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Introduction
In Spanish prisons, specific group treatment programs are one of the main means of achieving the social reintegration of inmates (Real Decreto 190/1996[Royal Decree 190/1996], Ley Orgánica 1/1979 General Penitenciaria, LOGP [Organic Law 1/1979 General Penitentiary Law, LOGP]). One of these programs, the Sexual Assault Control Program (PCAS in Spanish) (Garrido & Beneyto, 1996) is aimed at people convicted of crimes of sexual aggression against adults and minors. It was updated in 2005 (Redondo et al., 2005; Rivera et al., 2005; Valencia et al., 2008) and in 2018 exclusively for the Justice Administration of Catalonia (Martínez Catena, 2016). Specifically, it works on awareness and control of the crime committed, empathy for the victim, relapse prevention, cognitive distortions, and sex drive modification (Rivera et al., 2005). PCAS has been a pioneer in addressing sexual assault control in Spain and has been shown to reduce recidivism (Illescas & Genovés, 2008; Redondo et al., 2005; Redondo et al., 2014; Martínez Catena, 2016).
These programs are usually complemented by individualized treatment (art. 110b, Reglamento Penitenciario [Prison Regulations]). Nevertheless, penitentiary centers have average ratios of one psychologist for every 166 inmates (Bueno-Guerra, 2023). As the prison population in Spain has risen to 46,468 inmates (Ministerio del Interior [Home Office], April 2022), it is difficult to provide individualized and systematic attention in a sustained manner over time. For certain types of offenses, the provision of specific treatment, both group and individualized, is especially necessary for reintegration, as in the case of child sex offenders who also present pedophilia (Hernández-Jiménez & Rodríguez Padilla, 2022).
The literature differentiates pederasty (an act of sexual aggression to a minor) from pedophilia (sexual attraction to minors) (Herrero & Negredo, 2016; Seto, 2009), and inmates who have committed a crime of pederasty with or without pedophilia (primary and secondary abusers respectively, Echeburúa & Guerricaechevarría, 2021) can be found in prison. Primary abusers experience sexual desires and fantasies involving minors, which may lead them to the criminal act, to experience distress linked to the presence of this sexual interest, or to interpersonal problems (DSM 5; American Psychiatric Association, APA, 2013). Moreover, this sexual interest in minors (attention, arousal, sexual behavior, and romantic desire) is stable over time, persistent and difficult to modify (DSM-5, APA, 2013; Campo-Arias & Herazo, 2018; Seto, 2017). These preferences can occur exclusively (only towards minors) or non-exclusively (towards minors and adults), with exclusivity being more related to recidivism (Eher et al., 2015; McPhail et al., 2018). In secondary abusers, the commission of child sexual abuse is the result of different dynamics, such as hypersexuality or maladaptive sexual coping of negative situations (Echeburúa & Guerricaechevarría, 2021; Finkelhor, 1984; Ward & Siegert, 2002). Therefore, the motivations for committing sexual abuse are different depending on the existence of pedophilia: in primary abusers the motivation is based on sexual interest in minors (with a worse response to treatment); in secondary abusers the motives are circumstantial and unrelated to sexual attraction to minors, and there is a better response to treatment (Echeburúa & Guerricaechevarría, 2021).
The distinction between these two types of child molesters has relevant implications for the psychological treatment to be applied. For example, PCAS has traditionally included sexual behavior modification techniques such as orgasmic reconditioning (Rivera et al., 2005, p 377). In the case of primary abusers, given the stability of sexual preference, this technique would not be useful as modification or dissolution of the sexual drive is not possible, and psychological treatment for conversion is ineffective and raises ethical issues (Alempijevic et al., 2020, Trispiotis & Purshouse, 2021). Instead, the therapist would have to consider the subject's object of attraction as an unmodifiable arousal stimulus and focus intervention techniques on behavioral control (e.g., with acceptance and commitment techniques, such as accepting the sexual preference and committing not to act on it, or stimulus control) (Fernández-Montalvo & Echeburúa, 1998; Jiménez, 2016). Moreover, orgasmic reconditioning would also not be useful in secondary abusers, given that in them there is no sexual arousal towards subjects who cannot give consent.
It is estimated that between 30 and 50% of people who have been convicted of sexual crimes against children present pedophilia (Seto, 2012; Walker, 2020), this estimate being difficult to make due to social desirability (Echeburúa et al., 2011). That is, the prison psychologist in Spain may frequently attend primary abusers, so it is pertinent to consider whether the PCAS meets the needs of specific psychological intervention that these inmates would require. In this study we offer a specific intervention proposal for people with pedophilia in the prison setting based on the available scientific evidence, and we exemplify it on the needs of an inmate with pedophilia to assess its adequacy and appropriateness.
Specific Intervention Proposal for Pedophilia in the Prison Environment
Specific Psychological Intervention Needs for Pedophilia
Therapy in the penitentiary setting should focus on addressing the factors most related to the crime committed (art. 110b RP), which are reviewed below taking into account the presence, in addition, of pedophilia.
As discussed, a risk factor for committing sexual assault on minors is having sexual fantasies about minors (Marshall & Marshall, 2000; Rossegger et al., 2021; Tenbergen et al., 2015). Therefore, in the inmate with pedophilia, fantasies will be very present and will require central attention in the intervention. This suggests we should reconsider the current decision to have inmates both with and without attraction to minors in the treatment group, as the latter might judge harshly the sexual fantasies of the former given the social stigma of this sexual preference (Heasman & Foreman, 2019; Jahnke & Hoyer, 2013), thus hindering the sincere expression of fantasies. It seems then, that a specific intervention separately and in individual format would be advisable, since a group intervention only for people with pedophilia could generate a feedback of their preferences that would facilitate the validation of sexual aggression, which is undesirable for treatment.
Low self-esteem can be a risk factor for recidivism (Echeburúa & Guerricaechevarría, 2021; Finkelhor, 1984) and suicidal ideation, which is very high in the pedophile population (Jahnke & Hoyer, 2013). Low self-esteem may be a consequence of having committed a sexual offense against a minor or minors (Woodyatt & Wenzel, 2013) or may be due to the shame felt by the subject for their attraction to minors. PCAS proposes working on positive self-affirmations of the subject without exploring the source of the self-concept problem; a more in-depth intervention on self-esteem would be more beneficial, both cognitive and behavioral (e.g., looking for the origin of the low level of self-esteem; reevaluating biased thoughts in relation to negative self-judgments) and on the guilt and shame often associated with the presence of pedophilia (Knack et al., 2019). In addition, improving self-esteem will benefit other important areas such as empathy or the reduction of feelings of loneliness (Echeburúa & Guerricaechevarría, 2021), which are also of interest for working with people with pedophilia. Moreover, given the higher level of suicidal ideation in the pedophilic population and the evidence that low levels of self-esteem favor the appearance of these thoughts (Silva et al., 2017), it seems necessary to introduce the assessment of suicidal thoughts in order to, if necessary, activate the Suicide Prevention Protocol (PPS in Spanish).
Thirdly, through the cognitive distortions of primary abusers, they tend to justify the crime by attributing responsibility to the minor (e.g., seduction) or minimize the consequences of the crime (Echeburúa & Guerricaechevarría, 2021), favoring recidivism (Herrero, 2013). It is suggested to dedicate part of the treatment to identifying the distortions through narrating the events of the crime and to cognitively restructure those specific erroneous beliefs about minors (Beck, 2015; Echeburúa & Guerricaechevarría, 2021).
In addition, people with pedophilia tend to have problems in social skills and feel more comfortable interacting with minors, which is a risk factor for recidivism (Herrero, 2013). The work on reducing interactions with minors implies a decrease in social reinforcement for the individual, therefore it is advisable to focus on the individual being able to generate functional and satisfactory relationships with adults so that these can be maintained. However, PCAS intervenes in social skills in general, without analyzing specific difficulties in relationships with adults. The Berlin Dissexuality Therapy Program, BEDIT (Beier, 2013), could be followed, which explores attachment systems and seeks the creation of functional personal relationships with adults, working on emotional congruence and social skills training, or the Good Lives Model applied (Ward & Brown, 2004) seeking meaningful activities for the subject.
Fifth, although the abuser-abused hypothesis (Cohen et al., 2002) has been refuted, recently a connection has been among found between previous sexual victimization, precociousness, and later sexual behavior (Seto & Lalumière, 2010), which may constitute a risk factor for committing sexual offenses against minors (Willis, 2014). Personal history of trauma can influence personal development, although it does not determine criminal behavior (Herrero et al., 2021), so it would be appropriate to increase awareness of the past, its effect, and the precipitating factors of the criminal behavior, not specifically addressed in the PCAS.
Furthermore, people with pedophilia may feel misunderstood and hopeless (Heasman, & Foreman, 2019), and they rarely find assistance forums about their sexual desire. This favors feelings of loneliness, a risk factor for recidivism (Herrero, 2013); therefore, it seems necessary to include in the therapeutic intervention a part of psychoeducation about pedophilia, a fundamental point of international therapies such as BEDIT (Beier et al., 2021) not included in the PCAS. This information could include three fundamental ideas: being attracted to minors is not the subject’s choice and is unchangeable (Seto, 2017; Beier, 2013); accepting does not imply approving, that is, accepting sexual interest in minors means assuming their preference and knowing that it is immutable (Herrero, 2018), but not approving it, since its execution creates victims; and differentiating between pedophilia as attraction and pederasty as action, to raise the possibility of accepting the attraction but committing to not exercising it. Acceptance and Commitment Therapy (Hayes, 2015) could help the subject to accept their reality, but maintain a commitment to move away from risk behaviors and recidivism (Blagden et al., 2018).
In addition, people with pedophilia show abundant paraphilic diversity (Hernández, 2018); it being necessary to understand sexual fantasies and motivations and their possible relationship with the dynamics of sexual abuse to avoid the risk of recidivism (Beier, 2013, Herrero, 2013). This specific work is of common application in correctional institutions; and its specific focus on child sexual assault and the updating of sexual behavior intervention would be recommended. For example, covert sensitization, orgasm reconditioning, or redirected masturbation, present in PCAS, have not shown permanent effects on physiological arousal or behavior (Miner & Munns, 2021) and no longer appear as reference treatments in the recent literature (Seto, 2012).
It may also be of interest to detect dissexual behaviors, an unofficial term used by the Dunkenfeld Project (Beier et al., 2021) referring to non-illegal acts considered to be socially accepted (e.g., tickling a minor) but which the subject performs to satisfy sexual pleasure (e.g., getting aroused), therefore if the underlying motivation for the act were revealed, society would condemn the behavior. These behaviors can reinforce undesirable patterns close to illicit behavior (Beier, 2013), and are not included in the manuals in use or in the PCAS. Psychoeducation on these types of behaviors and their control would be advisable, making the individual aware of how engaging in them can bring them closer to the aggressive behavior they are trying to avoid.
Finally, viewing child sexual abuse material could be a risk factor for recidivism (Herrero et al., 2021) and, in addition, it does not promote awareness that the minors in the videos are being victimized. In Spanish prisons there is the program Fuera de la Red [Off The Internet Program] (Herrero et al., 2015), specifically for online aggressors, and it is recommended not to apply it together with offline aggressors to avoid them learning techniques to approach minors. A module of the Off The Internet Program could be included in the PCAS exclusively aimed at those who have abused minors, have pedophilia, and consume or have thought about consuming abusive material (e.g., Module 5 of the Practitioner's Manual, to develop empathy with victims, and Module 8, to reduce and eliminate the consumption of this material, Herrero et al., 2015).
In summary, from the above review, several aspects related to recidivism are evident that are currently not included in the PCAS. Therefore, given the presence of pedophilic sex offenders in the prison setting, it would be desirable to update the PCAS according to the new evidence available and adapt it to the characteristics of the participants in accordance with the principle of responsiveness (Andrews & Bonta, 2010). According to the needs outlined above, our proposal is summarized in Table 1.
Table 1. Intervention Proposals for Pedophilic Inmates Complementary to PCAS
| Area | Sub-area | Objective | Techniques |
|---|---|---|---|
| Psychosocial | Self-esteem |
To increase self-esteem To know the factors associated with self-esteem |
Behavioral techniques Cognitive techniques |
| Suicidal ideation |
To know the presence of suicidal ideation |
Assessment of suicidal thoughts Activation of the PPS (if applicable) |
|
| Cognitive distortions |
To neutralize cognitive distortions related to sexual aggression against minors |
Cognitive restructuring with examples on minors |
|
| Interpersonal | Emotional congruence |
To determine which aspects of the relationship with children are most attractive To reduce feelings of loneliness |
Social skills training with adults Search for intrinsic social reinforcers away from criminal behavior Development of coping strategies |
| Polyvictimization |
To inquire about the existence of traumatic victimization, especially sexual To detect possible consequences of victimization on behavior |
Increasing the awareness of their traumatic experience Functional analysis of criminal behavior Intervention in complex trauma |
|
| Sexual | Sexual preference and sexual behavior |
To explain the characteristics of sexual preference To accept sexual preference towards minors To encourage commitment not to engage in abusive behavior To seek prevention strategies |
Psychoeducation Acceptance and Commitment Therapy Relapse prevention model Good Lives Model |
| Sexual fantasies |
To understand the sexual motivation underlying paraphilic diversity |
Psychoeducation Impulse control |
|
| Dissexual behaviors |
To identify dissexual behaviors To learn to avoid dissexual behaviors |
Psychoeducation, awareness Impulse control Good Lives Model |
|
| Consumption of child abuse material |
To progressively reduce the consumption of child sexual abuse material until it is eliminated |
Develop empathy with the victim Special module of the Fuera de la Red [Off The Internet] Program |
Intervention Needs Through the Case of an Inmate With Pedophilia
The following are the characteristics of an individual convicted of a crime against minors evaluated in a penitentiary center in Madrid, after providing written informed consent, which exemplifies the intervention needs outlined above. The subject is a 51-year-old cisgender man convicted of a crime of sexual abuse of minors. At the time of the assessment he had served 3 years and 7 months of an 8-year sentence. Using an ad hoc semi-structured interview, including several measures depending on the variable to be studied (see Annex with specific methodological information on the tests used), the areas considered individual risk factors for the commission of sexual offenses were assessed (Brennan et al., 2018; Herrero, 2018; Marshall et al., 2011; Szumski et al., 2018) and also collected by the BEDIT program (Beier et al., 2021): psychosocial area (self-esteem, presence of suicidal ideation, and cognitive distortions), interpersonal area (social and emotional relationships), and sexual area (victimization, sexual fantasies and behaviors, consumption of abusive material).
The participant obtained the lowest score on the self-esteem scale (1 out of 5) and reported maintaining it since he was "about 14 years old", coinciding with the moment when he realized that he was attracted to minors. In fact, the inmate verbalized suicidal ideations, not recent, related to the awareness that his sexual preference was different from what he saw around him.
In addition, the inmate had abundant cognitive distortions about sexual aggression against minors: he considered the abuse of a minor "as an act of love" and qualified the harm caused to the victim as "little", due to the fact that in his opinion the main consequence on the victim would be "the social stigma of being labeled as an abused child" and he considered that the minor could have "enjoyed" the abuse.
The subject described himself as "lonely and sullen" and reported not wanting to have friends. His hobbies were solitary (e.g., walking, collecting knives) and in prison he hardly interacted with other people because "I prefer to be alone in the prison cell". In his life outside prison, he maintained adult friendships circumscribed to his pedophilic interest as a way to let off steam and to share pedophilic material, which he had consumed and found satisfying since he said he had discovered "another world".
The inmate reported two moments of revelation during adolescence: when he became aware of his homosexuality and when he became aware of his attraction to minors. His pedophilic interest was high and so was his possible risk of recidivism. He indicated a preference for male minors between the ages of 0 and pre-puberty and commented that he was upset because "the sentence had focused on genital touching", when for the inmate "everything was erotic, everything was love: the caressing of the back as well". The sexual preference he described is consistent with his sexual anamnesis: all his fantasies involve boys and male adolescents. He also related that he had tried to masturbate thinking about adults in order to "correct" his attraction to minors, to no avail, as he did not experience any arousal. During the interview he showed concern and ignorance about his sexual preference (e.g., he asked "if he could ever be cured and if he could ever desire adults"). In addition, he expressed distress over the arousal he feels towards minors (e.g., "Why do I enjoy something that is horrible?") but, contradictorily, he expressed his desire to live in countries where it would be allowed ("My crime is frowned upon because society considers it immoral, but there are other countries where this is normal, such as Papua New Guinea, Iran, Pakistan.... I have thought about going to live in these places"), and he expressed a deep relief at being able to share it with the interviewers ("I have never talked about this with anyone, and it is very necessary for psychologists to take an interest in the subject"), adding the need to express his feelings in a group with other inmates who shared his sexual preference in order to "stop feeling like a monster". That is, the subject was unaware of the etiology and course of his attraction, presented discomfort about it, sought open expression of his feelings and possibly external validation of his preference and abusive actions through contact with other people with pedophilia or living in other countries. The inmate described early and possibly victimized sexualization: at the age of 7, a neighbor, three years older than him, and his 6-year-old brother performed fellatio and anal sex on him together in the absence of parental supervision. Moreover, he had only one experience of consensual sex at age 21, when he had an unsatisfactory sexual relationship with a woman older than him. Since then, the subject reported "leading a life of masturbation," and he disclosed engaging in zoophilic behaviors with domestic animals where motivations similar to an abusive approach to minors, such as subjugation or offering rewards for sexual pleasure, appeared to be apparent.
He claimed to have never had a relationship with an adult. In accordance with his distortions, he described four "romantic relationships" with minors, proceeding to describe the abuses for which he had been convicted. He placed the first at age 14 with an 8-year-old neighbor. He commented that "the relationship" was short and that he masturbated thinking about the minor. The second happened when he was 22 years old and the victim was 7. He commented that "we loved each other" and placed the responsibility for the beginning of the abusive interaction on the victim: "The boy was coming on to me, looking for me". The third victim was 9 years old when the interviewee was 24 and it went on until the minor turned 11, and the subject attributed the first approach to the minor. Finally, the last victim was 10 years old. The subject described the abuse as a romantic relationship based on spending time together ("I liked spending time together; taking showers; going for walks...").
Conclusion
The present study focuses on the specific psychological care needs of pedophiles in prison. First, it offers a specific intervention proposal for this population based on the available updated evidence and the factors related to recidivism. Secondly, it exemplifies intervention needs through the case of an individual with pedophilia evaluated in prison.
It is proposed to adjust the specific intervention with individuals with pedophilia depending on whether they are primary or secondary abusers, since, as mentioned above, the same techniques used with secondary abusers would not be effective. In the subject described, his sexual arousal towards minors of developmental stages I, II, and III (Tanner, 1962) occurred at the age of 14, a preference that has remained unchanged up to the present (51 years), generating distress (criterion B of the DSM-V), despite the attempts that the subject mentions having carried out to extinguish it. Plus, he considers his attraction as romantic and not exclusively erotic. His attraction is exclusive, more related to recidivism (Eher et al., 2015; McPhail et al., 2018), as he fantasizes exclusively about minors and seeks exclusively child abusive material with which to become aroused, and he has not enjoyed or actively sought out consensual sex with adults. This suggests that the subject is a primary abuser who requires specific psychological attention, complementary to the PCAS administration, preferably individualized to avoid feeling judged by those who would not have that same preference (Heasman & Foreman, 2019; Jahnke & Hoyer, 2013).
It is also proposed to carry out interventions on self-esteem, a precipitating factor of crime in primary abusers (Echeburúa & Guerricaechevarría, 2021), which is affected by having committed a crime against minors and feeling attracted to children, and can even lead the person to suicidal thoughts (Jahnke & Hoyer, 2013; Woodyatt & Wenzel, 2013). In addition, it is proposed to intervene on the guilt and shame that are often associated with the presence of pedophilia (Knack et al., 2019). In the case presented, these self-esteem problems and the verbalization of suicidal thoughts in the past can be appreciated; and it would seem beneficial for the individual to receive specific attention to improve his self-esteem (Echeburúa & Guerricaechevarría, 2021) and to activate the PPS protocol if suicidal thoughts were maintained at present.
In relation to cognitive distortions, sex offenders with pedophilia tend to present more erroneous beliefs such as attributing sexual desires towards adults to the minor, believing that children seduce or voluntarily initiate a supposed sexual approach (Ward & Keenan, 1999), or believing that sexual aggression against minors is a way of expressing affection that does not cause harm (Echeburúa & Guerricaechevarría, 2021). In our case, the subject presented a very high level of distortions regarding sex with children. Therefore, it seems that he could benefit from the proposals of identification of distortions and specific cognitive restructuring.
In the interpersonal area, it is proposed to determine which aspects of the relationship with minors are more attractive and to reduce feelings of loneliness as a consequence of the sexual interest, a risk factor for recidivism (Herrero, 2013). In the case presented, the participant reported being a "lonely person" and having no social support, so it could be beneficial, as we proposed in Table 1, to develop social skills with adults, search for meaningful activities, and establish emotional coping strategies.
In addition, given recent research (Herrero et al., 2021) it is proposed to carry out therapeutic interventions focused on detecting previous victimization experiences and their possible relationship with criminal behavior (Seto & Lalumière, 2010; Willis, 2014). The subject confessed to sexual behaviors by other minors towards him during his childhood on repeated occasions and at a very early age. It could then be analyzed whether they could have functioned as prior victimization and whether they influenced his later criminal behaviors.
In the sexual area, it is proposed, firstly, to carry out psychoeducation increasing self-knowledge and information about pedophilia to reduce distress, and secondly, to consider Acceptance and Commitment Therapy (Hayes, 2015) as well as to encourage the acceptance of his preference and his commitment not to exercise it, with prevention strategies inspired by the Relapse Prevention Model (Prochaska & Diclemente, 1984) and the Good Lives Model (Ward & Brown, 2004). These intervention needs are reflected in the participant, who reported having doubts about his sexual interest, seeking validation for his abusive actions, and expressing a lack of meaningful adult relationships.
Moreover, it is proposed to understand the sexual motivation underlying the paraphilic diversity by detecting the sequence in which the fantasies take place in order to avoid the cycle of sexual abuse. In the case presented, the inmate acknowledged having current pedophilic fantasies and having engaged in zoophilic behaviors in the past with motivations and processes similar to those carried out during child abuse. To this end, retrospective work seems necessary on aspects such as at what time the fantasies appear, with what emotions, etc. (Beier, 2013) and the development of strategies to identify and control behaviors following sexual fantasies (Beier, 2013; Hernández, 2018).
The need to detect and intervene on dissexual behaviors is also considered, since, although they do not imply an abusive behavior, they bring the individual closer to a potential subsequent criminal situation. Dissexual behaviors, substitutes for sexual abuse, were identified in the subject interviewed.
Finally, given that viewing child sexual abuse material is a risk factor for recidivism (Herrero et al., 2021) and does not facilitate awareness of the harm suffered by victims, it is proposed to incorporate strategies applied in the Off the Internet Program into the intervention. In the case presented, the participant admitted having consumed this type of material and also found it rewarding.
As we have been able to verify, our intervention proposal on the specific factors of primary abusers is based on the scientific literature and international therapeutic experience with the population with pedophilia in a community setting, and is adjusted to the needs assessed in a subject convicted for sexual assault of minors and self-presented as a pedophile. Given that this is a theoretical study, we encourage future researchers to conduct empirical studies with individuals with pedophilia in prison, to confirm or otherwise the existence of specific care factors in this population and whether the application of an individual program complementary to PCAS is effective.
