Pedophilia is not a sexual orientation, and erroneous use of that phrase will be corrected

soon in its new manual on mental illnesses, the American Psychiatric Association said
Thursday.
The APAs statement came in response to media inquiries, including from The Washington
Times, about an uproar on the Internet that the APA had designated pedophilia as a sexual
orientation in its new Diagnostic and Statistical Manual of Mental Disorders, known as DSM5 or DSM-V.
About a week ago, a blog called NeonTommy, produced at Annenberg Digital News at the
University of Southern California, said the APA had drawn a very distinct line between
pedophilia and pedophilic disorder in its new manual.
According to the DSM-5, pedophilia refers to a sexual orientation or profession of sexual
preference devoid of consummation, whereas pedophilic disorder is defined as a compulsion
and is used in reference to individuals who act on their sexuality, NeonTommy wrote.
The item was picked up and circulated on countless other Internet sites. Many bloggers
bashed the APA for mainstreaming deviance and capitulating to pro-pedophile groups.
Others tied it to gay issues one wag wrote that it was time to change the LGBT letterhead
to LGBT&P.
The APA said in its statement that sexual orientation is not a term used in the diagnostic
criteria for pedophilic disorder and its use in the DSM-5 text discussion is an error and should
read sexual interest.
In fact, APA considers pedophilic disorder a paraphilia, not a sexual orientation. This
error will be corrected in the electronic version of DSM-5 and the next printing of the
manual, the organization said. The error appeared on page 698, said a spokeswoman.
It added: APA stands firmly behind efforts to criminally prosecute those who sexually abuse
and exploit children and adolescents. We also support continued efforts to develop treatments
for those with pedophilic disorder with the goal of preventing future acts of abuse.
The DSM-5 was released in May. For several years prior to that, major discussions were held
about the pedophilia category.
In the end, however, only a small change was made: Pedophilia was changed to
pedophilic disorder, to conform to other disorders in chapter on paraphilias, the APA said.
The diagnostic criteria essentially remained the same as in DSM-IV-TR, it added.
To be diagnosed with a paraphilic disorder, DSM-5 requires that people feel personal
distress about their atypical sexual interest or have a desire or behavior that harms another
person or involves unwilling persons or persons unable to give legal consent.
Other DSM-5 paraphilias are exhibitionistic disorder, fetishistic disorder, frotteuristic
disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder, voyeuristic
disorder and pedophilic disorder. Despite all these things being labeled a disorder in DSMs

for years, the actions some of them result in for example, flashing, assault and battery, and
peeping Tom behavior are all uncontroversially illegal.

Practice Essentials
Paraphilia is any intense and persistent sexual interest other than sexual interest in genital
stimulation or preparatory fondling with phenotypically normal, physically mature,
consenting human partners; if a paraphilia causes distress or impairment to the individual or
if its satisfaction entails personal harm (or the risk of such harm) to others, it is considered a
paraphilic disorder.

Signs and symptoms

A complete history (including psychiatric and psychosexual history) should be obtained.
People with paraphilic disorders may be difficult to interview because of guilt and reluctance
to share information openly with the interviewer. It is essential to establish rapport with these
patients to allow them to talk more freely about their disorder.
Many different paraphilias have been identified, but the American Psychiatric Associations
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), lists the
following 8 specific paraphilic disorders[1] :

Voyeuristic disorder

Exhibitionistic disorder (including type I, the inhibited flaccid exposer, and type II,
the sociopathic exposer who may have a history of other conduct)

Frotteuristic disorder

Sexual masochism disorder

Sexual sadism disorder

Pedophilic disorder

Fetishistic disorder

Transvestic disorder

Other paraphilias, almost any of which could develop into a paraphilic disorder in certain
circumstances, include (but are not limited to) the following:

Telephone scatologia

Necrophilia

Partialism

Zoophilia

Coprophilia

Klismaphilia

Urophilia

Autogynephilia

Asphyxiophilia or hypoxyphilia

Video voyeurism

Infantophilia (a newer subcategory of pedophilia)

In addition to a complete history, complete mental status, physical, and neurologic

examinations must be performed to assist with the evaluation and to rule out other disease
processes. Ruling out major medical or psychiatric illnesses is critical for diagnosis and
management.
See Clinical Presentation for more detail.

Diagnosis
Paraphilic disorders must be distinguished from nonpathologic use of sexual fantasies,
behaviors, or objects as stimuli for sexual excitement. Studies that may be considered in the
assessment of a patient with a paraphilic disorder include the following:

Standard medical workup, including sequential multiple analysis, complete blood

count, rapid plasma reagent, and thyroid-stimulating hormone level or thyroid
function test

HIV screen

Hepatitis panel

Unscheduled DNA synthesis

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Penile strain gauge

Abel assessment for interest in paraphilia

Phallometric testing

Electroencephalography (EEG)

See DDx and Workup for more detail.

Management
Treatment options vary and must take into account the specific needs of each individual case.
The following options are available:

Psychotherapy

Pharmacologic therapy

Surgical interventions (not widely used)

Psychotherapeutic interventions include the following:

Cognitive-behavioral therapy

Orgasmic reconditioning

Social skills training

Twelve-step programs

Group therapy

Individual expressive-supportive psychotherapy

Pharmacologic interventions may be used to suppress sexual behavior. Medications that may
be considered in the treatment of paraphilic disorders include the following:

Antidepressants (eg, selective serotonin reuptake inhibitors [SSRIs])

Long-acting gonadotropin-releasing hormones

Antiandrogens

Phenothiazines

Mood stabilizers

Numerous adverse effects of pharmacotherapy have been reported. Additionally, ethical,

medical, and legal questions have been raised regarding issues of informed consent,
especially in hospital and prison settings.
Surgical interventions that may be considered (though not widely used) are as follows:

Psychosurgery using stereotaxic tractotomy and limbic leucotomy

Bilateral orchidectomy (surgical castration)

See Treatment and Medication for more detail.

Background
Paraphilia is any intense and persistent sexual interest other than sexual interest in genital
stimulation or preparatory fondling with phenotypically normal, physically mature,
consenting human partners; a paraphilic disorder is a paraphilia that is causing distress or
impairment to the individual or that, if satisfied, entails personal harm (or the risk of such
harm) to others.[1]
Paraphilias are associated with arousal in response to sexual objects or stimuli not associated
with normal behavior patterns and that may interfere with the establishment of sexual
relationships. In modern classification systems, the term paraphilia (or paraphilic disorder, as
appropriate) is preferable to the term sexual deviation because it clarifies the essential nature
of this group of behaviors (ie, arousal in response to an inappropriate stimulus).
Paraphilia is a means by which some people release sexual energy or frustration. The act
commonly is followed by arousal and orgasm, usually achieved through masturbation and
fantasy. Paraphilic disorders are not well recognized and often are difficult to treat, for
several reasons. Often, people who have these disorders conceal them, experience guilt and
shame, have financial or legal problems, and can (at times) be uncooperative with medical
professionals.
Overall, the best criteria for diagnosis of paraphilic disorders come from the American
Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5)[1] or the International Statistical Classification of Diseases, 10th Revision
(ICD-10),[2] though the definitions of these conditions remain subject to some debate.[3] DSM5 describes 8 of the more commonly observed paraphilic disorders:

Voyeuristic disorder

Exhibitionistic disorder

Frotteuristic disorder

Sexual masochism disorder

Sexual sadism disorder

Pedophilic disorder

Fetishistic disorder

Transvestic disorder

Various other presentations exist in which symptoms typical of a paraphilic disorder are
present but do not meet the full criteria for any of the diagnoses above. Such presentations
include the following:

Telephone scatologia (obscene phone calls)

Necrophilia

Zoophilia

Coprophilia

Klismaphilia

Urophilia

When the clinician wishes to specify the reason why the criteria for a listed paraphilic
disorder are not met, such presentations are placed in the category other specified paraphilic
disorder. If the clinician elects not to specify the reason, the category unspecified paraphilic
disorder is employed.

Diagnostic criteria (DSM-5)

Generally, for each of the specific paraphilic disorders listed in DSM-5, the first diagnostic
criterion specifies the qualitative nature of the paraphilia (eg, an erotic focus on children or
on exposing the genitals to strangers), whereas the second criterion specifies the negative
consequences of the paraphilia (see below). Both criteria must be satisfied to establish a
diagnosis of a paraphilic disorder. An individual who meets the first criterion but not the
second is considered to have a paraphilia but not a paraphilic disorder.
Voyeuristic disorder
The DSM-5 diagnostic criteria for voyeuristic disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) involving the act of observing an unsuspecting person who is
naked, in the process of disrobing, or engaging in sexual activity; symptoms must be
present for at least 6 months

The patient experiences significant distress or impairment in social, occupational, or

other important areas of functioning because of the fantasies, urges, or behaviors, or
the patient has acted on the sexual urges

The individual experiencing the arousal or acting on the urges is aged at least 18 years

Further specifiers include the following:

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Exhibitionistic disorder
The DSM-5 diagnostic criteria for exhibitionistic disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) related to exposing the genitals to a stranger; symptoms must be
present for at least 6 months

The patient experiences significant distress or impairment in social, occupational, or

other important areas of functioning because of the fantasies, urges, or behaviors, or
the patient has acted on the sexual urges

Further specifiers include the following:

Whether the individual is sexually aroused by exposing genitals to prepubertal

children, to physically mature individuals, or to both

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Frotteuristic disorder
The DSM-5 diagnostic criteria for frotteuristic disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) involving touching and rubbing against a nonconsenting person;
symptoms must be present for at least 6 months

The patient experiences significant distress or impairment in social, occupational, or

other important areas of functioning because of the fantasies, urges, or behaviors, or
the patient has acted on the sexual urges

Further specifiers include the following:/p>

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Sexual masochism disorder

The DSM-5 diagnostic criteria for sexual masochism disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) involving the act (real, not simulated) of being humiliated,

beaten, bound, or otherwise made to suffer; symptoms must be present for at least 6
months

The fantasies, urges, or behaviors cause significant distress or impairment in social,

occupational, or other important areas of functioning

Further specifiers include the following:

Whether the individual engages in asphyxiophilia

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Sexual sadism disorder

The DSM-5 diagnostic criteria for sexual sadism disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) from the psychological or physical suffering of another person;
symptoms must be present for at least 6 months

The fantasies, urges, or behaviors cause significant distress or impairment in social,

occupational, or other important areas of functioning, or the patient has acted on these
sexual urges with a nonconsenting person

Further specifiers include the following:

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Pedophilic disorder
The DSM-5 diagnostic criteria for pedophilic disorder are as follows[1] :

The patient reports recurrent and intense sexually arousing fantasies, sexual urges, or
behaviors involving sexual activity with a prepubescent child or children (generally
13 years); symptoms must be present for at least 6 months

The disorder causes marked distress or interpersonal difficulty, or the individual has
acted on these sexual urges

The individual is age at least 16 years and at least 5 years older than the victim;
individuals in late adolescence involved in an ongoing sexual relationship with a 12or 13-year-old are excluded

Further specifiers include the following:

Whether the disorder is exclusive (with attraction only to children) or nonexclusive

Whether the individual is attracted to males, females, or both

Whether the acts are limited to incest

Fetishistic disorder
The DSM-5 diagnostic criteria for fetishistic disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) either from the use of nonliving objects or from a highly specific
focus on nongenital body parts; symptoms must be present for at least 6 months

The patient experiences significant distress or impairment in social, occupational, or

other important areas of functioning because of the fantasies, urges, or behaviors

The fetishes are not limited to articles of female clothing used in cross-dressing (as in
transvestic disorder) or devices designed for genital stimulation (eg, vibrators)

Further specifiers include the following:

Whether the fetish involves a body part, a nonliving object, or something else

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Transvestic disorder
The DSM-5 diagnostic criteria for transvestic disorder are as follows[1] :

The patient experiences recurrent and intense sexual arousal (manifested by fantasies,
urges, or behaviors) from cross-dressing; symptoms must be present for at least 6
months

These fantasies, urges, or behaviors cause significant distress or impairment in social,

occupational, or other important areas of functioning

Further specifiers include the following:

Whether the individual is sexually aroused by fabrics, materials, or garments

(fetishism)

Whether the individual is sexually aroused by thoughts or images of himself as female

(autogynephilia)

Whether the individual is in a controlled environment

Whether the disorder is in full remission

Etiology
Paraphilias may exist as discrete anomalies in otherwise stable personalities and thus may go
unnoticed by partners, families, and friends. More commonly, however, they coexist with
personality disorders, substance abuse, anxiety disorders, or affective disorders. It remains
unclear why some people act on deviant urges and others do not. Persons with personality
disorders who have problems with self-esteem, anger management concerns, difficulty
delaying gratification, poor empathetic ability, and faulty cognitions are particularly
vulnerable.
Many theories exist regarding the etiology of paraphilias, including psychoanalytical,
behavioral, biologic, and sociobiologic theories. To date, however, none have proved
conclusive; additional research is required.

Psychoanalytical theory
According to psychoanalytical theory, several possible factors may contribute to the origin of
paraphilias. Freund and his colleagues suggested that some paraphilias may be attributed to
possible distortion of the courtship phases. Normal courtship behavior is what brings males
and females together for the purpose of mating. It usually occurs during adolescence and may
or may not involve sexual intercourse at this early stage of sexual development.
Courtship is composed of the following 4 phases:
1. Search phase Location of a potential partner
2. Pretactile interaction phase - Talking or flirting with a potential partner
3. Tactile interaction phase Physical contact with a potential partner, usually consisting
of touching, hugging, hand-holding, and similar actions (this could also be considered
foreplay)
4. Genital union phase (ie, sexual intercourse)
Although most of the population is capable of appropriate engagement in the phases of
courtship, other people are unable to adhere to these socially acceptable norms. Freund and
his colleagues have indicated that certain deviant or unconventional sexual practices can be
viewed as exaggerations of the 4 phases of courtship. On the basis of Freunds research with
incarcerated sex offenders, one distortion of courtship behavior may result in others.
Certain paraphilias are associated with distortions of courtship behaviors. According to this
particular literature, however, such distortions are associated only with the first 3 phases.
Voyeurism
In this view, voyeurism is understood as a distortion of the initial courtship phase (ie, locating
a potential partner). Psychoanalysts postulate that voyeurism may be attributed to a child

witnessing episodes of his or her parents engaged in sexual intercourse. Individuals with
maladaptive social and sexual skills find voyeurism to be an outlet for sexual pleasure
without the threat of sexual interaction. The risk or danger of discovery may give the voyeur
a false sense of masculinity (as also tends to be the case with the exhibitionist).
Exhibitionism
Psychoanalysts consider exhibitionism a distortion of the second courtship phase (ie,
pretactile interaction). In psychoanalytical theory, gender identity for a little boy is held to
require psychological separation from his mother, so that he will not identify with her as a
member of the same sex, as a little girl would. Exhibitionists regard their mothers as rejecting
them on the basis of their different genitalia.
Through exhibitionism, the individual attempts to force women to accept him by forcing
them to look at his genitals. The act of self-exposure is also a way for the exhibitionist to
compensate for his introversion and lack of assertiveness. This act may give the exhibitionist
a false sense of power, and the danger of discovery may further reinforce this feeling. In
general, psychoanalysts theorize that an exhibitionists display of his penis is a way of
proving his manhood to the world but also, more importantly, to an adult woman.
Narcissism, the extreme form of self-admiration, is also believed to contribute to
exhibitionism. Many narcissist-exhibitionist men are married and have regular sexual contact
with their spouses. However, spousal appreciation of their genitalia is not sufficient by itself
to fulfill their insatiable need for admiration, and as a consequence, they constantly search for
other unsuspecting victims from whom to elicit admiration. The exhibitionist is sometimes
compared to an actor on stage who desires an audience but does not want to participate in the
act.
Frotteurism and toucherism
Frotteurism and toucherism are considered exaggerations of the third courtship phase (ie,
tactile interaction). These paraphilias provide a sexual outlet without the risk of rejection.
Toucherism tends to occur in conjunction with other paraphilias. Freund suggested that these
disorders result from unsuccessful negotiation in the developmental stages, which results in
sexual urges becoming blocked and expressing themselves at a later time as paraphilias.

Behavioral theory
Behavioral theory attributes the development of certain paraphilias to the process of
conditioning. Actually, paraphilias are a result of accidental conditioning. If nonsexual
objects are frequently and repeatedly associated with a pleasurable sexual activity, then the
object becomes sexually arousing.[4]
A small study was conducted with 7 heterosexual males, all of whom were free of any
fetishes. The men were repeatedly shown erotic stimuli that were paired with a slide of
womens black knee-high boots. Later, when the slide of the boots was shown alone, 5 of the
7 men experienced penile erection. This indicated that a boot fetish had been conditioned.
A similar small study conducted to determine whether women could be conditioned to
become sexually aroused by a stimulus found no significant differences in physiologic sexual

arousal between women in the experimental group and those in the control group. These
results imply that sexual arousal is not readily amenable to classic conditioning in women.
This might help explain why fetishism and other paraphilias occur almost exclusively in
males.
Conditioning does not always involve positive reinforcement; negative reinforcement may
also play a role. If an individual experiences unpleasant consequences with normal sexual
activity, an aversion to sex may occur, resulting in the development of deviant behavior. An
example of this would be a young boy who is humiliated and punished by his parents for
proudly displaying his erect penis. As the boy matures, he may associate guilt and shame with
normal sexual behavior.
Certain atypical sex acts, such as exhibitionism and voyeurism, that provide intense sexual
arousal may lead to individual preference of that behavior. Pedophiliacs, exhibitionists, and
voyeurs may be driven by risk-taking behaviors. Therefore, the constant threat of discovery
may be as arousing to them as the act itself.
Conditioning is not the only contributing factor in the development of paraphilias. Individuals
with paraphilias usually experience low self-esteem, which may lead to difficulty in forming
person-to-person sexual relationships.

Sociobiologic theory
In an article from 1993, Richard A Gardner proposed an approach that combined 2 theories,
Dawkinss theory of gene transmission and Darwins well-known theory of survival of the
fittest.[5] In a sense, this could be considered a sociobiologic theory.
Dawkinss theory
In Dawkinss theory of gene transmission, variations in human sexual behavior, even atypical
sexual behaviors (paraphilias), are seen as conducing to the survival of the species. According
to this view, the different paraphilias may be responsible for enhancing societys level of
sexual excitation. This higher level of excitation, in turn, would increase the likelihood that
people would engage in sex acts that would ultimately lead to procreation.
In earlier (eg, pre20th century) societies, males more often served the role of hunters and
fighters, with females having child-rearing as the primary role. Those men who were more
adept at hunting and fighting (protectors and warriors) were more likely to survive and attract
females as mates. Those who were weaker were less likely to attract women as desirable
mates, because they were unable to provide adequate food, clothing, and shelter, and they
were less able to protect their potential family from enemies.
Men were also more likely to be attracted to women who were stronger in child-rearing
abilities, because involvement with such women was more likely to ensure that their genes
would be passed down to subsequent generations. Therefore, stronger and more aggressive
men, as well as women with a stronger capacity for raising children, were more likely to
acquire mates. This would ensure propagation of their genes.
Today, this genetic programming is carried in both sexes. Although other primates are more
instinctually driven, humans are also affected to a certain degree. During the mating season,

animals are compelled to go through the mating ritual of their species. Humans also have
procreative urges, but not in a particular mating season or in a particular mating ritual, as is
seen in other primates. Unfortunately, this does not make us exempt from such mating
patterns with the resultant pattern of their expression.
Darwins theory
Darwinian theory relates more directly to reproductive capacity. Two of the operative factors
in Darwinian theory are quantity and quality. Each species produces more offspring than
could possibly survive (quantity); therefore, the individuals that are more capable of adapting
to their environment (quality) are more likely to survive and perpetuate the species. In
general, species that are less adaptable to their surroundings are more likely to become
extinct.[6]
Of the sexes, the male is physically able to produce a far greater quantity of offspring. If a
man devoted his whole life to procreation, he could conceivably father or produce as many as
30,000 offspring. On the other hand, if a woman were to devote her entire fecund life to
procreation, she could produce no more than 40-45 babies. Accordingly, the female is
responsible for quality control.
The female will also ultimately take on the responsibility of child-rearing. Of the other
necessary life activities besides fornication and propagation, child-rearing may be the most
important. If protection is not provided for the young, they will not survive. Thus, to devote
ones life to the sole purpose of manufacturing babies without the potential for survival would
be senseless.
The female tends to be selective in choosing a mateideally, one that will best provide for
and protect the family. To optimize their ability to make an appropriate choice a proper mate,
women tend to be more cautious in regard to their impulsivity with respect to sexual
gratification. Women with inhibited sexual arousal are more likely to select a proper mate and
increase their likelihood of survival. Also, once aroused, a woman is more likely to attempt
an ongoing relationship with her mate.
Men, on the other hand, tend to desire sex indiscriminately with large amounts of women.
Again, this is a means of spreading their sperm for the purpose of procreation and passing
down their genes. According to the literature, males are typically quicker to arousal than the
average female. After gratification from a sexual encounter, they are commonly less likely
than females to be interested in maintaining a relationship or commitment.
A commonly cited estimate is that men aged 12-40 years think of sex approximately 6 times
an hour. If this estimate is further broken down by age ranges, males aged 12-19 years think
of sex an average of 20 times per hour or once every 3 minutes, whereas males aged 30-39
years think of sex only about 4 times per hour. This may be one reason why paraphilias
usually occur in males aged 15-25 years.
Such findings suggest that most men are promiscuous, either physically or psychologically;
what distinguishes among them is the degree of control that is exerted toward action or
inaction in regard to the sexual urges.

Females are much more relationship-oriented, and this may contribute to their greater
orgasmic capacity. Although women may require more touching, caressing, and overall
romance to become aroused than men do, the resulting arousal is likely to last longer. Most
women have the potential for multiple orgasms, which may further enhance the procreative
capacity by enabling them to capture the sustained interest and involvement of males who
otherwise tend to be slow to ejaculation.
These findings may help explain why men are more like likely to be sexually aroused by
visual stimuli and women by tactile stimuli. The hunters (roving bands of men) spot their
prey (women) at a distance and are able to achieve excitement just by the sight of a possible
future conquest. Women are more susceptible to caressing, tenderness, and the reassurance of
a mans commitment. This commitment ensures that the male is emotionally invested in the
union and will remain around to supply food and protection for the female and their
offspring.

Epidemiology
United States and international statistics
Paraphilias are rarely diagnosed in clinical settingspossibly, in part, because many of the
acts are illegal and reporting methods (ie, self-reporting) may be unreliable. Large
commercial markets in paraphilic pornography and paraphernalia suggest that prevalence is
high. Pedophilia, voyeurism, and exhibitionism are the most commonly observed behaviors
in clinics that specialize in paraphilia treatment; sexual masochism and sadism are much less
common. About 50% of patients observed in clinics for treatment of paraphilias are married.
According to DSM-5, the frequency of voyeuristic disorder is unknown, but the estimated
highest possible lifetime prevalence is approximately 12% for males and 4% for females. The
frequency of exhibitionistic disorder is also unknown, but the highest possible prevalence in
males is 2-4%; prevalence in females less certain but is generally believed to be much lower
than that in males.
Frotteuristic disorder, including uninvited sexual touching of or rubbing against another
individual, may occur in as many as 30% of adult males in the general population; 10-14% of
adult males seen in the outpatient setting for paraphilic disorder and hypersexuality meet the
diagnostic criteria.
The frequency of sexual masochism disorder is unknown. In Australia, 2.2% of males and
1.3% of females were estimated to have been involved in bondage, sadomasochism, or
dominance and submission in the preceding 12 months. The frequency of sexual sadism
disorder is also unknown but has been estimated to range from 2% to 30%, depending on the
criteria used. Among sex offenders in the US, fewer than 10% have sexual sadism disorder;
however, 37-75% of those who have committed sexually motivated homicides have this
disorder.
The frequency of pedophilic disorder is unknown as well. The highest possible prevalence
among males is estimated to be 3-5%; the prevalence in females is thought to be a small
fraction of that in males.

International incidences of paraphilias are difficult to determine.

Age-, sex-, and race-related demographics

Most patients are aged 15-25 years. Paraphilic disorders rarely occur in individuals older than
50 years, and data on these disorders in older people are limited. Males are more likely to be
affected than females are, and most patients are white.

Prognosis
Predicting treatment outcomes is difficult. Long-term treatment gains appear to require
approaches that address the underlying dynamics that go beyond the simple paraphilia itself.
The morbidity or mortality of a paraphilia depends on the act practiced, the comorbidity
involved, the patients cooperation with the therapist, and whether or not the legal system is
involved.
Paraphilias can be transient, as demonstrated by experimentation during the teenage years, or
can remain a life-long problem involving legal, financial, interpersonal, occupational,
academic, and other problems. Death may occur in some circumstances, through acts such as
autoerotic asphyxiation. Treatment and prognosis must be based on individual assessment.
The following characteristics are generally associated with a good prognosis:

Cooperative attitude

Normal sex life

Motivated outlook, with a desire to change

Voluntary approach to treatment

The following characteristics are generally associated with a poor prognosis:

Early onset of paraphilia

Legal charges pending

Unmotivated attitude

Uncooperative attitude

Paraphilia as the only sexual activity or outlet

Comorbidity

Lack of remorse over acts

Patient Education
Paraphilias are not homogeneous phenomena; considerable variability exists. Nevertheless, a
number of issues can be constructively discussed with patients and, when appropriate, with
family members. The goal should be to enhance understanding about the issues being faced
and the options available to address them (eg, sex education, social skills training, coping
skills training, and relapse prevention).
Family education is of particular importance in the treatment of paraphilic disorders. The
family should receive education about the disorder, medications, side effects, and medication
compliance, the importance of psychotherapy, and what to do in case of an emergency. The
family will need contact information regarding community support programs for the patient
and the family.
The family may need to be involved in a support group (eg, church). If the patient is on
medication, the family must be informed of potential problems (eg, side effects and drug
interactions). If the patient is married, marital counseling must be part of the treatment plan.
The family also needs to be aware of local laws in regard to paraphilias. If the patient is on
probation, the family needs to be aware of court dates and any relevant legal matters.
For some patients with paraphilias, sex offender community notification may be required. It
should be kept in mind, however, that many patients with paraphilias have no legal charges
filed against them, and even health care workers are not required to report all paraphilias
(though reporting is mandatory for some, such as pedophilia).
Some patients may find such notification to be a deterrent to their paraphilia; others may not.
Some experts suggest that notification, though required, may act as a hindrance for some
patients who are trying to obtain help for their illness. This will continue to be a matter of
community concern and debate for the foreseeable future. The patient should address these
concerns with the treatment team. Intensive community supervision is important.
In paraphilic disorders where significant potential for negative consequences to others poses
genuine concern (eg, pedophilia, sexual sadomasochism), the need for long-term therapy and
monitoring must be emphasized. Partners, family, and friends should be encouraged to
understand the continuing potential for harm and their responsibility to take the necessary
steps to protect themselves and others who may be at risk. Warning signs and coping
strategies should be discussed and formulated.
The following Web sites may provide useful information and suggestions:

WebMD, Paraphilias

Merck Manuals, Paraphilias

en.wikipedia.org

Rind et al. controversy - Wikipedia, the free

encyclopedia
The Rind et al. controversy was a debate in the scientific literature, public media, and
government legislatures in the United States regarding a 1998 peer reviewed meta-analysis of
the self-reported harm caused by child sexual abuse (CSA).[1] The debate resulted in the
unprecedented condemnation of the paper by both Houses of the United States Congress. The
social science research community was concerned that the condemnation by government
legislatures might have a chilling effect on the future publication of controversial research
results.
The study's lead author is psychologist Bruce Rind, and it expanded on a 1997 meta-analysis
for which Rind is also lead author.[2] The authors stated their goal was to determine whether
CSA caused pervasive, significant psychological harm for both males and females,
controversially concluding that the harm caused by child sexual abuse was not necessarily
intense or pervasive,[3] that the prevailing construct of CSA was not scientifically valid, as it
failed empirical verification, and that the psychological damage caused by the abusive
encounters depends on other factors such as the degree of coercion or force involved.[1] The
authors concluded that even though CSA may not result in lifelong, significant harm to all
victims, this does not mean it is not morally wrong and indicated that their findings did not
imply current moral and legal prohibitions against CSA should be changed.[1]
The Rind et al. study has been criticized by various scientists and researchers, notably
Stephanie Dallam (2001; 2002), on the grounds that its methodology and conclusions are
poorly designed and statistically flawed.[4][5][6] Its definition of harm, for example, has been
subject to debate because it only examined long-term psychological effects, and harm can
result in a number of ways, including short-term or medical harm (for example, sexually
transmitted infections or injuries), a likelihood of revictimization, and the amount of time the
victim spent attending therapy for the abuse.[6] Seven years after the publication of the Rind et
al. study, however, Heather Marie Ulrich, with two colleagues, replicated it in The Scientific
Review of Mental Health Practice and confirmed its main findings, but did not endorse its
authors' conclusions.[7]
The Rind paper has been quoted by people and organizations advocating age of consent
reform, pedophile or pederasty groups in support of their efforts to change attitudes towards
pedophilia and to decriminalize sexual activity between adults and minors (children or
adolescents), and by defense attorneys who have used the study to minimize harm in child
sexual abuse cases.[8][9]

Studies and findings

In 1997, psychology professor Bruce Rind from Temple University and doctoral student
Philip Tromovitch from the University of Pennsylvania published a literature review in The
Journal of Sex Research of seven studies regarding adjustment problems of victims of child
sexual abuse (CSA). To avoid the sampling bias that, they argued, existed in most studies of
CSA (which drew from samples mostly in the mental health or legal systems and thus were,
as a sample, unlike the population as a whole), the 1997 study combined data from studies
using only national samples of individuals expected to be more representative of the
population of child sexual abuse victims. This study examined 10 independent samples
designed to be nationally representative, based on data from more than 8,500 participants.
Four of the studies came from the United States, and one each came from Great Britain,
Canada, and Spain.
Based on the results, they concluded that the general consensus associating CSA with intense,
pervasive harm and long-term maladjustment was incorrect.[2] The following year, Rind,
Tromovitch and Robert Bauserman (then a professor at the University of Michigan)
published a meta-analysis in the Psychological Bulletin of 59 studies (36 published studies,
21 unpublished doctoral dissertations, and 2 unpublished master's theses) with an aggregate
sample size of 35,703 college students (13,704 men and 21,999 women). In most of the 59
studies, CSA was defined by the authors based on legal and moral criteria.
Integrating the sometimes disparate and conflicting definitions, CSA was defined as "a sexual
interaction involving either physical contact or no contact (e.g., exhibitionism) between either
a child or adolescent and someone significantly older, or between two peers who are children
or adolescents when coercion is used." "Child" was sometimes defined, not biologically, but
as underaged or as a minor under the legal age of consent.
All these studies were included in the meta-analysis because many CSA researchers, as well
as lay persons, view all types of socio-legally defined CSA as morally and/or psychologically
harmful.[1] When this research, the U.S. Congress, and the APA refer to CSA and "children" in
the context of sexual relations with adults, they are not referring simply to biological
(prepubescent) children but to adolescents under the age of consent as well, which varies
between 16 and 18 years old in the U.S.[10]
The results of the meta-analysis indicated that college students who had experienced CSA
were slightly less well-adjusted compared to other students who had not experienced CSA,
but that family environment was a significant confound that may be responsible for the
association between CSA and harm. Intense, pervasive harm and long-term maladjustment
were due to confounding variables in most studies rather than to the sexual abuse itself
(though exceptions were noted for abuse accompanied by force or incest).[1] Both studies
addressed four "assumed properties" of CSA, identified by the authors: gender equivalence
(both genders affected equally), causality (CSA causes harm), pervasiveness (most victims of
CSA are harmed) and intensity (the harm is normally significant and long-term), concluding
that all four "assumed properties" were questionable and had several potential confounds.[1][2]

Based on the closely mirrored results of both studies, Rind, Tromovitch and Bauserman
questioned the scientific validity of a single term "child sexual abuse" and suggested a variety
of different labels for sexual contact between adults and non-adults based on age and the
degree to which the child was forced or coerced into participating. They concluded with a
discussion of the legal and moral implications of the article, stating that the "wrongfulness"
and "harmfulness" of sexual acts are not inherently linked, and finished with the statement:
the findings of the current review do not imply that moral or legal definitions of or views on
behaviors currently classified as CSA should be abandoned or even altered. The current
findings are relevant to moral and legal positions only to the extent that these positions are
based on the presumption of psychological harm.
Rind et al. (1998) p. 47
Controversy

The paper was first published by the American Psychological Association (APA) in July,
1998, in Psychological Bulletin to little reaction, though strong reactions were ultimately
demonstrated by social conservatives / religious fundamentalists, and psychotherapists and
psychiatrists who treat victims of sexual abuse who were concerned about the implications.
The first substantial and public reaction was a December criticism by the National
Association for Research & Therapy of Homosexuality, an organization dedicated to the
discredited view that homosexuality is a mental illness that can be cured by psychotherapy.[11]
In March 1999, talk show host Laura Schlessinger criticized the study as "junk science" and
stated that since its conclusions were contrary to conventional wisdom, its findings should
never have been released. She criticized the study's use of meta-analysis, saying. "I frankly
have never seen this in general science. ... This [pooling of studies] is so outrageous!"[12]
"This was not a study! They didnt do a study! They arbitrarily found 59 studies that other
people had done [and] combined them all."
Shortly thereafter, the North American Man/Boy Love Association posted an approving
review of the study on their website, furthering the impression that the piece was an
endorsement of pedophilia.[13] The paper eventually provoked a reaction from several
conservative American members of Congress, notably the Republican representatives Matt
Salmon of Arizona and Tom DeLay of Texas, who both condemned the study as advocating
for the normalization of pedophilia. In the process Delay confused the American
Psychological Association with the American Psychiatric Association, an error also made by
Schlessinger.[13]
In response, the APA declared in a press statement that child sexual abuse is harmful and
wrong, and that the study was in no way an endorsement of pedophilia.[14] The APA mandated
a policy change by which APA journal editors would alert the organization of potentially
controversial topics in order to be more proactive with politicians, the media and other
groups. In an internal organization email, APA Executive Vice-President Raymond D. Fowler

stated that because of the controversy, the article's methodology, analysis and the process by
which it had been approved for publication was reviewed and found to be sound.[15] In June
1999, Fowler announced in an open letter to DeLay that there would be an independent
review of the paper and stated that from a public policy perspective, some language used in
the article was inflammatory and inconsistent with the position of the APA's stance on CSA.
The APA also implemented a series of actions designed to prevent the study from being used
in legal circumstances to defend CSA and stated an independent review would be undertaken
of the scientific accuracy and validity of the report.[16] The request for an outside review of a
controversial report by an independent scientific association was unprecedented in APA's
107-year history.[13]
In April, 1999 a resolution was introduced in the Alaska Legislature condemning the article,
with similar resolutions introduced in California, Illinois, Louisiana, Oklahoma, and
Pennsylvania over the subsequent two months. Some of these states' psychological
associations reacted by asking the APA to take action.[17] On July 12, 1999, the United States
House of Representatives passed HRC resolution 107 by a vote of 355-0, (with 13 Members
voting "Present", the latter all members of the Democratic Party[18]) declaring sexual relations
between children and adults are abusive and harmful, and condemned the study on the basis
that it was being used by pro-pedophilia activists and organizations to promote and justify
child sexual abuse.[19] The condemnation of a scientific study by Congress was, at that time,
an unprecedented event.[20] The resolution passed the Senate by a voice vote (100-0) on July
30, 1999[18] and was greeted among psychologists with concern due to the perceived chilling
effect it may have among researchers.[13] Representative Brian Baird, who has a Ph.D. in
clinical psychology and was one of the 13 Congressmen to abstain from the condemnation of
the study, stated that of the 535 members of the House and Senate fewer than 10 had actually
read the study, and even fewer were qualified to evaluate it based on its merit.[18] In
September 1999 the American Association for the Advancement of Science (AAAS), upon a
request by the APA to independently review the article, stated that it saw no reason to secondguess the peer review process that approved it initially and that it saw no evidence of
improper methodology or questionable practices by the authors. The AAAS also expressed
concern that the materials reviewed demonstrated a grave lack of understanding of the study
on the part of the media and politicians and were also concerned about the misrepresentation
of its findings.[10] The AAAS stated that the responsibility for discovering problems with the
article lay with the initial peer reviewers, and declined to evaluate the article, concluding with
a statement that the decision to not review the article was neither an endorsement, nor a
criticism of it.
In August 2000, the APA drafted and adopted a position statement in response to the Rind et
al. controversy that opposed any efforts to censor controversial or surprising research findings
and asserting that researchers must be free to investigate and report findings as long as the
research has been conducted within appropriate ethical and research standards.[13]
Criticism and response

A series of 2001 papers published in the Journal of Child Sexual Abuse discussed and
criticized the findings of the Rind et al. study. Stephanie Dallam stated that, after reviewing
the evidence, the paper was best described as "an advocacy article that inappropriately uses
science in an attempt to legitimatize its findings".[21] Four other researchers also discussed
alleged flaws in the methodology and generalizability of Rind's findings, and concluded the
paper's results were scientifically invalid.[22][23] The criticisms were co-published in the 2001
book Misinformation Concerning Child Sexual Abuse and Adult Survivors.[24] In 2002, a
rebuttal to many of the claims made by critics, claims considered factually inaccurate by Rind
et al., was submitted to the flagship journal of the APA, the American Psychologist by Scott
Lilienfeld.[13] After passing a normal peer review, the editor of the journal re-submitted the
article in secret and, on the basis of this second review, the paper was rejected. Lilienfeld
reported this subsequent rejection on several psychology Internet fora, which produced an
intense response and resulted in the APA and American Psychologist ultimately printing the
article as part of a special issue focusing on the controversy.[20][25]
Sample bias accusation

The paper has been criticized for restricting its analysis to convenience samples of college
students, thought to introduce a systematic bias by excluding victims so traumatized that they
did not go on to attend college. Also noted was that Rind et al.'s conclusions may not be
generalizable beyond college populations in general as individuals with a history of CSA
were more likely than non-abused individuals to drop out of college after a single semester.[21]
[26]

Rind, Bauserman and Tromovitch responded to this criticism by emphasizing that "the
representativeness of college samples is in fact irrelevant to the stated goals and conclusions
of our study" since the purpose of their research was "to examine the validity of the clinical
concept" of CSA. According to the commonly understood definition of the term, child sexual
abuse is extremely and pervasively harmful, meaning that "in any population sampled - drug
addicts, psychiatric patients, or college students - persons who have experienced CSA should
show strong evidence of the assumed properties of CSA." The authors of the study note that
because the college sample did not show pervasive harm, "the broad and unqualified claims
about the properties of CSA are contradicted".[27] Rind et al. also noted that using college
samples was appropriate because their study found similar prevalence rates and experiences
of severity and outcomes between college samples and national samples.[10]
Non-standardization of variables

Dallam et al. asserted that Rind et al. did not standardize their definition of child sexual
abuse, leaving out certain studies that were appropriate, and including studies that were
inappropriate. That is, they allege that Rind et al. uncritically combined data from studies of
CSA with data from studies looking at other phenomena such as consensual peer experiences,
sexual experiences that occurred during adulthood, and homosexual approaches during
adolescence.[21]

Rind, et al. have also responded to this criticism, asserting the appropriateness of including
all five of the studies (Landis, 1956;[28] Schultz and Jones, 1983;[29] Sedney and Brooks, 1984;
[30]
Greenwald, 1994;[31] and Sarbo, 1985[32]) specifically identified by Dallam as inappropriate
to a study about child sexual abuse.[27]
Dallam claims that the first three studies focused on all types of child sexual activity, not just
child sexual abuse.[21] Rind et al. reject this claim. In regard to the Landis study, Rind et al.
note that it has been used by many other sex researchers (e.g., Finkelhor, Fishman, Fromuth
& Burkhart, Sarbo, and others) as an example of an early study about child sexual abuse. In
regard to the Shultz and Jones study, Rind et al. concede that the study "looked at all types of
'sexual acts' before age 12," but explained that the respondents in the study were all asked "if
their experience was with a person over the age of 16," thus allowing Rind et al. to include
only the relationships that were age-discrepant. In regard to the Sedney and Brooks study,
Rind et al. admit that the study used a broad definition of child sexual abuse, but explain that
the researchers themselves chose to use such a definition "because of the difficulty posed by a
priori decisions about what type of sexual experiences are 'problems.'"
Similarly, psychiatrist David Spiegel claimed that the inclusion of Landis' 1956 study[28] was
unjustified.[26][33] He argued that, while weighting larger studies more than smaller makes
sense, combining the results of a large study examining very mild trauma (such as fending off
an attacker) with studies of long-term physical and sexual abuse was inappropriate and led to
erroneous conclusions.[26] Rind et al. replied that Spiegel misrepresented their analysis, since
they did not use Landis' study in the meta-analysis of childhood sexual abuse symptom
correlations, but only for examining the self-reported effects of CSA. They conclude that the
way they handled Landis' data maximized negative reports and minimized the possible
deflating effect of Landis' data on the overall effect sizes.[34]
The last two studies, according to Dallam, were inappropriate because they included
respondents who were over the age of 17 when the CSA occurred. Persons 18 years old or
older are above the legal age of consent in all states of the USA, and thus are not "children"
even in the loosest definition of the term. Rind et al. refuted Dallam by pointing out that, in
the effect-size calculations of the Sarbo and Greenwald studies (i.e., the calculations that
show the alleged harmfulness of CSA), Rind et al. included only respondents aged 16 and 15
and under, respectively, at the time of the CSA.[27] All CSA incidents included in Sarbo's and
Greenwald's original analysis occurred before the age of 17.[20]:p.177
Measured variables

Spiegel criticized that Rind et al. included a long list of measured variables in order to appear
comprehensive, but remarkably omitted posttraumatic stress disorder - "the most salient
symptom" - from their analysis.[33]:65 Rind et al. replied that including PTSD was impossible
due to the fact that the original studies did not examine it.[34] Furthermore, they cited KendallTackett et al.[35] to illustrate the lack of a common pattern of symptoms in children who have
been abused.

Consent

David Spiegel also argued that Rind et al.'s suggestion of relabeling some forms of sexual
encounters between adults and children/adolescents as adult-child (or adult-adolescent) sex is
fundamentally flawed, because children cannot give meaningful consent to sexual relations
with an adult.[33][36] Some critics also argued that using value-neutral terminology would
normalize CSA and that redefining terminology is not in the interest of the general public
because it confuses the underlying moral issues.[10][21] Rind et al. replied that the construct of
consent used in their study was misinterpreted by critics; they only asserted that
children/adolescents are capable of simple consent (willingness) as opposed to informed
consent used in legal contexts, and used this as a variable in their study simply because it was
used in the original studies - where it had predictive validity.[10][34] Thus, they conclude that
although the construct of willingness might be morally unacceptable, it is a scientifically
valid term. A similar argument was put forward by Oellerich,[37] who stated that considering
all adult/non-adult sexual behavior as abusive and lacking consent can lead to bias in
scientific research in the area, and that recognizing this distinction does not necessarily lead
to considering adult/non-adult sexual interactions as morally permissible.
Statistical errors

Dallam et al. also contend that Rind et al. miscoded or misreported significant amounts of the
underlying study data, thereby skewing the results. Dallam et al. contend that Rind et al.
incorrectly used "Pearson's r" instead of "Cohen's d" to calculate the effect size, which
resulted in a failure to correct for base-rate differences of CSA in male and female samples,
and which led to the finding that males were less harmed by CSA. After correcting for baserate attenuation, Dallam et al. said they arrived at identical effect sizes for male and female
samples.[38]
In responding to this criticism, Rind et al. report that they did indeed describe the contrast
between the effect size estimates as "nonsignificant, z = 1.42, p > .10, two-tailed". However,
they continue, "What [they] did report as significantly different was the contrast between
male and female effect size estimates for the all-types-of-consent groups, where rus = .04
and .11, respectively. In "follow[ing] Dallam et al. (2001) [by] apply[ing] Becker's correction
formula to these values, they become rcs = .06 and .12 for men and women, respectively. The
contrast is still statistically significant (z = 2.68, p < .01. two-tailed), contrary to Dallam et
al.'s (2001) claim".[27]
Rind et al. said that their own "handling of Pearson's r in the face of base-rate differences was
methodologically proper and produced no important bias, if any at all." Furthermore, they
contend that Dallam's criticisms "exhibited bias ... [by] selectively ignoring key clarifying
quotes ... and citing them elsewhere in their critique to argue different points, and [by]
ignoring or overlooking a key caveat by Becker (1986) regarding appropriate use of his
correction formula".[27]

Critics also argued that Rind et al.'s statistical approach for controlling for family
environment as a cause of maladjustment was conceptually and methodologically invalid.
Spiegel stated that inferring the source of maladjustment from analyzing the shared variance
between CSA and family environment does not answer the question of which variable
explains maladjustment better;[33][36] the authors answered that this statement shows a
misunderstanding of the statistical procedure used their meta-analysis.[10] Dallam, however,
addressed the topic of several prior studies having found statistically significant relations
between CSA and maladjustment even after controlling for family environment.[21]
Conceptual issues

Rind et al.'s model of "assumed properties of child sexual abuse," (that is, of universal and
pervasive harm in all victims of CSA) has been criticized as a straw man assertion in that it is
both simplistic and misleading.[9][39] The reactions of victims in their adult lives have been
found to be extremely varied, ranging from severe to nearly unnoticeable, and many
pathologies are not diagnosable in the strictly clinical sense Rind uses. Victims often have a
flawed or distorted appraisal of their abuse, and fail to connect distressing and sometimes
debilitating pathologies with their experiences. Further, these studies make no accounting for
emotional support of the victim's family, clinical treatment of the victim prior to the study, or
personal resiliency, which can easily account for less severe outcomes.[6][9]
Assertions of bias

Rind, Bauserman and Tromovitch stated that research findings can be skewed by an
investigator's personal biases, and in Rind et al. claimed that "[r]eviewers who are convinced
that CSA is a major cause of adult psychopathology may fall prey to confirmation bias by
noting and describing study findings indicating harmful effects but ignoring or paying less
attention to findings indicating nonnegative outcomes". They defended their deliberate choice
of non-legal and non-clinical samples, accordingly avoiding individuals who received
psychological treatment or were engaged in legal proceedings as a way of correcting this bias
through the use of a sample of college students.[40]
Dallam and Anne Salter have stated that Rind and Bauserman have associated with age of
consent reform organizations in the past. In the years before the paper was written, both Rind
and Bauserman had published articles in Paidika: The Journal of Paedophilia, a journal
which was dedicated to "[demonstrating] that pedophilia has been, and remains, a legitimate
and productive part of the totality of human experience".[41] In addition, Dallam and Salter
stated that Rind and Bauserman were keynote speakers at a pedophile advocacy conference
occurring in the Netherlands.[41] Another article described Bauserman and Tromovitch's
involvement as "[presenting] their meta-analytic findings to a group of clinicians in the
Netherlands [and] Robert Bauserman (1989), had published an article in Paidika, a Dutch
journal that had previously featured manuscripts tolerant of pedophilia".[13]
Usage outside of scholarly discussions

Despite the authors' comments that the findings of the paper "do not imply that moral or legal
definitions of or views on behaviors currently classified as CSA" should be changed,[1] it
caught the attention of, and was used by, advocates for pedophilia.[8][9] The paper was cited,
reviewed, and posted to the Internet by numerous advocacy groups. It has been used to argue
that the age of consent should be lowered or abolished,[38] and it has been used in criminal
court in the U.S. by attorneys defending those accused of child sexual offenses.[38]
Social psychologist Carol Tavris noted several other groups that reacted negatively to the
study. The anti-homosexuality group National Association for Research & Therapy of
Homosexuality (NARTH), who "[endorse] the long-discredited psychoanalytic notion that
homosexuality is a mental disorder and that it is a result of seduction in childhood by an
adult",[11] objected to the study's implications that boys who are sexually abused are not
traumatized for life and do not become homosexuals as a result. Therapists who supported the
existence of recovered memories and recovered-memory therapy, as well as those who
attributed mental illnesses such as dissociative identity disorder, depression and eating
disorders to repressed memories of sexual abuse also rejected the study. Tavris attributed this
rejection to the fear of malpractice lawsuits. Tavris herself believed that the study could have
been interpreted positively as an example of psychological resilience in the face of adversity,
and noted that CSA causing little or no harm in some individuals is not an endorsement of the
act, nor does it make it any less illegal.[11]
Subsequent research and legacy

Numerous studies and professional clinical experience in the field of psychology, both before
and after Rind et al.'s publications, have long supported the stance that children cannot
consent to sexual activity and that child and adolescent sexual abuse cause harm. The then
American Psychological Association CEO Raymond D. Fowler succinctly reiterated the
prevailing view in a 1999 letter to Congressman Delay "that children cannot consent to
sexual activity with adults," and "sexual activity between children and adults should never be
considered or labeled as harmless or acceptable".[9][16][42][43] Others, like Rind et al. and Ulrich
et al., counter that that prevailing "simplistic" view of CSA fails to completely account for the
variety and complexity of documented sexual experience that many insist, for strong moral
reasons, "cannot" exist.[44][45][46][35]
A study published in The Scientific Review of Mental Health Practice attempted to replicate
the Rind study, correcting for methodological and statistical problems identified by Dallam
and others. It supported some of the Rind findings, both with respect to the percentage of
variance in later psychological outcomes accounted for by sexual abuse and in relation to the
finding that there was a gender difference in the experience of child sexual abuse, such that
females reported more negative effects. It, however, acknowledged the limitations of the
findings (college student sample, self-report data), and did not endorse Rind's
recommendation to abandon the use of the term child sexual abuse in cases of apparent
consent in favor of the term adult-child sex. In their conclusion, the authors address the
objection that Rind's work and their own would give support to those who deny that child

sexual abuse can cause harm: "The authors of the current research would hesitate to support
such a general statement. Instead, our results, and the results of the Rind et al. meta-analysis,
can be interpreted as providing a hopeful and positive message to therapists, parents, and
children. Child sexual abuse does not necessarily lead to long-term harm."[47]
There has been greater emphasis in subsequent work on the range of responses that are
possible from victims. For example, a few studies make reference to the paper's findings
about "consensual" encounters, but approach it from the opposite direction (i.e. that the use of
force causes more intense negative outcomes).[48] Heather Ulrich, author of the
aforementioned replication of the meta-analysis, later drew on the findings to study the
reasons for the variability in outcomes of CSA victims, such as attributional style
(individual's causal explanations for why the abuse occurred), family environment, and social
support.[49]