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Impulsive personality traits in male pedophiles versus healthy controls: Is pedophilia an impulsive-aggressive disorder?
Impulsive Personality Traits in Male Pedophiles Versus Healthy Controls: Is Pedophilia an Impulsive-Aggressive Disorder? Lisa J. Cohen, Sniezyna Watras Gans, Pamela G. McGeoch, Olga Poznansky, Yelena Itskovich, Sean Murphy, Erik Klein, Ken Cullen, and Igor I. Galynker Pedophilia is characterized by sexual attraction to prepubescent children. Despite the extensive literature documenting the pervasive and pernicious effects of childhood sexual abuse, there is surprisingly little psychiatric literature on pedophilia and its etiology remains enigmatic. In recent years, the psychiatric literature on the phenomenology, neurobiology, and treatment of impulsive-aggressive disorders has grown significantly. As some investigators have conceptualized pedophilia as an impulsive-aggressive disorder, it is of interest whether recent advances in the study of impulsive-aggressive disorders might shed light on pathological mechanisms underlying pedophilia. In the following study, 20 male subjects with a DSM-IV diagnosis of pedophilia, heterosexual type were recruited from an outpatient facility for sexual offenders and compared to 24 demographically simi-
lar control subjects. Groups were compared on three personality instruments—the Millon Clinical Multiaxial Inventory-II (MCMI-II), the Temperament and Character Inventory (TCI), and the Dimensional Assessment of Personality Impairment-Questionnaire (DAPI-Q)—to assess for select impairment in impulsive-aggressive personality traits. Pedophiles showed severe and pervasive personality impairment relative to controls. Although there was evidence of impulsivity, the findings do not suggest a predominance of impulsive-aggressive traits, and in fact provide evidence of inhibition, passive-aggression, and harm avoidance. The notion of “compulsive-aggression” in pedophilia is proposed. Copyright 2002, Elsevier Science (USA). All rights reserved.
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malities in serotonin function,11,12 hypofrontality on brain imaging studies,13 and decreased executive and verbal functions on neuropsychological studies.7-9 As Stein et al.5 discuss, considerable controversy exists over whether sexual paraphilias and paraphilia-related disorders reflect compulsive behavior, impulsive behavior, or even addictive pathology. Each of these classifications involves the failure to inhibit pathological behavior. For the purposes of this report, we will restrict our discussion to the notions of impulsivity and compulsivity. Compulsive behaviors serve to decrease anxiety and thus serve as negative reinforcement. Excessive rumination about potential negative consequences reflects cognitive hyperinhibition of behavior. By contrast, impulsive behaviors are inherently pleasurable and function as positive reinforcement.12,14 Lack of consideration of potential negative consequences reflects inadequate cogni-
EDOPHILIA, classified in DSM-IV as a paraphilia, is characterized by sexual attraction to preadolescent children. Although there exists a sizable literature on pedophilia, it is largely relegated to specialty journals, i.e., forensic or sex research, and is poorly integrated into the general psychiatric literature. Thus, despite the extensive literature documenting the pervasive and pernicious effects of childhood sexual abuse,1,2 there is surprisingly little psychiatric literature on pedophilia and its etiology remains enigmatic.3,4 In the past 10 to 15 years, the psychiatric literature on the phenomenology, neurobiology, and treatment of impulsive-aggressive disorders has grown significantly. As some investigators have conceptualized pedophilia as an impulsive-aggressive disorder,5,6 it is of interest whether recent advances in the study of impulsive-aggressive disorders might shed light on pathological mechanisms underlying pedophilia. Impulsive aggression can be loosely defined as any aggressive behavior that is not planned and, in effect, is committed without consideration of the consequences.7 Multiple and consistent abnormalities have been demonstrated in a range of impulsive-aggressive groups, such as juvenile delinquents and conduct-disordered boys,8,9 impulsive aggressive felons,7 and patients with borderline personality disorder.10 Consistent findings include abnor-
From the Montiefiore Medical Center, Bronx; New School for Social Research, New York; New York University, New York; CAP Behavior Associates, Brooklyn; and the Beth Israel Medical Center/Albert Einstein College of Medicine, New York, NY. Supported in part by Singer Grant No. I-480-400 to I.I.G. Address reprint requests to Lisa Cohen, Ph.D., Beth Israel Med. Center, 6 Karpas, 1st Ave & 16th St., New York, NY 10003. Copyright 2002, Elsevier Science (USA). All rights reserved. 0010-440X/02/4302-0004$35.00/0 doi:10.1053/comp.2002.30796
Comprehensive Psychiatry, Vol. 43, No. 2 (March/April), 2002: pp 127-134
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tive mediation of impulses. The arguments for characterizing pedophilia, in which there is failure to inhibit sexual urges, as an impulsive disorder, rest primarily on the inherently pleasurable nature of sexual behavior.5,6 In other words, out of motivation for short-term pleasure, pedophiles fail to inhibit a behavior that causes negative consequences in the long run. This model posits that inadequate consideration of long-term negative consequences underlies such inhibitory failure. Of note, this model does not address the abnormal choice of object in pedophilia (i.e., prepubescent children), only the inhibitory failure. If pedophilia can be characterized as an impulsive-aggressive disorder, we would expect psychological and neurobiological patterns to parallel those of other impulsive-aggressive groups. In impulsive-aggressive groups, neuropsychiatric and neuropsychological investigations have revealed consistent abnormalities in frontal lobe function. Imaging findings have revealed hypoactive frontal lobes in impulsive personality–disordered patients13 and in violent versus nonviolent psychiatric patients.15 Neuropsychological studies have revealed analogous impairment in frontal lobe-related executive functions in aggressive boys.8,16 Frontal lobe abnormalities appear to lie primarily in the orbital frontal region, which has been widely associated with behavioral inhibition. With regard to personality functioning in impulsive groups, unsurprisingly, there is ample psychometric evidence of elevated cluster B personality pathology and trait impulsivity. High rates of cluster B personality disorders and traits, including antisocial, borderline, and narcissistic pathology, have been demonstrated in incarcerated men,17 pathological gamblers,18 and bulimics.19 O’Boyle and Barratt20 have documented higher Personality Diagnostic Questionnaire-Revised (PDQ-R) scale scores of cluster B personality disorders relative to cluster A and C in substance abusers. Measures of trait impulsivity correlated with total personality disorder scores. Measures of trait impulsivity have also been elevated in impulsive-aggressive and impulsive groups, providing construct validity for the notion of an impulsive dimension underlying apparently diverse disorders. Subjects with impulse control disorders, such as pathological gambling,18 multiple impulse control disorders,21 and suicidal inpa-
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tients,22 have demonstrated high trait impulsivity on psychometric measures. Finally, impulsive and antisocial behavior has been associated with high novelty seeking scores on the Tridimensional Personality Questionnaire (TPQ), while anxiety disorders and avoidant behavior have been associated with high TPQ harm avoidance scores.23 In contrast to data on other areas of psychiatric function, personality data on pedophiles is relatively abundant. Nonetheless, systematic study of personality traits with multiple, standardized instruments is lacking. In addition, many investigations study general paraphilias as well as paraphilia-related disorders, which are the excessive practice of otherwise normal sexual behavior.6,24 Different paraphilias are highly comorbid, however, and in one study, 29% of 34 paraphiliacs reported comorbid pedophilia.25 One of the few studies using diagnostic interviews assessed 36 patients with compulsive sexual behavior (CSB), involving paraphilias and/or paraphilia related behavior.24,25 By PDQ/PDQ-R, cluster B disorders were the most common, with borderline (50%), narcissistic (35%), histrionic (35%), and paranoid (32%) the most frequent axis II diagnoses. By the Structured Interview for DSM-IV Personality Disorders (SIDP) and the SIDP-Revised (SIDP-R), histrionic (28%), passive-aggressive (28%), and paranoid (25%) were the most frequently diagnosed personality disorders, followed by narcissistic (19%), avoidant (19%), obsessive-compulsive (17%), and antisocial (14%). Likewise, a study of Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID II) diagnoses in 40 pedophiles noted that cluster B disorders were elevated (33%) but less prevalent than cluster C (43%) disorders.26 Eighteen percent met criteria for a cluster A disorder. Sociopathic traits, however, are a common finding, shown in studies of aggressive sexual offenders6 and pedophiles. On the Minnesota Multiphasic Personality Inventory (MMPI), 113 pedophiles had elevated psychopathic deviancy (Pd) and schizophrenia (Sc) scores.27 Regarding trait impulsivity, clinical reports of sexually aggressive paraphiliacs have noted elevated “thrill-seeking” characteristics28,29 and lifestyles characterized by impulsivity.30 Raymond et al.26 assessed 45 male pedophilic sex offenders by the Structured Clinical Interview for DSM-IV Axis
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I Disorders (SCID I). Sixty percent met criteria for any lifetime psychoactive substance disorder, 29% for any nonsexual impulse control disorder, with 11% for pathological gambling. Data from two studies of patients with compulsive sexual behavior also suggest high rates of comorbid impulsive disorders. In one study of 36 subjects with CSB, 58% met criteria for alcohol abuse/dependence, 33% for drug abuse/dependence, 11% for bulimia, and 6% for pathological gambling.25 In a sample of 26 patients with CSB, 38% met criteria for alcohol abuse/dependence and 29% for drug abuse/dependence.31 Thus data from clinical reports and systematic personality studies supports the notion of pedophilia as an impulsive-aggressive disorder. On the other hand, there is also considerable data suggesting that pedophilia is not well characterized as an impulsive-aggressive disorder. Many studies point to a degree of inhibition in pedophiles, who are often characterized as socially inhibited and selfconscious.4,6,27 Forms of aberrant sexual behavior in pedophiles have been labeled as more passive (e.g., exhibitionism, compulsive masturbation) than those found in rapists.32 High rates of cluster A and C disorders have been reported in addition to cluster B.24-26 Further, consistent findings of elevated Sc scores on the MMPI have led some investigators to postulate that pedophiles are schizotypal.27 Finally, a study of Rorshach ink blot test responses in pedophiles versus nonsexual offenders found that pedophiles had greater ideational productivity and complexity in their responses, arguing against the notion of them as specifically impulsive.33 Thus, there is evidence both supporting and failing to support the hypothesis of pedophilia as an impulsive-aggressive disorder. In the following study, 20 heterosexual male pedophiles and 24 demographically similar, healthy male controls were compared on three personality measures. It was hypothesized that pedophiles would show select impairment on personality measures associated with impulsive-aggression, such as cluster B personality scales. METHOD
Subjects Two groups of subjects were studied. Twenty male subjects with a DSM-IV diagnosis of pedophilia, heterosexual type, were recruited from CAP Behavior Associates, a facility specializing in outpatient treatment of court-referred sexual offend-
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ers. All pedophilia subjects had been convicted of a sexual offense against a prepubescent child (age 13 or younger) when they were at least 18 years of age or were at least 5 years older than their victim. Twenty-four demographically similar control subjects were recruited through advertising in a local newspaper. Exclusion criteria for both groups included substance abuse/dependence within the past 6 months, major medical or neurological disease, and mental retardation. Significant axis I psychiatric disorder (other than pedophilia) was also an exclusion criterion for both groups. For pedophiles, this was defined as any major mood disorder (major depressive disorder, bipolar disorder), psychotic disorder, or significantly debilitating disorder requiring psychiatric hospitalization. For controls, it was defined as any SCID I diagnosis. Further exclusion criteria for controls included any history of pedophilia or of sexual contact with a child of 14 or younger after the age of 16, or with a child of 16 or younger after the age of 18. All subjects expressed sexual attraction to women. One pedophilic subject labeled himself as bisexual.
Procedure This study was approved by the Beth Israel Medical Center Committee on Scientific Activities (COSA). Recruitment. In order to recruit pedophiles, a research assistant visited CAP Behavior Associates and spoke to the clients immediately prior to their group therapy appointment. The research assistant first described the project in general to the assembled group of CAP Behavior Associates clients. Pedophilic patients who expressed interest in the project were interviewed individually, at which point the project was described in greater detail. Interested subjects were scheduled for an appointment at Beth Israel Medical Center for further evaluation and explanation of study protocol. Those who met inclusion/ exclusion criteria and expressed interest in participation signed the COSA-approved informed consent form. Control subjects were screened by phone for initial eligibility. After primary inclusive criteria were met, subjects were interviewed in person by research staff. The study was explained in further detail. All control subjects who met inclusion/exclusion criteria were entered into the study after signing the COSAapproved informed consent form. To further insure eligibility for the study, control subjects then completed a SCID I interview,34 a sexual history questionnaire, and a clinical interview by a psychologist. After signing informed consent and completing initial screening evaluations, a battery of psychometric tests was administered. All subjects were paid $50.00 after they completed the battery of tests.
Materials Personality measures included the following: The Millon Clinical Multiaxial Inventory-II (MCMI-II)35 is a 175-item questionnaire measuring DSM III-R personality disorders as well as several axis I disorders and syndromes. Scale scores were calculated according to the scoring key in the MCMI-II manual.35 No corrections were used in scoring. Only axis II diagnoses were analyzed in this study. The Temperament and Character Inventory (TCI),36 adapted from the TPQ, is a 240-item questionnaire that assesses four dimensions of temperament and three dimensions of character.
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Only harm avoidance and novelty seeking were analyzed in this study. The Dimensional Assessment of Personality Impairment– Questionnaire (DAPI-Q)37 is a 248-item questionnaire that measures personality impairment in 16 scales grouped into six function clusters: regulation of affect (three scales), action (two scales), cognition (two scales), interpersonal function (four scales), self-organization (three scales), and societal function (two scales). The DAPI-Q has been adapted from the DAPI, a semistructured interview.37 For the purposes of this study, we were interested in the subscales putatively associated with impulsive aggression, including regulation of anger, impulse control, antisocial attitudes, and antisocial behavior. The selfinhibition scale, which should not be elevated in impulsiveaggressive groups, was included to provide some discriminative validity. In an attempt to further discriminate impulsive versus inhibited tendencies, six items from the self-assertion scale were averaged to form a dominance subscale and five other items were selected for a submissiveness subscale. As these subscales have fewer items than other scales, they are expected to have lowered psychometric properties.
Statistical Analysis Statistical methods appopriate for group comparisons were utilized. Multivariate analyeses of variance (MANOVAs) with follow-up univariate F tests compared pedophiles and controls on MCMI-II axis II cluster A, B, and C personality scores. Independent t tests were used to compare TCI harm avoidance and novelty seeking scores across groups. The DAPI variables were entered into a single MANOVA. Because of missing data in select scales, however, the individual scales were also compared across groups by t tests, with and without Bonferroni corrections. Analysis was performed on a personal computer using SPSS for Windows version 10.0 (SPSS, Inc, Chicago, IL).
RESULTS
Subjects Pedophiles and Controls did not significantly differ on age, marital status, employment status, or ethnicity (Table 1). Pedophiles did have significantly fewer years of education (12.30 ⫾ 2.6 v 14.54 ⫾ 1.5, t ⫽ ⫺3.51, df ⫽ 42, P ⫽ .001). Pedophiles averaged 38 ⫾ 8 years of age. Twenty percent were African American, 20% European American, and 50% Hispanic. Seventy percent were employed, and 25% were married. Controls averaged 37 ⫾ 10 years of age and 92% employment. Twenty-one percent were African American, 25% European American, and 50% Hispanic. Twenty-five percent were married. Personality Measures Pedophiles scored significantly higher than controls on many of the measures of personality impairment (Table 2). MCMI-II. On the MCMI-II, pedophiles scored higher than controls on cluster A (Hotelling’s T2 ⫽ 0.24, F ⫽ 3.2, df ⫽ 3,40, P ⫽ .035), cluster B (Hotelling’s T2 ⫽ 0.42, F ⫽ 3.2, df ⫽ 5,38, P ⫽ .016), and cluster C (Hotelling’s T2 ⫽ 0.34, F ⫽ 2.6, df ⫽ 5,38, P ⫽ .041) scales. Univariate F tests were significant for all three cluster A scales, three of five cluster B scales, and three of five cluster C
Table 1. Demographic Information 20 Pedophiles and 24 Controls
Age (yr) Years of education Marital status Single Married Separated Divorced Religion Christian Jewish Other None Ethnicity African American European American Asian Hispanic Other Employment Employed
Pedophiles (n ⫽ 20)
Controls (n ⫽ 24)
38.32 ⫾ 8.3 12.2 ⫾ 2.6
36.71 ⫾ 9.7 14.54 ⫾ 1.5
7 (35%) 5 (25%) 3 (15%) 5 (25%)
12 (50%) 6 (25%) 3 (13%) 3 (13%)
15 (75%) 2 (10%) 1 (5%) 2 (10%)
17 (%) 2 (%) 2 (%) 3 (13%)
4 (20%) 4 (20%) 1 (5%) 10 (50%) 1 (5%)
5 (21%) 6 (25%) 1 (4%) 12 (50%) 0 (0%)
14 (70%)
22 (92%)
Significance
t ⫽ .734, df ⫽ 42, P ⫽ .467 t ⫽ ⫺3.51, df ⫽ 42, P ⫽ .001 2 ⫽ 1.56, df ⫽ 3, P ⫽ .669
2 ⫽ .297, df ⫽ 3, P ⫽ .961
2 ⫽ 1.34, df ⫽ 4, P ⫽ .854
2 ⫽ 3.44, df ⫽ 1, P ⫽ .064
NOTE. Age, years of education compared by t test; marital status, religion, ethnicity, and employment compared by 2.
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Table 2. Personality Findings
MCMI-2 Cluster A Schizoid Schizotypal Paranoid Cluster B Histrionic Narcissistic Borderline Antisocial Aggressive-sadistic Cluster C Avoidant Dependant Obsessive-compulsive Passive-aggressive Self-defeating TCI Harm avoidance Novelty seeking DAPI Anger Impulse control Self-inhibition Antisocial attitudes Antisocial behavior Submissiveness Dominance
Pedophiles (n ⫽ 20)
Controls (n ⫽ 24)
20.55 ⫾ 8.1 20.90 ⫾ 17.7 30.90 ⫾ 16.2
16.42 ⫾ 5.1 8.79 ⫾ 6.3 21.50 ⫾ 12.9
34.95 ⫾ 12.3 40.05 ⫾ 14.1 33.00 ⫾ 24.6 34.75 ⫾ 13.9 33.00 ⫾ 12.7
27.58 ⫾ 8.9 34.96 ⫾ 11.0 12.50 ⫾ 13.4 22.92 ⫾ 12.3 26.04 ⫾ 12.2
22.30 ⫾ 16.6 27.05 ⫾ 6.7 37.35 ⫾ 8.1 29.65 ⫾ 17.0 21.25 ⫾ 16.4
10.38 ⫾ 6.9 25.33 ⫾ 5.9 37.54 ⫾ 7.1 17.25 ⫾ 13.3 8.92 ⫾ 8.0
12.55 ⫾ 4.8 19.00 ⫾ 4.1
9.64 ⫾ 4.6 17.50 ⫾ 5.4
1.24 ⫾ 0.9 1.37 ⫾ 1.2 1.72 ⫾ 1.0 1.33 ⫾ 1.0 0.30 ⫾ 0.3 1.35 ⫾ 0.9 1.26 ⫾ 0.7
0.87 ⫾ 0.6 0.59 ⫾ 0.4 0.74 ⫾ 0.8 0.80 ⫾ 0.5 0.07 ⫾ 0.1 0.73 ⫾ 0.8 0.43 ⫾ 0.5
Statistic (df )
P Value
Hotellings T2 ⫽ .24 (3,40) F ⫽ 4.21 (1,42) F ⫽ 9.74 (1,42) F ⫽ 4.59 (1,42) Hotellings T2 ⫽ .42 (5,38) F ⫽ 5.27 (1,42) F ⫽ 1.81 (1,42) F ⫽ 12.28 (1,42) F ⫽ 8.93 (1,42) F ⫽ 3.42 (1,42) Hotellings T2 ⫽ .34 (5,38) F ⫽ 10.23 (1,42) F ⫽ .081 (1,42) F ⫽ 0.01 (1,42) F ⫽ 7.35 (1,42) F ⫽ 10.60 (1,42)
.035* .046* .003† .038* .016* .027* .186 .001‡ .005† .072 .041* .003† .373 .934 .010† .002†
t ⫽ 1.459 (40) t ⫽ 1.013 (40) Hotellings T2 ⫽ .836 (7,28) t ⫽ 1.50 (38) t ⫽ 2.70 (20.7) t ⫽ 3.58 (41) t ⫽ 2.18 (39) t ⫽ 3.54 (21.5) t ⫽ 2.34 (39) t ⫽ 4.48 (39)
.053 .317 .010† .141 .013 .001§ .036 .002§ .025 .000§
*P ⱕ .05. †P ⱕ .01. ‡P ⱕ .001. §For DAPI, P ⱕ Bonferroni corrected value of .007.
scales. To assess the selectivity of cluster B pathology in pedophilia, the number of subjects who exceeded cut-off points for each disorder in each cluster was calculated and compared across groups. Groups did not differ in mean number of scores above cut-off points for either cluster B or C disorders. For cluster A disorders, however, pedophiles had marginally more scale scores above cut-off points than did controls (0.7 ⫾ 1.2 v 0.1 ⫾ 0.4; t ⫽ ⫺2, df ⫽ 23.29, P ⫽ .057). DAPI-Q. When all seven DAPI scale scores were entered into a single MANOVA, the overall MANOVA yielded significant differences across groups (Hotelling’s T2 ⫽ .836, df ⫽ 7,28, P ⫽ .010). On univariate F tests, pedophiles scored higher than controls on antisocial behavior, impulse control, self-inhibition, dominance, and submissiveness. There were no differences on antisocial atti-
tudes and anger. As only 36 cases were entered into the MANOVA, due to the large amount of subjects who failed to answer select scales, independent t tests were performed on each scale. By independent t tests, pedophiles scored higher than controls on all scales but regulation of anger. After Bonferoni correction, however, only dominance, self inhibition, and antisocial behavior maintained significance (Table 2). TCI. There was no difference between groups on novelty seeking. Moreover, contrary to our predictions, pedophiles scored marginally higher than controls on harm avoidance (19 ⫾ 4.1 v 17.50 ⫾ 5.4; t ⫽ 1.5, df ⫽ 40, P ⫽ .053). DISCUSSION
In the present study, 20 male pedophiles were compared to 24 healthy male controls on three measures of impulsive-aggressive personality traits.
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The data as a whole suggest severe and pervasive personality impairment in pedophiles. Although there was evidence of significant cluster B pathology on MCMI-II, the MCMI-II results do not support the selectivity of cluster B pathology in this sample of heterosexual, male pedophiles. Consistent with the MCMI-II, DAPI-Q results support the presence but not the selectivity of impulsive-aggressive traits. Results on TCI also failed to support evidence of impulsivity, with no difference across groups in novelty seeking and marginally higher harm avoidance scores in pedophiles. Our findings on the personality data are not consistent with the literature on impulsive-aggressive and impulsive groups, in which a predominance of cluster B disorders18-20 are consistently demonstrated as well as elevated novelty seeking and lowered harm avoidance on the TCI.23 Nor is our data consistent with several studies in the pedophilia literature that demonstrate high rates of cluster B disorder,24-26 as well as elevated thrill seeking traits,28,29and nonsexual impulse control disorders.24,25,31 Nonetheless, our study is consistent with several other studies that suggest pedophilia is not well characterized by impulsiveaggression. Although there were signs of impulsivity in the current study, impulsive personality traits did not predominate, and cluster A pathology on MCMI-II may have been more salient than cluster B pathology. This is consistent with an earlier study of axis II diagnoses in pedophiles, in which cluster B disorders were elevated but less predominant than cluster C disorders.26 In fact, shyness, introversion, and lack of assertiveness have been frequently documented in pedophiles,4,38 although the stereotype of the shy, inhibited pedophile is a matter of some controversy.3,39 Similarly, in our companion study with the same sample,40 pedophiles did not demonstrate impairment on measures of executive functions, contradicting the notion of inadequate cognitive mediation of behavior. Likewise in a 1967 study by Gebhard et al.,41 it is noted that “80% or more of the acts engaged in by all of the pedophile groups were planned, not impulsive.”4 Moreover, despite strong evidence of antisocial traits in the current sample, there was not evidence of excessive aggression. Several other studies suggest disinhibited aggression is not characteristic of
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pedophiles,3,42 even of those who commit sexually aggressive acts.43 The study is not without limitations, however, and all conclusions must be drawn with caution. Our sample size was relatively small and groups were not identical in size. Despite rigorous attempts to select a homogeneous group of heterosexual, male pedophiles, one subject identified himself as bisexual. We did not use direct measures of impulsivity and aggression but relevant subscales of more general personality measures. Moreover, the generalizability of our results is hampered by the heterogeneity of pedophile populations. Study subjects represent a particular subset of the total population of pedophiles, those who have been convicted of sexual abuse but are not in the prison system. Self-selection biases may have restricted our sample further. The control group, though rigorously screened, may be an inherently impulsive group due to their response to recruiting tactics. Finally, pedophiles are notoriously unreliable informants. Moreover, concern about confidentiality and the impact on their legal status may have led subjects to minimize their impulsiveaggressive features. Nonetheless, our study is one of few systematic investigations of impulsive personality traits in male pedophiles, which utilized stringent inclusion/exclusion criteria for pedophiles and controls along with multiple measures to assess personality pathology. Hence, despite the above limitations, it is worthwhile to consider possible interpretations of the data. First, we can hypothesize that the failure to inhibit pedophilic sexual urges may not be due to a global deficit in cognitive impulse control, but rather to other cognitive or motivational mechanisms. Cognitive distortions and denial of the implications of pedophilic behavior have been widely documented44 and are consistent with our findings of elevated cluster A scores. In other words, pedophiles’ inhibitory failure may be due less to an inability to conceptualize consequences, than to a propensity to distort the implications of their behavior. Likewise, a lack of motivation to inhibit pedophilic urges is consistent with an antisocial profile. The notion that pedophilia is not well characterized as an impulsive-aggressive disorder also raises the possibility of compulsive features in
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pedophilia. In fact, Balyk45 hypothesized pedophilia to be an obsessive-compulsive spectrum disorder. Compulsivity has been described as the complement of impulsivity.14 Whereas impulsive behavior is motivated to produce pleasure and is insufficiently mediated by the cognitive consideration of consequences, compulsive behavior is motivated to reduce anxiety and is associated with heightened ideational activity.14 Our findings, including marginally elevated harm avoidance on the TCI and increased self-inhibition on the DAPI-Q, are consistent with compulsive features. Further research could also investigate the possibility of “compulsive-aggression” as opposed to impulsiveaggression. The fact that pedophiles volitionally engage in behavior that has a profoundly damaging impact on its victims along with the common finding of antisocial traits raises the question of aggressive traits in pedophiles even if such aggression is not associated with impulsivity. Aggression may be over-controlled and indirectly expressed, perhaps in the form of severe passive-aggression. In fact, in our study, pedophiles scored higher than controls on the MCMI-II passive-aggressive scale (F ⫽ 7.35, df ⫽ 1.42, P ⫽ .01). Black et al., in
their sample of CSB patients, also reported high rates of passive-aggressive and obsessive-compulsive personality disorders.25 As the behavioral and pharmacological treatments of compulsive and impulsive disorders are quite different, the relationship between impulsivity, compulsivity and aggression in pedophiles merits further study. In conclusion, the present study investigated the question of whether pedophilia is well characterized as an impulsive-aggressive disorder. We hypothesized that pedophiles would demonstrate a predominance of impulsive-aggressive personality traits. Despite evidence of pervasive personality impairment, impulsive-aggressive traits were present but not predominant. We conclude that pedophilia might not be well characterized as an impulsive-aggressive disorder and may even involve compulsive or compulsive-aggressive features. Such notions have implications for pharmacological and psychotherapeutic interventions and merit further study. Given the widely documented sequelae of childhood sexual abuse, further psychiatric investigations of the psychopathology and pathophysiology of pedophilia are clearly warranted.
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intercorrelations among central 5-HT indices and aggressiveness. Psychiatry Res 1997;73:1-14. 11. Coccarro EF, Kavoussi RJ, Hauger RL, Cooper TB, Ferris CF. Cerebrospinal fluid vasopresin levels: correlates with aggression and serotonin function in personality-disordered subjects. Arch Gen Psychiatry 1998;55:708-714. 12. Kavoussi RJ, Coccarro EF. Biology and pharmacological treatment of impulse-control disorders. In: Oldham JM, Hollander E, Skodol AE (eds). Impulsivity and Compulsivity. Washington, DC: American Psychiatric Press, 1996:119-142. 13. Goyer PF, Andreason PJ, Semple WE, Clayton AH, King AC, Schultz SC, et al. PET and personality disorders. Biol Psychiatry 1991;29:43A-185A. 14. Hollander E, Cohen LJ. Psychobiology and psychopharmacology of compulsive spectrum disorders. In: Oldham JM, Hollander E, Skodol AE (eds). Impulsivity and Compulsivity. Washington, DC: American Psychiatric Press, 1996:143-166. 15. Volkow ND, Tancredi LR, Grant C, Gillespie H, Valentine A, Mullani N, et al. Brain glucose metabolism in violent psychiatric patients: a preliminary study. Psychiatry Res 1995; 61:243-252. 16. Seguin JR, Pihl RO, Harden PW, Tremblay RE, Boulerice B. Cognitive and neuropsychological characteristics of physically aggressive boys. J Abnorm Psychol 1995;104: 614-624. 17. Gacono CB, Meloy JR. The Rorschach Assessment of Aggressive Psychopathic Personalities. Hillsdale, NJ: Lawrence Erlbaum, 1994.
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18. Steel Z, Blaszczynski A. Impulsivity, personality disorders and pathological gambling severity. Addiction 1998;93: 895-905. 19. Sokol MS, Gray NS, Goldstein A, Kaye WH. Methylphenidate treatment for bulimia nervosa associated with a cluster B personality disorder. Int J Eat Disord 1999;25:233-237. 20. O’Boyle MO, Barratt ES. Impulsivity and the multiimpulsive personality disorder. Pers Individ Differ 1992;14: 609-611. 21. Stanford MS, Barrat ES. Impulsivity and the multi-impulsive personality disorder. Pers Individ Differ 1992;13:831834. 22. Horesh N, Rolnick T, Iancu I, Dannon P, Lepkifker E, Apter A, et al. Anger, impulsivity and suicide risk. Psychother Psychosomat 1997;66:92-96. 23. Cloninger CR. Assessment of the impulsive-compulsive spectrum of behavior by the seven factor model of temperament and character. In: Oldham JM, Hollander E, Skodol AE (eds). Impulsivity and Compulsivity. Washington, DC: American Psychiatric Press, 1996:59-96. 24. Black DW. The epidemiology and phenomenology of compulsive sexual behavior. CNS Spectrums 2000;5:26-35. 25. Black DW, Kehrberg LLD, Flumerfelt DL, Schlosser SS. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiatry 1997;154:243-249. 26. Raymond NC, Coleman E, Ohlerking F, Christenson GA, Miner M. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry 1999;156:786-788. 27. Henderson MC, Kalichman SC. Sexually deviant behavior and schizotypy: A theoretical perspective with supportive data. Psychiatr Q 1990;61:273-284. 28. Carnes P. Out of Shadows: Understanding Sexual Addiction. Minneapolis, MN: CompCare, 1983. 29. Wise TN, Fagan PJ, Schmidt CW, Ponticas Y, Costa PT. Personality and sexual functioning of transvestic fetishists and other paraphiliacs. J Nerv Ment Dis 1991;179:694-698. 30. Prentky RA, Knight RA. Identifying critical dimensions for discriminating among rapists. J Consult Clin Psychol 1991; 59:643-661. 31. Kafka M, Prentky RA. Preliminary observations of DSM-III-R axis I comorbidity in men with paraphilias and paraphilia-related disorders. J Clin Psychiatry 1994;55:481487. 32. Bard L, Carter D, Cerce D, Knight R, Rosenberg R, Schneider B. A descriptive study of rapists and child molesters:
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developmental, clinical, and criminal characteristics. Behav Sci Law 1987;5:203-220. 33. Bridges MR, Wilson JS, Gacono CB. A Rorschach investigation of defensiveness, self-perception, interpersonal relations, and affective states in incarcerated pedophiles. J Pers Assess 1998;70:365-385. 34. First M, Gibbon M, Spitzer RL, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders (Research version). New York, NY: Biometrics Research Dept, New York State Psychiatric Institute, 1996. 35. Millon T. Millon Clinical Multiaxial Inventory-II: Manual for the MCMI-II. Ed. 2. Minneapolis, MN: National Computer Systems, 1987. 36. Cloninger RC, Svraki DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry 1993;50:975-990. 37. Cohen LJ, Kingston P, Bell A, Kwon J, Aronowitz B, Hollander E. Comorbid personality impairment in body dysmorphic disorder. Comp Psychiatry 2000;41:4-12. 38. Fisher D, Beech A, Browne A. Comparison of sex offenders to nonoffenders on selected psychological measures. Int J Offender Ther Comparative Criminol 1999;43:473-491. 39. Barnard GW, Fuller AK, Robbins L, Shaw T. The Child Molester: An Integrated Approach to Evaluation and Treatment. New York, NY: Bruner/Mazel Clinical Psychiatry Series, 1989. 40. Galynker I, Cohen LJ, Cullen K, Poznansky O, WatrasGans S, Murphy S, et al. Frontal lobe related cognitive function and impulsivity in pedophilic men. Poster presented at the 152nd Annual Meeting of the American Psychiatric Association, Washington, DC, May 17-20, 1999. 41. Gebhard PH, Gagnon JH, Pomeroy WB, Christenson CV. Sex Offenders. New York, NY: Bantam Books, 1967. 42. Henn FA, Herjanic M, Vanterpearl RH. Forensic psychiatry: profiles of two types of sex offenders. Am J Psychiatry 1976;133:694-696. 43. Greenberg D, Bradford JMW, Curry S. Are pedophiles with aggressive tendencies more sexually violent? Bull Am Acad Psychiatry Law 1996;24:225-235. 44. Haywood TW, Grossman LS. Denial of deviant sexual arousal and psychopathology in child molesters. Behav Ther 1994;25:327-340. 45. Balyk ED. Paraphilias as a sub type of obsessive-compulsive disorder. A hypothetical biosocial model. J Orthomolec Med 1997;12:29-42.
lar control subjects. Groups were compared on three personality instruments—the Millon Clinical Multiaxial Inventory-II (MCMI-II), the Temperament and Character Inventory (TCI), and the Dimensional Assessment of Personality Impairment-Questionnaire (DAPI-Q)—to assess for select impairment in impulsive-aggressive personality traits. Pedophiles showed severe and pervasive personality impairment relative to controls. Although there was evidence of impulsivity, the findings do not suggest a predominance of impulsive-aggressive traits, and in fact provide evidence of inhibition, passive-aggression, and harm avoidance. The notion of “compulsive-aggression” in pedophilia is proposed. Copyright 2002, Elsevier Science (USA). All rights reserved.
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malities in serotonin function,11,12 hypofrontality on brain imaging studies,13 and decreased executive and verbal functions on neuropsychological studies.7-9 As Stein et al.5 discuss, considerable controversy exists over whether sexual paraphilias and paraphilia-related disorders reflect compulsive behavior, impulsive behavior, or even addictive pathology. Each of these classifications involves the failure to inhibit pathological behavior. For the purposes of this report, we will restrict our discussion to the notions of impulsivity and compulsivity. Compulsive behaviors serve to decrease anxiety and thus serve as negative reinforcement. Excessive rumination about potential negative consequences reflects cognitive hyperinhibition of behavior. By contrast, impulsive behaviors are inherently pleasurable and function as positive reinforcement.12,14 Lack of consideration of potential negative consequences reflects inadequate cogni-
EDOPHILIA, classified in DSM-IV as a paraphilia, is characterized by sexual attraction to preadolescent children. Although there exists a sizable literature on pedophilia, it is largely relegated to specialty journals, i.e., forensic or sex research, and is poorly integrated into the general psychiatric literature. Thus, despite the extensive literature documenting the pervasive and pernicious effects of childhood sexual abuse,1,2 there is surprisingly little psychiatric literature on pedophilia and its etiology remains enigmatic.3,4 In the past 10 to 15 years, the psychiatric literature on the phenomenology, neurobiology, and treatment of impulsive-aggressive disorders has grown significantly. As some investigators have conceptualized pedophilia as an impulsive-aggressive disorder,5,6 it is of interest whether recent advances in the study of impulsive-aggressive disorders might shed light on pathological mechanisms underlying pedophilia. Impulsive aggression can be loosely defined as any aggressive behavior that is not planned and, in effect, is committed without consideration of the consequences.7 Multiple and consistent abnormalities have been demonstrated in a range of impulsive-aggressive groups, such as juvenile delinquents and conduct-disordered boys,8,9 impulsive aggressive felons,7 and patients with borderline personality disorder.10 Consistent findings include abnor-
From the Montiefiore Medical Center, Bronx; New School for Social Research, New York; New York University, New York; CAP Behavior Associates, Brooklyn; and the Beth Israel Medical Center/Albert Einstein College of Medicine, New York, NY. Supported in part by Singer Grant No. I-480-400 to I.I.G. Address reprint requests to Lisa Cohen, Ph.D., Beth Israel Med. Center, 6 Karpas, 1st Ave & 16th St., New York, NY 10003. Copyright 2002, Elsevier Science (USA). All rights reserved. 0010-440X/02/4302-0004$35.00/0 doi:10.1053/comp.2002.30796
Comprehensive Psychiatry, Vol. 43, No. 2 (March/April), 2002: pp 127-134
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tive mediation of impulses. The arguments for characterizing pedophilia, in which there is failure to inhibit sexual urges, as an impulsive disorder, rest primarily on the inherently pleasurable nature of sexual behavior.5,6 In other words, out of motivation for short-term pleasure, pedophiles fail to inhibit a behavior that causes negative consequences in the long run. This model posits that inadequate consideration of long-term negative consequences underlies such inhibitory failure. Of note, this model does not address the abnormal choice of object in pedophilia (i.e., prepubescent children), only the inhibitory failure. If pedophilia can be characterized as an impulsive-aggressive disorder, we would expect psychological and neurobiological patterns to parallel those of other impulsive-aggressive groups. In impulsive-aggressive groups, neuropsychiatric and neuropsychological investigations have revealed consistent abnormalities in frontal lobe function. Imaging findings have revealed hypoactive frontal lobes in impulsive personality–disordered patients13 and in violent versus nonviolent psychiatric patients.15 Neuropsychological studies have revealed analogous impairment in frontal lobe-related executive functions in aggressive boys.8,16 Frontal lobe abnormalities appear to lie primarily in the orbital frontal region, which has been widely associated with behavioral inhibition. With regard to personality functioning in impulsive groups, unsurprisingly, there is ample psychometric evidence of elevated cluster B personality pathology and trait impulsivity. High rates of cluster B personality disorders and traits, including antisocial, borderline, and narcissistic pathology, have been demonstrated in incarcerated men,17 pathological gamblers,18 and bulimics.19 O’Boyle and Barratt20 have documented higher Personality Diagnostic Questionnaire-Revised (PDQ-R) scale scores of cluster B personality disorders relative to cluster A and C in substance abusers. Measures of trait impulsivity correlated with total personality disorder scores. Measures of trait impulsivity have also been elevated in impulsive-aggressive and impulsive groups, providing construct validity for the notion of an impulsive dimension underlying apparently diverse disorders. Subjects with impulse control disorders, such as pathological gambling,18 multiple impulse control disorders,21 and suicidal inpa-
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tients,22 have demonstrated high trait impulsivity on psychometric measures. Finally, impulsive and antisocial behavior has been associated with high novelty seeking scores on the Tridimensional Personality Questionnaire (TPQ), while anxiety disorders and avoidant behavior have been associated with high TPQ harm avoidance scores.23 In contrast to data on other areas of psychiatric function, personality data on pedophiles is relatively abundant. Nonetheless, systematic study of personality traits with multiple, standardized instruments is lacking. In addition, many investigations study general paraphilias as well as paraphilia-related disorders, which are the excessive practice of otherwise normal sexual behavior.6,24 Different paraphilias are highly comorbid, however, and in one study, 29% of 34 paraphiliacs reported comorbid pedophilia.25 One of the few studies using diagnostic interviews assessed 36 patients with compulsive sexual behavior (CSB), involving paraphilias and/or paraphilia related behavior.24,25 By PDQ/PDQ-R, cluster B disorders were the most common, with borderline (50%), narcissistic (35%), histrionic (35%), and paranoid (32%) the most frequent axis II diagnoses. By the Structured Interview for DSM-IV Personality Disorders (SIDP) and the SIDP-Revised (SIDP-R), histrionic (28%), passive-aggressive (28%), and paranoid (25%) were the most frequently diagnosed personality disorders, followed by narcissistic (19%), avoidant (19%), obsessive-compulsive (17%), and antisocial (14%). Likewise, a study of Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID II) diagnoses in 40 pedophiles noted that cluster B disorders were elevated (33%) but less prevalent than cluster C (43%) disorders.26 Eighteen percent met criteria for a cluster A disorder. Sociopathic traits, however, are a common finding, shown in studies of aggressive sexual offenders6 and pedophiles. On the Minnesota Multiphasic Personality Inventory (MMPI), 113 pedophiles had elevated psychopathic deviancy (Pd) and schizophrenia (Sc) scores.27 Regarding trait impulsivity, clinical reports of sexually aggressive paraphiliacs have noted elevated “thrill-seeking” characteristics28,29 and lifestyles characterized by impulsivity.30 Raymond et al.26 assessed 45 male pedophilic sex offenders by the Structured Clinical Interview for DSM-IV Axis
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I Disorders (SCID I). Sixty percent met criteria for any lifetime psychoactive substance disorder, 29% for any nonsexual impulse control disorder, with 11% for pathological gambling. Data from two studies of patients with compulsive sexual behavior also suggest high rates of comorbid impulsive disorders. In one study of 36 subjects with CSB, 58% met criteria for alcohol abuse/dependence, 33% for drug abuse/dependence, 11% for bulimia, and 6% for pathological gambling.25 In a sample of 26 patients with CSB, 38% met criteria for alcohol abuse/dependence and 29% for drug abuse/dependence.31 Thus data from clinical reports and systematic personality studies supports the notion of pedophilia as an impulsive-aggressive disorder. On the other hand, there is also considerable data suggesting that pedophilia is not well characterized as an impulsive-aggressive disorder. Many studies point to a degree of inhibition in pedophiles, who are often characterized as socially inhibited and selfconscious.4,6,27 Forms of aberrant sexual behavior in pedophiles have been labeled as more passive (e.g., exhibitionism, compulsive masturbation) than those found in rapists.32 High rates of cluster A and C disorders have been reported in addition to cluster B.24-26 Further, consistent findings of elevated Sc scores on the MMPI have led some investigators to postulate that pedophiles are schizotypal.27 Finally, a study of Rorshach ink blot test responses in pedophiles versus nonsexual offenders found that pedophiles had greater ideational productivity and complexity in their responses, arguing against the notion of them as specifically impulsive.33 Thus, there is evidence both supporting and failing to support the hypothesis of pedophilia as an impulsive-aggressive disorder. In the following study, 20 heterosexual male pedophiles and 24 demographically similar, healthy male controls were compared on three personality measures. It was hypothesized that pedophiles would show select impairment on personality measures associated with impulsive-aggression, such as cluster B personality scales. METHOD
Subjects Two groups of subjects were studied. Twenty male subjects with a DSM-IV diagnosis of pedophilia, heterosexual type, were recruited from CAP Behavior Associates, a facility specializing in outpatient treatment of court-referred sexual offend-
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ers. All pedophilia subjects had been convicted of a sexual offense against a prepubescent child (age 13 or younger) when they were at least 18 years of age or were at least 5 years older than their victim. Twenty-four demographically similar control subjects were recruited through advertising in a local newspaper. Exclusion criteria for both groups included substance abuse/dependence within the past 6 months, major medical or neurological disease, and mental retardation. Significant axis I psychiatric disorder (other than pedophilia) was also an exclusion criterion for both groups. For pedophiles, this was defined as any major mood disorder (major depressive disorder, bipolar disorder), psychotic disorder, or significantly debilitating disorder requiring psychiatric hospitalization. For controls, it was defined as any SCID I diagnosis. Further exclusion criteria for controls included any history of pedophilia or of sexual contact with a child of 14 or younger after the age of 16, or with a child of 16 or younger after the age of 18. All subjects expressed sexual attraction to women. One pedophilic subject labeled himself as bisexual.
Procedure This study was approved by the Beth Israel Medical Center Committee on Scientific Activities (COSA). Recruitment. In order to recruit pedophiles, a research assistant visited CAP Behavior Associates and spoke to the clients immediately prior to their group therapy appointment. The research assistant first described the project in general to the assembled group of CAP Behavior Associates clients. Pedophilic patients who expressed interest in the project were interviewed individually, at which point the project was described in greater detail. Interested subjects were scheduled for an appointment at Beth Israel Medical Center for further evaluation and explanation of study protocol. Those who met inclusion/ exclusion criteria and expressed interest in participation signed the COSA-approved informed consent form. Control subjects were screened by phone for initial eligibility. After primary inclusive criteria were met, subjects were interviewed in person by research staff. The study was explained in further detail. All control subjects who met inclusion/exclusion criteria were entered into the study after signing the COSAapproved informed consent form. To further insure eligibility for the study, control subjects then completed a SCID I interview,34 a sexual history questionnaire, and a clinical interview by a psychologist. After signing informed consent and completing initial screening evaluations, a battery of psychometric tests was administered. All subjects were paid $50.00 after they completed the battery of tests.
Materials Personality measures included the following: The Millon Clinical Multiaxial Inventory-II (MCMI-II)35 is a 175-item questionnaire measuring DSM III-R personality disorders as well as several axis I disorders and syndromes. Scale scores were calculated according to the scoring key in the MCMI-II manual.35 No corrections were used in scoring. Only axis II diagnoses were analyzed in this study. The Temperament and Character Inventory (TCI),36 adapted from the TPQ, is a 240-item questionnaire that assesses four dimensions of temperament and three dimensions of character.
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Only harm avoidance and novelty seeking were analyzed in this study. The Dimensional Assessment of Personality Impairment– Questionnaire (DAPI-Q)37 is a 248-item questionnaire that measures personality impairment in 16 scales grouped into six function clusters: regulation of affect (three scales), action (two scales), cognition (two scales), interpersonal function (four scales), self-organization (three scales), and societal function (two scales). The DAPI-Q has been adapted from the DAPI, a semistructured interview.37 For the purposes of this study, we were interested in the subscales putatively associated with impulsive aggression, including regulation of anger, impulse control, antisocial attitudes, and antisocial behavior. The selfinhibition scale, which should not be elevated in impulsiveaggressive groups, was included to provide some discriminative validity. In an attempt to further discriminate impulsive versus inhibited tendencies, six items from the self-assertion scale were averaged to form a dominance subscale and five other items were selected for a submissiveness subscale. As these subscales have fewer items than other scales, they are expected to have lowered psychometric properties.
Statistical Analysis Statistical methods appopriate for group comparisons were utilized. Multivariate analyeses of variance (MANOVAs) with follow-up univariate F tests compared pedophiles and controls on MCMI-II axis II cluster A, B, and C personality scores. Independent t tests were used to compare TCI harm avoidance and novelty seeking scores across groups. The DAPI variables were entered into a single MANOVA. Because of missing data in select scales, however, the individual scales were also compared across groups by t tests, with and without Bonferroni corrections. Analysis was performed on a personal computer using SPSS for Windows version 10.0 (SPSS, Inc, Chicago, IL).
RESULTS
Subjects Pedophiles and Controls did not significantly differ on age, marital status, employment status, or ethnicity (Table 1). Pedophiles did have significantly fewer years of education (12.30 ⫾ 2.6 v 14.54 ⫾ 1.5, t ⫽ ⫺3.51, df ⫽ 42, P ⫽ .001). Pedophiles averaged 38 ⫾ 8 years of age. Twenty percent were African American, 20% European American, and 50% Hispanic. Seventy percent were employed, and 25% were married. Controls averaged 37 ⫾ 10 years of age and 92% employment. Twenty-one percent were African American, 25% European American, and 50% Hispanic. Twenty-five percent were married. Personality Measures Pedophiles scored significantly higher than controls on many of the measures of personality impairment (Table 2). MCMI-II. On the MCMI-II, pedophiles scored higher than controls on cluster A (Hotelling’s T2 ⫽ 0.24, F ⫽ 3.2, df ⫽ 3,40, P ⫽ .035), cluster B (Hotelling’s T2 ⫽ 0.42, F ⫽ 3.2, df ⫽ 5,38, P ⫽ .016), and cluster C (Hotelling’s T2 ⫽ 0.34, F ⫽ 2.6, df ⫽ 5,38, P ⫽ .041) scales. Univariate F tests were significant for all three cluster A scales, three of five cluster B scales, and three of five cluster C
Table 1. Demographic Information 20 Pedophiles and 24 Controls
Age (yr) Years of education Marital status Single Married Separated Divorced Religion Christian Jewish Other None Ethnicity African American European American Asian Hispanic Other Employment Employed
Pedophiles (n ⫽ 20)
Controls (n ⫽ 24)
38.32 ⫾ 8.3 12.2 ⫾ 2.6
36.71 ⫾ 9.7 14.54 ⫾ 1.5
7 (35%) 5 (25%) 3 (15%) 5 (25%)
12 (50%) 6 (25%) 3 (13%) 3 (13%)
15 (75%) 2 (10%) 1 (5%) 2 (10%)
17 (%) 2 (%) 2 (%) 3 (13%)
4 (20%) 4 (20%) 1 (5%) 10 (50%) 1 (5%)
5 (21%) 6 (25%) 1 (4%) 12 (50%) 0 (0%)
14 (70%)
22 (92%)
Significance
t ⫽ .734, df ⫽ 42, P ⫽ .467 t ⫽ ⫺3.51, df ⫽ 42, P ⫽ .001 2 ⫽ 1.56, df ⫽ 3, P ⫽ .669
2 ⫽ .297, df ⫽ 3, P ⫽ .961
2 ⫽ 1.34, df ⫽ 4, P ⫽ .854
2 ⫽ 3.44, df ⫽ 1, P ⫽ .064
NOTE. Age, years of education compared by t test; marital status, religion, ethnicity, and employment compared by 2.
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Table 2. Personality Findings
MCMI-2 Cluster A Schizoid Schizotypal Paranoid Cluster B Histrionic Narcissistic Borderline Antisocial Aggressive-sadistic Cluster C Avoidant Dependant Obsessive-compulsive Passive-aggressive Self-defeating TCI Harm avoidance Novelty seeking DAPI Anger Impulse control Self-inhibition Antisocial attitudes Antisocial behavior Submissiveness Dominance
Pedophiles (n ⫽ 20)
Controls (n ⫽ 24)
20.55 ⫾ 8.1 20.90 ⫾ 17.7 30.90 ⫾ 16.2
16.42 ⫾ 5.1 8.79 ⫾ 6.3 21.50 ⫾ 12.9
34.95 ⫾ 12.3 40.05 ⫾ 14.1 33.00 ⫾ 24.6 34.75 ⫾ 13.9 33.00 ⫾ 12.7
27.58 ⫾ 8.9 34.96 ⫾ 11.0 12.50 ⫾ 13.4 22.92 ⫾ 12.3 26.04 ⫾ 12.2
22.30 ⫾ 16.6 27.05 ⫾ 6.7 37.35 ⫾ 8.1 29.65 ⫾ 17.0 21.25 ⫾ 16.4
10.38 ⫾ 6.9 25.33 ⫾ 5.9 37.54 ⫾ 7.1 17.25 ⫾ 13.3 8.92 ⫾ 8.0
12.55 ⫾ 4.8 19.00 ⫾ 4.1
9.64 ⫾ 4.6 17.50 ⫾ 5.4
1.24 ⫾ 0.9 1.37 ⫾ 1.2 1.72 ⫾ 1.0 1.33 ⫾ 1.0 0.30 ⫾ 0.3 1.35 ⫾ 0.9 1.26 ⫾ 0.7
0.87 ⫾ 0.6 0.59 ⫾ 0.4 0.74 ⫾ 0.8 0.80 ⫾ 0.5 0.07 ⫾ 0.1 0.73 ⫾ 0.8 0.43 ⫾ 0.5
Statistic (df )
P Value
Hotellings T2 ⫽ .24 (3,40) F ⫽ 4.21 (1,42) F ⫽ 9.74 (1,42) F ⫽ 4.59 (1,42) Hotellings T2 ⫽ .42 (5,38) F ⫽ 5.27 (1,42) F ⫽ 1.81 (1,42) F ⫽ 12.28 (1,42) F ⫽ 8.93 (1,42) F ⫽ 3.42 (1,42) Hotellings T2 ⫽ .34 (5,38) F ⫽ 10.23 (1,42) F ⫽ .081 (1,42) F ⫽ 0.01 (1,42) F ⫽ 7.35 (1,42) F ⫽ 10.60 (1,42)
.035* .046* .003† .038* .016* .027* .186 .001‡ .005† .072 .041* .003† .373 .934 .010† .002†
t ⫽ 1.459 (40) t ⫽ 1.013 (40) Hotellings T2 ⫽ .836 (7,28) t ⫽ 1.50 (38) t ⫽ 2.70 (20.7) t ⫽ 3.58 (41) t ⫽ 2.18 (39) t ⫽ 3.54 (21.5) t ⫽ 2.34 (39) t ⫽ 4.48 (39)
.053 .317 .010† .141 .013 .001§ .036 .002§ .025 .000§
*P ⱕ .05. †P ⱕ .01. ‡P ⱕ .001. §For DAPI, P ⱕ Bonferroni corrected value of .007.
scales. To assess the selectivity of cluster B pathology in pedophilia, the number of subjects who exceeded cut-off points for each disorder in each cluster was calculated and compared across groups. Groups did not differ in mean number of scores above cut-off points for either cluster B or C disorders. For cluster A disorders, however, pedophiles had marginally more scale scores above cut-off points than did controls (0.7 ⫾ 1.2 v 0.1 ⫾ 0.4; t ⫽ ⫺2, df ⫽ 23.29, P ⫽ .057). DAPI-Q. When all seven DAPI scale scores were entered into a single MANOVA, the overall MANOVA yielded significant differences across groups (Hotelling’s T2 ⫽ .836, df ⫽ 7,28, P ⫽ .010). On univariate F tests, pedophiles scored higher than controls on antisocial behavior, impulse control, self-inhibition, dominance, and submissiveness. There were no differences on antisocial atti-
tudes and anger. As only 36 cases were entered into the MANOVA, due to the large amount of subjects who failed to answer select scales, independent t tests were performed on each scale. By independent t tests, pedophiles scored higher than controls on all scales but regulation of anger. After Bonferoni correction, however, only dominance, self inhibition, and antisocial behavior maintained significance (Table 2). TCI. There was no difference between groups on novelty seeking. Moreover, contrary to our predictions, pedophiles scored marginally higher than controls on harm avoidance (19 ⫾ 4.1 v 17.50 ⫾ 5.4; t ⫽ 1.5, df ⫽ 40, P ⫽ .053). DISCUSSION
In the present study, 20 male pedophiles were compared to 24 healthy male controls on three measures of impulsive-aggressive personality traits.
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The data as a whole suggest severe and pervasive personality impairment in pedophiles. Although there was evidence of significant cluster B pathology on MCMI-II, the MCMI-II results do not support the selectivity of cluster B pathology in this sample of heterosexual, male pedophiles. Consistent with the MCMI-II, DAPI-Q results support the presence but not the selectivity of impulsive-aggressive traits. Results on TCI also failed to support evidence of impulsivity, with no difference across groups in novelty seeking and marginally higher harm avoidance scores in pedophiles. Our findings on the personality data are not consistent with the literature on impulsive-aggressive and impulsive groups, in which a predominance of cluster B disorders18-20 are consistently demonstrated as well as elevated novelty seeking and lowered harm avoidance on the TCI.23 Nor is our data consistent with several studies in the pedophilia literature that demonstrate high rates of cluster B disorder,24-26 as well as elevated thrill seeking traits,28,29and nonsexual impulse control disorders.24,25,31 Nonetheless, our study is consistent with several other studies that suggest pedophilia is not well characterized by impulsiveaggression. Although there were signs of impulsivity in the current study, impulsive personality traits did not predominate, and cluster A pathology on MCMI-II may have been more salient than cluster B pathology. This is consistent with an earlier study of axis II diagnoses in pedophiles, in which cluster B disorders were elevated but less predominant than cluster C disorders.26 In fact, shyness, introversion, and lack of assertiveness have been frequently documented in pedophiles,4,38 although the stereotype of the shy, inhibited pedophile is a matter of some controversy.3,39 Similarly, in our companion study with the same sample,40 pedophiles did not demonstrate impairment on measures of executive functions, contradicting the notion of inadequate cognitive mediation of behavior. Likewise in a 1967 study by Gebhard et al.,41 it is noted that “80% or more of the acts engaged in by all of the pedophile groups were planned, not impulsive.”4 Moreover, despite strong evidence of antisocial traits in the current sample, there was not evidence of excessive aggression. Several other studies suggest disinhibited aggression is not characteristic of
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pedophiles,3,42 even of those who commit sexually aggressive acts.43 The study is not without limitations, however, and all conclusions must be drawn with caution. Our sample size was relatively small and groups were not identical in size. Despite rigorous attempts to select a homogeneous group of heterosexual, male pedophiles, one subject identified himself as bisexual. We did not use direct measures of impulsivity and aggression but relevant subscales of more general personality measures. Moreover, the generalizability of our results is hampered by the heterogeneity of pedophile populations. Study subjects represent a particular subset of the total population of pedophiles, those who have been convicted of sexual abuse but are not in the prison system. Self-selection biases may have restricted our sample further. The control group, though rigorously screened, may be an inherently impulsive group due to their response to recruiting tactics. Finally, pedophiles are notoriously unreliable informants. Moreover, concern about confidentiality and the impact on their legal status may have led subjects to minimize their impulsiveaggressive features. Nonetheless, our study is one of few systematic investigations of impulsive personality traits in male pedophiles, which utilized stringent inclusion/exclusion criteria for pedophiles and controls along with multiple measures to assess personality pathology. Hence, despite the above limitations, it is worthwhile to consider possible interpretations of the data. First, we can hypothesize that the failure to inhibit pedophilic sexual urges may not be due to a global deficit in cognitive impulse control, but rather to other cognitive or motivational mechanisms. Cognitive distortions and denial of the implications of pedophilic behavior have been widely documented44 and are consistent with our findings of elevated cluster A scores. In other words, pedophiles’ inhibitory failure may be due less to an inability to conceptualize consequences, than to a propensity to distort the implications of their behavior. Likewise, a lack of motivation to inhibit pedophilic urges is consistent with an antisocial profile. The notion that pedophilia is not well characterized as an impulsive-aggressive disorder also raises the possibility of compulsive features in
IMPULSIVE PERSONALITY TRAITS IN PEDOPHILES
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pedophilia. In fact, Balyk45 hypothesized pedophilia to be an obsessive-compulsive spectrum disorder. Compulsivity has been described as the complement of impulsivity.14 Whereas impulsive behavior is motivated to produce pleasure and is insufficiently mediated by the cognitive consideration of consequences, compulsive behavior is motivated to reduce anxiety and is associated with heightened ideational activity.14 Our findings, including marginally elevated harm avoidance on the TCI and increased self-inhibition on the DAPI-Q, are consistent with compulsive features. Further research could also investigate the possibility of “compulsive-aggression” as opposed to impulsiveaggression. The fact that pedophiles volitionally engage in behavior that has a profoundly damaging impact on its victims along with the common finding of antisocial traits raises the question of aggressive traits in pedophiles even if such aggression is not associated with impulsivity. Aggression may be over-controlled and indirectly expressed, perhaps in the form of severe passive-aggression. In fact, in our study, pedophiles scored higher than controls on the MCMI-II passive-aggressive scale (F ⫽ 7.35, df ⫽ 1.42, P ⫽ .01). Black et al., in
their sample of CSB patients, also reported high rates of passive-aggressive and obsessive-compulsive personality disorders.25 As the behavioral and pharmacological treatments of compulsive and impulsive disorders are quite different, the relationship between impulsivity, compulsivity and aggression in pedophiles merits further study. In conclusion, the present study investigated the question of whether pedophilia is well characterized as an impulsive-aggressive disorder. We hypothesized that pedophiles would demonstrate a predominance of impulsive-aggressive personality traits. Despite evidence of pervasive personality impairment, impulsive-aggressive traits were present but not predominant. We conclude that pedophilia might not be well characterized as an impulsive-aggressive disorder and may even involve compulsive or compulsive-aggressive features. Such notions have implications for pharmacological and psychotherapeutic interventions and merit further study. Given the widely documented sequelae of childhood sexual abuse, further psychiatric investigations of the psychopathology and pathophysiology of pedophilia are clearly warranted.
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