Psychiatry & Psychotherapy Podcast - Forensic Pedophilia with Dr. Cummings

Episode Date: September 20, 2020

In this episode, Dr. Cummings and I discuss forensic pedophilia and the sexualization of children in our society. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. So today, I was thinking I was going to pick your brain about pedophilia and specifically maybe forensic pedophilia. I think there's been an increased interest in the news. You may have seen the hashtag save the children and other things.

And there was a recent movie, Cuties, which I'm going to be doing a dialogue with some other psychiatrists on. But I think. Yes, indeed about the sexualization of children and our children. society. Yeah. Yeah. It's very disturbing to me. I actually canceled my Netflix. I put it up on my social media that I was doing that and I got a bunch of mostly, mostly positive, but some feedback that was like, you know, disagreeing. A lot of the, a lot of the arguments, interestingly, were like, we're like, well, why are you so upset at this when there's so many other things going on in our culture that sexualizes children? And I was like, yeah, I think all of that is bad. I think we should

I think we probably should not do that at all. And I'm on here. Actually, Maddie Ulrich is joining me. She's a medical student who's been hanging out with me for a week working on this. Hi. Hello. I promised I wouldn't have her do one month of pedophilia and the like. So, yeah, where do you want to start with this?

You want to maybe go through some of the history of forensic pedophilia? I know you're an expert because you work at Padden State Hospital. You guys have a, how many, you guys have a ward, right? We do. We have a unit that's devoted to treatment of what are termed in California. Sex offenders are sexually violent predators, which has a legal definition. One of the chief groups, however, among those individuals are indeed individuals who are pedophilic. in terms of history, the concept really of, well, first childhood and then a division between childhood and adulthood really began to crystallize, not surprisingly, until the 19th century.

And, of course, in many cultures, marriage often followed. puberty by not very much. However, over time, that became less common and it became more socially acceptable for people to get married at later ages. And certainly that trend has continued. People now often delay marriage into their 20s or 30s if they're going to get married. And also, in many cases, delay their sexual activity as well. One of the interesting things about the parapherias in general is, despite having been a topic of interest for literally millennia, we still don't understand very much about how people become attracted sexually to the people they're attracted to.

You know, and this includes both normal attraction and paraphylic or abnormal attraction. Because what people find attractive develops very early in life through a myriad of exposures. Indeed, most individuals can't tell you why they like tall people or short people or blonde people or dark-haired people. And indeed, the people who develop parapherias often have a very very important. very hard time describing how they became paraphylic, although it's clear it starts fairly early. Most of the pedophiles that I've interviewed and talked to began experiencing fantasies or urges directed toward inappropriately young partners at a fairly early age, often around 11 or 12, right around the age of puberty.

and often their interests centered on either people their own age or not uncommonly people even younger than they were. And then that continued to evolve often with a lot of fantasies and these days fed by a fairly active pornography industry until they eventually begin to act on those fantasies and urges. which is how it gets to be forensic pedophilia, meaning they ultimately become arrested for pedophilic behaviors and activities, although most police departments and criminal organizations, crime-fighting organizations will tell you that the vast majority of pedophilic involvements go undiscovered and unpunished.

and indeed the number for true pedophiles, the number of victims is often in hundreds, which is often what ultimately gets them caught. Yeah. You know, so it's one of the most common of the parapherias. Frankly, the law, for the most part, does not care about parapheria's, that involve a consenting adult partner. Those that are proscribed or prohibited by the law are those that involve lack of consent,

either the person who is paraphylic in terms of coerced or involuntary sex, sexual sadism, that's not voluntary, or pedophilia in which the person lacks the legal capacity to give consent. Other parapherias are typically not legally prohibited, at least in the United States. They are in some portions of the world. Yeah.

I don't know if you heard of this story about Helm Mutt Kentler, who was a psychology professor and started in the 1970s. placing homeless children in West Berlin with known pedophilic men. And this continued for some years. The study went on for 30 years and was officially approved and supported by Berlin's child welfare welfare offices and Senate. There's been a big investigation or I don't know, an investigation on how this was allowed to continue.

But at the time, you know, he said, oh, this is not hurting the children, this is helping the children. You know, finally that the children have someone that loves them, that's taken care of them. And some victims have come out and are fighting for reparations because, you know, they were abused. And they suffered psychological consequences. And what's crazy when I hear this story is like, this was going on not too long ago, you know? Yes. Yeah, I don't know if you have any thoughts on this particular story.

That particular story indeed was a good example of what amounted to official governmental abrogation of its duty to protect its citizens. In this case, it's younger citizens. This is an area that, frankly, the law has not dealt very well with and at times not very effectively with. For example, there are still states in the United States where with parental consent, the legal age of marriage is 14. And certainly in some strata of society, we have the recent Jeffrey Epstein case where recruitment and provision of underage women for sexual contact was went on for decades. and was, at least in the initial case in Florida, was essentially not punished. He was convicted. However, all of his illicit activity led to, I believe, a 10-month sentence with his being able to serve the sentence only on the weekends and go home at night.

I think he had to sleep there, but he was allowed to leave during the day. He was allowed to pay an officer to accompany him. wherever he went on business trips or whatnot, but he was often left without supervision during that time. When I watched that documentary, I literally could not sleep well. I mean, I slept a little bit, but, you know, like, it was torturesome to watch.

Yes. It was, I imagine like yourself, having a daughter, me having a daughter. It's like, this is just horrible. And the fact that he was able to get away with it for years, that's very disturbingly. Yeah, it was inexcusable. In his case, it was an example of wealth can provide a lot of protection against legal intervention.

Wealth and political allies, I would assume, because you know, at some point money isn't going to stop the law, but... Only if the money has indeed promoted political connections, if you will. Yeah. You know, this is an area in which the law, though,

has not, you know, the egregious cases of what are clear examples of sexual victimization, the pedophile who kidnaps, injures, or kills, children in addition to having sex with them clearly violates the law and those people do wind up usually either being punished and or given very long-term commitments in

places like state hospitals the law deals less elegantly with people who are in other circumstances for example an 18-year-old boy who is dating a 16 year old girl. If they have sex, it is not legal. On the other hand, it's not typically punished, and frankly, it makes news when it is punished because it's a more acceptable social norm. In California, the law, because the law has to make definitive line some places, sexual contact with a child under the age of 14 is fairly vigorously punished. Between 14 and 18, however, it is called unlawful sex, and indeed it is illegal, but may not be nearly as stringently punished. And then, of course, on the day the person becomes 18, they also become legally able to consent to

sexual activity with anyone who is also 18 or over. Yeah, there was a recent law change in that, which I think it has allowed a 14-year-old to have sex with someone who's 10 years older, like a 24-year-old, which, I mean, I think there's people on both sides of that, you know, wanting or not wanting it. Yeah. Well, and I think where the law struggles with this is clearly if you have two 16-year-olds, for example, one may indeed be very much a child and not have emotionally and socially progressed very far. On the other hand, some 16-year-olds are much more mature. But, you know, you can't, the law basically can't deal very well with indefinite things like, well, how mature is the person? How able are they to make those decisions? We also have, me and Maddie were talking about how in TV shows now, like Riverdale,

you'll have these teenagers hooking up all the time. But what were you saying about that, Maddie? Oh, yeah. On the show, they, well, there's a lot of things about the show, but on the show, the main characters have sex with each other, like, all the time. And that's just not usually very realistic of what teenagers do. Like, most of them don't have sex every day. Most of them might not even think about it or, like, have the opportunity to, especially because they still live with their parents and things like that.

But on the show, they do it all the time in their parents' homes. Their parents are, like, never there. And it's just like, I feel like it shows teenagers, like an unrealistic depiction of what they should be doing at that age. It does. And, well, our society also, as you pointed out originally with the, movie cuties and other examples

has tended to sexualize very young individuals and continues to do so, which I think gives an unrealistic and in some ways permissive view of underage sex. I mean, I can't tell you how many

of the pedophiles that I've interviewed point out correctly that a huge percentage of both the non-pornographic and frankly pornographic films and film clips out there depict sex between older people and younger people. Yeah. Yeah. And to a great extent tend to normalize that sexual interaction. And indeed, I've had more than one of them tell me, well, in many ways, I was.

only following what society is already endorsing. That's, uh, I was talking to, um, someone, they were saying that at Patton, you wouldn't be able to stop the pedophilia unit from watching something like QD's because it is on Netflix. Is that true? Uh, that is true. Because it would not, uh, well, basically we also, um, By law, we cannot prevent, for example, a pedophilic, or for that matter, any patient from receiving and viewing pornographic material as long as it is not material that directly violates the law, because that would be an infringement of their First Amendment rights. So kind of getting back to the diagnosis of pedophilia, I think it's also, and the prevalence,

I'm wondering like what percent actually are physically abusing children watching pornography, which I think is in a sense abuse because someone had to be abused to watch child pornography versus what percent are abstaining, not, you know, trying to resist these sort of, desires, you know, and try to move out of it. The short answer is we don't have very good numbers because obviously most people who are pedophiles don't go around saying that they're pedophilic given that the vast majority of them have not been arrested.

Interesting, a few surveys done in colleges have asked the question of male undergraduate students, how many of you would have sex with an underage girl if you knew absolutely for certain that you could get away with it and there would not be any punishment? And the answer has typically been about 50%. Yeah. Is that under age under 18 or under 14? You know, like, under 18, in other words, under the legal age of consent? I mean, do you differentiate between like wanting sex with someone who's not gone through puberty with someone who has gone through puberty?

Like, how do you make that different differentiation? One of the things that's come out of the research in this area is that clearly people who desire to have sex with pre-puberal individuals are psychologically much more abnormal, much more likely to be, if you will, compulsive about their sexual desires and much more likely to be violent than people who are attracted to individuals who are underage,

meaning under the illegal age of consent, but are clearly post-puberable. That is, they resemble, they more closely physically resemble adults. And indeed, one of the, one of the elements of interview in dealing with any pedophilic individual is to ask them about the content of their fantasy and urges, including what would be the gender and sex and appearance of their most desirable victim. the more closely that victim resembles an age-appropriate partner, typically the less pathologic the person's parapheria is.

And as you might guess, it's kind of a progression, because obviously people change from the point of puberty to the point of adulthood and become progressively more adult in terms of mental, and emotional capacities as well as in terms of physical appearance. Yeah. That frontal lobe keeps developing, right, in us until the age of, what, 32, somewhere on there? Like the pruning going on? Somewhere around there.

Now, frankly, as you know, women's brains mature faster than males. And indeed, there are women who would opine that some males never quite make it to the end. Okay. Especially if there's some traumatic brain injuries in the process or some... Yes. A lot of alcohol drugs. So let's talk specifically about that. The person who's attracted to the prepubescent person, you said that they're psychologically

different. Yes. The psychological differences that have been found is that it is less... often a pure sexual attraction, although that's certainly a major element, but that seems to be fused with elements of desiring power, control over the partner. In other words, they're specifically picking a partner who is less physically large, less emotionally capable, less intellectually capable. So often their fantasies. run to elements of control and coercion much more so than the person who picks a partner who may be underage,

but who is much more adult in terms of characteristics. Wow, that's interesting, yeah. There's also, now that's one profile. Another profile that often comes into play with picking very young victims is that many of the pedophiles who tend to pick very young victims are themselves, both emotionally and very oftentimes very intellectually immature. Yeah, yeah. I was watching some of the, I don't know if you've ever heard of the, it's like pedophile

hunter on YouTube. And this guy pretends to be, you know, a young victim and then meets this pedophile, right? and then like forces them to do an interview. And they seem very underdeveloped often, often the people who are chasing these super young girls and boys. Yeah, they're often themselves emotionally very immature. And indeed, they've often, the ones I've interviewed have been very unsuccessful in attempting to establish adult,

intimate relationships because frankly mature adults are not interested in them because they are immature. I was looking at this, the penau plesmographie. Yes. Plessmography. And do you guys use this at all at a pattern? Or is it mostly a research tool? Yes, we do. No, it is used clinically as well. It's used here. It's also used at Department of State Hospital's Coalinga. Coalinga is actually where the vast majority of people who have been legally declared to be sexually violent predators are housed in the state hospital system. The SVP law, which is well for an institution's code section 6600 and onward, has as its requirements that the person has its requirements.

engaged in establishing relationships essentially for the purpose of sexual victimization. They have then engaged in sexually violent acts, and the law actually specifies a list of crimes. They have to also then suffer from a mental disorder. Any disorder can qualify, but certainly parapherias are high on the list. And then the mental disorder has to make it more likely than not that they will pursue further victims, if you will. And for California, that's a sexually violent predator. They're committed post their prison term for two years, but that two-year commitment can be renewed indefinitely as long as they continue to pose a risk.

The plasmithography is used to judge basically their response. response to treatment. It's done basically with a series of computer images of people who were clearly adults, younger people, and basically the measurement is how too mescent do they become looking at different sorts of images. There's also a parallel test that's used that It was developed by a psychiatrist named Gene Abel, in which the computer randomly shows the individual a series of images, some children, some adults, various levels of dress or undress, and the computer keeps track of just how long the person looks at each image.

And, of course, computers are very good at measuring time down to the millisecond. And over several hundred images, it can identify whether there's a pattern or whether it's just random. You know, Instagram is pretty good at that too. Yes. I was talking to one patient and she was looking at this guy's Instagram and from just looking at his feed could tell what kind of girls he was into. because, you know, after a while, the algorithm kind of shows that. So let me ask you a question. So I read this article by Mueller.

It was called Changes in Sexual Arousal as measured by penile plesmograithy in men with pedophilic sexual interest. and the article sort of tried to counter this thought that you're basically stuck with only having interest in children if you have interest in children. This study showed that there was a group that changed over time and had a huge increase in the interest or the increase in the size of the penis with watching adult. arousing content over time. Do you have any thoughts on this? You're probably much more an expert on this than I am. Yeah. And indeed, that's one of the things that our clinicians are looking for as they've worked in therapy with these individuals to try to essentially help them develop a healthier arousal pattern, if you will. And then, of course, they use the penile plesmography and the gene able image test

to track shifts and the person's arousal response. Because, you know, sexual arousal really begins subcortically, so it's not something that we can consciously control. There have been a number of event. related EEG studies that show that if an individual finds something sexually interesting, that there is an increase in the P50 wave, which is way subcortical wave before you become consciously aware of it. And those sorts of measures and, you know, these tests are not sort of one and done. They're used repeatedly across therapy.

to essentially provide an objective measure of whether the person's interests are changing over time. One of the conundrums that legally we have is that for sex offenders, the bar to be released into the community is incredibly high, essentially zero failure. Well, that's almost impossible. which is why only a tiny handful of people have ever been released from Kowlinga,

even though in many cases they've made a good deal of psychological and developmental progress, but you can't guarantee to the public they will never reoffend. There is a lot of difference between obviously the very predatory pedophile with hundreds of victims who's essentially a hunter, that person likely should remain locked up forever, versus the person who may not have been a dedicated pedophile, but may have had difficulty with impulse control sometimes as a result of drugs or alcohol. We see a number of cases like that occur, for example, within families where there's been one victim. you know a for example a near but not quite adult cousin or some other relative or somebody with whom it was inappropriate for them to have sexual contact but there was not really an established predatory pattern or in some cases people who simply engaged in inappropriate sexual behavior as a direct outgrowth not of a paraphrasing

but of another mental disorder like schizophrenia or bipolar mood disorder manic. Those individuals, we have a much better track record of being able to eventually release into the community as safe because in essence they're not the hardcore pedophiles. They engaged in pedophilic behavior, but they didn't really establish. the pattern I was talking about earlier, people who began having fantasies and urges around puberty, go on to develop and rehearse those mentally, and then eventually it spills over into behavior, and they become long-term pedophilic predators. Those people, frankly, we have not discovered a great way to improve their development to the point where they no longer pose a danger.

like the more psychopathic yeah the more psychopathic and indeed the individuals who are both pedophilic and psychopathic are even very difficult even with the testing that we have available to tell whether they've made progress or not because psychopaths are very good at well not very good at, actually their biological substrate is of course not having much of an affective response. And of course the penile tumensence and the

ABLE test are both highly responsive to the response to the limbic system. Interesting. Yeah, I was going to I was going to ask you about the sort of the comorbidity of psychopathy or antisocial personality disorder

with this group of, with this population. Yeah, for the people who are the true predators, if you will, there is a very high rate of core morbidity with psychopathy. Yeah. In part because, of course, psychopaths don't typically have a rather callous disregard for the welfare of others, so it doesn't bother them very much to victimize children. Whereas the pedophiles who are not psychopaths are themselves often quite.

tortured by their sexual urges. Yeah. I think it's really good to differentiate like OCD with sort of unwanted pedophilic, like, thoughts. I've had a couple of those cases. In those cases, like, you know, they also might have hand washing or some sort of other obsession and then, or compulsion. Like the obsession being, you know, I feel dirty.

Okay, compulsion, I'm going to wash my hands. and they you know but i i think that in that population i sometimes once i get build that therapeutic alliance enough we'll ask them if they have any unwanted sexual thoughts and those are some of the most distressing for someone with oCD um yeah it whereas indeed those people virtually never act on their obsessional thoughts you know whether they be uh because indeed you'll see obsessional, intrusive, unwanted sexual thoughts, unwanted, violent thoughts. These people, however, are not really at risk of acting on those.

Their compulsions are truly punishing for them and drive them to the compulsive behaviors to try to alleviate the anxiety induced by the thoughts and the thought content. But I, you know, to bring us back to the forensic population I have never met

an obsessive compulsive disorder patient who was a sexual predator or sex offender. I've also seen a schizophrenic patient he was having auditory hallucinations that he should or that he'd had molested his cousin and it was so intense

that he actually went to the police station and told them he was having these thoughts. He wasn't having the thoughts. It didn't happen, right? But he was hearing things and he was paranoid around this sort of topic. So, yeah, I don't know if you've seen that before. Probably not as much in the forensic area, though, right? We have occasionally seen it, and we've actually had people who, with psychosis,

who did behave sexually inappropriately. in response to delusional ideation, I've never seen one of those individuals who was truly pedophilic. It had more to do with loss of reality testing, loss of boundaries. And, you know, why did you do that? Well, the voice told me to.

You know, the voice told me if I didn't do this, the world would end that kind of thing. In some ways, almost a more psychosovoic. version of what you get from the obsessive-compulsive disorder patients. The other category of people we get sometimes who've done things that are very sexually inappropriate, but not really a reflection of parapheria, have been in some of our elderly demented patients. Like the frontal temporal dementias, especially, I imagine, you know, so they're missing that sort of gait. Yes, they're missing the ability to make social judgments or to impair impulses,

and often it gets them in trouble. Usually it's not the same sort of sexual behavior you see with the paralephylic individuals. Usually they wind up here as a result of sexual battery inappropriate touching. They'll see somebody who's in a, who's a track, have no impulse control and basically reach out and touch the person inappropriately, but it's not having sex with the individual per se. I've seen it with drugs and alcohol, specifically methamphetamines seems to be the drug where I've seen people change their sexual interest starkly. Yes, well, in part that's because the medial amygdala, which

is really where, if you will, the heart of sex drive is in human beings, is in part driven by dopamine. That's one of the reasons, for example, in Parkinson's patients, sometimes treatment with dopamine agonists or cinemat, al-dopa, carbidopa, will cause them to exhibit very inappropriate sexual behavior, even though that was not prior to the medication exposure, something that was part of their history. That's a good little pearl. Watch out for that. And I think it's important to know that that could happen

because often there'll be so much shame around that the family won't tell you or the patient won't tell you. Yes. Well, for example, we've had a patient here who, unfortunately, as soon as you, gave him enough levitopacarbidopa to control his braticanesia and his cogrile rigidity he also would become a thoroughgoing exhibitionist if you lowered the dose of elopa carbidopa

all of the inappropriate sexual behavior which is vanish which of course is a clinical conundrum because on one hand you don't want to leave the man rigid and unable to move on the other hand you don't want him you know engaging in inappropriate sexual exposure yep yep that's tough mattie why don't you ask some of the questions you have yeah so after researching this topic a lot this week i had a few questions that came up sure um so kind of going back to what you said about how sexual drive starts at like a subconscious level. Do you think that pedophilia is ever a choice? Because that's something that comes up a lot in the media. Or is it something, like is it something that can control at all?

Well, let me break that question down. Is having pedophilic interests a choice? No. we don't understand how we come to be attracted to what we find attractive. It would be the same as asking a question who's attracted to brunettes of the opposite gender who are tall. Do you have a choice about being attracted to those people? Probably not. Those choices became ingrained not as a... series of conscious choices but as of unconscious or subconscious conditioning. Do you have a choice about what you do with those or any other sexual urges? The answer is yes.

And that's one of the principal elements of treating people with parapheria is to help clarify for them. They may not have a choice about having pedophilic urges. But they do clearly have a choice about whether they act on them or not. You know, I would add one caveat, and I would be interested in your thoughts on this. I think that we have a choice on how we can change our environment. And this kind of goes with like if we act upon, you know, impulses maybe to watch pornography, it'll probably strengthen or change our interest in sexual things over time,

depending on what pornography we watch, especially if it's done earlier in life. Just like, you know, I had a patient who ended up in an abusive relationship where sex was always done with violence and she got out and she was a patient of mine about two years after the relationship was over. And she's like, I don't know what happens. happened in the relationship, but the only thing, like, for some reason, what's arousing to me is some form of violence mixed with sex. And so it was like not there before the relationship,

but then the pattern and the repetition over time changed things. So I wonder if you would agree with the statement that you have the choice to change the environment that potentially could change some of the unconscious things that are going on, but that may take time. It may very difficult and it may not be 100%. Indeed, that's also an element. You probably don't have a choice about having the initial pedophilic urges. You do have choices about whether you choose to reinforce those, avoid reinforcing those, acting on them, not acting on them. To give you a more mundane parallel example for you know if you know for example that you are prone to alcohol abuse perhaps not hanging out at the local bar would be a good choice yeah we were we were looking at this

one pedophilia website where they were there was a group of people who were committing to being abstinent. And one thing that they put in their sort of rules is that you won't be alone in a room with a child. Yeah, it's called virtuous pedophiles.org. Yes. Yeah. And indeed, they're a good example of the people, the people who are members of that group, indeed, are those individuals who are not the psychopaths. They're the individuals who indeed have pedophilic urges and orientation, but they are troubled by them. They don't. don't wish to victimize children, and consequently, they indeed, just like the people who joined alcoholics anonymous and don't want to drink, I've found a variety of things they can do that

will help them avoid that role. You know, again, coming back to the issue of you may not have a choice about having had the initial urges, but you do have choices about how you manage them over time. including, as you point out, things like environment. One of the interesting things about the underlying choices is, you know, all of us, obviously, if there weren't sex, we wouldn't have a species. And consequently, we're very hardwired to be interested in sex. If you go back to the EEG studies with the P50 wave, which is very early, this is a subcortical process, if somebody shows up that meets your profile, and they did this in Scandinavia, they had the person

start off very heavily dressed, and then they had them gradually remove clothing, not to the point where they were naked, but where they were much more skimply dressed, the less dressed the target became, the higher the amplitude of the P50 wave became. Which is why we should keep the clothes on the children when they're dancing, for goodness sakes. One of the interesting things in that study was they found that men responded to women that they found attractive. Women responded to both men and women, and they puzzled over that for a while.

And then they figured the women may be looking at potential competition, because the P50 wave essentially is a reflection of the anterior single at gyrus saying, oh, this is worth paying attention to. Yeah. Well, read the next one. Yeah. So one of the studies I found that was done in 2002, They just compared around 20 men with pedophilia to some that didn't have it.

And they said that 60% of the pedophiles compared with only 4% of the controls reported sexual advances as a child. And then on top of that, 75% of the pedophiles compared to only 22% of the control reported a first sexual encounter before they were 14. So in your experience, have you noticed that a history of child abuse, does it, influence whether or not you have pedophilia? Yes. More specifically, there have been a number of studies that have found that the earlier the individual becomes sexualized, the more likely it is they will choose inappropriately young partners.

And that may have to do with, you know, for all of us, you know, early or first sexual experiences are often very emotionally powerful. And if those occur at an inappropriately young age, there seems to be then a fixation with wanting to go back and repeat that. And of course, once you're older, you can't actually regress to that age, but you can't pick partners who are of that age. Yeah. I want to talk a little bit about treatment from your perspective.

now that you're at an inpatient setting. Do you guys use like SSRIs, like high dose, to decrease libido, or do you use antitestosterone treatment? We do use both. As you know, the selective serotonin re-uptake inhibitors do, in many people, decrease arousal and certainly delay orgasm, often cause an orgasmia. which for some people can be a help in terms of not reinforcing their sexual urges. The anti-androgens, most commonly deproprivera or luprolide, are also used to decrease circulating testosterone levels, usually by about 75 to 100%, which correspondingly decreased sex drive.

What is your goal when you're doing loop or light? Like how much, what percent decrease are you guys looking for? Are you looking for total testosterone decrease or free testosterone? Optimally, the way it's done most correctly is to get a baseline measurement of testosterone and then to aim for about a 75% reduction from baseline. For most people, that will substantially reduce the intensity of their sex. drive without making them very liable to the primary long-term adverse effect of testosterone inhibition, which is bone demineralization.

And indeed, one of the follow-ups for anybody on anti-androgen treatment is to be sure that we do annual bone density. Any other, like for providers who are actually considering treating, with looperlide, any other clinical pearls or things that they should know? Probably the attractive thing about luprolide, well, two things. It comes, of course, in a monthly injection, a quarterly injection, and a six-month injection. So for those people who, for whom this is a chronic problem, obviously the longer half-life, longer dose interval may be desirable.

The other element to know about is this is a genetotropin releasing hormone analog. So for the first two weeks after the initial injection, there will actually be an increase in testosterone. And there may be an actual increase in sex drive and sex behavior that will then decline over time. Oh, that's really, that's good. Yeah. Yeah. Okay. What about the depot-provera? Anything with that? that that people should consider? Depo-Provera is used less often these days, mostly because unlike the luprolide,

it poses a much greater risk of causing hepatitis. Deppro-Pri-Pra can cause inflammation of the liver. It's not a very frequent outcome, but because Depo-Provera, Medoxy progesterone is given much more frequently for suppression of testosterone than, for example, when it's used to provide contraception, there's a higher risk because you're using much higher doses. Okay. Okay. Let's see here.

Yeah. Any other big questions you wanted to get off? Maybe we have one time for one more. Yeah, one thing that I just wanted to ask, especially for psychiatrists, how should we view pedophiles in general? And then what should we try to promote to the public about them? It's important to, I think, in looking at pedophiles, well, for that matter, with all of the paraphylic disorders, to essentially go a bit further and try to characterize them in terms of, if you have contact with them, are you looking at a person who has engaged in pedophilic behavior as part of a predatory pattern?

Or is this somebody who is in one of the other categories such as pedophilic behavior that's a result of another mental disorder like mania or intoxication? the ones who are not predatory are much better treatment candidates in terms of having lower inherent risk. The predatory ones are going to be much more difficult to treat and remain much more dangerous. That's good. And if you were a therapist, what would you recommend if someone came in who was wanting to be

abstinent, not wanting to watch porn or be? in a relationship, like what would you say are some of the things that they could do to help themselves? One, as you pointed out, there are support groups available, just as there are for substance abuse. And enjoining and being active in one of those groups is a very large help. The dominant form of psychotherapy for parapherlias is our modified versions of cognitive behavior. behavioral therapy typically done in groups, the group therapies tend to be more effective than individual therapy.

In large part, because just as in substance abuse disorders, pedophiles are much better at calling each other out and keeping each other honest than therapists are. Yeah, I've seen that. And consequently, that, you know, I'd be looking. and certainly for anybody in practice, one of the responsibilities, I think, for any individual therapist is wherever you practice, become familiar with the resources in your area, including groups that deal with things like pedophilia. Yeah.

Well, thank you so much, Dr. Cummings, for coming on. I think this is an important topic to discuss at this time. Any final pearls or reflections that you would want people to walk away with from this discussion? I, you know, this is an area in which our treatments are still fairly limited. There has been progress.

You know, I think as a society, our own attitudes and responsiveness and responsibilities, frankly, with respect to sexuality and general need to mature. Where, as a, you know, I think some of the pedophiles, talk with are right their own sort of titillation with inappropriate sexual behavior is too

much reinforced by our society yeah well i feel very strongly about that too i think just because what wires together fires together right and i think that our brain lights up you know it's like why do beer commercials have beautiful women standing in a bar next to a guy drinking a beer. You know, it's because they're trying to pair the two things, right? Yes. Drinking a beer, which, you know, prior to the pairing probably doesn't have very much sexual stimulating things, although it can reduce some sort of maybe inhibitions a little bit, but it's the pairing over time that you start to associate two things together. And my concern is, you know, if you look at a lot of music videos, they pair either very young,

females with sexuality or they're pairing sexuality with violence often going back and forth between violent scenes and sexual scenes and it's it's pairing things that potentially can be harmful and doing it on a very sort of subconscious unconscious level like you said before a lot of this stuff develops yeah indeed we might do better if we actually spent some effort toward pairing a more adult appropriate intimacy with entertainment rather than inappropriate things. Very good. Well, Dr. Cummings, thank you for coming on. And once again, I'm really thankful for you, and I know the people who listen to this are. So, you know, it's great to put your brain out there and your thoughts and your expertise. As long as you give it back at the end, I'm okay.

Yeah. All right. Take care. Okay. Thanks. Bye-bye.