Dynamic Consultations with Psychiatrists. Jason Maratos

thanked the doctor for the comprehensive presentation. He also praised the doctor for managing to establish a good relationship with Bob because he is someone who has difficulties in interpersonal relationships. JM then proceeded asking the doctor to clarify if there was a diagnosis of severe depression as well as a diagnosis of autistic spectrum disorder. Regarding the sexual dysfunction, the doctor stated that he saw this as part of the autistic disorder. As such, he did not feel that it merited special diagnostic classification. The case of him suffering from pedophilia (a disorder of sexual preference) had not been established yet. And the difficulty in consummating the marriage was again seen as part of the autistic disturbance.

      The doctor added that he knew that the couple had some help from a fertility clinic, which found that there was no physiological reason for them not to be able to have children. To JM's question, the doctor responded that the couple do not have sexual intercourse. JM then queried the logic of going to a fertility clinic when they don't have sexual intercourse, though this is not a rare phenomenon. The doctor stated that Bob had told him that he “was not sure” whether they have had intercourse. JM questioned the veracity of this statement and suggested that because one cannot be not sure whether they have had intercourse that Bob is avoiding answering this question meaningfully. The doctor added that Bob had expressed fear of penetrating his wife. What became clear was that embarrassment inhibits Bob from giving a full history of his sexual life, and a full history is essential for a proper diagnosis of his difficulties. The doctor then expanded on Bob's sexual development. The onset of secondary sexual characteristics seemed to have proceeded naturally. Bob began masturbating at the age of 11. The doctor added that Bob had told him that he thinks he is heterosexual. In recounting the images that were associated with his masturbation Bob made some vague mention of boys but subsequently he made it clear that he was only interested in women. The doctor remained unsure whether Bob was interested in boys or not. Bob did mention to the doctor that once he had been attracted to a 12‐year‐old boy.

      JM then raised the issue of confidentiality and the law regarding pedophilia. JM pointed out that in the UK if a doctor is treating a patient who is a threat or a danger to anyone else, they have a duty to take whatever action is necessary to protect the public. This is much more so when the welfare of children is concerned. The legal situation will need to be clarified with Bob even before the psychiatric or the therapeutic consultations are initiated. The doctors need to be aware that according to UK law, a court can subpoena the records of a doctor if there is an issue of possible harm to children.

      In view of the prevailing legal situation, it is important for Bob to know that if he has been found to be downloading pornographic pedophile material, that he accepts this as his own personal problem so that he can proceed to explore it openly within the therapeutic sessions and reach a level where he can receive the appropriate therapy and work toward overcoming this dysfunctional situation. It is not only that he may be attracted to boys aged 12 and that he feels trapped in a 12‐year‐old body, but it is also the global sexual dysfunction that he has and his attitude about tenderness, warmth, sexual foreplay, and the other aspects of heterosexual interaction.

JM then reflected on the management of pedophiles especially because this is a condition that is particularly resistant to therapeutic interventions. He should certainly avoid working in environments where he would be coming into contact with children and that means that he should change his job as a primary school teacher. In any case, if this case goes to court and he is found guilty, then presumably his name will be put on a register, and would have to disclose this with any application for job that he makes. JM pointed out the predilection of pedophiles for jobs that bring them into contact with children and that one finds frequently pedophiles among the professions of teachers, gymnastic coaches, foster parents, care workers, priests, and even doctors who deal with children such as pediatricians and psychiatrists for children. JM pointed out that many of these unfortunate people choose a profession that will give them access to children. JM referred to the numerous cases of historical sexual abuse that have come to the surface and have shaken many institutions including the Catholic Church.

      JM then referred to psychotherapy of pedophilia. This is a highly specialized branch that requires trained professionals who have experience in the field. General psychotherapeutic interventions have not been shown to be therapeutically effective. For practical purposes pedophilia should be considered a condition with guarded prognosis that needs to be managed as well as treated.

      JM made a comment about the doctor's record and where he refers to facts , information that is only an allegation against Bob. More specifically, Bob's attribution of his confession to pressure from the police must be clearly stated that this is what Bob felt not that this was a fact, although such interrogations are almost never without a personal sense of threat and pressure.

      It is of interest that Bob seems to want to shift the responsibility for the downloaded images to the other people who had access to his computer. This is a matter for the police investigation and the psychiatrist needs to keep an open mind until a judgment is passed. JM pointed out that for the police to be involved, this must have been an activity that he was engaged in for some time and for which he probably paid money. He must have accessed these sites in a naïve way because currently, sophisticated pedophiles use the “dark web” and make themselves undetectable. The psychiatric approach needs to be informed by the details of this activity and by the methods Bob used to record this in his hard drive.

      JM then pointed out that the event that Bob described when he was telephoned (aged 12) and ordered to carry out certain sexual acts may have been defining and traumatic for him, taking to account the overall personal structure of his psychology that was that of somebody who is suffering from an autistic spectrum disorder. JM pointed out that Bob does have some abilities that mainline autistic people do not have such as the ability to communicate and the well‐developed language.

      JM then questioned the diagnosis of a depressive illness. He pointed out that the present emotional state could be a reaction to an enormous stress and threat that he must be under. The present detection and interrogation by the police has implications on Bob losing his job, going through court, his private difficulties becoming public, having to register as a pedophile, having to declare this on every job that he seeks an appointment, and challenging the relationships with his wife and with his family. It would be surprising if somebody facing this enormous constellation of changes and losses was not in some emotional turmoil. JM then asked if the doctor knew if there was a service that was oriented therapeutically toward the treatment of people with sexual dysfunction of Bob's type. The doctor was not sure, although he had the impression that the forensic department does treat some cases with antiandrogens. JM's view was that prescription of antiandrogens was not a highly effective way of helping people with this condition.

      JM then began his conclusion by saying that the role of a general psychiatrist would be to get Bob to accept that he has a complex problem for which he needs treatment. Denying its existence is not a good foundation for any kind of treatment.

      JM then pointed out that Bob may not think that viewing child pornography is harmful. That is pure ignorance because he denies the process by which children are made to take part in acts that are then filmed and put on the internet. The process of developing the pornographic images is itself enormously damaging to children, and by viewing them, he is funding this crime. If he saw the viewing of this activity as innocuous, he simply needs to be informed why viewing these images is criminal.

       References on Autism and Pedophilia

A good introduction to the subject of paraphilia is the chapter by (Fedoroff, 2009) in the New Oxford Textbook of Psychiatry. It is general and does not address adequately the issue of autism and these disorders. The same limitation applies to the volume on DSM‐V. Several studies establish a link between autism spectrum disorder and the paraphilias (Fernandes et al., 2016; Schottle et al., 2017). Of special interest is the study of Kolta and Rossie (2018), which describes a case with both these conditions.

      Obviously, the fields of paraphilias and of autistic spectrum disorders are vast. Those interested in the psychoanalytic aspect of paraphilias could study the works of Socarides