AN INTEGRATIVE LITERATURE REVIEW ...

AN INTEGRATIVE LITERATURE REVIEW ASSESSING THE NEED FOR A HEALTH EDUCATION INTERVENTION FOR ADULTS WITH PEDOPHILIA IN ALABAMA

by LYNN V. ENGLISH

LARRELL L. WILKINSON, PhD, COMMITTEE CHAIR LAURA T. FORBES, PhD WAJIH AHMAD, PhD

A THESIS Submitted to the graduate faculty of the University of Alabama at Birmingham in partial fulfillment of the requirements for the degree of Master of Arts in Education BIRMINGHAM, ALABAMA 2014

Copyright by Lynn V. English 2014

AN INTEGRATIVE LITERATURE REVIEW ASSESSING THE NEED FOR A HEALTH EDUCATION INTERVENTION FOR ADULTS WITH PEDOPHILIA IN ALABAMA LYNN V. ENGLISH HEALTH EDUCATION ABSTRACT The purpose of this study was to assess the need in the State of Alabama for a health education intervention for adults with pedophilia. Following the PRECEDE half of the PRECEDE-PROCEED planning model, the author examined the health issue of pedophilia within the State of Alabama. There are three constructs by which a health issue may be examined using PRECEDE: Predisposing, Reinforcing, and Enabling. The extant literature on pedophilia and child sexual abuse (CSA) was reviewed organized by these constructs. PRECEDE also consists of five assessment phases: social assessment; epidemiological assessment; behavioral assessment; educational, environmental, and ecological assessments; and administrative and policy assessments. The actual study followed the guidelines of these assessment phases: first, by assessing the social structure of Alabama; next, by conducting a count of the state’s sex offender registry by county, then aggregating the data into established public health regions and analyzing the data for prevalence; third, by presenting the medical and legal definitions of pedophilia; fourth, by exploring the attitudes, knowledge, and beliefs about the disease; and finally, looking at the laws as they exist on Alabama’s books. The results of the literature review revealed pedophilia is a health issue. From the myriad health problems experienced by survivors to the cognitive distortions, addictive

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behaviors, and brain aberrations suffered by the offenders themselves; health is a constant problem for all involved in childhood sexual abuse (CSA). The results of the epidemiological assessment revealed the highest prevalence was in public health regions comprised exclusively of rural counties; the median prevalence was in public health regions comprised of majority rural counties but with some urban counties mixed in; finally, the lowest prevalence was in public health regions comprised exclusively of urban counties. This paper was conducted as a needs assessment for a health education intervention for adults with pedophilia in Alabama, because the author believed that writing a treatment program for pedophiles was needed in the state. The results of the study indicated a potential need for such a program in Alabama’s rural areas; such a program may be beneficial in reducing CSA in those areas.

Keywords: Alabama, Child Sexual Abuse, CSA, Health, Pedophile, Pedophilia

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TABLE OF CONTENTS Page ABSTRACT

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LIST OF TABLES

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LIST OF FIGURES

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CHAPTER 1: INTRODUCTION

1

A Brief History

1

A Current View

3

CHAPTER 2: LITERATURE REVIEW

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The Problem Addressed Federal Government State Governments Nationwide Alabama Statistics Theory What the Literature Reveals Database Search Literature Review Predisposing Factors Reinforcing Factors Enabling Factors CHAPTER 3: METHODOLOGY

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Phase 1 Social Assessment Phase 2 Epidemiological Assessment Phase 3 Behavioral Assessment

60 60 61 61 68 68

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10 10 13 13 14 17 17 18 19 27 38

Phase 4 Environmental, Educational, and Ecological Assessment Phase 5 Administrative and Policy Assessment

69 69 72 72

CHAPTER 4: RESULTS

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Phase 1 Phase 2 ADPH Region 1 ADPH Region 2 ADPH Region 3 ADPH Region 4 ADPH Region 5 ADPH Region 6 ADPG Region 7 ADPH Region 8 ADPH Region 9 ADPH Region 10 ADPH Region 11 State of Alabama Phase 3 Phase 4 Phase 5

74 76 79 84 89 94 99 104 109 114 119 124 129 134 143 145 148

CHAPTER 5: DISCUSSION

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Limitations and Strengths

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Recommendations

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LIST OF REFERENCES

171

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LIST OF TABLES Table

Page

4.1.1

The available data for the six counties comprising ADPH Region 1

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4.1.2

U.S. Census (2010) demographic breakdown of the populations of the counties comprising ADPH Region 1

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4.1.3

Demographic data of Region 1 offenders on ALSOR, obtained from the count of the registry

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4.1.4

Age demographics of Region 1 offenders on ALSOR, obtained from the count of the registry

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4.1.5 Resources available to ADPH Region 1

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4.2.1

The available data for the seven counties comprising ADPH Region 2

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4.2.2


86

4.2.3


87

4.2.4


87


88

4.3.1


89

4.3.2


91

4.3.3


92

4.3.4


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4.3.5 Resources available to ADPH Region 3 vii

93

4.4.1

The available data for Jefferson, the one county comprising Region 4

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4.4.2

U.S. Census (2010) demographic breakdown of the population of Jefferson County (ADPH Region 4)

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4.4.3


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4.4.4


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4.4.5

Resources available to Jefferson County (ADPH Region 4)

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4.5.1


99

4.5.2


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4.5.3


102

4.5.4


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4.5.5

Resources available to ADPH Region 5

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4.6.1

The available data for the eight counties comprising ADPH Region 6

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4.6.2


106

4.6.3


107

4.6.4


107

4.6.5


108

4.7.1


109

4.7.2


111

4.7.3


112

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4.7.4


112

4.7.5


113

4.8.1


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4.8.2


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4.8.3


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4.8.4


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4.8.5


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4.9.1


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4.9.2


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4.9.3


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4.9.4


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4.9.5


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4.10.1 The available data for the eight counties comprising ADPH Region 10

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4.10.2 U.S. Census (2010) demographic breakdown of the populations of the counties comprising ADPH Region 10

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4.10.3 Demographic data of Region 10 offenders on ALSOR, obtained from the count of the registry

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4.10.4 Age demographics of Region 10 offenders on ALSOR, obtained from the count of the registry

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128

4.11.1 The available data for Mobile, the one county comprising Region 11

129

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4.11.2 U.S. Census (2010) demographic breakdown of the population of Mobile County (ADPH Region 11)

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4.11.3 Demographic data of Region 11 offenders on ALSOR, obtained from the count of the registry

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4.11.4 Age demographics of Region 11 offenders on ALSOR, obtained from the count of the registry

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4.11.5 Resources available to Mobile County (ADPH Region 11)

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4.12.1 The available data for the state from each of the regional summaries

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4.12.2 U.S. Census (2010) demographic breakdown of the population of Alabama

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4.12.3 Demographic data of Alabama sex offenders on ALSOR, obtained from the count of the registry

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4.12.4 Age demographics of Alabama sex offenders on ALSOR, obtained from the count of the registry

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4.12.5 Resources available to the State of Alabama, according to the 2010 U.S. Census

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4.12.6 Prevalence of sex offenders per 100,000 population; proportion of pedophiles to sex offenders; and prevalence of pedophiles per 100,000 population

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4.12.7 Human resources available to the State of Alabama via ADPH Regions

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4.12.8 Financial resources available to the State of Alabama via ADPH Regions

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LIST OF FIGURES Figure

Page

2.1

Diagram of Reciprocal Determinism

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2.2

Constructs of SCT

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3.1

Diagram of the PRECEDE-PROCEED Model

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3.2

Demographic Count Sheets

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3.3

“Dummy” Sheet

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3.4

Literature Review Map

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4.1.1

Region 1 Sex Offenders

80

4.2.1


85

4.3.1


90

4.4.1


95

4.5.1


100

4.6.1


105

4.7.1


110

4.8.1


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4.9.1


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4.10.1 Region 10 Sex Offenders

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4.11.1 Region 11 Sex Offenders

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4.12.1 State Sex Offenders

136

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CHAPTER 1: INTRODUCTION “One girl in four, one boy in six; on average, one person in five survives childhood sexual abuse (CSA), and 98% of all pedophiles are also survivors,” (Personal communication, Deegan Malone, Summer 2009, citing statistics from the Adverse Childhood Experiences Survey, 1997). Pedophilia is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, 2000) as a paraphilic sexual disorder in which an individual 16 years or older has intense urges or fantasies about prepubescent children, and either acts on those urges or fantasies or suffers marked distress or interpersonal difficulties as a result. A Brief History Although the practice of adults having sex with children is recorded in ancient writings, pedophilia and child sexual abuse is a relatively modern problem. The difference has been in how the society has viewed the behavior. According to the Love Stories found in Plutarch’s Morals, the ancient Greeks practiced pederasty, in which a young boy (usually between eight and twelve years of age) moves in with a mature man. The man mentors the boy, and they live in a sexual arrangement. The ancient Hebrews practiced what today would be considered child marriages. According to Rich (2011), the minimum age appropriate for marriage in ancient times was 13 for boys, 12 for girls. The betrothal – or engagement – usually took place a year or two earlier. This was a business deal – marriage for love was uncommon in those days, and men were permitted as many wives as they could afford. And yet, we read in Genesis that Lot, anxious not to commit the grave sin of inhospitality, offered his young daughters – “who have not yet 1

reached the age of marriage” – to his neighbors “to do with as you will” so that his neighbors will not rape his visitors – who are actually angels from God. (Genesis 19:113; NIV). Later in the chapter we learn that Lot’s daughters are betrothed. If the marriage age for girls was 12, and Lot is offering his daughters, who have not reached marriageable age but are betrothed, then he is offering his pre-pubescent daughters – roughly 10 or 11 years old – to be sexually abused by his neighbors. So, if the practice of adults having sex with children has been around for millennia, and has been widely accepted for much of that time, why is it that now it is viewed as a sick perversion? Katherine Beckett, as published in Social Problems (1996), addressed this phenomenal change. As she states: “Child abuse did not receive a significant degree of attention in the United States until the 1960s,” (Beckett, 1996), p. 59). She goes on to explain that the American Humane Society (an outgrowth of the American Society for the Prevention of Cruelty to Animals, or ASPCA) and other, private, child-protection specialists introduced the concept of child abuse with their focus on child neglect in the 1950s. The concept of abuse widened to include physical abuse in the 1960s when pediatric radiologists began using X-rays to document broken bones. “In the late 1940s doctors attributed children’s broken bones, bruises, and other injuries to ‘internal medical causes,’ but by the early 1960s they were diagnosed as evidence of ‘battered child syndrome,’ (Beckett), p. 59). The Children’s Bureau (established by President Taft in 1912) took on the newlyidentified problem of child abuse, and made a policy recommendation for the development of a model child abuse reporting law. “Between 1963 and 1967, all states and the District of Columbia passed legislation mandating that teachers, doctors, and

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other professionals report suspected child abuse to authorities,” (Beckett, 1996), p. 60). For states to qualify for federal money, the federal government required they adopt a uniform definition of abuse, and in 1974 passed the Child Abuse Prevention and Treatment Act (CAPTA) providing a guideline for this uniform definition. Ignoring socioeconomic factors associated with child abuse, CAPTA adopted a narrow construct that included sexual abuse. Beckett’s study is explored in further detail in Chapter 2, the Literature Review. A Current View The State of Alabama has declared both the behavior of child sexual abuse and the associated disease of pedophilia as felonies (Ala. Code § 13A-6-69, 1967; Ala. Code § 13A-6-69.1, 2006; Ala. Code § 13A-6-111, 1997; Ala. Code § 13A-6-121, 2009; Ala. Code § 13A-6-122, 2009; Ala. Code § 13A-6-124, 2009; and Ala. Code § 13A-6-125, 2009). The state codes, and Ala. Code § 13A-5-6 sentences of imprisonment for felonies, outline very specifically which punishment goes with which offense. The offenses, and their respective punishments, range from Class A felony (life, or not more than 99 years or less than 10 years), to Class B felony (not more than 20 years or less than two years), to Class C felony (not more than 10 years or less than one year and one day). However, imprisonment is always the consequence. It is believed by the author that offenders do not offend with intent to do harm, rather they act in response to a health issue. Three types of factors exist that address health issues: predisposing factors, reinforcing factors, and enabling factors. Research into the disease of pedophilia and its symptom of child sexual abuse can be viewed through the lens of these three factors.

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“Predisposing factors are antecedents to behavior that provide the rationale or motivation for the behavior; they include individuals’ knowledge, attitudes, beliefs, personal preferences, existing skills, and self-efficacy beliefs,” (Gielen, McDonald, Gary, & Bone, 2008), p. 415). Predisposing factors of pedophilia include the disease itself (Mackaronis, Strassberg, & Marcus, 2011), physical responses to erotic suggestion (Blanchard, Klassen, Dickey, Kuban, & Blak, 2001; Freund & Blanchard, 1989), addictive behaviors (Cohen, Nesci, Steinfeld, Haeri, & Galynker, 2010), and mental impairment (Hucker et al., 1986; Schiffer et al., 2008; Walter et al., 2006). “Reinforcing factors are those factors following a behavior that provide continuing reward or incentive for the persistence or repetition of the behavior. Examples include social support, peer influence, significant others, and vicarious reinforcement,” (Gielen et al., 2008), p. 415). Reinforcing factors of pedophilia look at how being a survivor of CSA impacts an individual’s adult life (Camuso & Rellini, 2010; Colangelo & Keefe-Cooperman, 2012; Finkelhor, Turner, Hamby, & Ormrod, 2011; Hill, Vernig, Lee, Brown, & Orsillo, 2011; Leahy, Pretty, & Tenenbaum, 2003; Wilson, 2010) and the sexually charged portrayal of young children in the media (Babchishin, Nunes, & Hermann, 2013; Byers, Sears, & Weaver, 2008; Durham, 2009; Gavin, Roche, Ruiz, Hogan, & O'Reilly, 2012; Gill, 2012; Gillman & Whitlock, 1987; Goodin, Van Denburg, Murnen, & Smolak, 2011; Graff, Murnen, & Smolak, 2012; Janssen, 2012; Malon, 2011; Moore & Gebbie, 1996; Near, 2013; Pfaus et al., 2012; Senn, Carey, & Coury-Donleger, 2012; Starr & Ferguson, 2012; Tribunella, 2012; Wollek, 2011). “Enabling factors are antecedents to behavioral or environmental change that allow a motivation or environmental policy to be realized. …They include programs,

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services, and resources necessary for behavioral and environmental outcomes to be realized and, in some cases, the new skills needed to enable behavior change,” (Gielen et al., 2008), p. 415). Internal factors that enable pedophilia consist of surviving child abuse, including CSA (Seifert, Polusny, & Murdoch, 2011) and prior consumption of pornography (Eke, Seto, & Williams, 2011; Endrass et al., 2009; Howitt & Sheldon, 2007). External factors that enable pedophilia consist of policy factors (Lussier & Davies, 2011; Prentky, Lee, & Knight, 1997), social factors (Dar-Nimrod, Heine, Cheung, & Schaller, 2011; Russell & Giner-Sorolla, 2011), and any combination of policy and social factors (Maguire, 2009). Some readily observed gaps in the literature discussing pedophilia are: 1) the identification of adults with pedophilia – for example, not every CSA case is reported, and not every child molester meets all diagnostic criteria for pedophilia (Harvard Medical School, 2010); 2) Only men are identified as exhibiting pedophilic tendencies; however, a previous experience in clinical work with a female patient with pedophilia made the author aware that all people are susceptible to the disease; 3) A lack of consensus among the professions which deal with sufferers – medical, psychological, social, and criminal justice – regarding the most efficient treatment of the disease (Pogge & Stone, 1990). Traditionally the fields of psychology, sociology, and criminology have been the leaders in addressing this problem. The author believes pedophilia and CSA belong under the domain of “health issue” rather than “criminal issue” and in this study intends to assess the need Alabama has for a health education intervention for adults with pedophilia by determining the prevalence of pedophilia within each county, aggregated into public

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health regions. This will be accomplished by an epidemiological count of the Alabama Sex Offender Registry (ALSOR).

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CHAPTER 2: LITERATURE REVIEW One girl in four, one boy in six; on average, one person in five is a survivor of childhood sexual abuse (CSA), and an estimated 98% of perpetrators are also survivors of CSA (Personal Communication, Deegan Malone, 2009; citing the 1997 ACES Report). According to the United States Census Bureau, the 2010 Census reported 4,779,736 residents of the State of Alabama, of which 51.5% (or 2,461,564) are female. Considering the above statistics that means almost one million Alabamians are survivors of CSA, and just over half of these survivors are female. The word pedophilia first appeared in a report abstract by Krafft-Ebing in 1900, the derivative pedophilic first appeared in 1920, and the further derivatives pedophile and pedophiliac first appeared in 1951. The word pedophilia was coined by merging two Greek words, paidos, meaning child, and philios, meaning love. Thus the word used to describe the social problem of the rape of a child is a misnomer, literally translating to child love. If the word pedophilia, and its derivatives, did not appear in the lexicon until the 20th century, how long has the practice of adults having sex with children been going on? As explored in chapter one, texts from ancient writers such as the Greek Plutarch and the Hebrew author of Genesis have recorded accounts of adult-child sex, and report the practice was both common and socially encouraged. So exactly when did a common, socially encouraged practice become a social problem, and identified as a disease?

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Beckett (1996) gave both a timeline, and the rationale behind this change in her article Culture and the politics of signification: The case of child sexual abuse. According to Beckett’s timeline, it was not until the 1960s that child abuse gained national attention. In the 1950s, the American Humane Society, the American Society for the Prevention of Cruelty to Animals (ASPCA), and other not-for-profit groups began focusing national attention on child neglect. In the 1960s, the concept of child abuse widened from neglect only to include physical abuse. The federal government, through the Children’s Bureau, made a policy recommendation for the reporting of suspected child abuse, and by the mid-1960s, every state had a law identifying teachers, doctors, and other professionals as mandated reporters. In order for states to receive federal funds, the federal government required them to adopt a uniform definition of child abuse, and in 1974, the Child Abuse Prevention and Treatment Act (CAPTA) was passed, providing that uniform definition, which included sexual abuse. Using frame analysis techniques and organizing the frames into interpretive packages, Beckett (1996) then addressed the introduction of the concept of CSA into modern American culture by examining mainstream media over the course of 15 years. Seven packages were identified regarding CSA: Positive Pedophilia; Collective Denial; Male Prerogative (a Collective Denial sub-package); Survivors Speak (a Collective Denial sub-package); False Accusations; Official Misconduct (a False Accusations subpackage); and False Memories (a False Accusations sub-package). Between 1980 and 1984, Collective Denial was the dominant frame of reference – “valid indicators of a previously ignored social problem,” (Beckett, p. 68). In response, over the next six years (1985-1990) the frame False Accusations (along with its sub-package Official

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Misconduct) emerged and ascended into the public view. The final four years of her examination (1991-1994), saw the re-emergence of both Collective Denial with its subpackage Survivors Speak, and False Accusations with its sub-package False Memories. Beckett (1996) looked to three factors that influenced the shifting perceptions over the fifteen-year period: “the activities of claims makers or sponsors of the various packages, media practices, and cultural resonances,” (Beckett, p. 71). She then went on to illuminate the founding of two False Accusations sponsor groups: Victims of Child Abuse Laws (VOCAL) and False Memory Syndrome Foundation (FMSF). These two groups have been strong voices, primarily because of their objective to influence media coverage. Conversely, Positive Pedophilia and Male Prerogative lack strong supporting groups, and therefore have been effectively nullified in the discussion. The second factor named – media practices – speaks to the insidious influence media has on cultural definition. Media have a flair for the dramatic, as exemplified by a memo from NBC executive Reuven Frank to his staff: “Every news story should, without any sacrifice of probity or responsibility, display the attributes of fiction, of drama,” (Beckett, 1996, p. 72). The fact that Collective Denial along with its subpackage Survivors Speak, and False Accusations with its sub-packages Official Misconduct and False Memories, have victims to promote and “display the attributes of fiction, of drama” helps to explain why these packages have flourished. Her third and final factor – cultural themes and resources – explains the saliency of the themes. Because culture is by nature ambivalent, one theme cannot exist without its countertheme. So, when the thematic package Collective Denial propelled the theme of children as innocent victims, it allowed for the rise of the thematic package False

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Accusations and its theme of children as malicious and manipulative beings reacting against parental or adult control. It is the complexity of cultural discourse that makes possible disarticulation and rearticulation of issue frames; the process of severing, realigning, and recombining such discourse makes ideological transformation possible. Thus, while the behavior of adults having sex with children is as old as mankind, the identified problems of CSA and pedophilia are thoroughly modern. The Problem Addressed Federal Government Healthy People is the nation’s health barometer. Every decade, the government produces an update to Healthy People, addressing the health topics currently facing the nation. The current edition of Healthy People is Healthy People 2020. A search of the Healthy People website (healthypeople.gov) using the keyword “pedophilia” yielded the following result: “Your search – pedophilia – did not match any documents. No pages were found containing ‘pedophilia’”. A second search using the more general keyword “sex offense” yielded 12 results. Of these twelve results, two discussed violent crimes (attack, threatened attack, kidnapping, attempted kidnapping, and hate crime or bias); two discussed substance abuse; two discussed mandatory ignition lock laws for impaired drivers; two discussed norms and attitudes, exposure to crime and demographics; and four discussed adolescent health issues. None discussed the health issue of pedophilia. A search of the CDC website revealed the result of the 1997 Adverse Childhood Experiences Survey (ACES). These statistics were first introduced to the author in 2009, while taking a class on “The Dynamics of Child Sexual Abuse” taught by a mental health counselor who specialized in treating adolescent offenders. Other than ACES, the

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nation’s doctors and health researchers revealed no information regarding CSA and pedophilia. So, if adult-child sex is not on the nation’s health barometer, nor a current concern of the nation’s doctors and health researchers, where does the federal government address this health issue? An investigation of the U.S. Department of Justice (DOJ, n.d.) website revealed the department is comprised of 53 agencies. Of these agencies, the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking (SMART, n.d.) was the site perceived to be most closely associated with the topic. The home page of the SMART website explains what the office does: “The SMART Office was authorized in the Adam Walsh Child Protection and Safety Act of 2006, which was signed into law on July 27, 2006. The responsibilities of the SMART Office include providing jurisdictions with guidance regarding the implementation of the Adam Walsh Act, and providing technical assistance to the states, territories, Indian tribes, local governments, and to public and private organizations. The SMART Office also tracks important legislative and legal developments “related to sex offenders and administers grant programs related to the registration, notification, and management of sex offenders,” (para. 1-2). Links to web pages for two subsites – Sex Offender Registration and Notification Act (SORNA, n.d.) and Comprehensive Approach to Sex Offender Management (CASOM, n.d.) – were also found on the SMART home page. The pages for SORNA and CASOM explain their function within SMART: “SORNA refers to the Sex Offender Registration and Notification Act which is Title I of the Adam Walsh Child Protection and Safety Act of 2006 (Public Law 109-248). SORNA provides a comprehensive set of minimum standards for sex offender registration and notification in the United States. SORNA aims to close potential gaps and loopholes that existed under prior law and generally strengthens the nationwide network of sex offender registration and notification programs. Additionally, SORNA: 11

      

Extends the jurisdictions in which registration is required beyond the 50 states, the District of Columbia, and the principal U.S. territories, to include also federally recognized Indian tribes. Incorporates a more comprehensive group of sex offenders and sex offenses for which registration is required. Requires registered sex offenders to register and keep their registration current in each jurisdiction in which they reside, work, or go to school. Requires sex offenders to provide more extensive registration information. Requires sex offenders to make periodic in-person appearances to verify and update their registration information. Expands the amount of information available to the public regarding registered sex offenders. Makes changes in the required minimum duration of registration for sex offenders.”

SORNA addresses the national sex offender registry, CASOM speaks to treatment of sex offenders. According to the CASOM website: “The evolution of sex offender management has brought about changes in the ways that criminal justice professionals supervise and treat offenders, as well as the ways in which they communicate and collaborate with others involved in the management of sex offenders. Sex offender management is much more than simply supervision and treatment conducted by a few knowledgeable individuals in a community, effective sex offender management necessitates a comprehensive approach, one that the SMART Office supports. The Comprehensive Approach to Sex Offender Management is a framework that has been developed to define and encourage a strategic and collaborative response to managing sex offenders and reducing recidivism. The Comprehensive Approach offers a promising and well–grounded framework that jurisdictions can consider using to build an informed, integrated set of policies and practices to promote the shared goal of ensuring victim and community safety.” The CASOM website goes on to discuss funding grants they make available to state SOTPs. Thus, the federal government mandates state registration of sex offenders, and provides a template for the registries; and also encourages states to create sex offender treatment programs and provides grant monies to help fund them. But the federal government is not directly involved in treatment of sex offenders. And the federal government does not acknowledge pedophilia to be a health issue.

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State Governments Nationwide In 2000, the State of Colorado (CO) Department of Corrections (DOC) hired Paula Wegener, a consultant, to conduct a survey of all 50 states and the District of Columbia (DC) regarding Sex Offender Treatment Programs (SOTPs). Forty-three states and DC responded to the 21-page, 78 question survey. The survey addressed such areas as legislative influence on programs and program designs within prison systems. Many responding states included program tools such as curriculum, assessment tools, and standards of care with their survey responses. Of the 51 self-governing entities comprising the United States, 49 were found to provide some type of intervention for sex offenders. The only two who do not? Alabama and Mississippi. The purpose of this study is to assess the need for a health education/health promotion intervention program for adults with pedophilia in Alabama. Alabama Statistics The Alabama Department of Public Health (ADPH) manages the state’s equivalent of Healthy People. A search of the ADPH website (http://www.adph.org/) revealed the state has one agency that addresses sex offenses – the Alabama Coalition Against Rape (ACAR) – a statewide nonprofit agency with 15 member rape crisis centers. “ACAR provides training and educational resources to law enforcement personnel, hospital, universities, schools, prosecutors, legislatures and the public.” (http://www.acar.org/). The ACAR website also offered these statistics: “According to the most recent National Crime Victimization Survey, 169,370 female rapes or sexual assaults were reported to law enforcement. In 73% of these cases, the victims knew or were related to the offender. In Alabama, 1,404 rapes were reported to law enforcement.

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About 55% of these rapes were committed by someone the victims knew. Nearly 31% of these victims were between the ages of 13 and 16.” These statistics illuminate another problem: not all incidents are reported. There are two Department of Justice websites for Alabama: the Middle District of Alabama DOJ and the Southern District of Alabama DOJ. The websites for these two DOJ are actually the websites of the U.S. Attorney’s Office in Alabama and their stated purpose is to educate the public on the role of the U.S. Attorney in upholding the law and securing justice for the region. These websites do not speak to Alabama’s legislation. However, a search of the Alabama Legislative Information System Online (ALISON) provided the state’s legislation – the crime and punishment – for pedophilia. These statutes appear later in this paper; however, a thorough examination reveals the only treatment approved for sex offenders – and pedophiles in particular – in Alabama is imprisonment. Theory There are two types of theoretical models in health education: explanatory theories and design models. Explanatory theories are theories which help to explain a particular health issue, while design models are blueprints for creating intervention programs. The explanatory theory that best fits pedophilia is the Social-Cognitive Theory (SCT). SCT, created by Bandura in the 1970s, was first known as Social Learning Theory (SLT), because “it was based on the operation of established principles of learning within the human social context,” (McAlister, et.al., 2008, p. 170). In the 1990s the name changed to SCT when it was expanded to include constructs from cognitive psychology – constructs that addressed growing concepts of human capabilities

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to process information and the biases that influence these capabilities. There are nine constructs of SCT, and the foremost construct also provides a visual diagram of the theory. The nine constructs – illustrated through the lens of pedophilia – and the diagram illustrating the theory appear below.

Figure 2.1; Diagram of Reciprocal Determinism PERSON

RECIPROCAL DETERMINISM Illustrating how the person and their environment interact to influence each other and the targeted behavior.

ENVIRONMENT

BEHAVIOR

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Figure2.2; Constructs of SCT CONSTRUCT Reciprocal Determinism

DEFINITION Environmental factors influence individuals and groups, but individuals and groups can also influence their environments and regulate their own behavior.

ILLUSTRATION Perpetrators are taught CSA as children, thus, the environmental influence on the person; as adults, perpetrators offend against children, thus, the person's influence on their environment. Both factors work together to influence the behavior of CSA. Outcome Belief about the likelihood and "I expect to experience sexual gratification if Expectations value of the consequences of I engage in CSA; my abuser did not suffer behavioral choice negative consequences for abusing me, why should I expect to suffer negative consequences for molesting a child?" Self Efficacy Beliefs about personal ability to "My daughter lives in my house, I will be perform behaviors that bring alone with her on Friday. I can do as I please desired outcomes with her, and I am confident she will not tell ‐ I can do this without threat of any unpleasant consequence ‐ because she has not told so far." Collective Beliefs about the ability of a group "We want thus‐and‐so to happen; in order for Efficacy to perform concerted actions that thus‐and‐so to happen, we must do this‐or‐ bring about desired outcomes that; we are confident we can do this‐or‐that to make thus‐and‐so happen." Observational Learning to perform behaviors by "Uncle Jimmy told me this is how Learning exposure to interpersonal or grownups love children." media displays of them, particularly through peer modeling Incentive The use and misuse of rewards Imprisonment has not been an effective Motivation and punishments to modify motivator to stop CSA. behavior Facilitation Providing tools, resources, or States that provide treatment programs have environmental changes that make a much lower recidivism rate than states that [new] behaviors easier to perform do not. Self Regulation Controlling oneself through self‐ Although the majority of monitoring, goal setting, feedback, perpetrators are also survivors of self reward, self instruction, and CSA; the vast majority of survivors enlistment of social support do not go on to engage in the behavior. Moral Ways of thinking about harmful "Children are sexual beings, and Disengagement behaviors and the people who exposing them to sexual behaviors are harmed that make infliction only liberates their sexuality." of suffering acceptable by disengaging self‐regulatory moral standards

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But the stated purpose of this paper is to assess the need the state has for the creation of a SOTP. And a program design model is the best lens through which to explore a health issue in relation to the possibility of creating an intervention program. The PRECEDE-PROCEED model is perhaps one of the best known models of program design. As the hyphen indicates, PRECEDE-PROCEED is a two-part model: the PRECEDE part examines the need for the program, the PROCEED part guides the program development. Because this study is a needs assessment, the PRECEDE portion will be the lens through which pedophilia is examined. PRECEDE is an acronym for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation. Thus, there are three constructs – predisposing, reinforcing, and enabling – through which the literature is reviewed. What the Literature Reveals Database Search The first database searches were through both the “Health and Medicine” and “Psychology” databases available at Mervyn H. Sterne Library. Databases accessed were ProQuest (PsycArticles, PsycInfo, and Criminal Justice Periodicals Index), EBSCO Host (Social Sciences Full Text), PubMed, and National Criminal Justice Reference Service (NCJRS). Full-text articles from peer-reviewed journals, using the parameters “Health and pedophil* or child* sex*” were utilized, resulting in a total of 780 hits. Further searches included a parameter of “past ten years.” In addition, Alabama State Law was

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accessed through Alabama Legislative Information System Online (ALISON) at http://alisondb.legislature.state.al.us/acas/ACASLoginie.asp.

Literature Review “Predisposing factors are antecedents to behavior that provide the rationale or motivation for the behavior; they include individuals’ knowledge, attitudes, beliefs, personal preferences, existing skills, and self-efficacy beliefs,” (Gielen et al., 2008) p. 415). Predisposing factors of pedophilia include the disease itself, as explored by Mackaronis et al. (2011); physical responses to erotic suggestion, as discussed by Blanchard et al. (2001) and Freund and Blanchard (1989); addictive behaviors, as discussed by Cohen et al. (2010); and mental impairment, as discussed by Hucker et al. (1986); Schiffer et al. (2008); and Walter et al. (2006). “Reinforcing factors are those factors following a behavior that provide continuing reward or incentive for the persistence or repetition of the behavior. Examples include social support, peer influence, significant others, and vicarious reinforcement,” (Gielen et al., 2008), p. 415). Reinforcing factors of pedophilia look at how being a survivor of CSA impacts an individual’s adult life, as explored by Camuso and Rellini (2010); Colangelo and Keefe-Cooperman (2012); Finkelhor et al. (2011); Hill et al. (2011); Leahy et al. (2003); and Wilson (2010) as well as media sexualization of young children, as explored by: (Babchishin et al., 2013; Byers et al., 2008; Durham, 2009; Gavin et al., 2012; Gill, 2012; Gillman & Whitlock, 1987; Goodin et al., 2011; Graff et al., 2012; Janssen, 2012; Malon, 2011; Moore & Gebbie, 1996; Near, 2013; Pfaus et al., 2012; Senn et al., 2012; Starr & Ferguson, 2012; Tribunella, 2012; Wollek, 2011).

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“Enabling factors are antecedents to behavioral or environmental change that allow a motivation or environmental policy to be realized. …They include programs, services, and resources necessary for behavioral and environmental outcomes to be realized and, in some cases, the new skills needed to enable behavior change,” (Gielen et al., 2008), p. 415). Internal factors that enable pedophilia consist of surviving child abuse, including CSA, as studied by Seifert et al. (2011) and prior consumption of pornography, as explored by Eke et al. (2011); Endrass et al. (2009); and Howitt and Sheldon (2007). External factors that enable pedophilia consist of policy factors, as described by (Lussier & Davies, 2011; Prentky et al., 1997); social factors, as described by (Dar-Nimrod et al., 2011; Russell & Giner-Sorolla, 2011); and any combination of policy and social factors, as explored by Maguire (2009). Predisposing factors. Internal aspects of the individual that incline an individual to engage in a specific behavior. In the case of pedophilia, predisposing factors are the disease itself, physical responses to erotic stimuli, addictive compulsion, and mental disorders. The first of the predisposing factors, the disease itself has not been well studied. In their study The Latent Structure of Multiphasic Sex-Inventory Assessed Pedophilic Interest, Mackaronis et al. (2011) strove to answer the questions: What is the latent structure of pedophilia? Are men with pedophilia qualitatively different from other child sex offenders, or does pedophilia exist on a continuum? Without any knowledge of the latent structure of pedophilia, diagnostic theory and practice are often in conflict. In order to reconcile diagnostic theory and practice, the development of a psychometrically sound instrument is imperative. The purpose of this study was to apply taxometric

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analyses to Multiphasic Sex Inventory (MSI) data from a sample of adjudicated child sex offenders. Three hundred seventy one men ranging in age from 19 to 75 years were recruited during their mandated stay in one of three residential treatment centers run by the Utah Department of Corrections to be participants in the study. A battery of self-report inventories, including the MSI, was completed by all participants. The MSI is a 300item, true-false self-report instrument, composed of 20 scales, including scales for evaluating sexually deviant behaviors, cognitions, and attitudes. The Child Molest (CM) scale is composed of 40 items covering five aspects of child molestation: fantasy, cruising, sexual assault, aggravated assault, and incest. Scores from the CM scale were used in the present study. The MSI scales that measure self-reported interest in children, sexual obsessionality, cognitive distortions and immaturity indicate pedophilia has a dimensional latent structure. Among men who have committed and been convicted of child sex offenses, it appears to be more accurate to speak of degrees of pedophilic interest instead of dichotomizing as “pedophiles” or “nonpedophiles”. This finding supports Blanchard, et.al.’s conclusion that sex offending occurs along a continuum, rather than as discrete taxa, and serves to inform the same to the current work. The second of the predisposing factors, physical responses to erotic stimuli were first explored in Freund and Blanchard (1989) study, Phallometric Diagnosis of Pedophilia. Answering the research question: Is phallometry – defined as the measurement of penile blood volume during the presentation of potentially erotic stimuli – able to accurately diagnose pedophilia in men who deny their sexual attraction to children?, the researchers exposed 210 adult men between the ages of 18 and 55 who

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were outpatients at a psychiatric teaching hospital to visual erotic stimuli while phallometric tests were taken. Two erotic preference indexes were compiled from the raw data: a sex-preference index (does the participant respond to male or female targets?) and an age-preference index (does he participant respond to adult, pubescents, or children?) In order to accurately diagnose pedophilia and hebephilia, objective rules had to be developed. The first of two aspects for the development of these rules was to identify the cutting scores for the erotic preference indexes, which the authors used to assign subjects to discrete diagnostic categories. The second aspect was to develop a hierarchical decision tree used to direct the flow of successive categorizations. These cutting scores and decision tree were the basis for the Phallometric Expert System (PES), a computer program designed to diagnose pedophilia and hebephelia from phallometric test results. The authors found that this method appeared unable to diagnose heterosexual hebephilia, therefore the PES does not yield this diagnosis. This work by Freund and Blanchard (1989) is relevant to the current study, as it illuminates one possible diagnostic tool for the identification of pedophilia. Two limitations of this work are: as the authors indicated, it cannot distinguish men who are sexually attracted to pubescent girls; and also that only males can be diagnosed using the phallometric instrument. The subject of phallometric screening tools for pedophilia was revisited in 2001 with the work Sensitivity and specificity of the phallometric test for pedophilia in nonadmitting sex offenders (Blanchard et al., 2001). In order to consider the sensitivity, specificity, and predictive value of the phallometric screen, quantitative evidence that

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someone who offends against adults is truly teleiophilic, while someone who offends against children is truly pedophilic must first be considered. Participants in the study were adult male patients at the Kurt Freund Laboratory of the Centre for Addiction and Mental Health-Clarke Division who denied any sexual interest in children, although they had been referred by attorneys, courts, law enforcement, or others in positions of authority due to their pedophilic behaviors. This study was a modification of the study originally conducted by Freund and Blanchard, Phallometric Diagnosis of Pedophilia: instead of visual stimuli, auditory stimuli were used. The collected data were reduced to seven final scores for each examinee by averaging his four composite scores in the seven stimulus categories. These seven category scores were taken as measures of the examinees relative erotic interests. The category scores were then used to compute a Pedophilic Index; calculated by the highest of the four category scores for children minus the higher of the two category scores for adults. The study revealed the specificity of the test – the measurement that offenders against adult women are true teiliophiles – was 96%. This score made it possible to interpret the minimum sensitivity – the measurement that offenders against children are true pedophiles – was 61%. While the terms sensitivity and specificity are usually applied to diagnostic screens for conditions that are either present or absent, the authors concluded that for sexual offending, pedophilia, hebephilia, ephebophilia, teiliophilia, and gerontophilia are points along a continuum, rather than discrete taxa. The implications of this Blanchard, et.al. study for An Integrative Literature Review Assessing the Need for a Health Education Intervention for Adults With Pedophilia in Alabama are

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that phallometry is moderately reliable as a diagnostic screening tool for pedophilia, and that sex offending is not dichotomously distinguishable, that is, that sex offenders are not as specific when seeking targets as the strata might suggest. The word Addiction – referring to the third predisposing factor –is defined by Dictionary.com as: “The state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.” Pedophilia has been called a behavioral addiction by many, and compared to opiate addiction. Cohen et al. (2010) addressed Investigating the Relationship Between Sexual and Chemical Addictions by Comparing Executive Function in Subjects With Pedophilia or Opiate Addiction and Healthy Controls. Pedophilia is a psychiatric disorder characterized by criminal behavior, is difficult to treat, and prone to relapse. Because disorders of driven sexual behavior have been conceptualized by some as addictions and related to other addictive behaviors such as chemical addictions, the authors wondered if it might be efficacious to change our conceptualization of pedophilia to that of a sexual addiction to gain new insights into treatment of this disease. The purpose of this study was to explore the utility of a behavioral addiction model of pedophilia. The sample was comprised of 188 English-speaking subjects between 18 and 65 years of age. The cohort was divided into three groups: 51 male pedophiles; 53 male and female subjects with opiate addiction in sustained remission; and 84 healthy male and female subjects. While the three groups did not differ significantly on ethnicity, they did differ on education, age, and gender. Education was the one differing factor that had a

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significant correlation with the compound score; thus the authors entered education into all analyses as covariate. The study analyzed data gleaned from neuropsychological tests that proved four cognitive function clusters related to executive functions: set switching/cognitive flexibility, sustained attention, impulsivity, and verbal fluency. The battery consisted of: Controlled Oral Word Association (COWA); Matching Familiar Figures Test (MFFT); Porteus Mazes; Stroop Color-Word Test; Trailmaking Test; and Wisconsin Card Sorting Test (WCST). Executive function is robustly associated with behavior control, and the authors’ hoped comparisons of the similarities and differences of mechanisms underlying pathological behaviors across groups may shed light on behavioral and chemical addictions. Subjects in both the pedophile and opiate addict groups demonstrated impairment on the executive function tests, although the opiate addicted group had less impulsivity control than the pedophile group. Due to the inherent differences between impulsivity and addiction – impulsivity is generally viewed as a failure to inhibit pleasurable behavior due to inadequate consideration of consequences, while addictive behavior is considered to be a reflection of abnormal reward function or goal-driven behavior – the authors felt it was logical to conclude that pedophilia as an addiction may relate more to abnormal reward function than to inhibitory failure. The fourth predisposing factor, Mental Impairment examines the function (or dysfunction) of the brain in response to sexual stimuli. While exploring the addictive nature of pedophilia does have a component of mental impairment, it also has a physical component, which is why it was explored separately.

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Answering the question: Does cerebral impairment contribute appreciably to the expression of a sexual preference for children, Hucker et al. (1986) explored Neuropsychological Impairment in Pedophiles. Their cohort consisted of 39 men who faced sexual assault charges on a minor or who were seeking clinical attention for pedophilia, and were examined as outpatients. A second cohort of 14 nonviolent, nonsex offenders was used to control for patient status and offender status. In order to not confound their results, nonviolent controls were selected because violence has been linked with brain pathology. The Reitan Neuropsychological Test Battery; the Luria-Nebraska Neuropsychological Test Battery; the Weschler Adult Intelligence Scale-Revised (WAISR); the Michigan Alcohol Screening Test (MAST); and an Alcohol and Drug Use Survey were administered by Hucker et.al.(1986) to the pedophilic offenders. Standard procedures described in the Reitan, Luria-Nebraska, and WAIS-R manuals were applied. CT Scans without contrast were performed; 14 slices, each 10mm thick, were taken from skullbase to vertex, with overlapping cuts in the temporal area. The scans were interpreted by a neuroradiologist who was unaware of the experimental condition and other test results. Overall, the pedophiles in this study demonstrated neuropsychological impairment in the region expected, specifically, the left temporoparietal lobe. These results were not influenced by age, education, socioeconomic or intelligence differences. Walter et al. (2006) explored a link between pedophilia and reduced activation in hypothalamus and lateral prefrontal cortex during visual erotic stimulation. The stated research hypothesis of this quantitative study was “Whether pedophilic patients show

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altered neural activity in those brain regions implicated in sexual arousal.” The authors had a sample of 13 adult males with pedophilia and a control group of 14 healthy males matched to the test group by age, education, and intelligence. Subjects viewed erotic and non-erotic emotional images from the International Affective Picture System (IAPS) while neural activity was recorded using functional magnetic resonance imaging (fMRI). The 1.5 Tesla General Electric Signa Scanner was used to collect data, and inversion recovery T1 weighted echo planar images coplanar with functional images and echo planar functional images and T2 weighted gradient echo sequence was used in data interpretation. Statistical Parametric Mapping 2 (SPM2) was used for image processing and statistical analysis. Results showed adults with pedophilia are unable to access and utilize the vegetative-autonomic component of healthy sexual arousal, which subcortical regions (hypothalamus and dorsal midbrain) are involved in producing. Because previous research yielded data suggesting a link between early neurodevelopmental perturbations and pedophilia, and yet the neurobiological basis of the disorder remained unidentified, Schiffer et al. (2008) investigated Brain Response to Visual Sexual Stimuli in Homosexual Pedophiles. The authors hypothesized that pedophiles would have alterations in the activation pattern in the frontostriatal system and closely related structures such as the hypothalamus. To conduct their study, 23 participants were recruited: 11 pedophilic patients who met the DSM-IV criteria for pedophilia and were exclusively attracted to male children; and 12 healthy homosexual volunteers who were exclusively attracted to male adults and matched the patient group for age, handedness, socioeconomic strata and education level. Central processing of sexual stimuli was investigated in pedophilic and nonpedophilic (control) gay men using

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functional magnetic resonance imaging (fMRI) and visual stimuli. In the pedophiles, as compared with the control subjects, activation patterns during visual sexual stimulation seems to refer more strongly to subcortical regions that are possibly involved in the process of reward signals and also play an important role in addictive and stimuluscontrolled behavior. These three studies by Hucker et al. (1986), Walter et al. (2006), and Schiffer et al. (2008) all contribute to the general body of knowledge about pedophilia, and inform on the abnormal brain functioning of adults with pedophilia in response to sexual stimuli. This information presents a causative relationship – other than simply surviving CSA – for the development of pedophilia. Reinforcing factors. External aspects surrounding the individual that are perceived to support the individual to engage in a specific behavior. In the case of pedophilia, reinforcing factors would be the social impact surviving CSA has on the individual, and media portrayal of young children as sexual beings. Childhood sexual abuse (CSA) is often an ongoing trauma, and survivors frequently carry the resulting psychological and physical scars throughout their lives. Wilson (2010), in her article Health Consequences of Childhood Sexual Abuse, provided a summary of the health consequences for survivors of CSA from a holistic perspective. She found that survivors of CSA manifest myriad health issues, both psychiatric and somatic. Survivors – regardless of gender or ethnicity – were found to be 1.63 times more likely to have poor health and twice as likely to suffer from mental health disorders than their peers who were not abused. Wilson succinctly diagramed these health issues, which can be outlined as:

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B. Somatic Manifestations a. Pain i. Headaches ii. Chronic back pain iii. Pelvic disorders iv. Medication abuse and overuse b. Conditions i. Fatigue ii. Stress iii. Fibromyalgia iv. Irritable Bowel Disorder v. Other Autoimmune Diseases vi. Obesity vii. STDs c. Systemic Disorders i. Respiratory ii. Gastrointestinal iii. Musculoskeletal iv. Neurological v. Gynecological

A. Psychiatric Manifestations a. Behavioral i. Dysfunctional relationships ii. Maladaptive communication iii. Aggression iv. Hostility v. Substance abuse vi. Sexual promiscuity b. Conditions i. Insomnia ii. Memory loss iii. PTSD c. Emotional i. Fear ii. Anxiety iii. Anger iv. Depression v. hypervigilance

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Wilson’s diagram placed Childhood Sexual Abuse in the middle, with Psychiatric Manifestations and Somatic Manifestations above and below respectively, indicating they were the types of problems encountered by CSA survivors. Blocks with the subheadings were connected by double arrows (), indicating these are the specific manifestations survivors of CSA may exhibit. Finkelhor et al. (2011) explored Polyvictimization: Children’s exposure to multiple types of violence, crime and abuse. The research question answered was: Are children who experience both repeated victimizations and several types of victimizations at greater risk for complex trauma and/or traumatic stress disorders? This paper summarizes some of the key findings on polyvictimized youth based on the National Survey of Children’s Exposure to Violence (NatSCEV) and the closely related Developmental Victimization Survey (DVS). Victimization was measured against the Juvenile Victimization Questionnaire (JVQ), distress was measured against the Trauma Symptom Checklist for Children (TSCC) for children 10-17 years of age, and the closely related Trauma Symptom Checklist for Young Children (TSCYC) for children younger than 10 years of age. Both the NatSCEV and DVS surveys were cross-sectional national telephone survey involving target sample populations. Participants included youth aged 10-17 who were interviewed about their own experiences, and the parents or other caregivers of children aged 2-9 who provided information about the younger children. In both surveys, victimization was measured using versions of the Juvenile Victimization Questionnaire (JVQ), which asked questions about type and frequency of exposure. Distress in youth 10 to 17 years was measured by the Trauma Symptom Checklist for Children (TSCC),

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and in children younger than 10 years, distress was measured by the closely related Trauma Symptom Checklist for Young Children (TSCYC). Finkelhor et al. (2011) determined that in assessing the victim status of children, a broad range of victimizations need to be considered. Identifying a child as a victim in one domain should be a cue to assess for further domains of victimization. Children are polyvictimized when they experience multiple domains of victimization and adversities that specify four distinct pathways to polyvictimization. Polyvictims demonstrate a particular vulnerability to mental health, behavioral, school performance, and other problems. The authors also found that bully victims (victims of violence who also bully others) are more likely to be polyvictims, and have worse outcomes than other victims. Finkelhor et.al. asserted that intervention programs needed to be designed with multifaceted therapies to encompass multiple victimizations, strategies for reducing stigma and traumatic reminders, and exhorted clinicians not to ignore the victimizing histories of their clients. It was further argued that those prevention interventions that address underlying risk factors were likely to offer the greatest benefit. Finally, Finkelhor et.al. indicated that children who are polyvictims not only suffer from multiple victimizing situations, but are also quite often caught in an overall environmental condition perpetuating victimization. Polyvictimization is associated with much distress, making it a priority to learn how to interrupt the pathways into the condition. Intervention systems that only helps children respond to threats from family members are too narrow. A greater benefit would be yielded if the current Child Protective System (CPS) could be broadened to consider polyvictimization: if workers were trained to

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assess multiple victimizations and implemented service responses pertinent to a variety of threats. Because most pedophiles are survivors of CSA, and because quite often CSA is only one of many types of abuses a child may endure, it stands to reason that polyvictimization may play a role in a survivor of CSA becoming a perpetrator. While my paper is focused on assessing the need for a health education intervention for adults with pedophilia in Alabama, all factors that influence the ongoing cycle need to be considered. This study illumines just one more of these factors. When discussing therapeutic recovery work with adult survivors of CSA, clinical and empirical studies are not always clear nor consistent. The research question posed by Leahy et al. (2003) was “How do clinically and nonclinically distressed adults differentially, and over time, perceive the experience of, and attribute meaning to, CSA experiences?” (Leahy et al., 2003), p. 658). The purpose of the Leahy et.al. study was to address criticisms of current research with a therapy-relevant, contextualized investigation into the long-term traumatic sequelae associated with CSA. From a sample of 44 volunteer participants, 20 participants – only those participants reporting a CSA history that involved penetration and/or genital contact – were purposefully selected. Based on scores from the Trauma Symptom Inventory (TSI) scales, this cohort of 20 was then categorized in clinically distressed and nonclinically distressed groups. The clinically distressed group was comprised of eight females and seven females; of these 15 individuals, five males and five females were randomly selected to form a gender-balanced, clinically distressed group. A second cohort of five males and five females were randomly selected from the remaining 24 participants to

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comprise a gender-balanced, non-clinically distressed group. The participants ranged in age from 21 to 47 years, were well-educated (70% were university graduates), high achievers (75% were in professional or managerial occupations) and active in competitive sports (35% competed at the international level, 45% competed at the local level). None of the participants reported a psychiatric diagnosis. Data for this qualitative study was collected using interviews and questionnaires and assessment tools included the TSI, the Childhood Trauma Questionnaire (CTQ), and the Sexual Abuse Interview Schedule (SAIS). The collection of participants’ stories, and the meanings they attribute to them, allowed Leahy et al. (2003) to support their admonition that understanding the complexity of CSA and reducing countertransference contamination requires clinicians to be vigilant in maintaining training and peer supervision. As the authors stated: “If we as therapists do not care enough to deal with our own pain and hurt, then we are likely to treat others with the same lack of empathy and compassion with which we treat the wounded parts of ourselves,”(Leahy et al.), p. 664). Although this study focuses on therapeutic interventions with non-offending survivors, it speaks to the present study assessing the need for a health education intervention for adults with pedophilia in Alabama in that therapeutic care for survivors – whether they be offenders or non-offenders – requires a heightened sense of vigilance and care of the clinician so that the compassion with which therapy is administered is always ethical. According to the Adverse Childhood Experiences Survey (ACES)(Centers for Disease Control, 2013), approximately one girl in four or 25% of the female population

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survives CSA. Not surprisingly, these survivors often report difficulty with their sexuality. Three studies addressed this issue. Given the prevalence rates and long-term negative consequences, and because CSA is often a factor in later sexual difficulties and dysfunctions; the purpose of Colangelo and Keefe-Cooperman (2012)’s qualitative study Understanding the Impact of Childhood Sexual Abuse on Women’s Sexuality was to explore how CSA affects the sexuality of a female survivor. Survivors of CSA can experience emotional damage and be severely traumatized, resulting in: adult onset mental disorders; disruptive and disturbed interpersonal relationships; adolescent pregnancy and sexual problems; high-risk sexual behaviors; PTSD; elevated risk of suicidal behavior; self-mutilation; clinical eating disorders; alcohol and substance abuse; accidental fatal drug overdoses; and depression, anxiety, and low self-esteem. This study was a case history, reporting on the single case of “Marie”. Much of therapy today focuses on cognitive-behavioral therapy (CBT), building on a phase approach to treatment. Effective treatment requires clinicians to be comfortable with both individual and couples therapy, and with talking about sex. This case study exemplifies why clinicians must be willing to examine the attitudes, experiences, and feelings associated with the trauma of CSA – all critical components of the client’s developmental history. Camuso and Rellini (2010) answered the question: Do female survivors of CSA have more violent sexual fantasies than non-survivors of CSA, and is the frequency of violent fantasies directly proportional to the degree of sexual arousal difficulties in

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survivors in their study Sexual Fantasies and Sexual Arousal in Women With a History of Childhood Sexual Abuse. The purpose of this study was to determine the relationship between sexual fantasies and sexual arousal in women, in order to ascertain the relevance of targeting sexual fantasy when treating sexual arousal disorders in women with a history of CSA. Participants were 180 sexually active, English speaking adult females recruited from various cities across the U.S.A. via Internet (craigslist, Spidersales). 60 were female survivors of CSA and 120 were women without a history of CSA. Participants in the CSA group were those who indicated on Finkelhor’s CSA Measure they had experienced sexual encounters prior to age 14 by someone at least 5 years their senior. This group was equally distributed among different relationship status types (single, single but dating, in a committed relationship, and married). Participants in the NCSA group were those who answered negatively on all items in Finkelhor’s CSA Measure. Most participants in this group reported being in committed relationships. Participants completed three scales: The Female Sexual Functioning Index (FSFI); the Derogatis Sexual Functioning index: Fantasy Questionnaire (Section VIII_ DSFI); and the Child Sexual Abuse Measure (CSAM). Both the CSA and NCSA groups reported conventional fantasies most frequently; and frequency of violent fantasies were not related to a history of CSA. The hypothesis that violent sexual fantasies were associated with sexual arousal problems in CSA survivors was not supported. “This study emphasizes the relevance of sexual fantasies for female sexual arousal. One clinical implication that can be derived is that it may be beneficial for CSA survivors with sexual arousal problems to focus on developing

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detailed fantasies of normative sexual experiences. Facilitation of sexual fantasies that are about forcing others or being forced into sex may not be useful if the goal of treatment is increasing sexual arousal. Find this quote! It has been argued that one of the shortcomings of existing sexual assault prevention programs is the absence of an all-encompassing, theoretical model to guide future empirical studies of revictimization and, ultimately, to develop effective riskreduction programs. Thus, Hill et al. (2011) explored The Development of a Brief Acceptance and Mindfulness-Based Program Aimed at Reducing Sexual Revictimization Among College Women With a History of Childhood Sexual Abuse. Although the authors’ primary interest was the development of a sexual assault prevention program aimed at college women with a history of CSA, the program was designed to be broader in content to focus more generally on healthy development and risk-reducing behaviors. The premise was that one intervention with a broader scope would be more beneficial and cost effective than many disparate programs. The intervention was presented as a workshop aimed at reducing stress and increasing well-being. Ninety-five women enrolled in psychology courses at a private New England University were invited to participate. Two groups, the intervention group and the nonintervention group, were created. Twelve women with a history of CSA, and 21 women without a history of CSA comprised the intervention group. Twenty women with a history of CSA and 24 women without a history of CSA comprised the non-intervention (control) group. Thus, 77 college-age women met the exclusionary criteria and comprised the sample. At the initial screening, all participants completed three selfreport instruments: the Sexual Experiences Survey (SES); the Kentucky Inventory of

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Mindfulness Skills (KIMS); and the Acceptance and Action Questionnaire (AAQ). The intervention group was divided into the CSA and NCSA groups; the intervention was conducted in two 2-hour sessions spaced approximately one week apart. Approximately two months later, all participants again completed the three self-report instruments they completed at the initial screening – the SES, KIMS, and AAQ. Members of the Intervention Group also completed the Program Utility and Practice Questionnaire (PUPQ). Of the original 77 participants, 71 returned to complete the follow-up assessments. Women with CSA history were revictimized at a rate three times higher than those without, supporting the hypothesis that a history of CSA is a risk factor for future victimization. Women in the control group were more likely to experience a rape-related victimization compared with those who received the program; however, the program was ineffective at reducing overall rates of sexual assault. “Finally, it should be emphasized that programs such as this are designed to enhance skills with hope that the likelihood of sexual victimization will be minimized. These skills do not control the perpetrator’s behavior and in no way divert responsibility for the assault from the perpetrator to the victim,” (Hill et al., 2011), p. 978). These three studies: Colangelo & Keefe-Cooperman (2012), Camuso & Rellini (2010), and Hill et.al. (2011) looked at very disparate facets of the effects CSA has on survivors. Colangelo & Keefe-Cooperman explored how CSA can affect the sexuality of a single survivor; Camuso & Rellini looked at sexual fantasies and wondered if surviving CSA affected the fantasies of women and thus impacted their sexual arousal; and Hill et.al. delved into developing an intervention designed to reduce revictimization. All three

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studies impact the current study by speaking to all the effects surviving CSA has on sexuality and exploring possible intervention venues. Do Toddlers in Tiaras have any impact on pedophilia? Is the sexualized portrayal of young children in today’s media an enabling factor for child sexual abuse? A database search using the keywords “Child* Sexuali* and Child* Sex*” and “Child* Sexuali* and Pedophil*” yielded 13 relevant hits; however, none of these articles addressed the influence of the sexualization of children on pedophilia and childhood sexual abuse. Instead, these 13 articles focused either on the sexualization of children, surviving CSA, pedophilia, or cultural influence without considering their mutual influence. Two articles were reviews of books – which were themselves reviews of classic literature: The Lolita Effect: The Media Sexualization of Young Girls and Five Keys to Fixing It (Durham, 2009) and Lost Girls (Moore & Gebbie, 1996). These two books explore how young girls have been sexualized in classic literature: Lolita, from Vladimir Nabokov’s 1955 novel of the same name was explored by Durham – whose exploration was further examined by Wollek (2011); and in their novel Lost Girls, Moore and Gebbie (1996) have Alice (from Lewis Carroll’s classics Alice’s Adventures in Wonderland (1865) and Through the Looking-Glass (1871)), Dorothy (from L. Frank Baum’s (1900) classic The Wonderful Wizard of Oz), and Wendy (from J.M. Barrie’s Peter Pan (1902) and Peter and Wendy (1911)) “meeting as adults and sharing their true stories, which include tales of childhood sex and sexual abuse, behind the familiar accounts of their respective adventures,” (Tribunella, 2012). The other articles explored the sexualization of children (Goodin et al., 2011; Graff et al., 2012; Near, 2013; Starr & Ferguson, 2012); surviving CSA (Gillman &

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Whitlock, 1987; Malon, 2011; Senn et al., 2012); pedophilia (Babchishin et al., 2013; Gavin et al., 2012); and cultural implications (Byers et al., 2008; Gill, 2012; Janssen, 2012; Near, 2013; Pfaus et al., 2012). None of these authors explored the relationship between the sexualization of children and childhood sexual abuse. Because this author believes that media portrayal of children as sexual beings is an enabling factor for pedophilia, this is an area that warrants further study. Enabling factors. Those aspects that occur before the behavior and support – or repress – the behavior. Internal aspects that enable pedophilia are surviving CSA and prior pornography consumption. External aspects that enable pedophilia are policy and laws, social pressure and societal norms, and any combination of the two. The long-term adverse consequences of abusive childhood experiences, specifically CSA, on later mental health sequelae have been well-documented in both civilian and military populations. Since the Gulf War, the military has engaged in health surveillance, or the process of systematically evaluating threats to service members’ health, well-being, and performance to identify unmet needs and intervene when necessary. Recently, some have begun advocating for health surveillance questionnaires to assess childhood abuse experiences. It is in this context that Seifert, Polusny, & Murdoch (2011) explored The Association Between Childhood Physical and Sexual Abuse and Functioning and Psychiatric Symptoms in a Sample of U.S. Army Soldiers. It was anticipated that individuals with a history of childhood abuse would have poorer functioning and more severe psychiatric symptoms than those without such histories. It was also hypothesized that individuals who experienced both childhood physical and sexual abuse would describe poorer functioning and more psychiatric symptoms than

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individuals who experienced childhood physical abuse or CSA alone. The current study examined not only work functioning but also social, role, and physical functioning and psychiatric symptoms in a sample of US Army soldiers; as well as the impact of childhood physical abuse with and without CSA on these outcomes. Two hundred four active duty enlisted soldiers (108 men; 96 women) from a single Southern Army installation, who had completed basic training and were in their first tour of duty completed a consent document and 21-page health surveillance questionnaire. The health surveillance questionnaire completed by these participants included items indicative of childhood abuse – the independent variables in this study. Six items from the Childhood Trauma Questionnaire – two focusing on physical/emotional abuse, four focusing on sexual abuse – were included in the health surveillance questionnaire, and participants were assessed to have suffered childhood abuse if they endorsed any of these six items. (Childhood physical abuse was assessed by answering “yes” to one of the two items focusing on physical/emotional abuse; CSA was assessed by answering “yes” to one of the four items focusing on CSA.) The dependent variables were assessed using well-established valid and reliable tools. The modified Social Adjustment Scale, Self-Reporting (SAS-SR), which measures adjustment in work roles, social and community activities, economic self-sufficiency, and marriage, extended family, family unit, and parental relationships was chosen to assess work, role, and social functioning. Post-Traumatic Stress Disorder (PTSD) symptom severity was assessed using the Penn Inventory for Post-Traumatic stress Disorder; the five-item RAND Mental Health Battery assessed depression; and Alcohol misuse was assessed using TWEAK, a CAGE variant with improved sensitivity for alcohol-related

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problems in reproductive-aged women. The 204 participants were classified in three childhood abuse categories: no childhood abuse (57, or 29%); childhood physical abuse only (90, or 46%); and childhood physical and sexual abuse (49, or 25%). Seven of the participants did not complete the childhood abuse items, and were excluded from the analyses, as was the one participant who answered CSA only. Consistent with other research illustrating the preponderance of trauma exposure, including childhood abuse, in the military, the sample had a higher proportion of childhood abuse than the general population. Contrary to the stated hypothesis, few differences between participants with and without childhood abuse histories in terms of psychiatric symptoms and general functioning were found. Although prevalence of problem drinking appeared clinically elevated in soldiers reporting both childhood physical and sexual abuse, only the severity of PTSD symptom was statistically associated with childhood abuse experiences. Specifically, it was found that soldiers who reported a history of both physical and sexual childhood abuse also reported greater PTSD symptom severity. Is experiencing childhood abuse – physical, sexual, or both – conducive to the development of mental disorders? With the exception of PTSD, according to this study, No. This responds to a statistical anomaly this author has encountered: 1. It is accepted as fact that more females than males are offended against. 2. It is accepted as fact that surviving CSA compels one to become a pedophile. 3. It is accepted as fact that all pedophiles are male. The disparity in this assumption – that all three of the statements are accepted as true – is responded to in part by the Seifert et.al. (2011) study.

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Eke et al. (2011) answered two research questions: 1) Does consumption of child pornography lead to contact offending against children; and 2) Do sexual offending and other violent offenses contribute to each other with their paper Examining the Criminal History and Future Offending of Child Porn Offenders: An Extended Prospective Follow-Up Study. The purpose of this study was to research the factors that predict recidivism in this population in order to be able to predict and explain whether child pornography offenders are likely to subsequently commit a contact offense and why. The sample in the Eke et.al. (2011) study consisted of 541 adult males on the Ontario Sex Offender Registry (OSOR) convicted of possessing, accessing, making, or distributing child pornography. Two female offenders were excluded from the sample to maintain gender homogeneity. This was a follow-up study, so the authors used the same procedures and coded the same outcome variables as their 2005 paper. Distinctions were drawn between violent and nonviolent offenses, and between contact and noncontact sexual offenses. Recidivism with pornography was coded as a separate outcome. The results of this study were twofold: First, sex offender registries may be utilized to better identify those individuals with a high proclivity for recidivism, giving police departments a stronger tool for managing sex offenders; and second, this study reveals that while child pornography offenders are exhibiting sexual interest in children in illegal behaviors, they are not likely to engage in direct contact offenses. Consumers of child porn are thus the least likely of any sex offender group to benefit from a health education intervention program for adults with pedophilia in Alabama. Does consumption of child pornography lead to CSA? This question drove Endrass, Urbianok, Hammermeister, Benz, Elbert, Laubacher, & Rossegger (2009) to

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their study The Consumption of Internet Child Pornography and Violent and Sex Offending. The purpose of their study was to examine the recidivism rates for contact and non-contact sex offenses in child pornography consumers. In 1999, the U.S. Postal Service shut down Landslide Productions, owners of a website which distributed illegal pornography worldwide via the Internet. It was found to have over 75,000 customers worldwide, and user data was provided to judicial authorities in the respective countries, leading to well-coordinated international police operations. Four hundred individuals in Zurich, Switzerland were found to have consumed illegal pornographic material from Landslide Productions. Of these, only those who consumed child pornography (231) were included in the sample. The date range for this study was 2002 to 2008; all convictions prior to 2002 were considered “previous convictions;” all convictions between 2002 and 2008 were considered to be “reoffending” or recidivism. The source of data collected was criminal and judicial files held by the Canton of Zurich. Two sources provided information on recidivism: the database of the Zurich criminal system and the judicial files provided by the Department of Public Prosecution. Two definitions of recidivism were considered: The stricter definition, which stated only new convictions subsequent to the initial offense of child pornography consumption was registered in the criminal records. The broader definition included ongoing investigations and charges. In those subjects without prior convictions for hands-on sex offenses, the consumption of child pornography alone does not seem to represent a risk factor for committing future contact sex offenses The current study is exploring whether Alabama needs a health education intervention for adults with pedophilia. This paper explored whether consuming

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pornography leads to contact offending against children. The authors of this study found that in subjects who did not have prior convictions for contact offending, the consumption of child pornography is not a risk factor for future contact offending. This is important, because it demonstrates a group that can be eliminated from a future health education intervention for adults with pedophilia. A significant gap exists in the current literature regarding cognitive distortions and offending. Because Internet pornography consumers frequently lack a history of contact offending, it was hypothesized by Howitt and Sheldon (2007) their cognitive distortions differ substantially from those of contact offenders. The purpose of their study, The Role of Cognitive Distortions in Paedophilic Offending: Internet and Contact Offenders Compared was to explore the differences in cognitive distortions between contact and Internet pornography offenders. Study participants were 61 adult male volunteers, the majority of which were inmates at a privately run prison in the U.K., although a small number came from Probation Service. Thirty-five were classified as Contact-Only offenders. These men had no history of Internet pornography consumption but did have contact sexual offenses against children. Sixteen were classified as Internet-Only offenders. These men had no history of contact offenses against children, but did have Internet pornography consumption offenses. Ten were classified as Mixed Contact-Internet offenders. These men had a history of both contact offenses against children and Internet pornography consumption. The three groups were matched on age, with a median age being between 46 and 47 years. Of note, the Internet-Only group had significantly more years of education than the other two groups.

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The authors presented three disparate definitions of cognitive distortions. The first definition was “Cognitive distortions are a set of beliefs which offenders generate in order to overcome inhibitions against and guilt about offending,” (Howitt & Sheldon, 2007), p. 470). The second definition was “Cognitive distortions are rationalizations which offenders generate to excuse or justify their actions when required to account for their crimes,” (Howitt & Sheldon), p. 471). The third definition was “Cognitive distortions do not reflect altered cognitions at all, but reflect the distorted experiences of the offender,” (Howitt & Sheldon), p. 471). These disparate definitions may reflect different aspects of cognitive distortions, o(r all – or none – may precisely grasp the crux of cognitive distortions. Cognitive distortions are a concept rather than a physical substance, and these three approaches illumine the difficulties inherent in defining them. The surveys already in existence focused solely on cognitive distortions among contact pedophiles only, and none addressed the cognitive distortions of internet offenders. Drawing partially on the existing scales, the authors’ professional experiences working with sex offenders including internet offenders, and Ward and Keenan’s typology of five core implicit themes or schemas, the authors developed a new 39-item scale – the Children and Sexual Activities (C&SA) scale. The five themes of the scales were: Children are sexual objects – 11 items. Illustrative items: “Sometimes children don’t say no to sexual activity with an adult because they are curious about sex or enjoy it”; “Sometimes a child instigates sexual activity with an adult,” (Howitt & Sheldon, 2007, p. 474).

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Uncontrollability – 6 items. Illustrative items: “For many men their sex offenses involving children were the result of stress and the offending behavior helped to relieve that stress”; “A lot of the time men do not plan their sex offenses involving children – they just happen,” (Howitt & Sheldon, p. 474). Entitlement – 5 items. Illustrative items: “Children are supposed to do what adults want and this might include serving their sexual needs”; “A person should have sex whenever it is needed,” (Howitt & Sheldon, p. 474). Nature of harm – 11 items. This scale can be further divided into “levels of harm” and “sex is beneficial for children” subscales. Illustrative items: “Just looking at a naked child is not as bad as touching and will probably not affect the child as much”; “Sexual activities involving adults and children can help the child learn about sex,” (Howitt & Sheldon, p. 474). Dangerous world – 6 items. This scale can be further divided into “world is hostile” and “children are reliable” subscales. Illustrative items: “Professionals pursue some people involved in sexual activities with children to make themselves look good”; “Children can give adults more acceptance and love than other adults,” (Howitt & Sheldon, p. 475). In order to eliminate the possibility of ambiguity, questions were asked on a fourpoint Likert scale (Strongly Agree, Agree, Disagree, Strongly Disagree). The maximum score was 156, a higher score meant more agreement to cognitive distortions. Three items were reversed for scoring purposes. A substantial number of cognitive distortions are accepted by – if not a majority, at least a significant minority of – offenders. The cognitive distortions most commonly

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endorsed lack the bizarre and extreme elements usually considered part of cognitive distortions. These distortions may play a role in offending behavior because of their ordinariness and acceptability. These cognitions endorsed by offenders tend to portray CSA as reasonable consequences of exceptional circumstances. Consequently, they may better be referred to as “cognitions conducive to offending” rather than “cognitive distortions”. The way in which an individual’s cognitions – or thought processes – interpret behaviors is imperative to the effectiveness of an intervention. Behavior modification programs – 8especially such approaches as cognitive-behavioral therapy (CBT) address “unlearning” the old, bad behaviors and replacing them with new, learned behaviors. If we consider cognitions as reflections in a mirror, then approaching cognitive distortions as a permanent stay in a carnival fun house means we deny people the opportunity for growth. A major concern of policy makers is predicting recidivism. This concern was addressed in two articles. Prentky et al. (1997) considered Risk Factors Associated With Recidivism Among Extrafamilial Child Molesters. Research has demonstrated the predictive superiority of actuarial methods over clinical judgment; however, only recently have concerted empirical efforts been made to develop and test actuarial prediction devices for sex offenders. In order to accurately predict recidivism risk, a full range of variables extending beyond criminal history capturing both state and trait factors must be considered. The purpose of this study was to test a range of risk factors both empirical and clinical literature identified as critical to recidivism for child molesters. Instead of having actual subjects on whom tests were performed, the authors collected data from

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archived records on 111 male child molesters who had been treated at the Massachusetts Treatment Center for Sexually Dangerous Persons and released over the 25-year period between 1960 and 1984. Data was collected from two sources, prison records and criminal records. Four sources were contacted for criminal records: Massachusetts Board of Probation, Massachusetts Parole Board, Massachusetts Treatment Center Authorized Absence Program Records, and the Federal Bureau of Investigation. Multiple sources allowed for cross-checking of information, however, the data only identified offenders who came into contact with the law. The Massachusetts Treatment Center: Child Molester Typology (MTC:CM3) construct examined the following variables: amount of contact with children; degree of sexual preoccupation with children; impulsivity; juvenile antisocial behavior; frequency of prior sexual offenses; paraphilias; alcohol use history; social competence; and sex of the victim. This data was gleaned exclusively from prison records. To test the validity of the construct, participants were classified as either recidivist or nonrecidivist, determined by data indicating they had been charged with a new offense during the study period. Further, the classification was made for each of three domains of criminal offending: (a) any new charge for a serious sexual offense, such as one involving physical contact with a victim; (b) any new charge for a nonsexual, victiminvolved offense; and (c) any new charge for a violent offense. Although using archival data to assess risk is never as efficient as clinical data, and may possess reasonable discrimination across samples, it does have several advantages including the ease of use (it requires neither the compliance nor even presence of the offender), it is cost efficient, and has relatively high reliability.

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This study collected data from archived records, and in the methodology section of my study, data is collected from public records. The ability to consider crime and persistence as process is vital to neither underestimating nor overestimating risk. Building an approach on between- and withinindividual changes over time is a novel concept in the field of public policy. Lussier and Davies (2011) embraced this challenge with their study A Person-Oriented Perspective on Sexual Offending Trajectories and Risk of Recidivism: A New Challenge for Policymakers, Risk Assessors, and Actuarial Prediction. Choosing a different focus by relying on a person-oriented perspective, the authors examined the heterogeneity of the criminal careers of adult sex offenders, how changes within individual offending occur over time, and the dynamics of offending over the life course. All individuals consecutively admitted to a federal penitentiary in the province of Quebec, Canada, for a sex crime between April 1994 and June 2000 were recruited. In total, 93% of individuals approached (n=553) agreed to participate. All participants were incarcerated at the Regional Reception of Ste.-Anne-des-Plaines, a maximum security facility where they stayed for six weeks while their level of risk and rehabilitative needs were assessed; then they were transferred to an institution that could best meet their needs. Detailed criminal activity allowing for the computation of the criminal trajectory was obtained only for the first 393 cases recruited. Of these 393 cases, only information on offenders older than 35 years at the time of their prison release (n=246) was used. In contrast with the variable-oriented perspective, which assumes the static aspect of risk as well as the linear association between prior offending and future offending, the person-oriented approach takes into account both the static and the dynamic aspect of

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offending and the imperfect association between prior offending and future offending. Criminal career research with adult sex offenders has shown that, typically, child molesters have a higher number of official sexual crime charges and/or convictions than sexual aggressors of women; while the opposite is true for nonsexual violent crimes. The findings of this study illustrate the complexities of the offending careers of adult sex offenders, and more specifically, the dynamic aspect of offending in adulthood. This result is consistent with other findings showing age is a significant factor impacting the likelihood of reoffending, and that more recent reoffending has better predictive accuracy than prior offending. Predicting recidivism risk is the domain of policymakers, but average citizens, too, have opinions about pedophilia. Dar-Nimrod et al. (2011) asked Do Scientific Theories Affect Men’s Evaluations of Sex Crimes? The purpose of this study was to explore the extent to which exposure to the divergent explanations provided by evolutionary psychology and social constructivism psychology of mate selection strategies influence the thoughts and behaviors of men. One hundred twenty five male students at the University of British Columbia were divided into two cohorts. The first study consisted of 56 men between the ages of 18 and 67 years recruited from psychology classes, whereas the second study consisted of 67 men between the ages of 18 and 28 years. In study 1, Participants were given a test ostensibly to measure reading comprehension in which the constructs of evolutionary psychology, social-constructivist psychology, and a control were embedded. Participants were then given two bail-setting tasks: the control group was assigned to set bail for a woman convicted of shoplifting; the

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two experimental groups were assigned to set bail for a man arrested for soliciting sexual favors from a female police officer. In study 2, Participants were randomly assigned to one of three conditions (evolutionary psychology, social-constructivist psychology, and control) and given relevant articles to read. The articles given to the two experimental conditions related rape in terms of the psychology, the control article discussed sexual relations in the golden years. The two experimental groups were then given a vignette about a man who committed date rape, a questionnaire assessing evaluations of sexually aggressive behavior, a questionnaire assessing perceptions of a man’s control over sexual urges, then asked to assign an appropriate punishment for the man in the vignette. Clear evidence was found that the presence of the initial article (article manipulation) influenced men’s perceptions of male sexual aggression. Those exposed to the social-constructivist explanation judged men as having greater control over their sexual urges, leading to more negative evaluations of male sexual aggression and to harsher punishments for male sexual aggressors. Russell and Giner-Sorolla (2011) conducted a related study: Social Justifications for Moral Emotions: When Reasons for Disgust are Less Elaborated Than for Anger. Reason is an interesting phenomenon, serving as the social output reinforcing and validating moral judgments. When considering moral judgment toward groups transgressing moral values, a comparison of the types of reasons people give for feeling anger and disgust toward these groups would be a salient explanation. Two hypotheses were proposed:

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The unreasoning disgust hypothesis which stated that in comparison to anger, disgust is less likely to be justified using elaborated reasons, and equally or more likely to be justified with nonelaborated reasons. It was further hypothesized this difference would be most pronounced in situations that can give rise to bodily moral disgust, which is a moral violation involving breaking a norm about the use of the body, such as a sexual violation. The availability hypothesis stated that if plausible elaborated reasons were made available to participants, they would use them to justify feelings of disgust and the difference in elaborate reasons between anger and disgust would disappear. Experiments 1 and 2 seemed to support the unreasoning disgust hypothesis, leading to a further research question: Is there something special about bodily moral disgust that leads to a lower level of elaborated reasons? The purpose of this study was to compare the reasons given for feelings of anger and disgust toward groups that transgress moral values. Three experiments were conducted. The sample for Experiment 1 was 52 students at the University of Kent (Kent, UK) between the ages of 18 and 58. Twelve were male, thirty-nine were female, one failed to complete the gender question. The sample for Experiment 2 was 70 students at the University of Kent (Kent, UK) between the ages of 18 and 43. Twenty were male, fifty were female, and none had participated in Experiment 1. The sample for Experiment 3 was 155 students at the University of Kent (Kent, UK) between the ages of 17 and 43. Thirty-nine were male, one hundred seventeen were

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female, two failed to complete the gender question and none had participated in either Experiment 1 or Experiment 2. Three independent graduate students – native English speakers who were unaware of the hypothesis – were employed as coders. There was an intraclass correlation of .81 between the coders, indicating good agreement. In Experiment 1, participants were given a brief description of Pedophilia and then completed a four-section questionnaire; each section addressed one of the four measured emotions – anger, disgust, contempt, and fear. Participants were asked if they experienced the emotion towards the given description of Pedophilia (yes/no), and asked to write down the reasons they experienced the emotion. Four variables were created for each of the four emotions. First, the total amount of statements given were counted. Then, the elaborated reasons variable was based on the mean of all three coders’ judgments about the number of elaborated reasons. The nonelaborated reasons were calculated by subtracting the number of elaborated reasons from the total statements given. In Experiment 2, instead of pedophilia, this experiment used seven other groups: four that could be perceived to violate a sexual bodily norm (prostitutes, LGBT, voyeurists, necrophiliacs – the definition of the last 2 being provided to participants); and 3 that may violate nonbodily norms (activist feminists; Islamic religious fundamentalists, and crooked politicians). The same questionnaire used in experiment 1 was used in this experiment. Participants were randomly assigned to either the anger or disgust emotion; and the questionnaire presented the emotion with each group, asking participants (1) Do you feel this emotion when considering this group? (2) Please rate the intensity of the

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emotion on a scale of 1 – 9 (1 = not at all; 9 = completely); and (3) Please give the reason/s you experience this emotion with this group of people – separate from any other emotions you might experience. (The reasons were coded the same way as in Experiment 1). In Experiment 3, the design of the study was a 2x2x2 design: Whether explanations were provided or not; whether the emotion reported was anger or disgust; and whether the group type had a bodily or nonbodily moral violation. Before the experiment began, ten psychology postgrad students (five male, five female) between the ages of 22 and 32 rated 44 statements that could be used as explanations for this experiment. The participants grouped in “explanations provided” were given the list of statements rated by the psychology postgrads (above), and instructed to use the statements to build emotion explanations. Those grouped in “explanations not provided” were asked to give a list of statements they would use to explain their anger or disgust toward one of the groups (bodily or nonbodily violators). The general instructions were to explain their emotion as they would to others. Participants then rated the following emotions in relation to the moral violation: sickened, outraged, moral disgust, inspired, sympathy, infuriated, proud, physical disgust, hatred, contempt, angry, and afraid – on a 7 point Likert scale (0 = not at all; 6 = extremely). The author coded the responses from the group “explanations not provided” using the same coding scheme used in the first two experiments, because the coding scheme achieved reliability across the two previous experiments. In Experiment 1, there was a significant difference between the number of elaborated reasons for different emotions. Anger elicited more elaborated reasons than

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disgust; and there was a trend toward more elaborated reasons for fear than disgust. No other comparisons were significant. Conversely, in comparing nonelaborated reasons, there were significantly more nonelaborated reasons for disgust than anger; no other comparisons were significant. Of the participants, 29 reported feeling both anger and disgust. To increase the validity of the comparison, the authors performed a paired sample t-test on this subsample; and found significantly more elaborated reasons to explain anger over disgust. In Experiment 2, utilizing the same analytical procedure as experiment 1 revealed people reported experiencing disgust proportionally more than anger when presented with groups who violated sexual bodily norms than those who did not. Conversely, there was no difference on the anger measure for the group types. Importantly, there was no significant relationship between emotion intensity and elaborated reasons, rendering control for emotion intensity as a confound unnecessary. In Experiment 3, when the experiment made elaborate reasons available, this eliminated the significant differences between anger and disgust found in bodily moral violations in experiments 1 & 2. Conversely, when elaborated reasons were not made available, the results of experiments 1 & 2 were replicated (participants still gave fewer elaborated reasons for disgust vs. anger toward a group violating a bodily norm). The authors concluded that groups that are viewed as violating bodily moral norms (such as adults with pedophilia) demonstrate different ways of establishing and changing public prejudice against them. Taken in context with extensions of prejudice theory in the realm of intergroup emotions – which emphasize the ability of specific negative emotions to predict different prejudicial action tendencies – the results of these

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experiments show that different negative emotions carry different cognitive consequences for justifying prejudices against marginalized groups. In terms of law and legal judgments, anger rests on reasoning that can be publicly articulated and publicly shaped; whereas the primary elicitors of disgust are shared among members of a given society, making the elaborated reasons of disgust more difficult to cognitively retrieve. Thus, people might be more likely to accept and support another person’s moral anger when it is expressed using appropriate reasons, whereas reasoning would make less of a difference for moral disgust. What is the proportion of CSA cases designated by police as “founded” in which an arrest is made? What is the effect of police departmental structure on CSA case attrition (decrease in number)? Maguire (2009) attempted to answer these questions with his study Police Organizational structure and Child Sexual Abuse Case Attrition. The purpose of this study was to explore the effects of formal police organizational structure on child sexual abuse attrition. Data from two pre-existing surveys: a 1988 survey of child abuse enforcement in U.S. police departments and the 1987 Law Enforcement Management and Administrative Statistics (LEMAS) database produced by the Bureau of Justice Statistics were merged for this analysis. Using the structure-performance link described in the structural contingency theory, the study examined the effects of both global and specific structural features on two case disposition ratios. The size and organizational height of a police department affect the number of arrests made, and the rate at which CSA arrests are determined to be founded. The global structure of the police organization does not have any influence on attrition rates.

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CHAPTER 3: METHODOLOGY The PRECEDE-PROCEED model is a two-part model of program design, and the vehicle by which this needs assessment was conducted. PRECEDE, the first half of the PRECEDE-PROCEED model, is the template for a needs assessment and is an acronym for Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis. Developed in the 1970s by Dr. Lawrence W. Green and colleagues, PRECEDE is “based on the premise that, just as medical diagnosis precedes a treatment plan, so should educational diagnosis precede an intervention plan,” (Gielen, McDonald, Gar, & Bone, 2008, p. 409). There are five phases of PRECEDE: 1) Social Assessment; 2) Epidemiological Assessment; 3) Behavioral Assessment; 4) Environmental, Educational and Ecological Assessment; and 5) Administrative and Policy Assessment. These five assessment phases will comprise the outline for this chapter. A diagram outlining the PRECEDE-PROCEED model appears on the next page.

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Figure 3.1; Diagram of the PRECEDE-PROCEED Model PHASE 5: ADMINISTRATIVE & POLICY ASSESSMENT Health Promotion

EDUCATIONAL STRATEGIES

PHASE 4: EDUCATIONAL & ECOLOGICAL ASSESSMENT

PHASE 3: PRECEDE BEHAVIORAL ASSESSMENT

PHASE 2: EPIDEMIOLOGICAL ASSESSMENT

GENETICS PREDISPOSING FACTORS

REINFORCING FACTORS

BEHAVIOR HEALTH

POLICY REGULATION ORGANIZATION PHASE 6: INTERVENTION ALIGNMENT & IMPLEMENTATION

ENABLING FACTORS PHASE 7: IMPLEMENTATION

QUALITY OF LIFE

ENVIRONMENT PHASE 8: PROCESS EVALUATION

PROCEED

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PHASE 1: SOCIAL ASSESSMENT

PHASE 9: IMPACT EVALUATION

PHASE 10: OUTCOME EVALUATION

Social Assessment refers to an expansion of understanding of the target community, articulating the community’s needs and desires, considering their resources, strengths, problem-solving ability and readiness to change. Usually, a social assessment is conducted via multiple data collection activities such as interviews, focus groups, observations, and surveys. However, legal and ethical constraints prohibited direct contact with either perpetrators or victims; therefore an examination of the landscape of CSA and pedophilia across the state was conducted using only public access data. Epidemiological Assessment “identifies the health priorities and their behavioral and environmental determinants,” (Gielen et.al., 2008, p. 412). Because of the legal and ethical constraints mentioned above, the epidemiological assessment of adults with pedophilia in Alabama was conducted by counting the Alabama State Sex Offender Registry (ALSOR). This registry is comprised solely of Alabama citizens who have been convicted of a sex crime – including the crime of CSA. Although information may be gleaned from the registry by a predetermined address radius, ZIP code, or county, accessing the information by county was determined to be the most efficacious method. After the counties were counted, the data was aggregated into ADPH Public Health Regions, making it more manageable for analysis. Further information on the county populations was obtained from the 2010 census data (http://quickfacts.census.gov/qfd/states/01000.html). Behavioral Assessment was conducted following the diagnostic guidelines for the health issue pedophilia and its symptomatic behavior CSA, as reported in the DSM-IVTR, as well as the broader criminal justice/law enforcement definition by which offenders are convicted. Additionally, since pedophilia is a disease of opportunity – that is, it is

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impossible to commit CSA without children being available – a brief count of schools, child-care centers, and other organizations exclusively geared to children was conducted. Environmental, Educational, and Ecological Assessment looks at the three types of factors – Predisposing, Reinforcing, and Enabling – that affect a particular health behavior: in this case, the sexual assault of children. Predisposing factors are internal aspects of the individual that incline an individual to engage in a specific behavior. According to the literature, predisposing factors for pedophilia are the disease itself, physical responses to erotic stimuli, addictive compulsion, and mental disorders. Reinforcing factors are external aspects surrounding the individual that are perceived to support the individual to engage in a specific behavior. According to the literature, reinforcing factors for pedophilia would be the social impact surviving CSA has on the individual, and media portrayal of young children as sexual beings. Enabling factors are external, organizational aspects that make engaging in a behavior easier or more difficult. According to the literature enabling factors for pedophilia would be policy factors or laws, social implications, and any combination of the two. Administrative and Policy Assessment will examine the laws concerning pedophilia: first the federal laws, then the state laws. Since PRECEDE was inspired by the medical community’s penchant for diagnosing before treating, this study will serve as a diagnostic tool for the State of Alabama regarding the health issue of Pedophilia and it’s symptomatic behavior, Childhood Sexual Assault (CSA).

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Phase 1 Social Assessment Between 1995 and 1997, the pharmacological firm Kaiser Permanente conducted the Adverse Childhood Experiences Survey (ACES) in conjunction with the CDC. More than 17,000 participants – of whom 54% were female and 46% were male – completed a survey about adverse experiences in their childhood, and are still being followed to see how those experiences affect their adult health. One of the adverse experiences addressed was childhood sexual assault. The prevalence of surviving CSA was women: 25% (one girl in four); men: 16% (one boy in six). Sexual abuse was defined by the study in this way: “An adult or person at least 5 years or older ever touched or fondled you in a sexual way, or had you touch their body in a sexual way, or attempted oral, anal, or vaginal intercourse with you or actually had oral, anal, or vaginal intercourse with you,” (Centers for Disease Control, 2013).

These national statistics – showing that on

average 20% (or one child in five) survive CSA are sobering reminders of the prevalence of pedophilia. However, a search of the CDC website for information regarding “reported cases of pedophilia,” “reported cases of child sex abuse,” and “child sex” resulted in 1,700 hits of unrelated topics. One of the hits was information about the sex tourism trade – the most closely related topic in all the 1,700 hits – in which the CDC states: Although commercial sex work may be legal in some countries, sex trafficking, sex with a minor, and child pornography are always criminal activities according to US law and can be prosecuted in the United States even if the behavior occurred abroad. The Trafficking Victims Protection Act makes it illegal to recruit, entice, or obtain a person of any age to engage in commercial sex acts or to benefit from such activities. Federal law also bars US residents from engaging in sexual or pornographic activities with a child aged