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Online-Issues » 1-2016 » Janssen

Erotic Age Preference Development: A Medico-Legal Quagmire

Diederik F. Janssen
Nijmegen, The Netherlands

[Sexual Offender Treatment, Volume 11 (2016), Issue 1]

Abstract

The 2013 DSM-5 specified several observations and caveats regarding age of onset of, and age required for diagnosing, "paraphilic disorders", and by arguable implication, for "ascertainment" of "paraphilias". These gestures enduringly warrant interdisciplinary reflection. Particular attention is due with regard to erotic age preference (EAP) development, as has been duly recognized in biosocial and forensic texts since the early 1990s. However, EAP remains fractured along a nineteenth-century medico-legal dichotomy of "paraphilic" pedophilia and its long unnamed adult "normophilic" pendant, "teleiophilia". This dichotomy disallows wider, more nuanced, and more critical understandings of EAP development during childhood and adolescence, reducing the topic either to the "etiological" question of "mental disorders" or to the psychophysiological profiling of young offenders. Yet even within this narrow forensic-etiological frame, little is known about young people actually receiving, identifying with, or more generally living with or amidst, paraphilia labels.

Keywords: adolescent offenders, erotic age preference, human development, paraphilia, pedophilia, review



In 1968, Gigeroff, Mohr and Turner ventured the following observation. "Each of us in his own life has moved through a period of pedophilic-like activity when we ourselves were children, when early sexual exploration was experienced as a pleasurable, secret activity. From this recognition can emerge a deeper understanding of the heterosexual [sic] pedophile who has not yet emerged from, or has returned to, that same period. If a probation officer has strong negative feelings on this subject, he is well advised to look into his own background; or if he prefers to avoid this, he should refer cases of this kind to a fellow officer" (p. 20).

This psychodynamically informed call for professional introspection will sound scandalous to twenty-first-century ears, but it importantly alluded to what today remains a sexological quandary: "paraphilic development". Long pertinent to LGBT advocacy and research, the questions of "developmental milestones" and "sexual identity trajectories" have on occasion been extended to sexual inclinations still nominally classified as "paraphilias". As virtually all research on LGBT youth (see Savin-Williams, 2005), research on "paraphilic" development, old and recent, has been suggestive of diffuse trajectories of becoming, including points of initial awareness of attraction, conscious arousal and fantasizing, coming-out (or conversely, self-aware "passing"), and self-labeling, and often stretching continuously from prepubescent into postpubertal ages. However, most research that might shed a light here has for long obeyed the culturally overriding medicolegal distinction summed up by the term paraphilia, sponsoring the framing of most questions in blunt medicalizing terms, rather, of "onset", "etiology", and "early symptoms".

This fundamental problem of distinguishing "typical" and "atypical" sexual development has long been recognized in the juvenile sex offender treatment world (e.g., IATSO: Miner et al., 2006; ATSA, 2012; WFSBP: Thibaut et al., 2016) and its critical observers (e.g., DiCataldo, 2009, pp. 39-48). Moreover, developmental perspectives are critical for important discussions, including adolescent sex offender registration policies (Najdowski et al., 2016). Developmental approaches seem indispensable to recent and still rare outreach initiatives targeting adolescents who "exhibited sexually deviant behaviors or fantasies indicative of a sexual preference for the prepubescent and/or early pubescent body of children" (Beier et al., 2016, p. 5; see also Rothman, 2016).

Although not always stressed, these concerns and developments are integral to the wider critique of the psychiatric demarcation of criminal, or otherwise problematic, sex. For instance, the APA's 2012 unwillingness to adopt "hebephilia" as a dimensional element of what became DSM-5 "pedophilic disorder" was significant also given that most if not all early-through mid-adolescents, even preadolescents, may well be "pedohebephiles" sensu stricto. The proposed strict sense, incidentally, entailed either or both of "recurrent and intense sexual arousal from prepubescent or pubescent children" and "equal or greater arousal from such children than from physically mature individuals" (APA, 2010, n.p.). While this proposed scope expansion of "pedophilic disorder" was referred back to the plethysmographic lab where it came from, the question of the due place of these pushy labels in sexology, and in sexual culture more broadly, begs to be specified with reference to the lived experience of all young people.

As is briefly reviewed below, psychiatric classifications and research still largely pay lip service to this specification. I take Gigeroff et al.'s comment to extend beyond pedophilia to the broader research scope of erotic age orientation or erotic age preference (EAP) development. This choice of terms must remain tentative in light of the discussion below, although they are important. Any definitional nuance between adult sexual attraction, sexual preference, and sexual orientation, speaks to cultural appropriations of such distinctions for procedural ends (civil commitment assessment and review, access to treatment, LGBT rights advocacy) and outside the clinic may prove significant predominantly in terms of their post-Stonewall political implications in the Western world. Whatever the case may be, both the notion of sexual orientation and its deconstructions remain fixated on gender categories, while maturity/age categories come in only secondarily, if at all (e.g., Bailey et al., 2016, pp. 48, 67-68, 83; Savin-Williams, 2016).

This situation, along with concomitant definitional nuances and distinctions, begs for close assessment especially in the pre-adult years, but little assessment has been forthcoming. "Our understanding of how teenagers of any orientation experience sexuality is shockingly primitive", wrote Savin-Williams in 2005 (p. 44); he himself avoided the question of EAP altogether. Seminal articles by Feierman (1990), Freund and Kuban (1993) and Quinsey et al. (1993) all explicitly signaled the virtual absence of developmental research on EAP, and all three formulated a research agenda for EAP development modeled on erotic sex/gender preference. Authors of contemporaneous texts agreed (e.g., Hunter & Becker, 1994). Yet what "normal development" should entail here has remained both virtually unstudied and, where the question was left to the discretion of the diagnostician or psychometrician, essentially arbitrary. The available Anglophone research addresses only North American, West-European and South African samples, and is lacking in cross-cultural or international comparisons. No normative or longitudinal developmental studies are available. Normative research into EAP typically lacks a developmental dimension and excludes minors as research subjects (e.g., Antfolk et al., 2015).

When one can, or must, speak of age-based attraction, preference or orientation, then, may be a question deliberately left unresolved. This would make EAP less an empirical than a cultural intrigue. Both the research and the cultural dimensions are probed below to explore this problem.

Erotic Age Preference: Between Psychiatry and Law

Psychiatric provisions not to diagnose in the cases of underage involvement or small age-gaps, as have been variably formulated since the DSM-III, are revealingly comparable to discretionary legal provisions either not to classify sexual interactions or behaviors as sex offences, or to down-classify offences, in kindred forensic situations. In the U.S. as of 2016, for instance, 31 of 50 states are cited to have "age-gap provisions" (http://www.ageofconsent.us; for a possibly dated overview of U.S. state law, see Zimring, 2004, pp. 161-169). Such provisions make sense to people, research suggests (Reitz-Krueger, Warner, Newsham & Reppucci, 2016).

The impetus to psychiatricize EAP has in fact always been legal. "Atypical" age of attraction has classically been understood in terms of a retention of what most would consider normal patterns (attraction to what are age-mates when young) into later stages of development where the qualification "age-mates" would only gradually become semantically untenable, and finally legally circumscribed. Thinking about atypicality here has been timely not least since the globally ubiquitous legal accommodation of consenting "adults" in private. It should be recalled that historically, erotic sex/gender preference and EAP jointly entered the scientific mindset at the precise occasion of law reform: the moment that male homosexuality (urnische Liebe) was being differentiated from male "boy-love" (Knabenliebe), in 1864 by sodomy law reformer Karl Heinrich Ulrichs (Janssen, 2015). EAP remained a key problem in homosexuality advocacy and research for over a century to come. However, it was gradually orphaned as a clinical problem after homosexuality's decriminalization, and after the homosexual's depsychiatricization, during the 1960s and 1970s.

EAP's legal ramifications (including mandatory reporting laws), combined with the physiological penchant of today's sex offender research, must have intimidated social scientists, developmental psychologists, and nonclinical sex researchers into desisting from more general approaches. The little that has been said about EAP development, has been said almost exclusively from a forensic, "sexual psychopathology" vantage point rolled out, in West-European literature at least, since the 1880s. Illustratively, today's purportedly leading EAP experts Ray Blanchard, James Cantor, and Michael Seto are co-authoring, Canada-based clinical/forensic psychologists who have not studied preadolescent or early adolescent EAP outside limited clinical settings. Mentioned authors predictably favor research tools and diagnostic criteria that bypass the untrustworthy perpetrator or "predator" altogether and refer to either the purported physiological indicators, or else the supposed criminal predictors, of "deviant" EAP, i.e., those preferences that would predispose to or correlate with law-breaking.

Erotic Age Preference Development: Dearth of Research

This led them to suggest, incidentally, that "pedophilic interests can be detected in offenders as young as 14 years old" and that "the factors influencing the development of pedophilic interests operate in early adolescence or perhaps even earlier" (Seto, Lalumière & Blanchard, 2000, p. 326). Psychophysiological assessment of "deviant arousal patterns", more often than not narrowed down to "pedophilic interests", in adolescents has been described since the mid-1980s, indeed "with clients as young as 12" (Knopp, 1985, p. 20) while clearly "no standards or norms [had] been established for assessment" (Freeman-Longo, 1985, p. 134). Widespread deployment was reported by the early 1990s (Knopp, 1992, as cited by Michael & Donohue, 1996, p. 57), however. It has more recently given way to viewing time measures (McGrath et al., 2010, p. 62). Becker, Kaplan and Kavoussi (1988) already published on phallometric assessment of treatment outcome in juvenile offenders. Test kits specifically designed for use with young offenders were subsequently developed (for a review, see Worling, 2012). In 2009, "Among [North American] community and residential programs for male adolescents, slightly less than 10 percent used the penile plethysmograph, whereas slightly over one-third used viewing time measures" (McGrath et al., 2010, p. 59).

Regardless of the colossal ironies involved (state-sanctioned sexual stimulation of minors by way of illicit imagery), little is known about whether and how assessment translated, or currently translates, to formal diagnoses beyond what are classically referred to as "atypical", "anomalous", "deviant" or "problematic" sexual interests or arousal patterns. Illustratively, Graves et al. (1996) recognize the "pedophilic youth" as one of three types of offenders, with a typical age of first offense between 6 to 12, and a typical intervention moment of Grade 7-9 (ages 12-15). However, as the authors admit in an endnote, "Inasmuch as there exists controversy surrounding the identification of adolescents as pedophiles, this term is used descriptively rather than in a true diagnostic sense according to DSM-IV criteria" (p. 315n1). In Becker, Cunningham-Rathner and Kaplan (1986), male 13- to 19-year-old sex offenders with victims more than 5 years younger than themselves were simply defined as "pedophiles".

According to a U.S. study of 30 boys aged 12 to 14 at the time of being apprehended for a most recent sexual offense (mostly involving children under age 13), the average subject began having "deviant" sexual fantasies at age 9 years, 2 months (Wieckowski et al., 1998). But no definition of deviance was offered. In another U.S. study of "nondeviant" and "deviant" sexual fantasies in offending and non-offending males aged 10 and upward, the question of EAP was similarly avoided (Daleiden et al., 1998). Most teenaged sex offenders are not found to show "deviant" or "atypical" sexual arousal as defined in current North American juvenile sex offender literature. In fact, an undifferentiated erotic responsivity has long been cited as typical for U.S. male teens (Ramsey, 1943, pp. 221-223). The distinction of an "undifferentiated" and a "differentiation" stage in sexual development had been proposed in forensic psychological contexts already in the 1890s (Dessoir, 1894, pp. 941-947), in an article that incidentally details two cases of adult men with histories of young adult, episodic and/or non-exclusive erotic receptivity to young boys. These case histories were such that a definitive diagnosis of "homosexuality" was problematic, Dessoir argued. Of note, this differential diagnostic appraisal of erotic interest in (prepubescent and teenage) boys predates Richard von Krafft-Ebing's 1896 seminal article on "pedophilia erotica" (of further note, Krafft-Ebing was a co-editor of the journal in which Dessoir's article appeared). Pioneering sexologist Albert Moll (1898, pp. 421-433) would later prominently engage with Dessoir's theoretical gesture, solidifying its place in late nineteenth-century sexological thought. The nuance between abnormal and unforthcoming normal sexual attraction, in any case, is older than the nomination of sex research for the status of an academic discipline in its own right (in 1906, by Iwan Bloch).

Today, although sexual interest studies have sporadically included adolescent non-sex-offending control groups, no normative psychophysiological data are available to base mentioned makeshift categories on anything other than legal, classificatory or some other arbitrary, age limits or brackets. For instance, Zimring (2004, pp. 50, 64-66) offers good reasons why psychopathology rates in adolescent sex offenders may be low when observing DSM-IV criteria for the paraphilias, but these reasons, apart from crime statistics, predominantly are the criteria themselves (excusing under-16s from the diagnosis of pedophilia).

As empirical research on "normative sexual development in childhood" more broadly (especially since the early 1990s), research informing EAP development typically either simply obeys or ignores these criteria. Researchers often set out to explain attitudes or behavior pertinent to partner age and partner age parity in biosocial-adaptationist models of "mate selection" (e.g., Buunk et al., 2001; Feierman, 1990; Grøntvedt & Kennair, 2013) and/or in neurodevelopmental models of structural brain "abnormalities" and "vulnerabilities". The former paradigm has informed interpretation of data on adolescent and early adult romantic partner age preference (e.g., Kenrick et al., 1996, and subsequently Carver, Joyner & Udry, 2003, pp. 26, 36-38; Young, Critelli & Keith, 2005) but likely connections to EAP, whether "normophilic" or "paraphilic", remain unstudied. This is also true of the wider research on adolescent attitudes toward age-parity and age-disparity in romantic relationships (e.g., Cowan, 1984) and on actual age differences in adolescent dating, relationships, and coitarche. On the latter, a sizeable number of correlational studies exists, although on the whole, the research focusing on age disparity and romantic relationships is not large (Lehmiller & Agnew, 2010).

Another area of EAP research involves retrospective accounts by (self-identified) adult pedophiles and/or adult sex offenders against minors. See Table 1 for 16 quantitative studies reporting on the variable of "age of onset" putatively pertinent to "pedophilia". This pertinence, as indicated above, is cross-cut by DSM-III-R and subsequent APA recommendations not to diagnose, or by implication to "ascertain" (DSM-5), "pedophilia" until age 16. All of these studies involve exclusively men, and involve little more than self-report measures of the timing of initial feelings, awareness or interest. As many self-identified LGBTs, self-identified pedophiles are reported to claim having been "born this way" (e.g., Li, 1990; Silva, 1990). This underscores the need for in-depth study of the peripubescent establishment of EAP. However, such research is frequently pronounced incompatible with ethical standards pertinent to research involving minors.

Table 1: “Pedophilia”: “Age of Onset”
Reference N Sample Subject Ages Measure Findings
Abel, Mittelman, & Becker (1985); Abel & Rouleau (1990, pp. 13-14) [561] male "sexual assaulters", USA [13-76] "age of onset of the first paraphilia" 50% of male nonincest pedophiles by age 16; "majority of sexual assaulters develop deviant sexual interest prior to age 18"
Marshall, Barbaree & Eccles (1991) 129 male "outpatient child [<14y] molesters (91 nonfamilial and 38 father/daughter offenders)", Canada m = 29.8 (nonfam. girls), 29.9 (nonfam. boys), 36.7 (incest) "age of onset of deviant sexual interest" in incest and nonincest "pedophiles" "Of those men in our study who admitted to having entertained sexual fantasies of children (52.7% of the total sample), 38 (i.e., 29.5% of the total sample) declared that they had developed these fantasies prior to age 20"
Houtepen, & Bogaerts (2014, p. 103); Houtepen, Sijtsema & Bogaerts (2016, p. 53) 15 "self-identified males with pedophilic [or hebephilic] interest", Netherlands (1 from Belgium) n.a. "onset of pedophilic feelings" No specific ages given. Awareness gradual in 11, quite sudden in 4
Elliott, Browne & Kilcoyne (1995) 91 men convicted of sex offenses against children, England 19-74 "under the age of 16 when first attracted sexually to children" 34%
Freund & Kuban (1993) (a) 589 gynephilic paid volunteers; androphilic clients; pedophilic sex offenders against children (<12y), all male, Canada m (SD) = 21.7 (6.0) to 34.8 (10.0) Curiosity for nudity of peers and of "adults" at ages <7 and 7-11 Significant between-group differences found
Freund & Kuban (1993) (b) 78 "self-professed gynephilic male university students", Canada 18-43 "age of loss of curiosity directed toward nude children" if any "Forty-three [55%] students gave a positive answer to the question of whether at any given time their curiosity to see nude children [?] of their later erotically preferred sex substantially diminished or stopped. The mean age reported as the point at which this happened was 11.7 years, SD = 1.7 years."
Bernard (1975, p. 246) 50 male "pedophiles", Netherlands 4% <21y; 58% <41y "How old were you when you first became aware that you were a paedophile?" 8% "<10y" (!); "20% at the age of 15; 12% at the age of 16; 6% at the age of 17; 10% at the age of 18; [cumulative] total [at age 20] 66%."
Gaffney et al. (1984, p. 547) 33 male inpatients with DSM-III pedophilia / paraphilia 39 ± 3 "age at onset" [?]; "age of risk for paraphilia" [?] m = 27 +/- 3 (nonpedophilic paraphilia: 16 +/- 1)
Huizinga (1977, p. 388) 21 nonclinical self-identified pedophiles, Netherlands =20 age of first awareness of "pedophilic feelings" and age of self-labeling 4 in 21 claimed awareness before age 6 [!], another 6 before age 12, another 10 ages 12-16 and one later than age 17; the Dutch term pedofilie was associated with awareness first at age 17 (10 respondents abstained from replying to this question)
Ilcken (1981) 19 nonclinical nonforensic self-defined pedophiles, Netherlands   first "awareness of paedophilic feelings" 11 out of 19: before or during puberty, usually during puberty. Another 6: at or after age 18
Ivey & Simpson (1998) 6 male sex offenders with sexual attraction to ages <16, South Africa n.a. "onset of sexual interest in children" 2 "adolescent" onset, 4 "adult" onset
Pfenninger (1990, pp. 61-62) 36 outpatient men who admitted to sex offenses against children (<14y), U.S. 21-68 age of first becoming aware of erotic interest in children 8 - 65 years (M = 22.7, SD = 15.7) for "fixated" group; 18 - 63 years (M = 33.4, SD = 10.1) for "regressed" group
D'Elia (1988, pp. 117-118) 18 adult males legally charged with sexual assault of a minor, Canada 19-53 age at first sexual attraction to a child 12 and upward; 8 before age 22; 85.7% (homosexual) before age 21 vs 81.8% (heterosexual) after age 21
Tozdan & Briken (2014) 75 men with self-identified sexual interest in children [<11y and 11-13y], online [Germany] 20-69 age at first "recognizing" sexual interest in children mean = 17.0, SD = 6.5, median = 15.0, range 6 - 44.
Schaefer et al. (2010, p. 158) 160 male self-identified pedophiles and hebephiles; "Dunkelfeld" vs potential offenders, Germany 18-64 "Since when are you aware that children [prepubescent minors] sexually arouse you?" "The mean age at which participants had become aware of their sexual preference for minors was recalled to be 20.5 (SD = 9.067; range 6-57; median 17). Being aware of their sexual interest in minors by age 20 was reported by 64.6%, and by age 30 by an additional 22.8%."
Grundmann et al. (2016, p. 1157) 494 non-prosecuted self-identifying pedo-/hebephilic men seeking professional help and meeting DSM-IV-TR pedophilia or paraphilia NOS ("hebephilia") criteria, Germany m (SD) = 37.8 (11.3) "Since when do you experience sexual arousal during masturbation to [prepubescent / early pubescent / adult males / females]"? Mean ages of onset in years (SDs) ranging from 26.2 (10.7) (to adult females) to 30.1 (9.5) (to early pubescent females)


A third area of EAP research includes survey studies of nonforensic, nonclinical college, community and online samples using self-reported measures of sexual interest in children or in early teens among young adults (for references, see e.g. Wurtele, Simons, & Moreno, 2014). Few teens under age 18 have ever been involved in these studies, however, and no study specifies data for the latter age group. Moreover, few of these studies reported on EAP per se and none reported on EAP development proper in any detail.

In sum, very few available studies, even non-U.S. studies, adequately move beyond legal and psychiatric frames for EAP. The very few studies that tune in on normative teenage EAP, conversely, stay clear of addressing the limitations of such frames. One study by Hegna, Mossige and Wichstrøm (2004) provided data on hypothetical likelihood of sexual interaction with children and early teens among 18- and 19-year old Oslo senior high school students. Although many such interactions may have risked being construed as criminal [1], nothing is said about forensic-psychiatric ramifications or implications. Seto et al. (2010, p. 222) reported that 4.2% of a representative Swedish survey of 1,978 male high school students (mean age 18,0, range 17-20) admitted to the crime of ever having watched "child pornography", a finding with possible, if unexplored, clues to late teenage EAP. However, the latter variable was not defined other than as involving "sex between adults and children" (p. 221), while according to Swedish law [2] as well as international legal consensus, it extends to a much broader scope of any involvement of persons, or simulacra of persons, that would appear to be under 18. What this says about EAP, in any case, remains unclear, certainly in light of the often much higher figures reported for mutually consensual "sexting" in this age group (which globally risks construal in terms of often multiple "child" pornography offences: IMEC, 2016).

Paraphilic and Erotic Age Preference Development: DSM and ICD

To sum up the above findings, questions about the development or "onset" of EAP have almost exclusively arisen in the form of the question of the etiology and early indicators of pedophilia (Seto, 2008, pp. 111-113/2012a, pp. 165-166; 2012b, p. 233), a "mental disorder" according to post-WW2, APA (pre-DSM-5) and WHO consensus. The context of studying the latter, certainly after the 1980s, has been almost exclusively forensic-clinical. If one accepts the verdict and frame of "mental disorder", one would need to leave room for something like "normal development". This need has classically been addressed in the form of explicit caveats in diagnostic criteria. See Table 2 for a breakdown by DSM revision.

Table 2: Paraphilias and Ego-Dystonic Sexual Orientation: Typical or Common Age of Onset and Diagnostic Guidelines for Adolescent Diagnosis, by DSM Revision
 
DSM
 
III
III-R
IV
IV-TR
5
 
(APA, 1980)
(APA, 1987)
(APA, 1994)
(APA, 2000)
(APA, 2013)*
Ego-dystonic Homosexuality "The most common age at onset is during early adolescence when the individual becomes aware that he or she is homosexually aroused and has already internalized negative feelings about homosexuality." n.a. n.a. n.a. n.a.
Paraphilia (in general) - - "Certain of the fantasies and behaviors associated with Paraphilias may begin in childhood or early adolescence but become better defined and elaborated during adolescence and early adulthood" idem -
Exhibitionism "preadolescence to middle age" "usually occurs before age 18, although it can begin at a much later age" idem idem "Adult males with exhibitionistic disorder often report that they first became aware of sexual interest in exposing their genitals to unsuspecting persons during adolescence, at a somewhat later time than the typical development of normative sexual interest in women or men. Although there is no minimum age requirement for the diagnosis of exhibitionistic disorder, it may be difficult to differentiate exhibitionistic behaviors from age-appropriate sexual curiosity in adolescents"
Frotteurism [Atypical] "Usually the paraphilia begins by adolescence. Most acts of frottage occur when the person is ages 15-25 years" idem idem "Adult males with frotteuristic disorder often report first becoming aware of their sexual interest in surreptitiously touching unsuspecting persons during late adolescence or emerging adulthood. However, children and adolescents may also touch or rub against unwilling others in the absence of a diagnosis of frotteuristic disorder. Although there is no minimum age for the diagnosis, frotteuristic disorder can be difficult to differentiate from conduct-disordered behavior without sexual motivation in individuals at younger ages."
Voyeurism "likely ... early adulthood" "Usually the onset of voyeuristic behavior is before age 15" idem idem "Adult males with voyeuristic disorder often first become aware of their sexual interest in secretly watching unsuspecting persons during adolescence". "Adolescence and puberty generally increase sexual curiosity and activity. To alleviate the risk of pathologizing normative sexual interest and behavior during pubertal adolescence [sic], the minimum age for the diagnosis of voyeuristic disorder is 18 years (Criterion C)"
Sexual Masochism fantasies likely present in "childhood"; acts "commonly by early adulthood" idem idem idem "Community individuals with paraphilias [?] have reported a mean age at onset for masochism of 19.3 years, although earlier ages, including puberty and childhood, have also been reported for the onset of masochistic fantasies";
Sexual Sadism fantasies likely present in "childhood"; acts "commonly by early adulthood" idem idem idem "One study reported that females became aware of their sadomasochistic orientation as young adults, and another reported that the mean age at onset of sadism in a group of males was 19.4 years."
Fetishism "disorder begins by adolescence, although the fetish may have been endowed with special significance earlier, in childhood" idem idem idem "Usually paraphilias have an onset during puberty, but fetishes can develop prior to adolescence."
Transvestism / Transvestic Fetishism "disorder typically begins with cross-dressing in childhood or early adolescence" idem idem idem "In males, the first signs of transvestic disorder may begin in childhood, in the form of strong fascination with a particular item of women's attire. Prior to puberty, cross-dressing produces generalized feelings of pleasurable excitement. With the arrival of puberty, dressing in women's clothes begins to elicit penile erection and, in some cases, leads directly to first ejaculation.
Zoophilia "unknown" NOS** NOS** NOS** NOS**
Pedophilia "may begin at any time in adulthood; most frequently it begins in middle age"; adolescent onset acknowledged "usually begins in adolescence"; Criterion C: "The person is at least 16 years old and at least 5 years older than the child or children in A. Note: Do not include a late adolescent involved in an ongoing sexual relationship with a 12- or 13-year-old" idem idem Idem Criterion C; "Adult males with pedophilic disorder may indicate that they become aware of strong or preferential sexual interest in children around the time of puberty—the same time frame in which males who later prefer physically mature partners became aware of their sexual interest in women or men. Attempting to diagnose pedophilic disorder at the age at which it first manifests is problematic because of the difficulty during adolescent development in differentiating it from age-appropriate sexual interest in peers or from sexual curiosity."
* Pertinent to respective “paraphilic disorders”; ** Subsumed under Paraphilia Not Otherwise Specified.

The first to stipulate diagnostic criteria for "paraphilias", the 1980 DSM-III required an age difference between "adult pedophiles" and the "prepubertal children" engaged with or fantasized about of, arbitrarily, "at least ten years". For the "late adolescent, no precise age difference is required, and clinical judgment must take into account the age difference as well as the sexual maturity of the child [engaged with or fantasized about]" (APA, 1980, pp. 271-272). Before "late adolescence" (not defined) no guidelines were offered. It was also postulated, curiously, that "The disorder may begin at any time in adulthood; most frequently it begins in middle age". In sum then, APA relied simultaneously and confusingly on (1) absolute age brackets (a decade), (2) physiological markers ("prepubescent child"); (3) undefined socio-psychological life stages ("adolescent"; "adult"), and (4) unspecified legal categories ("children [minors, by implied definition] or other nonconsenting persons").

It seems that here the APA tried to balance biology, law, culture, and what is admitted (p. 271) to be simple arbitrariness. More confusion occurred given that the invocation of these four parameters, as well as the typical age of onset, shifted on various points already in the 1987 DSM-III-R, apparently reflecting the early attention to adolescent sex offenders in the U.S. According to the latter, "[t]he age of the [?] child is generally 13 or younger. The age of the [diagnosed] person is arbitrarily set at age 16 years or older and at least 5 years older than the [?] child"; and by now, the "disorder" was said to "usually [begin] in adolescence" (APA, 1987, pp. 284-285).

The 1992 ICD-10 adopted the 16-year minimum age and 5-year minimum age-gap criteria (WHO, 1993, p. 137); the WHO also notably extended the pedophilic preference range to what it called "early pubertal age" (WHO, 1992, p. 219). Additionally, it was specified that: "An isolated incident, especially if the perpetrator is himself [sic] an adolescent, does not establish the presence of the persistent or predominant tendency required for the diagnosis" (p. 219, emphasis added). Of note, the ICD's Disorders of Sexual Preference (F65) were subsumed under Disorders of Adult Personality and Behaviour, although there was no intention to pin the disorders to an adult onset or appearance, or, for that matter, to define "adult" (1992, p. 200). This omission is curious, given that we are working on the interface of (international) law and mental health, and that clarification should have resolved the obvious confusion of biological, legal, and vernacular allusions to age.

Of note, the 2013 DSM-5 fares little better in generically defining the absence of "paraphilia" in terms of the legal ability to consent (presumably whatever happens to be defined as the local age of consent) and the "sexual maturity" of the preferred partner (APA, 2013, pp. 685-686). Consent being a legal concept contoured by statutory rape laws and "Romeo-and-Juliet" provisions based on the calendar age of two individuals in specific legal situations, one wonders whether the APA means that psychiatry here indeed is to co-inflect with (state-level?) law texts and jurisdiction. The ICD-11 Beta draft (WHO, 2016, n.p.) invites the same wonder. It follows the DSM-5 in defining "pedophilic disorder" as involving "pre-pubertal children", a diagnosis that would happily "not apply to sexual behaviours among pre- or post-pubertal children with peers who are close in age [sic]". Yet "paraphilic disorders" are defined in general terms of involvement of "others whose age or status renders them unwilling or unable to consent".

Historically, we know little of the frequency of young people being diagnosed as "pedophiles" and if so, in which part of their assessment, therapy, parole, or other modality of follow-up. Galli et al. (1999) reported that based on ad hoc interviews, all 22 of their sample of adolescent sex offenders aged 13-17 met DSM-III-R criteria for "pedophilia (with the exception of the age requirement)", with some also meeting criteria for other "paraphilias". The former, contorted qualification is notable in showing authors' apparent interest to diagnose in spite of what they cite to be vital criteria. More importantly, they do not report whether or when subjects actually had been given this manqué diagnosis prior to, or anywhere beyond, the interview.

ICD-10's F66 diagnosis of "Sexual Maturation Disorder" has also, if sporadically, been named in reference to juvenile sex offenders against younger minors, in which case it would provide an alternative to "pedophilia" (Aebi et al., 2014, p. 385). Indeed, F66 invited specification of a "prepubertal sexual orientation" if such would be the case. However, in that same year an ICD-10 Working Group recommended the declassification of F66 on the sound basis of it being a legacy of homophobic classification that, if anything, risked facilitating the medicalization of LGBT youth (Cochran et al., 2014). Irrespective of what the ICD-11 (due out 2018) will do with the APA distinction of paraphilia and paraphilic disorder, this criticism seems to extend to "atypically" sexually orientated youth and adolescent sex offenders as well (Janssen, 2016).

Noting that the DSM-IV and ICD-10 barred diagnosis of "pedophilia" before age 16, Vizard et al. (1996) suggested that "the creation of a new disorder Sexual Arousal Disorder of Childhood would help to identify vulnerable sexually aroused children and target resources towards early prevention of abuser behaviours" (p. 262). The call has sporadically been repeated (Bladon et al., 2005, pp. 121-122); however, little has come of it. For good reason: it is not clear how "the creation of a new disorder", would, onto itself, facilitate early identification, prevention, or counseling. The latter seem more grounded in the will to problematize, demarcate, prioritize and professionalize issues than in having a checkbox to check on a form.

Of note, by defining paraphilia as involving "unusual or bizarre imagery or acts […] necessary for sexual excitement" (1980, p. 266) the APA attributed "sexual excitement", and contingently "sexual preference", to the variably young ages of onset cited as typical. This admittance is problematized in the 1994 DSM-IV and 2000 IV-TR: "Certain of the fantasies and behaviors associated with Paraphilias may begin in childhood or early adolescence but become better defined and elaborated during adolescence and early adulthood" (APA, 1994, p. 524; 2000, p. 568). The DSM-5 went on to introduce several specific caveats, and some data, related to adolescent sexual experimentation, and in the case of Voyeuristic Disorder (in explicit contradistinction to Exhibitionistic Disorder) even introduces a minimum age for diagnosis (18 years, versus 16 for Pedophilic Disorder). However, it also notably eliminates the "In Remission" qualification for "Pedophilic Disorder" previously available for Pedophilia and still available for all other Paraphilic Disorders. Criticism of this situation (Briken, Fedoroff & Bradford, 2014) seems relevant to young offenders against children and to pre-adult EAP. Of further note, several revisions proposed by the DSM-5 Paraphilias Subworkgroup for what became Pedophilic Disorder were left unratified. One proposal was to raise the minimum age for diagnosis to 18 years (APA, 2010), ostensibly to bring it in line with the proposed introduction of child pornography use (again, internationally defined as involving seeming ages of less than 18 years) as a "B" criterion; neither proposal was ratified.

Discussion: Onto a Cultural-Historical Frame for Erotic Age Preference Development Research

Even neuroscientists cannot deny their research is cued by, appropriated by, needs to speak to and ultimately sell itself to, a sexual culture. The latter answers first and foremost to a mythology-demonology of "OK" and "not-OK" intimacies, reflected in laws. The final court of appeal for sex offender research and EAP research, in any case, is ultimately the law, and more broadly, the cultural situation that asks for the law and, over time, law review and reform.

Specifications of "sexual development" obviously remain burdened by the purely cultural circumstance that ideas about what was left of "sexual deviance" after societal accommodation of homosexuality continued to trigger deeply ingrained (and prescientific) tendencies to deny any possible continuity between sick and healthy sex. If paraphilia has a development, it has at least a conceptual continuity with what would be called normal development, which makes the application of developmental perspectives, although unproblematically interesting to the sexologist, culturally dissonant (as notes Feierman, 1990). The perennial conclusion that, in dry medical jargon, "little is known about the etiology of paraphilia", then, is culturally convenient: it denies the pervert a history, a story of becoming, and as such, a link to humanity.

Related issues make the notion of hebephilia culturally (and hence clinically) inassimilable: it risks bridging the hated pervert and what the APA calls the "normophile", placing them on an arguable continuum and diversifying what otherwise is a conveniently single rubric of evil or aberration. Not incongruently, Anglo-American etiologists in sex research have long abandoned psychodynamic theories. Moreover, they have long preferred speculation about fetal development to actually researching childhood and early adolescence. Regardless of the cogency or outcome of this neurobiological shift in research focus, it obeys and congratulates the interlocking nineteenth-century postulates of born-this-way "normophilia", "degenerate" perverts, and asexual childhood. It is all the more culturally appropriate, because it keeps as short and biological as possible a story of sexual becoming, which onto itself, even in the postmillennial West, brings about inarticulate species of unease, caution, and withheld funding. Even early psychoanalysts rarely researched children, to recall: the epochal idea was to reconstruct early infantile life on the basis of the adult's symptoms and free associations. Where child psychoanalysts went on to research children, they soon tended to de-emphasize sexuality.

For these reasons, anthropologically speaking, the specter of the "adolescent paraphile" is a central one. It puts due pressure on labels ("paraphilia" as well as "adolescence") as they cut through diffuse-onset, ongoing and never quite finished journeys of aesthetic, social and erotic investments and disinvestments, and (in time) of identification and disidentification. And the latter are very probably more continuous with any professed normality than admitted by the typical labeler - or by, who is most often the same person, the typical guardian of normality. Labels importantly accomplish the situation of which they purport only to speak: they disqualify, disenchant, recruit, summon, intimidate, seduce, coerce into Manichean and confrontational identity positions such as offender and victim. Yet as both offenders and victims will appreciate, labels almost always disappoint, if not betray, the lived reality of those involved. They might pay, but they always shortchange.[3]

Posing the question of EAP development is posing the question of what it is that we want to understand the development of. The fashionable operationalization of "pedophilic interests" in terms of differential phallometric reaction to Tanner stages (which also goes back to the mid-1980s: Barnard et al., 1987, p. 344) reduces the patient to an involuntary physiological response. Biosocial theories invite different operationalizations of "age", namely in terms of "mate value" (Antfolk et al., 2015). Where in other contexts "pedophilia" is pronounced a "disorder of sexual preference" (WHO, 1992), perhaps very little is intended beyond a recitation of the cultural truism that sex and age encompass architectural elements of social organization. To dishonor their usual organizing properties is to be sick in the head. Diagnosis entails the naming of social turmoil, at the occasion of which the world is split in half, with one offending pole punished and humiliated, and the opposite, victim pole exculpated and compensated. At these occasions, diagnosis says little about the patient beyond his or her posing a threat to what is perceived to be social order. Diagnosis has never been necessary in handling the calamity of stolen innocence, but it became and it has remained symbolically indispensable. Diagnostic criteria are there because without rules, symbolism loses its power; this is why, as can laws, they can operate by what are frankly admitted to be arbitrary criteria ("5 years difference", "16 years", "a period of 6 months"). These do not reflect an abnormal situation; they reflect the will to impose the idea of normality.

The "adolescent pedophile", the sexting teen, and Romeos and Juliets have the propensity to deconstruct this polarizing cultural intrigue, as malicious offender and innocent victim blur into one. The safeguarding of this polarity may be one solid cultural reason for not diagnosing minors, or relaxing diagnoses for minors into fuzzy rubrics such as "sexual behavior problems", but also for not empirically probing EAP development, indeed sexual development more broadly, other than in forensic contexts. Equally, the paraphile's disorder is the site of an imposition of law and order, and how it ends up being defined and understood is a cardinal feature of that imposition. To submit troubled teenage boys to penile plethysmography or their brains to fMRI, is to give a hating world the diagnosis and the neurological localization it has come to prefer. It does not clarify a problem; it accomplishes a problematization.

To appreciate this, one needs an historical, not a scientific, frame. The definitional reduction of pedophilia to an atypical, outlying, or morbid EAP, congratulated by most classifications and many physiology-centered experts, may well be an erratic narrowing down of a larger clinical, or even human, tragedy. The post-WW2 translation of Von Krafft-Ebing's 1896 concept of Pädophilia erotica to a "pedophilia" that is by definition limited to a morbid eroticization, seems to work precisely against the more comprehensive understanding of erotic investment Krafft-Ebing, famously, also never offered. For instance, the once-esteemed clinical correlate of "emotional congruence with children" (a pop-psychological appropriation of psychodynamic postulates of regression/fixation thought to inform the etiology of "perversion", popularized in Araji & Finkelhor, 1985) suggested that "pedophilia" is complex in a way that diagnostic criteria, psychiatric dictionaries, and phallometrics have never reflected, and which even could have led researchers to reconsider the sexual, and hypersexual, profiling of "the pedophile" in the popular mind. This never happened: beyond the "mental health" calamity it is made to articulate, the trope of "the pedophile" is incompatible with any elaborate back story, any significant "character development" other than, perhaps, the fragile claim to a saintly abstinence. Consider that "emotional congruence" was faded out when "cognitive distortion" was faded in.

There are other urgent reasons to focus, contra cultural conventions, on childhood and adolescent experience in a changing global context. Modern, West-European notions of sexual abnormality have often been synonymized with household or otherwise administrative or community intuitions about "inappropriateness". The concept often identifies what an older generation is able to force upon a younger; to psychiatricize or neurologize it is a banal, and arguably tragic, form of cultural complicity. Modern homosexuality, for instance, has been problematic predominantly in terms of it posing the alleged problem of seduction and "corruption" of sons. "Just a phase", according to the pioneers of developmental psychology. We have had in masturbation, indeed modern "sexuality" quite generally, a household problem managed in increasingly medical terms. This is apparent in the world of "sexual behavior problems in children", a diagnostic-therapeutic scene that mushroomed, also since the late 1980s and largely in the U.S., around makeshift labels and categories of purportedly age-inappropriate intimacy. Where formerly professionals theorized "sexual delinquency", "promiscuity", onanism, and "homosexual recruitment" in youth, after the sexual revolution professionals gravitated toward childhood "sexualized behaviors" and the pedophiles who could be blamed for them (e.g., Okami, 1992). "We are paying attention to inappropriate sexual behavior that juveniles have engaged in for generations," according to David Finkelhor (Jones, 2007). Today the once-quarantined, inner-psychological scandal of "pedophilia" can indeed be seen to more and more blur into everyday twenty-first-century household dilemmas such as purportedly ambient "sexualization" of minors (e.g., American Psychological Association Task Force on the Sexualization of Girls, 2007). By virtue of definition, incidentally, it was inescapable that middle and high school "sexters" became today's most prolific "child-pornographers" (e.g., Klettke, Hallford & Mellor, 2014, p. 46). This begs for updates on what we want to call "psychosexual development", certainly if we want to continue to demarcate the "atypical" or, in time, the "paraphilic".

Conclusion

After 150 years of commentary, age-based and age-preferential erotic attraction is denied recognition as the general dimension of psychosexual development that it is made to be, whether in spite of or because of the interlocking machineries of law and medicine. That EAP is delivered almost exclusively to the mercy of legislators and forensic psychologists should be considered the cultural and epochal intrigue that it wants to be. Here is largely a normative, not a scientific, intrigue. In this light, I will resist the familiar exhortation that "more research is needed". But it would certainly be eventful to take seriously the unanimous biosocial and psychophysiological proposal to model EAP after "sexual" (gender) orientation, as nineteenth-century commentators on homosexuality had already done - indeed at the very outset of scientific commentary on sexual orientation (Janssen, 2015). In the absence of normative data, we may want to begin with documenting the history of EAP's medicalization and "teleiophilia's" normalization. Apropos the hybrid term heteronormativity, some or other hybrid word such as, say, horaionormativity (from horaios, GR, belonging to the right hour or season; timely), may facilitate thought at this point - if not the professional introspection advocated by pioneering colleagues Gigeroff, Mohr and Turner.

Notes

[1] The current Swedish age of consent is 15, or 18 in case of relation of kinship or dependence, although persons are not to be held criminally responsible "if it is obvious that the act did not involve any abuse of the child in view of the slight difference in age and development between the person who committed the act and the child and the circumstances in general" (Criminal Code, ch. 6, §§ 4, 6 and 14; http://www.government.se, accessed April 1, 2016).

[2] In the Swedish Act on Child Pornography of 1999, "By child is meant a person whose pubertal development is not complete or, if it is apparent from the picture and its attendant circumstances, who is less than 18 years of age" (Criminal Code, ch. 16, § 10a; https://www.unodc.org, accessed April 1, 2016).

[3] The socializing properties of labels also make for a key historical question, as historians of sexuality know. Yet even sexual interest in children has often been characterized - by White men in by-gone positions of authority at least - as ubiquitous, indeed as continuous with normality. At age 50, Freud is cited to have stated that "the libido of every one of us has probably been stimulated by little girls" (in Nunberg & Federn, 1962, p. 88). Havelock Ellis advised that sexologists "are not called upon to regard as morbid, even if it is sexually tinged, the pleasure which the aged take in the freshness of the young" - as long as such pleasure remains easily restrained (1913, p. 126). One of the first psychoanalysts to reflect on the issue, Wilhelm Stekel characterized pedophilia as a "peculiarly ubiquitous", "almost normal" dimension of sexuality ("as any analyst knows" it to be, he wrote) and claimed to have found "traces of pedophilic tendencies in nearly every neurotic" (Stekel, 1922, p. 311).

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Author address

Diederik F. Janssen, MD
Independent Researcher
Nijmegen
The Netherlands
diederikjanssen@gmail.com



 

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