are not offenders. Both sexual compulsives and sex offenders however do report a loss of control and life consequences.
1. They can both come from rigid and disengaged families.
2. There is usually a history of addiction in the family, trauma in their childhood, with a high percentage of emotional abuse.
3. They may have multiple addictions.
4. High stress levels
5. Use of pornography
6. High use of thinking errors (cognitive distortions) such as Rationalization, Excuses, Blaming, “Poor Me”, Victim Stance, Denial, Justification, Lying, Anger, Keeping Score, Sense of Entitlement, etc.
7. History of sexual difficulties
Sex offenders are more likely to have the following:
1. Criminal lifestyle history
2. Criminogenic thinking
3. Distrust of authority
4. History of violence
5. Past sexual aggression
6. Escalation of violence
7. Overall pattern of assaults
8. Unstable relationship history (can be a similarity as well).
There is a significant controversy surrounding the term, “sex addict.” This writer uses that term to describe a particular set of behaviors surrounding sexual activities. The preoccupation, obsessive quality, and the compulsions are part of the diagnostic criteria. Their behaviors may also be seen in diagnostic categories such as Bipolar Disorder, or other mood or anxiety disturbances, like Attention Deficit Disorder, etc. The thorough clinician will take all of this into consideration when making a differential diagnosis.
It is true that at this point there is no diagnosis in the DSM-IV-R (2004) that adequately defines this. There are however some components of this problem which one could give an appropriate Axis I diagnosis. The future holds great promise that these clusters of symptoms will begin to be taken into consideration in the new DSM.
Consider Sharon’s Story:
Sharon was referred to me by her primary care physician. Her husband, Brady, had been arrested for sexually chatting with a 13-year-old girl while online. Apparently all during their marriage, he had been looking at adult pornography and there were times when they both viewed it as an adjunct to their sexual life. Over the years, her husband had become more distant and was spending hours on the computer. When she confronted him about his behaviors, an argument would always take place. He would blame her for his viewing porn, saying she was no longer exciting, too caught up with the children, and there was no time for him. Sharon began to believe she was at fault and tried to engage in looking at porn with him. It became apparent that he still was not interested. After his arrest, Brady told her he had been chatting with women online and engaging in sexual talk. He became bored with that and when he noticed a younger girl in the room, he found it to be new and exhilarating. In his “fantasy chat,” he became the teacher and the “important person in someone else’s life.” Clearly his behaviors were an apparent escalation of his compulsive behaviors and his method of gaining approval and feeling validated were satisfied by talking to girls in their early teens. Brady had no history of any hands- on offenses and had not been sexually abused; however, he had been subjected to emotional abuse by his father much of his life. He worked with his father who on a daily basis, criticized him and showed contempt. It was about this time that his wife became pregnant and the thought of increased responsibility and having to put up with his father’s increased demands overwhelmed him. He retreated into the computer and his continued use of pornography brought him to a place he had never been.
Brady has to go to prison and he and his wife and son are trying to rebuild their lives. His wife had to make some tough decisions because staying with a sex offender brings consequences, both to her and their son. They are both dedicated to treatment and if allowed to, after his incarceration, he will return to his family. That is when even harder work starts.
For appropriate diagnosis and subsequent formulation of a treatment plan, the following are recommendations:
a) Use instruments that have specific relevance for evaluating sex offenders or
b) Integration of collateral information. It is very helpful to include the
partner in a beginning session for a number of reasons, i.e. to get the full
picture seen by the partner, to assess the amount of trauma caused to the
partner and family, to get a more accurate description of the behaviors and
sequence of events, and to provide support and therapy for the partner and/
or the family.
Evaluation of deviant arousal/interest.
This should be done by a Licensed
Sex Offender Treatment Provider. An initial Sexual Dependency Inventory (SDI)
(Carnes, 2008) can be done and if the therapist believes that the patient needs more in
depth testing or has committed a hands-on offense and if there is a current risk, then the
clinician will have to take additional measures to assure safety of the parties concerned
and the community. The patient may need to be seen by another professional to ascertain
dangerousness. Additional testing may need to be done.
c) Intelligence tests
d) Cognitive assessment
e) Neurological screening
f) MMPI-II (Minnesota Multiphasic Personality Inventory) and/or PAI (Personality Assessment Inventory)
g) Mental Status
h) Substance Abuse Screening
i) Hare Psychopathy Checklist
j) Complete Sexual History
Other testing is relevant if you are doing an assessment on a sex
offender which may include all of the above and in addition (Salter,
a) MSI-II (Multiphasic Sexual Inventory)
b) Abel & Becker Cognitive Scale
d) The Shipley Institute of Living Scale
e) Trails A & Trails B
f) Negative Attitudes Toward Masturbation Inventory (NAMI)
g) Attitudes Toward Women Scale
h) Buss-Durkee Hostility Inventory
i) Abel & Becker Cognitions Scale
j) Burt Rape Myth Acceptance Scale
k) Levinson Victim Empathy Scale (L-VES)
l) Interpersonal Reactivity Index
m) Social Avoidance and Distress Scale
n) Wilson Sex Fantasy Questionnaire
o) Abel and Burke Sexual Interest Card Sort
p) Internet Sex Screening Test
One of the most important considerations in treatment is in regards to the partner, safety of the children and the ability of the spouse to make good decisions. The therapist must report to the appropriate agency if there is any suspicion of child abuse or neglect. Careful consideration needs to be given to disclosure to the partner and then disclosure to the children and/or other family members. If disclosure is not dealt with in a structured format with the help of the therapist, it can be a disastrous situation. If done properly, it can be an opportunity for growth for each participant, even though it is painful.
Clinicians who treat these populations must be well-trained in the areas of sexuality, sexual abuse, addiction, and sex offenders. A judgment or critical therapist who moralizes and reacts in a negative way can do more harm than good. If there is need to report a behavior and if the family does not do it, the therapist must do the report. One cannot wait for a relationship to be established because the first priority is the safety of the children. Treating these types of clients is extremely challenging and takes every bit of focus, compassion, knowledge and the ability to make some very difficult decisions that can affect people’s lives forever. With all this being said, the clinician must be skilled and have enough support to reach out when difficulties arise.
Asking for help and using a consultant and or making a referral may be the best avenue to take. The therapist has a heavy burden and needs to ensure that they are acting within their ethics code and the law. Every case is an opportunity to do great good but also great harm.
Barbara S. Levinson, PhD, RN, LMFT, is owner and director of the Center for Healthy Sexuality in Houston, TX. She is an AAMFT Clinical Member and has been instrumental in the development of Family Program Services in several in-patient treatment centers around the country. She is an AASECT Certified Sex Therapist Diplomate, an ITAAP Certified Sex Addiction Therapist and Supervisor, and a Licensed Sex Offender Treatment Provider. Levinson has extensive training in individual, family, group, and marital therapy. She has a program for the treatment of sex addiction and co-sex addiction and has lectured extensively on the topic. In addition, she does psycho-sexual evaluations for the Federal Government and is hired by attorneys to provide comprehensive assessments for persons charged with a sex offense.
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