Diagnosis of Pedophilia 1 Running Head: DIAGNOSIS OF PEDOPHILIA The Utility of the Diagnosis of Pedophilia: A Comparison of Various Pedophilic Classifications

This study examined the utility of the diagnosis of pedophilia in a sample of extra-familial child molesters assessed at a university teaching hospital between 1983 and 1995. Pedophilia was defined in one of four ways: 1) A DSM diagnosis made by a psychiatrist 2) A deviant phallometric profile 3) A DSM diagnosis and a deviant phallometric profile, and 4) high scores based on the Screening Scale for Pedophilic Interest (Seto & Lalumière, 2001). Demographic data and information on psychological tests, offence history and recidivism were gathered and group differences were analyzed along with the ability of certain variables to uniquely contribute to the classification of pedophilia. Results indicated that few differences existed on psychological measures between pedophilic and nonpedophilic sexual offenders regardless of the classification system used. Additionally, results indicated that the construct of pedophilia was unable to reveal differences in sexual, violent, or criminal recidivism rates. These results are discussed as they relate to the usefulness of this diagnosis with sexual offenders. Diagnosis of Pedophilia 3 The Utility of the Diagnosis of Pedophilia: A Comparison of Various Pedophilic Classifications Issues of classification have significant implications for the assessment and treatment of sexual offenders. Previous research has suggested that sexual offenders are a heterogeneous group, such that those who offend against adults and children differ on important dimensions, such as criminal history, and risk to reoffend (Hanson & Bussière, 1998). With regards to child molesters, it is evident that there are additional differences with respect to victim selection (i.e., intra-familial or incest versus extra-familial) (Hanson & Bussiere; Quinsey, Lalumiere, Rice, & Harris, 1995) and victim gender (Barbaree & Seto, 1997; Walsh, 1994). However, most research on child molesters has neglected to differentiate this group based on the presence or absence of a diagnosis of pedophilia, despite the fact that such a diagnosis implies a more deviant sexual interest, and differential consequences for the prediction of recidivism. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000), specifies three criteria to make a diagnosis of pedophilia. Criterion A requires that the individual has experienced recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally aged 13 years or younger) over a period of at least 6 months. Criterion B states that the person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. Lastly, Criterion C requires that the person is at least 16 years-old and at least 5 years older than the child or children in Criterion A (p. 572). The DSM-IV-TR further qualifies the diagnosis with specifiers indicating an attraction to males, females, or both; limited to incest; exclusive type (i.e., attracted only to children); or nonexclusive type. The purpose of diagnoses is to categorize individuals into homogeneous subgroups, which is intended to promote accurate prognosis and effective treatment. Despite this, the Diagnosis of Pedophilia 4 diagnosis of pedophilia is often ignored by clinicians and rarely addressed by researchers who work with sexual offenders (Marshall, 1997). As a result, the terms “pedophile” and “child molester” have been used interchangeably, which can create conceptual confusion (Barbaree & Seto, 1997). The literature describes a child molester as an individual who has engaged in a sexually motivated act against a prepubescent child, without an indication of preference, whereas a pedophile is described as an individual who has displayed a preference for sexual behavior against a child (O’Donohue, Regev, & Hagstrom, 2000). This distinction is important, as not all child molesters are pedophiles, and some pedophiles may not have committed a sexual offence against a child (Konopasky & Konopasky, 2000). Concerns regarding the reliability and validity of the Sexual and Gender Identity Disorders as a group have been raised (Zucker, Finegan, Doering, & Bradley, 1984). Issues surrounding the diagnosis of pedophilia have also been summarized, and researchers have questioned the value added by the use of such a label (Marshall, 1997; O’Donohue et al., 2000). For example, the ambiguous nature of the terms “recurrent” and “intense” within criterion A force clinicians to draw inferences as to the nature of the disorder. Another concern is the requirement that the behavior/urges/fantasy cause distress or impairment. Given the accuracy of clinical judgment (Meehl, 1996), these inferences may adversely affect the reliability and validity of this diagnosis. It should be noted that, DSM-IV-TR states; “Because of the egosyntonic nature of Pedophilia....Experiencing distress about having the fantasies, urges or behaviors is not necessary for a diagnosis of Pedophilia” (APA, 2000, p. 571). Other concerns with the diagnosis of pedophilia include the fact that child molesters are frequently reluctant to admit that they have deviant sexual fantasies and they often minimize their deviant sexual Diagnosis of Pedophilia 5 interests, which makes it difficult to gather accurate information (Marshall, 1997; Ward, Hudson, Johnston, & Marshall, 1997). In an examination of the value of the diagnosis of sadism in a forensic population, Marshall, Kennedy, and Yates (2002) compared sadists and non-sadists (as delineated in the DSM-III-R and DSM-IV) on a variety of offence features (e.g., use of threats), self-reports (e.g., sexually violent fantasies), and phallometric data. Overall, the results indicated that the designation of sadism was not based on the diagnostic criteria and that the sadists and nonsadists were not reliably differentiated on the features assumed to be characteristic of sadistic sexual offenders (e.g., deviant arousal to rape). Moreover, the results demonstrated that those defined as non-sadists were in fact, more deviant on numerous variables (e.g., use of torture in the offence) than those diagnosed with sadism, calling into question the validity of the diagnosis and raising concerns about the implications for an offender diagnosed with sadism. Due to the apparent difficulties with the DSM criteria indicated above, it has been suggested that phallometric testing may provide reliable evidence of pedophilia in the absence of an accurate diagnosis (Freund & Blanchard, 1989; Freund & Watson, 1991) or, at least, contribute to the diagnostic process (Eccles & Marshall, 1993). Moreover, phallometric testing allows for the assessment of deviant sexual preference, while attempting to overcome deliberate impression management, which may undermine self-reported information in forensic populations in particular (Nugent & Kroner, 1996). In an examination of the diagnostic ability of the phallometric test for pedophilia, Freund and Watson (1991) found that the sensitivity of the phallometric test for pedophilia was satisfactory, such that only 3.1% of the sexual offenders against adult victims demonstrated sexual preference to children, whereas 78.2% of the child molesters with female victims and 88.6% of the child molesters against male victims Diagnosis of Pedophilia 6 demonstrated deviant sexual arousal to children. More recently, Blanchard, Klassen, Dickey, Kuban, and Blak (2001), examined the specificity and sensitivity of phallometric testing for pedophilia. Results indicated that the rapists with the greatest number of adult victims had the lowest probability of being diagnosed with pedophilia according to phallometric assessment (specificity = 96%). In contrast, the phallometric results for those men with the greatest number of child victims revealed a 61% sensitivity rate. These studies lend support to the hypothesis that phallometric assessment may serve as a useful screening device to indicate pedophilic interest. Although phallometric testing should provide evidence as to the degree of pedophilic interest, there are limitations when relying on this approach. For example, numerous studies have demonstrated that a significant proportion of offenders were able to suppress penile responses (Howes, 1998; Kalmus & Beech, 2005; Marshall & Fernandez, 2000). Furthermore, the interpretation of arousal is difficult, as some offenders may not be aroused to a certain stimulus, while others may be aroused to deviant stimuli but are not known to be sexual offenders (Bahroo, 2003). Therefore, the problems with low responding (O’Donohue & Letourneau, 1992) along with the lack of reliability (Barbaree, Baxter, & Marshall, 1989) and validity (Hall, Proctor, & Nelson, 1988) have led some researchers to question the utility of this procedure with sexual offenders (Marshall & Fernandez, 2000). Despite the concerns about phallometric assessment, relative sexual interest in children remains an excellent predictor of sexual recidivism (Hanson & Bussière, 1998). However, practical limitations, such as limited access to phallometric laboratories, may preclude the ability to assess offenders phallometrically. For this reason, Seto and Lalumière developed the Screening Scale for Pedophilic Interests (SSPI; 2001), to identify those individuals most likely to display sexual interest in children. Research to date using the SSPI has suggested that scores are Diagnosis of Pedophilia 7 significantly related to deviant phallometric responding, and identified pedophilic interest better than chance. The SSPI is also related to both sexual and violent recidivism in child molesters (Seto, Harris, Rice, & Barbaree, 2004). In an examination of the predictive utility of the SSPI, the authors found that it made a significant contribution to the prediction of sexual offending, beyond that of phallometric testing alone. Currently, what is known about risk to re-offend, general psychological attributes, and recidivism in pedophiles is largely extrapolated from studies on intraand extra-familial child molesters who may or may not meet the diagnostic criteria for pedophilia. The current investigation examines the utility of the diagnosis of pedophilia in a sample of extra-familial child molesters in a forensic psychiatric setting. This study includes many of the assessment procedures currently used with sexual offenders and hypothesized that a diagnosis of pedophilia would result in a more deviant profile with regards to psychological tests and offence history than those offenders not so diagnosed. Furthermore, it was hypothesized that when more stringent criteria for pedophilia was used (i.e., a diagnosis of pedophilia and a deviant phallometric score) and compared to a less stringent group of non-pedophilic sexual offenders (i.e., no diagnosis of pedophilia and a non-deviant phallometric profile), that the pedophilic group would display a more deviant profile with regards to psychological and offence factors. An additional hypothesis was that a classification of pedophilia, regardless of the method used, would reveal a significantly greater proportion of sexual, violent, and criminal recidivists compared to the nonpedophilic groups. No specific hypotheses were made with respect to which category alone (DSM, phallometric, or SSPI) would result in the more deviant profile, or what differences between profiles would exist. Diagnosis of Pedophilia 8 Method Participants All participants (N = 206) were adult males, and had been convicted of a hands-on sexual offence against an unrelated male or female child (extra-familial child molester) who was under the age of 16 at the time of the offence. The participants were assessed at a university teaching hospital in a large Canadian city, between 1983 and 1995. If the police records indicated that the participants had offended against an adult or against a family member, they were excluded from the analysis. The sample was divided into four categories based on different definitions or methods of determining pedophilia. Each pedophilic group was compared to a group of men determined to be nonpedophilic based on the same type of classification. The first comparison included men who had been diagnosed with pedophilia based on the DSM criteria (DSM, n = 85). This group was compared to those individuals not diagnosed as a pedophile based on the DSM criteria (n = 79). The second comparison studied men defined as pedophilic based on a deviant phallometric index score (i.e.,≥1) on either the Pedophile Index and/or the Pedophile Assault Index (PD, n = 110) to men determined to be nonpedophilic based on a phallometric score of less than one (n = 45). The third comparison distinguished between those offenders classified as pedophiles when they received a diagnosis of pedophilia in addition to receiving a deviant phallometric index score (i.e.,≥1) on either of the indices mentioned above (DSM+PD, n = 49). Again, this group was compared to those offenders who were not given a diagnosis of pedophilia and received a phallometric score less than one (i.e., non-deviant, n = 43). The last set of comparisons included men described as pedophilic based on the SSPI (Seto & Lalumière, 2001). Those men with score Diagnosis of Pedophilia 9 of 3 to 5 were defined as pedophilic (SSPI, n = 103). Those with scores below 3 were considered nonpedophilic (n = 103). Procedures The standard procedure in the Sexual Behaviors Clinic, was that each patient was first interviewed by a psychiatrist who, after a couple of sessions, would provide a DSM diagnosis, in addition to filling out demographic information. The psychiatrist would have previous medical charts and police reports available. These diagnoses were made by seasoned psychiatrists whose major clinical work was with sexual offenders. Participants would then be assessed in the phallometric lab and fill out various questionnaires including the psychological tests. The assessment battery administered at the hospital is part of the clinical assessment used with all men charged and/or convicted of sexual offending. All participants signed an informed consent form at the time of their assessment. This form permits researchers to use information obtained from the assessment for research purposes. The specific version of the DSM used in the determination of the diagnoses varied depending on the year of assessment (DSM-III, DSM-III-R, DSM-IV). The progression of the DSM has resulted in more specific and comprehensive criteria. Specifically, the DSM-III is rather vague when compared to later versions. Perhaps the most significant difference between editions is the requirement in DSM-IV that the individual be distressed or experience some form of impairment as a result of his/her behavior, urges, or fantasies, which changed with DSM-IVTR. These more stringent criteria might result in fewer diagnoses. However, as Marshall (1997) Diagnosis of Pedophilia 10 notes, many diagnosticians ignored this statement in order to justify treating individuals who were clearly engaging in deviant sexual behavior, regardless of their own lack of distress. Measures Michigan Alcoholism Screening Test The Michigan Alcoholism Screening Test (MAST) is a 24-item self-report inventory which is used to identify behaviors that are suggestive of alcohol abuse (Gibbs, 1983; Seltzer, 1971; Seltzer, Vinokur, & van Rooijen, 1975). The degree of problems associated with alcoholism is reflected in the total number of “yes” responses. Scores of 5 or 6 are indicative of alcohol problems and scores of 7 or more are suggestive of alcohol abuse (Allnutt, Bradford, Greenberg, & Curry, 1996). The MAST has been utilized in many studies involving sexual offenders (e.g., Allnutt et. al., 1996; Firestone, Bradford, Greenberg, Larose, & Curry, 1998; Firestone, Bradford, McCoy, et al., 1998; Hucker, Langevin, & Bain, 1988; Rada, 1975; Rada, Laws, & Kellner, 1976). The internal consistency has a reported overall alpha coefficient of .87, a validity coefficient of r = .79, and is relatively unaffected by age of respondent or socially desirable responding (Magruder-Habib, Stevens, & Alling, 1993; Magruder-Habib, Durand, & Frey, 1991). Derogatis Sexual Functioning Inventory The Derogatis Sexual Functioning Inventory (DSFI), consists of 10 subscales, and assesses dimensions of sexual functioning (Derogatis & Melisaratos, 1979). The Sexual Functioning Index (SFI) is a global measure derived by summing the 10 subtest scores and provides an overall measure of an individual’s level of sexual functioning, where higher scores represent healthy sexual functioning (Derogatis, 1980). The DSFI has good validity and good internal consistency with correlations ranging from .56 to .97 for the 10 subscales, and test-retest Diagnosis of Pedophilia 11 reliability ranging from .42 to .96 for the 10 subscales (Derogatis, & Melisaratos). Although the DSFI has been used with large non-forensic samples, its use with sexual offenders is limited (see Firestone, Bradford, Greenberg, et al., 1998; Firestone, Bradford, McCoy, et al., 1998; Hanson, Cox, & Woszcsyna, 1991). Buss-Durkee Hostility Inventory The Buss-Durkee Hostility Inventory (BDHI; Buss & Durkee, 1957) contains 75 truefalse statements which provide a measure of general hostility, where higher scores are suggestive of higher levels of hostility. A total score of 38 and above is consistent with high levels of hostility (Buss & Durkee). The BDHI consists of the subscales: Assault, Indirect Aggression, Irritability, Negativism, Verbal Aggression, Resentment, and Suspicion. Among rapists, BDHI scores have been consistently higher than nonoffending controls (Firestone, Bradford, Greenberg et. al., 1998; Rada, et al, 1976), and lower than both intra-familial and extra-familial child molesters (Firestone, Nunes, Moulden, Broom, & Bradford, 2005). Psychopathy Checklist-Revised The Psychopathy Checklist-Revised (PCL-R) consists of 20 items designed to assess behaviors and personality characteristics considered fundamental to psychopathy. Factor analyses have consistently yielded two distinct and stable factors representing (a) the degree of personality, interpersonal, and affective traits deemed relevant to the construct of psychopathy, and (b) the degree of antisocial behavior, unstable, and corrupted lifestyle (Hare, 1991; Hare et. al., 1990). Scores of 30 and above are generally considered indicative of psychopathy (Hare, 1991). The psychometric properties of this instrument are well established. The reported alpha coefficient, aggregated across seven samples of incarcerated males from Canada, the United States, and England was .87 (Hare, Forth, & Strachan, 1992). Using five prison samples and Diagnosis of Pedophilia 12 three forensic samples, Hare et al. (1990) found the correlation between the two factors averaged r = .48. The PCL-R is currently being used widely in sexual offender research (Firestone, Bradford, Greenberg, & Serran, 2000; Serin & Amos, 1995; Serin, Malcolm, Khanna, & Barbaree, 1994), and is consistently identified as an important predictor of violent and sexual recidivism (Quinsey, et al., 1995). In the present investigation, research assistants completed PCL-R assessments retrospectively from descriptive material contained in medical files. A random sample of clinic files was independently rated by each researcher, resulting in satisfactory interrater reliability correlation, r = .85. Valid PCL-R ratings can be achieved through quality archival information (Harris, Rice, & Quinsey, 1994; Wong, 1988). Cognition Scale The Cognition Scale, which was designed for use with adult child molesters, is composed of 29 statements which reflect values regarding sexual contact with children. Factor analysis has indicated that the Cognition Scale is one-dimensional (Abel et al., 1989; Hanson, Gizzarelli, & Scott, 1994). Scores range from 1 to 5, where lower scores are indicative of a greater degree of acceptance towards adult sexual contact with children. This scale has demonstrated good discriminant validity, in that child molesters have been distinguished from non-offending controls (Hanson et al.; Stermac & Segal, 1989). Reliability is adequate, with an alpha coefficient of .92 for internal consistency (Hanson et. al., 1994). A Pearson product-moment coefficient of .76 indicates good test-retest reliability (Abel et. al., 1989). Screening Scale for Pedophilic Interests The SSPI (Seto & Lalumière, 2001) is a brief screening instrument based on historical/static offence variables. The scale includes four items including presence of a male Diagnosis of Pedophilia 13 victim, more than one victim, victim is 11 years-old or younger, and unrelated victim. The SSPI has been shown to be highly correlated with measures of pedophilic interest based on phallometric assessment (pedophilic index), and to identify pedophilic interest in child molesters significantly better than chance (Seto & Lalumière, 2001). Although this measure was not designed with a cutoff score, we chose to dichotomize our participant group based on high versus low scores for the purpose of comparing this nonintrusive and relatively simple measure to the more traditional methods of determining pedophilic interest. Measurement of Sexual Arousal Changes in penile circumference in response to audio/visual stimuli were measured by means of an Indium-Gallium strain gauge and processed on an IBM compatible computer for storage and printout. Stimuli Presentation. The order of the stimuli presentation, held constant for all participants, was computer-controlled. Participants were presented with one or more of three series of audiotapes. The audiotape battery consisted of vignettes (Abel, Blanchard, & Barlow, 1981) of approximately two minute duration describing sexual activity between two people varying with respect to age, sex, and degree of consent, coercion, and violence portrayed. Each participant was presented with a full set containing one vignette from each category following instructions to allow normal arousal to occur. The female child series consisted of descriptions of sexual activity with a female partner/victim for eight categories. The male child series consisted of eight corresponding vignettes involving a male partner/victim but also included one scenario involving an adult female partner. For each of the female child and male child series, two equivalent scenarios for each category were included. Categories were as follows: (a) child initiates, (b) child mutual, (c) non-physical coercion of child, (d) physical coercion of child, (e) Diagnosis of Pedophilia 14 violent sex with child, (f) nonsexual assault of child, (g) consenting sex with female adult, and (h) sex with female child relative (incest). Scoring. The Pedophile Index was calculated by dividing the participant’s highest response to a child initiates or child mutual stimulus by the highest response to an adultconsenting stimulus. The Pedophile Assault Index was calculated by dividing the highest response to an assault stimulus involving a child victim (non-physical coercion of child, physical coercion of child, sadistic sex with child, or nonsexual assault of child) by the highest response of the child initiates or child mutual stimulus. Criminal Offence Histories Offence information was gathered from the Canadian Police Information Center (CPIC) at the Ottawa Police Station. This information was based on a national database of criminal arrests and convictions including INTERPOL reports from the Royal Canadian Mounted Police. CPIC records contain the individual’s criminal history and include details such as the date of charge or conviction, the nature of the offense, the disposition of the incident (e.g., convicted, charges withdrawn, etc.) and sentence/penalty imposed in cases of convictions. Offence Characteristics Offence characteristics included a measure of the violence of the sexual offence, and the intrusiveness of the sexual act. The level of violence and the intrusiveness of the sexual act were rated by the interviewing psychiatrist. The level of violence used a 10point scale indicative of increasing levels of force and violence. The specific descriptors along with their corresponding scores were as follows: nil (0), threat of assault with no weapon (1), threat of assault with weapon (2), minor injury with no weapon (3), minor injury with weapon (4), severe beating with no weapon (5), severe beating with weapon (6), potential homicide (7), homicide (8), and Diagnosis of Pedophilia 15 homicide with post-death mutilation (9). The intrusiveness of the sexual act was scored based on a six-point scale where higher scores represent increasing levels of sexual intrusion. The specific descriptors along with their corresponding scores were as follows: nil (0), verbal threat (1), attempt (2), touching (3), penetration (4), and sexual assault with excessive violence (5). Recidivism Analyses A definition of sexual recidivism was any charge or conviction for a sexual offence after the index offence. Violent recidivism was any charge or conviction for violent and sexual offences and finally, criminal recidivism was any charge or conviction noted in the Canadian Police Information Center’s (CPIC) report. The length of follow-up in this particular study was up to 15 years. It should be stressed that recidivists were those individuals that have been charged or convicted of reoffending. It is evident that this is a major under representation of all reoffending. This cumulative hierarchy in which each additional category includes the previous category is employed to account for plea bargaining, a common practice, as men would generally prefer to be convicted of virtually any offense other than a sexual assault, and to allow comparison with prior recidivism studies. Statistical Treatment of the Data Prior to performing statistical tests, the data were screened to ensure that assumptions underlying the tests were not violated. Outlying cases were detected using a criterion of plus or minus three standard deviations from the mean or by visual inspection of normal probability plots. Values of outlying cases were adjusted upward or downward according to the direction of the problem. Diagnosis of Pedophilia 16 Results The groups (pedophilic versus nonpedophilic) were compared within each labeling category: DSM, PD, DSM+PD, and SSPI. Each set of analyses of variance compared the two groups within each category across a number of variables: demographic (e.g. age, education), offence (e.g. number of victims, level of violence), psychological (e.g. alcohol abuse, sexual functioning) and offence history variables (e.g. prior convictions). Chi-square analyses were performed to examine differences regarding the dichotomous variables, marital status and recidivism. Finally, logistic regression analyses were performed to determine which variables made significant unique contributions in the prediction of the various pedophilic determinations. Table 1 presents the differences between the pedophilic and nonpedophilic child molesters based on DSM criteria. The violence of the offence was significantly different, where those diagnosed as nonpedophiles were more violent in the commission of the offence compared to those defined as pedophiles. Nevertheless, it is clear that this difference between pedophiles and nonpedophiles is not clinically significant. Additionally, the Pedophile Index was significantly different, where those diagnosed as pedophiles displayed greater deviant phallometric arousal compared to those not diagnosed as pedophiles. However, it is interesting to note that both groups, on average, score in the deviant range of sexual arousal. No other significant differences were found. ---------------------------Insert Table 1here ---------------------------To assess the predictive accuracy of the violence of the offence and the Pedophile Index on the diagnosis of pedophilia, a direct logistic regression analysis was performed. A test of the Diagnosis of Pedophilia 17 full model against a constant-only model was statistically significant, χ (2, N = 139) = 10.87, p < .01, suggesting that the predictor variables reliably distinguished between pedophilic and nonpedophilic sexual offenders as determined by a DSM diagnosis. The variance in pedophilic diagnosis accounted for was small with a Nagelkerke adjusted R = .101, indicating that 10% of the variability in pedophilic and non-pedophilic sexual offenders was accounted for by the violence of the offence and the Pedophile Index. Prediction success was poor, with 24.6% of the nonpedophiles and 91% of the pedophiles predicted, for an overall success rate of 61.9%. Additionally, the area under the Receiver Operating Characteristic (ROC) curve was used to assess the predictive accuracy for the pedophilic group, and revealed a predictive accuracy (ROC = .58, p < .20) that was not significantly above chance levels. According to the Wald Criterion, the Pedophile Index reliably predicted pedophilic sexual offenders according to DSM diagnosis. The odds ratio of 1.32 indicated that for every unit increase in the Pedophile Index, an offender was 1.3 times more likely to be diagnosed as a pedophile. Table 2 summarizes the differences between pedophiles and nonpedophiles based on PD results. The phallometric results were used to determine group membership and as such, the scores for pedophiles and nonpedophiles were included in the table for descriptive purposes only. The pedophilic group was more hostile as indicated by the BDHI, demonstrated poorer sexual functioning on the DSFI and was rated more psychopathic on the PCL-R, compared to the nonpedophilic group. ---------------------------Insert table 2 here --------------------------Diagnosis of Pedophilia 18 The logistic regression for the PD group was statistically significant, χ (3, N = 133) = 30.90, p < .001. The overall variance accounted for in pedophilic designation was small with a Nagelkerke adjusted R = .30, indicating that 30% of the variability in pedophilic and nonpedophilic designation was predicted by the above variables (BDHI, DSFI, and PCL-R). Prediction analysis revealed that 44.7% of the non pedophiles and 92.6% of the pedophiles were predicted, for an overall success rate of 78.9%. The ROC curve was adequately accurate (ROC =.79, p <.001). According to the Wald Criterion, sexual functioning predicted pedophilic sexual offenders according to PD criteria. The odds ratio of .91 shows little change in the likelihood of being diagnosed as a pedophile on the basis of one unit change in sexual functioning. Table 3 shows the differences between pedophiles and nonpedophiles based on the DSM+PD criteria. Again, a deviant or non-deviant phallometric profile contributed to the determination of group membership and as such, the phallometric scores for pedophiles and nonpedophiles were included in the table for descriptive purposes only. The pedophilic group demonstrated less violence in their offences, scored higher on the BDHI, and demonstrated poorer sexual functioning on the DSFI compared to the nonpedophilic group. ------------------------Insert table 3 here ------------------------Again, logistic regression was used to test the ability of these variables to predict pedophilia for the DSM+PD group. A test of the full model with all three predictors (Violence of Offence, BDHI, DSFI) against a constant-only model was statistically significant, χ (3, N = 74) = 26.33, p < .001, which suggested that the predictors, as a set, reliably distinguished between pedophilic and nonpedophilic sexual offenders based on DSM+PD criteria. The overall variance Diagnosis of Pedophilia 19 accounted for in pedophilic designation was small with a Nagelkerke adjusted R = .40, indicating that 40% of the variability in pedophilic and non-pedophilic designation was predicted by the variables indicated above. Prediction success was adequate, with 60% of the nonpedophiles and 79.5% of the pedophiles predicted, for an overall success rate of 71.6%. The ROC curve revealed moderate predictive accuracy (ROC =.70, p <.01). According to the Wald Criterion, the violence of the offence and sexual functioning reliably predicted pedophilic sexual offenders according to DSM+PD criteria. The odds ratio of .32 for the violence of the offence indicated that for every unit increase in the violence of the offence, an offender was 68% less likely to be diagnosed as a pedophile. The odds ratio of .94 showed little change in the likelihood of being diagnosed as a pedophile on the basis of one unit change in sexual functioning. Table 4 demonstrated differences between those defined as pedophilic or nonpedophilic based on SSPI scores. Results indicated that the pedophiles had significantly more prior sexual charges and/or convictions, were less intrusive with their sexual offence and had a greater number of victims than the nonpedophilic group. The logistic regression was statistically significant, χ (2, N = 198) = 20.98, p < .001. The overall variance accounted for in pedophilic designation was small with a Nagelkerke adjusted R = .13, indicating that 13% of the variability in pedophilic and non-pedophilic designation was accounted for by the variables, prior sexual charges and/or convictions and sexual intrusiveness. Note that the number of victims was not used in this regression as it is an item used in the dependent measure. Prediction analysis revealed that 50.5% of the nonpedophiles and 74.3% of the pedophiles were predicted, for an overall success rate of 62.6%. Additionally, the ROC curve revealed an adequate predictive accuracy (ROC =.62, p <.01). Diagnosis of Pedophilia 20 According to the Wald Criterion, the number of prior sexual charges and/or convictions and the intrusiveness of the sexual assault predicted pedophilic sexual offenders according to SSPI. The odds ratio of 1.29 indicated that an offender is 1.3 times more likely to be classified as a pedophile based on one unit change in the number of prior sexual offences (charges and/or convictions). Furthermore, the odds ratio of .56 indicated that an offender is 44% less likely to be classified as a pedophile based on one unit change in the degree of sexual intrusiveness. Logistic regression analyses, including, regression coefficients, Wald statistics, odds ratios, and 95 per cent C.I. for odds ratios can be found in table 5. ------------------------Insert tables 4 and 5 here -----------------------Discussion This study examined factors that putatively differentiate between pedophiles and nonpedophiles based on four different definitions. It was hypothesized that a diagnosis of pedophilia would result in a more deviant profile with regards to psychological and offence factors than those offenders not so diagnosed. An additional hypothesis was that a diagnosis of pedophilia would produce a greater proportion of recidivists regardless of the classification system used. Results indicated that few meaningful differences were revealed on any of the measures utilized across the various classification systems. Most importantly, there were no differences evident between pedophiles and nonpedophiles with regards to sexual, violent, or criminal recidivism. This finding is consistent with previous research questioning the validity of Diagnosis of Pedophilia 21 DSM diagnoses for the paraphilias and sadism in particular (Marshall, 1997; Marshall, Kennedy, & Yates, 2002; O’Donohue et al., 2000). There were some variables that differentiated between pedophiles and nonpedophiles based on the various definitions but not in any systematic manner. The degree of violence used in the commission of the offence reliably differed between pedophiles and nonpedophiles based on DSM and on DSM+PD. This revealed that nonpedophiles were significantly more violent as a group. However, the means indicate that this difference was not clinically meaningful. Hostility and sexual functioning were also differentiating factors in the PD and the DSM+PD analyses. In both cases, pedophilic men demonstrated more hostility and extremely poor levels of sexual functioning (less than the 4 percentile). These findings are consistent with other research suggesting that problematic levels of hostility and sexual functioning differentiated pedophiles from other types of sexual offenders (Lee, Pattison, Jackson, & Ward, 2001). However, it is of interest to note that in our lab, rapists and incest offenders have also scored at the same low level of sexual functioning as the child molesters in the present investigation (Firestone et al., 1998; Firestone, Bradford, Greenberg, McCoy, Larose, & Curry, 1999). Limitations Certain limitations should be considered when interpreting these findings. A limitation consistently identified in forensic research involves self-report, and response bias (Nugent & Kroner, 1996). Both issues exist in the two main forms of categorization of pedophilia (interviews for DSM diagnosis, and phallometric assessment). Given the social undesirability of sexual interest and contact with children, most individuals are reluctant to acknowledge and admit to such thoughts and behaviors. Some individuals included in nonpedophilic groups may have denied experiences consistent with the DSM criteria, or faked responses on the phallometric Diagnosis of Pedophilia 22 assessment. This issue is a possible alternative explanation for finding few differences between groups. The DSM criteria against which the participants were assessed changed over the span of the investigation and it has been noted that previous versions of the DSM have been criticized due to the requirement that an individual must be distressed by their fantasies, urges, and/or behaviors in order to warrant a diagnosis. In DSM-IV-TR, this specification has been removed, acknowledging that some individuals are not distressed by their pedophilic interest/behavior. Therefore, the change in the DSM criteria might also have contributed to the lack of statistical differences in the present study. Another potential problem might be that the psychiatrists making the diagnoses in the present investigation were not aware that the validity of their diagnoses was going to be studied. Furthermore, neither were these psychiatrists trained to criterion to make such a diagnosis for research purposes. However, they were senior forensic psychiatrists working in a highly acclaimed academically oriented forensic ward specializing in sexual behaviors, often called upon to provide assessments for medical-legal purposes. In our view, these findings are not necessarily a criticism of these individuals. In fact, one might argue that the present process assured ecological validity to the utility of the diagnosis of pedophilia. Interestingly, although, men diagnosed with pedophilia scored significantly higher on the Pedophile Index than men not so diagnosed, both groups, on average, scored in the sexually deviant range. This argues against the usefulness of the DSM diagnosis of pedophilia in distinguishing sexually deviant from nondeviant men. Psychometrically, much controversy surrounds the reliability and validity of both the diagnosis of pedophilia (O’Donohue et al., 2000) and phallometrics (Marshall, & Fernandez, Diagnosis of Pedophilia 23 2000). This is problematic given that both were used to define pedophilic groups. Nevertheless, this decision was based on the fact that these are the two most commonly used procedures to make such a categorization in the field. Clearly, these methodological issues might impact on the integrity of these results. However, given that they remain the standard of practice, the practicality and generalizability of these results argued for the use of these tools and once again, also increased the ecological validity of this investigation. Conclusions A diagnosis of pedophilia in clinical or judicial procedures can be particularly onerous, imputing certain levels of dangerousness, and may affect the sentencing and disposition of a case. Furthermore, it may bear on required programming of an individual while incarcerated or on community release. Given that a diagnosis, especially pedophilia, is designed to convey clinical information about an individual and address prognosis, the fact that there were few meaningful differences associated with such a designation in the present investigation is of concern. Most importantly, the inability of the diagnostic process to produce meaningful differences with respect to sexual, violent, or criminal recidivism is troublesome. The results of the present study suggest that, for forensic purposes at least, until there is evidence that a diagnosis of pedophilia has some demonstrable utility, such as predicting recidivism, the emphasis of deviant preference should remain on overt behavior. That is, the commission of an offence and victim characteristics ought to be considered as sufficient evidence of sexual interest in individuals being assessed, and these factors should guide legal or treatment dispositions.