Journal of Child Sexual Abuse

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Obstacles to Help-Seeking for Sexual Offenders:

Implications for Prevention of Sexual Abuse

Jill S. Levenson, Gwenda M. Willis & Claudia P. Vicencio

To cite this article: Jill S. Levenson, Gwenda M. Willis & Claudia P. Vicencio (2017) Obstacles to
Help-Seeking for Sexual Offenders: Implications for Prevention of Sexual Abuse, Journal of Child
Sexual Abuse, 26:2, 99-120, DOI: 10.1080/10538712.2016.1276116

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JOURNAL OF CHILD SEXUAL ABUSE
2017, VOL. 26, NO. 2, 99–120
[Link]

Obstacles to Help-Seeking for Sexual Offenders:

Implications for Prevention of Sexual Abuse
Jill S. Levensona, Gwenda M. Willisb, and Claudia P. Vicencio a

a
School of Social Work, Barry University, Miami Shores, Florida, USA; bSchool of Psychology, Tāmaki
Innovation Campus, The University of Auckland, Auckland, New Zealand

ABSTRACT ARTICLE HISTORY

Persons with potentially harmful sexual interests such as attrac- Received 5 May 2016
tion to minors are unlikely to seek or receive treatment before a Revised 3 December 2016
sexual offense has been committed. The current study Accepted 3 December 2016
explored barriers to help-seeking in a sample of 372 individuals KEYWORDS
in treatment for sexual offending. Results revealed that the child sexual abuse;
shame and secrecy resulting from stigma associated with ped- minor-attracted persons;
ophilic interests often prevented our respondents from seeking pedophilia; sexual offender;
professional counseling, and only about 20% tried to talk to treatment
anyone about their sexual interests prior to their arrest. Barriers
to seeking and receiving psychological services included con-
cerns about confidentiality, fears of social and legal conse-
quences, personal shame or confusion about the problem,
affordability, and challenges finding competent therapists
who were adequately equipped to help them. Understanding
and ultimately reducing obstacles to help-seeking can improve
the quality of life for people with harmful sexual interests and
potentially prevent sexual abuse of children or other vulner-
able individuals.

As applied to behavioral health, help-seeking is defined as an adaptive coping

process by which persons with distressing psychological symptoms choose
options for seeking external assistance from professionals or other support
systems (Mechanic, 1975; Rickwood & Thomas, 2012). Help-seeking is a
pathway to intervention, treatment, and recovery when someone is faced
with psychosocial discomfort or behavioral health symptoms (Gulliver,
Griffiths, Christensen, & Brewer, 2012). Despite improvements in availability
of and accessibility to treatment for behavioral health conditions, counseling
services remain underutilized: less than a quarter of people with serious
mental illness receive treatment (Kessler et al., 2005).
Persons with potentially harmful sexual interests such as attraction to
minors are even less likely to seek or receive treatment, at least before a
sexual offense has been committed (Piché, Mathesius, Lussier, &
Schweighofer, 2016). Understanding the barriers to help-seeking and

CONTACT Jill S. Levenson jlevenson@[Link] Professor of Social Work, Barry University, 11300 NE
2nd Ave, Miami Shores, FL 33161.
© 2017 Taylor & Francis Group, LLC
100 J. S. LEVENSON ET AL.

improving treatment availability and access can improve the quality of life for
people with harmful sexual interests and also prevent sexual abuse of chil-
dren and other vulnerable individuals. The current study sought to add to the
small but growing literature exploring barriers to help-seeking in this extre-
mely stigmatized population.

Factors affecting psychological help-seeking

Although structural factors such as access, cost, and availability of services
play a role in mental health service utilization, psychological factors also
influence intentions to seek professional help (Gulliver, Griffiths, &
Christensen, 2010). Psychological determinants include internalized social
norms such as stigma about psychiatric treatment as well as a person’s
conceptualization of their own distressing symptoms (Biddle, Donovan,
Sharp, & Gunnell, 2007). Studies on barriers to mental health services have
consistently shown that personal determinants have a significantly greater
impact on help-seeking than structural factors (Andrade et al., 2014). For
example, individual influences on help-seeking include resilience and emo-
tional competence (defined as awareness of and ability to express one’s own
internal states), positive attitudes toward seeking professional help, and
mental health knowledge (Rickwood, Deane, Wilson, & Ciarrochi, 2005).
However, such personal strengths may be lacking in individuals most in
need of professional help. It is well established that clients presenting with
serious mental health problems have disproportionately high rates of child-
hood abuse and neglect and that the accumulation of such adversities is
associated with a multitude of negative psychosocial outcomes in adulthood
indicative of poor resiliency and coping (Anda et al., 2006). Adverse child-
hood experiences (ACEs) may pave the way for maladaptive cognitive
schema that discourage help-seeking (Bloom & Farragher, 2013; SAMHSA,
2013; Young, Klosko, & Weishaar, 2003). Positive influences on help-seeking
include favorable experiences in asking for help, social and cultural accep-
tance of therapeutic interventions, and psychological factors such as emo-
tional competence and mental health literacy (Rickwood & Thomas, 2012).
The perceived social stigma of behavioral health disorders can also create a
deterrence to help-seeking (Biddle et al., 2007). Stigma is defined by the
Merriam-Webster dictionary as a mark of shame or discredit, and Charles
Cooley theorized in 1922 that our “looking-glass self” is conceived based on
several interrelated elements: one’s self-perception of how we imagine we
appear to others, our belief about the judgment of that appearance by others,
and a resulting feeling such as pride or shame (Scheff, 2014). Goffman (1963)
conceptualized stigma as an undesirable characteristic that makes one “dif-
ferent from others . . . in the extreme. . . . He is thus reduced in our minds
from a whole and usual person to a tainted, discounted one” (p. 3). When
 JOURNAL OF CHILD SEXUAL ABUSE 101

this intensely negative quality becomes known to others, it “spoils the social
identity of the person carrying it and cuts him off from society and from
himself so that he stands a discredited person facing an unaccepting world”
(Goffman, 1963, p. 19).

Help-seeking for pedophilic interests

Paraphilic disorders, especially pedophilic disorder, carry a great deal of
stigma in our society (Imhoff, 2015; Jahnke & Hoyer, 2013; Jahnke, Imhoff,
& Hoyer, 2015). Perhaps the epitome of stigma is embodied by the term
“pedophile.” The word is often used synonymously with the term “child
molester,” but not all persons who have sexually abused a child meet criteria
for pedophilic disorder (American Psychiatric Association, 2013), and not all
persons with pedophilic or hebephilic (attractions to pubescent teens) inter-
ests have sexually abused a minor (Kingston, Firestone, Moulden, &
Bradford, 2007; Seto, 2008). The etiology of pedophilia and the bio-psycho-
social factors that contribute to it remain an area of empirical inquiry, but
there is evidence to support the concept of pedophilia as akin to a sexual
orientation with biological underpinnings (Cantor et al., 2015; Seto, 2012).
People with pedophilic attractions are typically perceived as a threat, with
negative attributions of evil intentions, uncontrollable urges, and non-amen-
ability to treatment (Jahnke & Hoyer, 2013). However, there are some
individuals who refer to themselves as “minor attracted persons” (MAP) or
“virtuous pedophiles” who do not act on their attractions because they
understand and appreciate that sexual abuse is harmful to children. The
scholarly literature about pedophilia comes primarily from research studies
conducted with convicted child abusers, however, and non-offending MAPs
remain somewhat misunderstood.
Studies have revealed that most MAPs become aware of their unusual
sexual interests in early adolescence (B4UAct, 2011b; Buckman, Ruzicka, &
Shields, 2016), and that about 42% report a primary attraction to prepubes-
cent youngsters (Mitchell & Galupo, 2016; Piché et al., 2016). Despite want-
ing help from a mental health professional, most report that they were
reluctant to seek services due to beliefs that they would be treated disrespect-
fully or judgmentally, fears of unethical treatment or breaches of confidenti-
ality, and apprehension that counselors would not have a knowledgeable
understanding of minor-attraction (B4UAct, 2011b). As a result, most
MAPs, if they received mental health care, did not obtain it until many
years after first recognizing their attractions (average age of care = 32,
mode = 30), and less than half reported satisfaction with the services they
received (B4UAct, 2011b). Many described multiple attempts to seek therapy
with various counselors before finding one who was viewed as helpful, with
therapists often knowing little about minor attraction and endorsing
102 J. S. LEVENSON ET AL.

assumptions of prolific and uncontrollable offending commonly heard in

media accounts about sexual crimes.
A survey of 209 non-offending MAPs (B4UAct, 2011a) revealed that over
half wanted to seek mental health services but did not do so due to fear that a
professional would have a negative or judgmental reaction, report them to
someone, or would lack sufficient knowledge with which to help them. About
40% of those who sought services elected not to proceed with counseling
after receiving a discouraging reaction from a mental health professional who
was unfamiliar with MAPs, endorsed inaccurate stereotypes and presump-
tions of criminal behavior, or told them that they would be reported to
authorities. Many said they encountered disdainful or hostile attitudes and
that counseling approaches often emphasized a focus on social control rather
than a compassionate and empathic style of client-centered assessment and
treatment planning. Many reported that they would never consider sexually
abusing a child and that they had other mental health needs that were
neglected by therapists who saw their role as preventing victimization rather
than understanding the experience of the MAP. Nearly half who wanted
services but did not receive them said that the failure to obtain proper help
resulted in negative ramifications, including an exacerbation of mental health
symptoms such as depression, suicidality, withdrawal and isolation, lost
productivity, fear and anxiety, hopelessness, and substance abuse. A small
group (3–4%) said that after being unable to obtain counseling, their attrac-
tion to youngsters continued or escalated and that they were later convicted
for abusing a child. Other studies (Houtepen, Sijtsema, & Bogaerts, 2016;
Van Horn et al., 2015) concurred that external (awareness of resources) and
internal (fear, shame, and denial or minimization) barriers to help-seeking
exist for MAPs, and that attempts were often met with negative judgments or
a lack of professional competence. Noteworthy is that the majority of studies
about non-offending MAPs have been conducted outside the United States,
where confidentiality laws provide more protection from mandated reporting
and therefore diminish some of the fear of disclosing this secret sexual
interest.
The reluctance of MAPs to seek help is understandable given that studies
indicate that many mental health professionals are unwilling to take on
patients with sexual interests in minors due to presumptions of high risk
or engagement in criminal sexual abuse (Jahnke & Hoyer, 2013). For
instance, a study of German psychotherapists (Stiels-Glenn, 2010) revealed
that less than 5% said they would treat patients with pedophilia or would
work with child sex offenders. Some therapists justified their reluctance with
a lack of knowledge (20%), but others described negative feelings toward
pedophilic groups (13.3%), negative experiences from past encounters
(13.3%), or skepticism about these clients’ genuine motivation for seeking
help (11.7%). However, it has also been found that educational interventions
 JOURNAL OF CHILD SEXUAL ABUSE 103

with psychotherapists can reduce negative affective responses to people

diagnosed with pedophilia and improve their willingness to work with
these clients (Jahnke, Philipp, & Hoyer, 2015).
Researchers surveyed 100 convicted sex offenders in treatment in order to
understand their awareness of interventions that might have been available
prior to offending and their willingness to take advantage of such services
(Piché et al., 2016). Results revealed that lack of knowledge and/or restricted
access to counseling services as well as fears of being reported to authorities
prevented them from talking to professionals about their sexually deviant
interests. Most reported having problematic sexual fantasies or behaviors
prior to their first arrest, such as preoccupying sexual thoughts, sexualized
coping to deal with negative emotions, and excessive use of pornography.
About 20% said that prior to being arrested, they had had thoughts about sex
with children, had used underage prostitutes, or had viewed images of child
abuse (child pornography). Nearly half noted that the onset of their proble-
matic sexual interests were long-standing for 5 to 20+ years prior to arrest,
yet only a minority (18%) had sought counseling for sexual problems or
spoken to someone about their concerns. More than half said they were
ashamed and did not know who to talk to about it. They opined that free
therapy services, a telephone helpline, online counseling, or self-help books
would have been beneficial resources for them prior to offending (Piché
et al., 2016).
Researchers comparing child sex offenders who had acted on their sexual
interests (n = 29) with MAPs who had not (n = 71) also found that few had
received treatment perceived to be helpful in their endeavors to deal with
their sexuality (Mitchell & Galupo, 2016). Notably, those who had not acted
were more likely to identify internal incentives for not offending: they were
more in tune with the idea that engaging in sexual activity with a child would
be inappropriate and exploitative and were further motivated by a desire not
to damage a relationship they had with a youngster by taking advantage of
his or her trust or vulnerability. Non-offending MAPs were much more able
than offenders to recognize and acknowledge the potential direct and indirect
harmfulness of child sexual abuse (Mitchell & Galupo, 2016). Those in non-
forensic samples tend to have higher education and socioeconomic status,
which may reflect a greater willingness and opportunity to engage in formal
and informal help-seeking through various professional or online resources.
A yearlong voluntary treatment program in Germany called the
Dunkelfeld Project devised an outreach program through ads in community
venues such as public transportation to reduce barriers to treatment for those
with sexual preferences for children. After participants completed the inter-
vention, researchers observed decreases in emotional deficits, offense-sup-
portive cognitions, and risk-related behaviors along with an increase in
sexual self-regulation (Beier et al., 2009, 2015). Similarly, a telephone helpline
104 J. S. LEVENSON ET AL.

in the U.K. and the Netherlands (Stop It Now!), publicized through media
campaigns and talk shows, encouraged preventive help-seeking, and callers
identified a number of risk-reducing and desistence-promoting effects after
talking with a hotline counselor (Van Horn et al., 2015). In contrast, in the
United States, individuals with pedophilic sexual interests (whether they are
at risk to act on their attractions or not) are reluctant to seek counseling due
to shame as well as fear of legal and social consequences. Barriers to seeking
and receiving psychological services in the United States include affordability
(especially for teens or young adults who rely on financial assistance from
parents), concerns about confidentiality, and challenges to finding competent
therapists who are adequately equipped to help them (Buckman et al., 2016).

The current study

The purpose of this study was to contribute further to the knowledge about
help-seeking behaviors of individuals with criminal convictions for sexual
offending. Specifically, the current study sought to explore and describe prior
help-seeking experiences as well as the obstacles to help-seeking for those
currently in treatment for criminal sexual behavior. A further aim of this
study was to compare men with sexual interest in minors versus adults to
determine differences between the groups in help-seeking behaviors prior to
arrest. An additional aim was to elucidate relationships between childhood
adversity and later help-seeking behavior. By clarifying the reasons why
persons with harmful sexual interests may choose to seek help (or not),
and by understanding their experiences, we can better design outreach
programs and enhance training for clinical counselors to aid in preventing
victimization.

Method
Sample
Sex offenders tend to be a difficult-to-reach population to study. Shame and
stigma, along with fears of the social and legal consequences of disclosure,
make them understandably reluctant to participate in research projects.
When sex offenders have been recruited via random selection (for example,
sending surveys through U.S. mail to addresses on a sex offender registry),
sample sizes and response rates are quite low (e.g., Tewksbury & Zgoba,
2010). An online survey is not a feasible data collection method for U.S. sex
offenders, because many have restricted Internet access as part of their
probation or treatment conditions. Researchers have achieved better partici-
pation by recruiting sex offenders from treatment programs, where a trusted
professional can address their apprehensions about engaging in research
 JOURNAL OF CHILD SEXUAL ABUSE 105

studies. Thus, the current study utilized a convenience sample recruited

through treatment programs for sexual offending.
The participants included 372 male adults (age 18+) who were known to
be convicted for a sexual offense. A non-random, purposive recruitment of
data collection sites was utilized to obtain the sample. Data collection sites
included five U.S. outpatient treatment programs recruited from the listserv
of the Association for the Treatment of Sexual Abusers (ATSA), a profes-
sional organization whose members include clinicians who provide counsel-
ing services to people who have committed sex crimes. The programs were
located in California, Georgia, Florida, Maryland, and Washington. The
programs typically served clients who were court ordered to treatment as
part of their probation or parole requirements following a criminal convic-
tion, or, in a few cases, as part of a family court plan in a child protective
services case. All clients attending treatment at the facilities (n = approxi-
mately 500) were invited to participate in the project; 372 subjects voluntarily
agreed to participate, resulting in a response rate of about 74%.

Data collection and measures

Participants were invited via their treatment providers to complete a pen-
and-paper survey. Participants were instructed not to write their names on
the survey, and when finished, to place the completed questionnaires in a
sealed envelope in a closed box with a slot opening, which was then mailed to
the researchers. No names or identifying information were collected from the
participants, who were not asked to sign a consent form in order to ensure
anonymity. All participants were provided with a full written and verbal
explanation of the study in order to make an informed decision about
participation, and completion of the survey was considered implied consent
to participate in the project. Safeguards were in place to reduce the minimal
risks of coercion, incrimination, or traumatization. The project was approved
by the first author’s institutional review board.
The survey was developed by the authors and included questions about
unusual sexual interests, past help-seeking behavior, obstacles to help-seek-
ing, adverse childhood experiences, and demographic items. The survey also
asked a series of questions about the nature of past sex offenses committed,
such as preferred victim types and the number of prior arrests. Some open-
ended questions were asked as well in order to elicit narrative responses.
Importantly, no information that could potentially identify offenders or
victims was sought.

Help-seeking questions
The help-seeking questions were derived from the General Help-Seeking
Questionnaire, which was designed to assess future help-seeking intentions
106 J. S. LEVENSON ET AL.

as well as recent and past help-seeking experiences (Wilson, Deane,

Ciarrochi, & Rickwood, 2007). The questionnaire was not used in its original
form but instead (with permission from Dr. Rickwood) borrowed from some
of the conceptualizations of help-seeking intentions and behaviors in order to
create questions of relevance for this population. Questions inquired about
whether they sought help and from whom as well as ratings of helpfulness.
Ratings ranged from 0 to 4, with 0 being “not helpful at all” and 4 being “very
helpful.”

Adverse childhood experiences

The Adverse Childhood Experiences (ACE) survey was included because
early maltreatment can be a risk factor for adult criminal and sexually
abusive behavior (Grady, Levenson, & Bolder, 2016; Levenson, Willis, &
Prescott, 2014), and childhood trauma can produce negative expectations
of help-seeking, thereby deterring requests for assistance from formal and
informal supports (Bloom & Farragher, 2013; SAMHSA, 2013; Young et al.,
2003). Little research has been conducted to ascertain the link between early
adversity and help-seeking, but further research is needed to gain informa-
tion about the relationship between these variables among the notably high
risk and underserved population of sexual offenders. The ACE survey is a
measure of childhood maltreatment and family dysfunction and is publicly
available for research use from the Centers for Disease Control (CDC) (Anda
et al., 2006; Centers for Disease Control and Prevention, 2013a). The ACE
scale includes 10 dichotomous (yes/no) items asking participants to endorse
whether they ever experienced, prior to age 18, any of five child maltreat-
ments (physical or emotional abuse, sexual abuse, or physical or emotional
neglect) and five common household dysfunctions (domestic violence, men-
tal illness, substance abuse, incarceration, or unmarried parents). The ACE
score ranges from 0 to 10, with higher scores indicating a higher frequency of
childhood adversity.

Analyses
This study was exploratory and comparative. Univariate statistics were used
to describe the sample characteristics as well as the frequencies and means of
help-seeking experiences. Group comparisons using t-tests and chi-square
analyses were conducted to explore differences between those who identify as
attracted to minors (AM) and those who identify as attracted only to adults
(AA). Group differences were compared on items related to help-seeking
intentions and obstacles as well as other items related to sexual interests and
offense behaviors. Narrative responses to open-ended questions were ana-
lyzed by grouping answers into broad categories that corresponded with
constructs in the quantitative survey; these qualitative data will be analyzed
 JOURNAL OF CHILD SEXUAL ABUSE 107

systematically in a future publication, but some illustrative quotes are

included to provide a richer and contextualized understanding of the current
findings.

Results
Descriptive statistics
The sample contained 372 individuals in treatment for sexual offending
behavior (see Table 1). As illustrated in Table 1, the “average” participant
was a white male in his early 40s, but minorities were overrepresented
compared with the U.S. population. Nearly half had never been married,
most had completed high school, and more than one-quarter earned less
than $50,000.
Most of the participants had female minor victims, with one-third report-
ing that they had victims under 12 years of age (see Table 2). Most of the
victims were known to the offenders. The average number of victims (8.6)
was skewed due to a few high-value outliers, but the median and most
frequently reported number of victims was one. On average, participants
had been arrested one time for a sexual crime, with 90% reporting one sex
crime arrest, 8% reporting two or more arrests, 8 individuals (2%) saying that
they had never been arrested for a sexual crime, 90% reporting that they are
listed on a sex offender registry, and 86% saying that they were currently on
parole or probation. Approximately half (52%) had never been arrested for a
nonsexual crime, and about 7% acknowledged that they had used force or a
weapon or caused physical injury to a victim in the commission of a sex
offense. On average they had spent about 7 years in prison and 4 years on

Table 1 Sample Demographics

Demographic Categories (N = 372)
Race
White 75%
Minority 25%
Mean age 42
Marital Status
Never married 42%
Married 24%
Divorced/Separated 32%
Widowed 2%
Education
12th grade or less 14%
High school graduate or GED 66%
College graduate or higher 20%
Income
Under $20,000 25%
$20,000–$29,999 18%
$30,000–$49,999 19%
$50,000+ 28%
108 J. S. LEVENSON ET AL.

Table 2 Offender, Offense, and Victim Characteristics

Mean (%) Median/Mode
Female Victim 72%
Male Victim 16%
Family Victim 27%
Unrelated Victim 37%
Stranger Victim 19%
Victim Under 12 34%
Teen Victim 53%
Adult Victim 10%
Total Sex Crime Arrests 1.11 1 /1
Total Victims 8.6 1 /1
Ever Used Force 4%
Ever Used Weapon 1%
Ever Caused Injury 2%
Total Nonsex Arrests 1 0 /0
Months in Treatment 31 23 /12
On Probation 86%
Months on Probation 44 27 /24
Lifetime Months in Prison 85.25
Lifetime Months on Probation 47.31
Note: Percentages may not add up to 100% because some categories
were not mutually exclusive.

probation. For those who identified as attracted to minors, they first realized
this attraction on average at age 24, but 40% said they recognized these
attractions prior to age 20.
About 39% reported that prior to their arrest, they felt concerned about
their sexual interest, with the majority of these concerns related to
attractions to minors and fewer individuals concerned about sexual inter-
ests in rape, frottage, voyeurism, or exhibitionism (see Table 3). Only one
out of five participants had tried at some point to talk to someone about
their concerns, most often a friend, family member, or romantic partner.
About 12% of the sample sought help from a professional because they
were concerned they might engage in illegal or harmful sexual activity,
most often a therapist, medical doctor, or religious leader. Those who
sought help described the most helpful part of the experience as a
counselor who listened and seemed to understand, did not judge, offered
some hope that he could change his behavior, or offered practical solu-
tions for changing thoughts or behavior. On a scale of 0–4, the average
helpfulness rating of the counseling service was 2, with 45% rating the
help as a 3 or 4.
Participants were given an option to write narrative answers about what
was most helpful or least helpful about their past counseling experience.
About 5% of participants gave illuminating examples and described being
able to open up to someone who engaged in “active listening” and offered
hope: “Said I would always have thoughts but not to act on them which gave
me hope for change.” Others felt that their counselor was judgmental or
 JOURNAL OF CHILD SEXUAL ABUSE 109

Table 3 Help-Seeking Intentions and Experiences

Prior to arrest % Yes
Feel concerned that you might have some unusual sexual interests 39.2 %
If yes, what kinds of concerns?
Attracted to prepubescent children age 12 or under 11.6 %
Attracted to minor teens age 13–15 17.7%
Attracted to minor teens age 16–17 26.3%
Turned on by rape or coercion (engaging in sex acts against someone’s will) 2.7%
Rubbed up against or touched people without their knowledge or consent 2.2%
Watched (peeping) someone without their knowledge or consent 8.6%
Exposed your private parts to an unsuspecting person without their consent 3.5%
Masturbated in public places where people might see you 2.4%
Talked to anyone about having unusual sexual interests 20%
If yes, who?
Friend 10.8%
Parent 3.0%
Family member 3.2%
Spouse/partner/girlfriend/boyfriend 5.4
Other friend 1.9
Contacting a website or Internet forum 3.0
Counselor/therapist/social worker/psychologist 5.4
Medical doctor 0.3
Religious leader (priest, rabbi, minister, etc.) 3.2
Gone to a mental health professional to get help about a different kind of personal or 44.4%
emotional problem (for example, depression, anxiety, substance use or relationship
problems, etc.)
Note: The percentages do not add up to 100% because some participants endorsed more than one category.

unable to help: “Twice I tried, twice I was told not to go any further because
they would have to report me to the police. I was offered no help, no
suggestions.”

Comparative analyses
A new variable was created to assign participants to a group depending on
whether they endorsed any concerns about having attractions to minors (the
first three items in Table 3). Those who endorsed one or more of these three
concerns were coded as AM (attraction to minors; valid n = 123), and those
who did not were coded as AA (attracted to adults only; valid n = 237). The
AMs were more likely to have shared their concerns (33%) than AAs (13%)
(χ2 = 20.979, df = 1, p < .001), with 20% of AMs saying they sought
counseling compared with 8% of the AAs (χ2 = 11.721, df = 1, p < .01).
On a scale of 0–4, AMs seemed to rate the professional as slightly more
helpful than AAs, but the difference was not statistically significant (M = 2.4
versus 1.9, respectively, t (101) = −1.451, ns).
Many (44%) participants had sought counseling from a mental health
professional for other kinds of personal or emotional problems, and there
was no significant difference between AMs and AAs in their likelihood to
have done so. No significant differences were found in the mean ratings of
110 J. S. LEVENSON ET AL.

helpfulness for such help-seeking experiences (M = 2.3 versus 2.0 respec-

tively). Those who found their other counseling experiences more helpful
were not significantly more likely to seek help for their concerns about their
sexual interests. Again, however, they endorsed the most helpful part of
counseling as being that the professional listened and understood (21%),
did not judge (18%), offered hope for change (14%), and offered practical
solutions for changing thoughts or behavior (16%).
Several significant differences between AMs and AAs were found in
relation to developmental sexuality and early adversity (see Table 4), with
AMs showing earlier exposure to sex and higher ACE scores. The Bonferroni
correction for multiple comparisons was utilized by dividing the p value of
.05 by the number of items (7), requiring a p value of less than .007 for
statistical significance. On average, AMs were first exposed to sexual material
or contact at a significantly younger age than AAs and first masturbated at a
younger age. Not surprisingly, AMs were more likely to rate their attraction
to minors higher on a 10 point scale than were AAs. The mean ACE score for
the combined sample was 3.06 (median = 3, SD = 2.49), and 26% participants
had an ACE score of 4 or more, compared to 9% of the 7,970 males studied
by the CDC (Centers for Disease Control and Prevention, 2013b). The AMs
had significantly higher ACE scores (3.5) than AAs (2.8) t (364) = −2.431,
p < .05. When the distribution of individual ACE items was further examined
in group comparisons, it was revealed that a significantly higher percentage
of AMs reported childhood verbal abuse (χ2 = 8.734, df = 1, p < .05), physical
abuse (χ2 = 4.310, df = 1, p < .05), sexual abuse (χ2 = 16.451, df = 1, p < .001),

Table 4 Mean Differences Between AM and AA Groups on Developmental Sexuality and ACEs
AM AA t df
How old were you when you were first exposed to 10.5 13.7 4.448* 336
sexual material, play or contact of any sort?
How old were you when you had your first 16.6 16.1 −.753 336
consensual/desired sexual experience with any
other person?
On a scale of 1–10, with 1 being primarily or 4.1 2.2 −6.706* 348
exclusively attracted to adults, 10 being primarily
or exclusively attracted to minors, and 5
representing equal attraction to both, how would
you rate yourself?
On a scale of 1–10, with 1 being primarily or 2.6 2.0 02.03 353
exclusively attracted to females, 10 being primarily
or exclusively attracted to males, and 5
representing equal attraction to both, how would
you rate yourself?
How old were you when you first masturbated? 11.9 14.4 2.620* 322
On a scale of 0–4, with 0 being not at all satisfying 2.9 3.3 1.646 194
and 4 being very satisfying, how satisfying do you
find your current sexual relationship?
ACE score 3.5 2.8 −2.431* 362
*p < .007; AM = attracted to minors; AA = attracted only to adults.
 JOURNAL OF CHILD SEXUAL ABUSE 111

and emotional abuse (χ2 = 7.055, df = 1, p < .05); the prevalence of sexual
abuse was particularly noteworthy, with AMs reporting nearly twice the rate
of AAs (45% versus 24%). Of the household dysfunction items, AAs had a
significantly greater proportion of parental separation (χ2 = 4.133,
df = 1, p < .05).
When asked about their reasons for not seeking help for concerns about
their sexual interests and asked to endorse a scale of 0–4 (with 0 being not
true at all and 4 being very true), the most frequent reasons were worry that
they would be judged, not understanding the seriousness of the consequences
if arrested, and believing that they could control their attractions and beha-
viors themselves (see Table 5). Other reasons that rang true for participants
were worries that they would get in trouble, not knowing where to go to seek
help, and not thinking that they were hurting anyone. When differences
between AM and AA groups were explored, AMs endorsed significantly
higher ratings on 10 out of the 13 items. The Bonferroni correction for
multiple comparisons was utilized by multiplying the p value of .05 by the
number of items (13), requiring a p value of less than .003 for statistical
significance. Specifically, AMs (those with self-reported attraction to minors)
were more likely to be deterred by news stories about sex crimes as well as
media reports characterizing sex criminals as not amenable to treatment.
They were more likely to say that they did not fully appreciate why their
behavior was harmful to victims or the seriousness of the consequences of
offending, and they worried more that they would not be understood, would
get in trouble, or would be judged. AMs were more likely to say that they did

Table 5 Reasons for Not Seeking Help for Concerns About Sexual Interests: Comparisons
Between AM and AA
On a scale of 0–4, with 0 being “not true at Mean Mean Mean
all” and 4 being “very true” (all) Med Mode SD (AM) (AA) t df
News stories encouraged me to ask for help. .76 .00 0 1.301 .71 .78 .471 349
News stories made me afraid to ask for help. 1.34 .00 0 1.913 2.03 .98 −5.202* 350
I did not understand why CSA was harmful to 1.34 .00 0 1.929 1.97 1.03 −3.826* 346
children.
I did not understand why CSA was harmful to .89 .00 0 1.402 1.03 .82 −1.278 343
adults.
I worried no one would understand. 1.71 1.00 0 1.709 2.8 1.14 −0.706* 350
I worried I would get in trouble. 1.92 2.00 0 1.807 2.95 1.39 −8.895* 351
I worried I would be judged. 2.14 3.00 4 1.744 3.14 1.62 −9.418* 357
I believed based on stories in the news that 1.67 1.00 0 1.684 2.23 1.39 −4.594* 356
sex offenders can’t be helped.
I did not know where to seek help. 1.81 2.00 0 1.726 2.65 1.36 −7.282* 353
I did not fully understand the seriousness of 2.33 3.00 4 1.667 2.69 2.14 −3.175* 354
the consequences if arrested.
I did not think I was doing anything wrong. 1.45 1.00 0 1.496 1.76 1.29 −2.851 358
I did not think was really hurting anyone. 1.84 2.00 0 1.596 2.35 1.57 −4.671* 356
I felt I could control my attractions and 2.59 3.00 4 1.533 2.72 2.52 −1.187 352
behavior myself.
*** p < .003; AM = attracted to minors; AA = attracted only to adults.
112 J. S. LEVENSON ET AL.

not know where to seek help. Interestingly, when group comparisons were
analyzed using a breakdown of those with child victims versus adult victims
(as opposed to self-reported attraction), no significant differences were found
on any of the 13 items, suggesting that it is the acknowledged attraction to
minors rather than the actual abuse of minors that seems to best explain the
internal and fundamental barriers to help-seeking.
Finally, help-seekers were compared to non-help-seekers on minor attrac-
tion, ACE score, education, income, current age, and race. Help-seekers had
significantly higher ACE scores (mean = 4 versus 2.9; t = −2.750, p = .006)
and were more likely to be minor attracted (54% of AM versus 30% of AA;
p = .007) but did not differ on any of the demographic variables.

Narrative responses
Participants were given space to answer open-ended questions about the
hurdles they faced seeking help for their unusual sexual attractions, and
about 55% of participants did so, offering revealing insights that spoke to
several common themes. While an extensive and systematic qualitative ana-
lysis is beyond the scope of this article and is planned for a subsequent
article, a selection of descriptive narrative responses were grouped into
categories that corresponded with the conceptual variables in our quantita-
tive analyses and are included here to illustrate prominent points.
Many participants talked about the fear, shame, and stigma that kept them
from disclosing, sometimes even to themselves, the truth about their attrac-
tions. One identified “fear of arrest, fear of losing my military career, fear of
losing my family, fear of physical harm.” Others agreed that anxiety about
being ostracized by their families or others was a salient feature in their
reluctance to seek help, identifying “being truthful to yourself, fear of the way
people will look at you, and letting family down” as challenges. Some said it
was hard “admitting to yourself you have a problem,” as was “facing the fact
that you victimized someone.” Fears of being reported or arrested were
glaringly featured in the narrative comments, and one referred to his concern
about sharing his secret as “social suicide.” One worried that his security
clearance would be threatened if he saw a therapist.
Others referred to the “taboo” of minor attraction and the societal beliefs
“that ‘those people cannot be cured.’” One related hearing “stories of people
who confessed to inappropriate sexual desires being separated from their
own children . . . even if they did not act on those desires or have desires for
their own children.” One described “being demonized as an evil person for
something you have no control over,” and another said, “People with those
urges get burned at the stake. You can’t come forward without being
ostracized and handicapped to the point [that] living is nearly impossible.”
Still another concurred: “When trying to reach out, people label and treat you
 JOURNAL OF CHILD SEXUAL ABUSE 113

like a monster.” Fears of going to jail were common, along with “fear of not
getting help, but being persecuted for my deviant thoughts.”
As well, they highlighted that not knowing where to find help was an
impediment for them. One participant said he had “no idea who I could talk
to,” while another shared, “Prior to my arrest, I twice tried and twice failed to
get help. So, I think a severe lack of education in the community about how
to get help before it is too late is the biggest obstacle.” Others agreed that
“there is really no place for help—until after arrest and incarceration—and
that is not right” and observed that “there isn’t a place which advertises the
fact that you can get help for sexual issues like there is AA/NA or drug
rehabs. Also coming out and sharing this issue with those close to you is very
difficult.” One explained that he did not know “how to explain or verbalize
[my] attraction. . . . . [Didn’t] know who to seek or who is qualified to go to
. . . sex therapists aren’t really advertised as much as drug/alcohol/family
therapists.” Some participants added that “therapy is expensive” and that
cost was a deterrent. Several respondents talked about the wish for self-help
books, informational websites, or online forums but also related that they
were “afraid to even search the Internet about the issue” due to concern
about “getting ‘flagged.’”
Finally, some respondents focused on their confusion about their thoughts
or behaviors and a lack of recognition that they had a problem, that it was
serious, and how harmful it was to victims. One said that “years of alcohol
abuse kept me from even realizing I had a problem,” and another described
the isolating and self-perpetuating nature of distorted thinking about sexual
abuse: “My sickness includes depression and isolation. No system support.
Part of this was learned responses from an abusive childhood that I never
sought help for.” Others also talked about the legacy of their own childhood
abuse as a contributor to their confusion: “I was barely an adult myself and I
did not see anything wrong with it because it was done to me.” Another
stated, “I think that if I would have got the treatment that I needed as a kid
when it was done to me, I would have learned different.”

Discussion
These results confirm the findings of other qualitative and quantitative
surveys (Buckman et al., 2016; Mitchell & Galupo, 2016; Piché et al., 2016),
which highlight several common and important themes about preventive
counseling prior to sexual offending. First, concerns about one’s own sexual
interests are often first recognized in adolescence or young adulthood, but
few individuals share their secret with others. Second, although some parti-
cipants acknowledged trying to talk with family members, friends, or other
confidants, the shame and secrecy that results from stigma often prevented
our respondents from seeking professional help. Consistent with prior
114 J. S. LEVENSON ET AL.

research (e.g., Piché et al., 2016), only one-fifth of our sample tried to talk to
someone about their sexual interests prior to their arrest. Finally, barriers to
seeking and receiving psychological services included concerns about con-
fidentiality, fears of social and legal consequences, personal shame or confu-
sion about the problem, affordability, and challenges finding competent
therapists who were adequately prepared to help them.
Noteworthy is that there were many significant differences in help-seeking
obstacles when comparing clients with self-reported attractions to minors
with those exclusively attracted to adults. Prominent disincentives included
two main areas: (a) shame, fear, and stigma as well as (b) distorted percep-
tions of the harmfulness or seriousness of sexual abuse. However, when
group comparisons were analyzed by assigning participants to groups by
child victims versus adult victims (rather than self-reported sexual interest),
no significant differences were found on any of the items, suggesting that it
may be the self-identified attraction to minors rather than the actual abuse of
minors that surfaces as a significant explanatory variable in fortifying barriers
to help-seeking. Victim choices as documented in crime reports, therefore,
may not always be reflective of fundamental sexual interests and a more
nuanced assessment of sexually deviant attractions may help identify risks,
needs, and treatment responsivity factors.
Contrary to expectations, help-seekers were more likely to be attracted to
minors and to have higher ACE scores but did not differ significantly from
non-help-seekers on age, income, education, or minority race. Based on past
general research about help-seeking, we would have expected more educated
and affluent Whites to be more likely to seek help and that those attracted to
minors and those with greater childhood adversity would be less likely to
seek help. Though few sought help, and they identified many barriers to
help-seeking, perhaps those who identified as attracted to minors felt a more
urgent need (than those without this affliction) to attempt to gain assistance.
Clearly more research is needed to understand the factors that contribute to
help-seeking for sexually offending persons in general and those attracted to
minors specifically, but it may be that they differ from the general population
due to the unique stigma around pedophilia and child abuse.
The findings have some important implications for more macro-oriented
prevention schemes. First, the labels that society (largely through the media but
also in political rhetoric) attributes to sexual criminals (e.g., “monsters,” “pre-
dators,” and “deviants,” along with declarations of inevitable offending) are
enormously harmful in shaping the self-concepts of those who suffer from
paraphilic disorders. This may be particularly salient for AMs who, prior to
offending, found themselves internalizing negative and stigmatizing rhetoric,
such as beliefs that they cannot be helped or will not benefit from counseling.
The relatively recent introduction of online resources like B4UAct and Virtuous
Pedophiles may be helpful in de-isolating those who experience these attractions
 JOURNAL OF CHILD SEXUAL ABUSE 115

and might help them find role models who have successfully navigated the
complexities of minor-attraction and found ways to lead satisfying and healthy
lives. Unfortunately, public services to engage minor-attracted persons in coun-
seling exist primarily outside of the United States (for instance, the Dunkelfeld
Project and Stop It Now!). Enhanced training and education for therapists is also
needed to help them understand the disorder of pedophilia and to enhance their
willingness and their sense of competence in working with these clients.
Another noteworthy finding in these data is that AMs had significantly
higher ACE scores as well as significantly higher prevalence rates of various
sorts of child maltreatment, most notably sexual abuse. They also reported
earlier onset of masturbation and sexual contact with others (consensual and
otherwise) than AAs. The exact reasons for the disparities are unclear, and
additional research is needed to better understand the complex relationship
between early adversity and later offending. Some possible explanations are
contemplated: for some children who are exposed early to sexual material or
sexual molestation, these experiences may become incorporated into their
sexual development and sexual “template.” For others, early molestation may
normalize sexual behavior between children and adults. And for some,
sexualized relationships may be part of a distorted learned strategy for
defining one’s value or worth and lead to maladaptive tactics of using sex
to meet emotional needs for attention, affection, control, or intimacy.
Growing up in neglectful, chaotic, or unpredictable environments character-
ized by parental absence, substance abuse, and/or mental health difficulties
may thwart the development of secure bonds to caregivers and predispose
insecure attachments in adulthood (Grady et al., 2016; Marshall, 2010).
Individuals who struggle to form healthy, trusting relationships with adults
may view children as less threatening and gravitate toward youngsters to get
their relational needs met. Notwithstanding the causal mechanisms under-
pinning the association between early adversity and acting out on sexual
attraction toward minors, research suggests that the intergenerational cycle of
abuse would be disrupted by ensuring that maltreated children from disor-
dered social environments receive early and effective intervention services
(Anda, Butchart, Felitti, & Brown, 2010; Larkin, Felitti, & Anda, 2014).
Social workers, psychologists, and other mental health counselors are
often called on to provide services to challenging populations such as
forensic clients, substance abusers, or domestic batterers. However, the
diagnosis of pedophilic disorder is commonly misunderstood, revulsion
about the disorder can preclude the provision of appropriate prevention
services, and clinicians are sometimes confused about what falls under child
abuse reporting mandates. Furthermore, therapists may respond to these
consumers in ways that seem judgmental or invalidating. Clinical training
protocols should be devised for therapists to clarify the diagnostic criteria
for pedophilic disorder, discuss issues related to mandatory reporting, and
116 J. S. LEVENSON ET AL.

offer a framework for providing effective, ethical, and compassionate coun-

seling services to non-offending MAPs. Clinicians should be exposed to an
understanding of the complex and diverse treatment needs of persons with
pedophilic interests. Clinicians are encouraged to explore their own perso-
nal attitudes about working with minor attracted persons and to seek
training and supervision to improve capacity for empathy and positive
therapeutic alliance with this population. When provided with strategies
to identify and respond effectively to countertransference issues, and given
knowledge of effective delivery of relevant cognitive-behavioral interven-
tions, practitioners will be better able to serve the needs of people diag-
nosed with pedophilia.

Limitations
This study had some limitations, the most evident being the intrinsic problems
of self-reported data. Although efforts were made to guarantee confidentiality
and anonymity, it is possible that some respondents were not entirely forth-
coming or answered questions in a socially desirable manner. The results may
not be representative of the population of men in treatment for sexual offend-
ing and may not represent non-offending MAPs. Regional and other differ-
ences may be present, and replication will be necessary to obtain a complete
picture of barriers to help-seeking. The ACE scale in its dichotomous form is
limited in its ability to ascertain the scope, frequency, and severity of early
adversity. As well, some offenders may not readily recognize adverse childhood
experiences as pertaining to themselves, perhaps underreporting child mal-
treatment. Given the retrospective and dichotomous nature of the measure-
ment of the ACE scale and other variables and the cross-sectional design,
statements of causal influence cannot be made. However, the study provides
preliminary descriptive and comparative data to enrich extant knowledge
about the help-seeking experiences of sex offenders prior to arrest, and it is
hoped that this information can inform prevention efforts.

Summary and conclusions

Protecting children from sexual abuse is certainly paramount in the values,
best practices, and ethical codes of the helping professions. By reducing the
obstacles to help-seeking for individuals with paraphilic disorders, and spe-
cifically those with pedophilic interests, a new paradigm for prevention of
sexual violence can be realized. Strategies for engaging potential offenders in
preventive services include accessible and affordable counseling services,
online or telephone forums, and self-help materials, whereby individuals
can receive cost-effective and anonymous help and information.
Community outreach efforts that encourage proactive help-seeking for this
 JOURNAL OF CHILD SEXUAL ABUSE 117

stigmatized group are crucial. Finally, therapists should be exposed to train-

ing opportunities that enhance their ability to deliver ethical and effective
services for this population.

Acknowledgments
The authors thank Dr. Ryan Shields for his contributions to the development of the survey
instrument and conceptualization of the concepts being studied.

Notes on contributors
Jill S. Levenson, PhD, LCSW, is a professor of social work at Barry University in Miami. Her
research interests focus on the impact and effectiveness of interventions and policies designed
to prevent sexual victimization. She received her MSW from University of Maryland and her
PhD from Florida International University.
Gwenda M. Willis, PhD, is a clinical psychologist and founder of the Advancing Sexual Abuse
Prevention (ASAP) Research Group in the School of Psychology at the University of
Auckland, New Zealand. Her research interests are in strengths-based approaches to working
with people who have sexually harmed and sexual abuse prevention.
Claudia P. Vicencio, LCSW, LMFT, is a clinical social worker with a practice focus on trauma-
informed care, dialectical behavior therapy, and effective treatment for co-occurring disor-
ders. She is a doctoral student at the Barry University School of Social Work. Her research is
on the impact of early childhood adversity on help-seeking behaviors in adulthood.

ORCID
Claudia P. Vicencio [Link]

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