Abstract
Paedophilic disorder remains a profoundly stigmatised mental health condition, posing significant challenges to effective treatment, both internationally and in South Africa. Ethical and pragmatic considerations necessitate providing stigma-free support and treatment for individuals with this disorder. Despite the critical need, there is a notable scarcity of local and international research on effective management and treatment strategies for those diagnosed with paedophilic disorder. The study explored South African psychologists’ experience of psychotherapeutic approaches and models to counsel and treat individuals diagnosed with paedophilic disorder. Data were collected through semi-structured interviews with six Health Professions Council of South Africa-registered psychologists who responded to a targeted recruitment advert on social media platforms. Thematic analysis was systematically applied to the interview data, revealing participants’ use and experiences of psychotherapeutic approaches and models, further distinguished by their clinical experiences, perceptions of training adequacy, and reliance on the international Risk-Need-Responsivity Model and Good Lives approach, in the absence of local guidance. Findings highlight the urgent need for specialised professional training, locally relevant treatment protocols, and public education to reduce stigma and enhance access to care. The study contributes a foundational understanding of the therapeutic landscape of paedophilic disorder in South Africa and offers directions for future research and training.
Keywords
Background to the study
Child sexual abuse is a human rights violation, with serious physical and mental-health consequences (Bowman, 2010; Selengia et al., 2020). South Africa reports some of the highest rates worldwide, and community studies – such as the study by Meinck et al. (2017) – evince widespread physical, emotional, and sexual abuse within this context (Ajayi et al., 2021; Artz et al., 2016). Against this background, the study of paedophilic disorder becomes particularly relevant to public-health and human rights discourses. Paedophilic disorder, as defined by the Diagnostic and Statistical Manual of Disorders (
Individuals with paedophilic disorder are considered to have an increased risk for child sexual abuse (De Tribolet-Hardy et al., 2025); however, the disorder is distinct from the abuse. Whereas certain individuals with paedophilic disorder may engage in abusive behaviour, the disorder itself refers to persistent sexual interest that may or may not lead to actions. Despite this distinction, the condition is highly stigmatised, often conflated with child sexual abuse, resulting in significant challenges related to the diagnosis, treatment engagement, and societal perception (Stelzmann et al., 2020). Such conflation not only deepens public hostility but also shapes the therapeutic environment, influencing how clients present and how clinicians manage ethical obligations such as confidentiality and mandatory reporting (Carstens & Stevens, 2016). For psychologists, balancing empathic engagement with statutory duties presents an ongoing ethical challenge, reinforcing the necessity of stigma-free, evidence-based therapeutic spaces.
Furthermore, while cultural differences ought to be considered in the practice of sexual medicine (Zgourides, 2020), in South Africa’s multicultural setting, psychotherapeutic approaches to paedophilic disorder remain under-researched. Although the history of the emergence of the paedophile for psychological study in South Africa has been well documented (Bowman, 2010), when symptoms of the disorder are under-disclosed, its prevalence is, in all probability, under-reported. Empirical studies on current clinical practice are sparse and often obscured by under-disclosure, under-reporting, and moral sensitivities surrounding sexuality and crime. Under-treatment may also signal broader tensions between developmental aspirations and human rights commitments within South African mental health systems.
One of the assumptions concerning paedophilic sexual impulses is that they can be controlled (De Tribolet-Hardy et al., 2025). However, globally, research on effective management and treatment strategies for individuals with paedophilic disorder remains limited, with even fewer studies originating from the African continent. The absence of culturally responsive, contextually appropriate models leaves practitioners dependent on imported frameworks whose applicability to local legal and cultural realities is uncertain. This lack of empirical evidence creates a significant knowledge gap that reflects broader challenges in mental healthcare provision and research capacity across sub-Saharan Africa (Owen et al., 2016), rendering studies such as this one essential. The need to understand and address paedophilic disorder is further emphasised by studies on self-referred individuals, highlighting some individuals’ willingness to seek support and manage associated risks (Wittström et al., 2020).
In the South African context, understanding the pathways from victimisation to perpetration (Naidoo & Van Hout, 2021) and the offenders’ specific mindsets and grooming strategies (Naidoo & Sewpaul, 2014) are critical for designing prevention and treatment strategies towards minimising the risk of offending. Equally important is recognising how statutory frameworks governing sexual offences and mandatory reporting (Carstens & Stevens, 2016; Hendricks, 2014; Mphatheni, 2022; South African Human Rights Commission, 2003) directly influence clinical decision-making and the perceived safety of therapeutic disclosure. South Africa, with its unique sociocultural dynamics and high prevalence of child abuse, faces an urgent need to comprehend and address paedophilic disorder. The absence of local research exacerbates the difficulties faced by mental-health professionals in providing evidence-based care and necessitates an exploration of international guidelines employed in this field. In addition, the legal framework governing child sexual abuse and the management of sex offenders in South Africa (Carstens & Stevens, 2016; Mphatheni, 2022) directly affects the environment in which mental health practitioners operate.
This study represents one of the first explorations of how South African psychologists currently conceptualise and apply psychotherapeutic approaches when working with individuals presenting with paedophilia. It builds upon emerging local research highlighting gaps in practitioner training, supervision, and ethical guidance (Mphatheni, 2022, 2024; Pienaar, 2023). By examining the lived professional experiences of clinicians, the study sought to (1) identify the current therapeutic approaches used, (2) evaluate perceptions of professional training adequacy, and (3) explore the influence of international guidelines and organisations on clinical practice and their relevance to the South African context. By exploring participants’ perceptions and experience(s) of the aforementioned, the research aims to contribute foundational insights to inform evidence-based, ethical, and locally relevant interventions for paedophilic disorder in South Africa.
Literature review
Defining paedophilia and addressing stigmatisation
The interchangeable use of terms, such as ‘paedophile’ and ‘child abuser’, in public discourse, contributes significantly to the dehumanisation and profound stigmatisation experienced by individuals with paedophilic disorder (Bowman, 2010; Stelzmann et al., 2020). It is crucial to differentiate between the paraphilic disorder itself – a mental health condition characterised by a specific sexual interest – and the criminal act of child sexual abuse. While a diagnosis of paedophilic disorder can increase the risk of offending, not all individuals with the disorder act on their urges, and many seek treatment precisely to manage these urges and prevent harm (APA, 2022). Viewing paedophilia as a mental health disorder requiring treatment, rather than solely a moral failing or criminal act, is fundamental to fostering an environment where individuals can access necessary psychological support. From a legal and professional-practice standpoint, the South African framework governing sexual-offence reporting (Carstens & Stevens, 2016) places clinicians in ethically delicate positions, requiring them to balance client confidentiality with statutory child-protection duties. This distinction remains essential for promoting help-seeking and ethical care.
According to the
Therapeutic approaches to paedophilic disorder
The treatment of paedophilic disorder is complex, multifaceted, and often controversial. While no single psychotherapeutic approach has been identified as universally superior, a range of modalities have been applied to address its cognitive, emotional, and behavioural components. Recent scholarship encourages integrative formulations that consider neurobiological, social, and moral dimensions within culturally specific contexts (De Tribolet-Hardy et al., 2025). While their suitability and direct relevance to the South African context have yet to be empirically established, this section reviews prominent therapeutic approaches, detailing theoretical underpinnings, application to paedophilic disorder, and available evidence regarding efficacy.
Cognitive behavioural therapy (CBT)
CBT is a widely utilised therapeutic approach to paedophilic disorder, owing to its focus on identifying and modifying maladaptive thoughts, feelings, and behaviours (Beech, 2018). The core principle of CBT is that dysfunctional thoughts contribute to emotional distress and problematic behaviour. Beech (2018) outlined that, in the context of paedophilic disorder, CBT interventions typically target:
Cognitive distortions: Challenging and restructuring distorted thoughts that rationalise or minimise sexual urges towards children, such as ‘children are not harmed’ or ‘it’s just a fantasy’;
Sexual arousal control: Employing techniques, such as covert sensitisation and imagery rescripting, so as to reduce or redirect deviant sexual arousal. Covert sensitisation involves pairing deviant fantasies with aversive imaginary consequences, aiming to create a negative association. Early South African studies have also explored the role of sexual arousal in paedophiles as a factor for intervention (Conradie, 2007).
Social skills training: Enhancing social competence and healthy relationship skills, to reduce isolation and improve adaptive ways of relating to others; and
Relapse prevention: Developing strategies to identify high-risk situations, manage triggers, and implement coping mechanisms to prevent re-offending or acting on urges. This often includes developing a ‘safety plan’ and engaging in ongoing self-monitoring.
Whereas direct efficacy studies on CBT for paedophilic disorder are challenging, owing to ethical constraints and sample availability, CBT principles are foundational to many sex offender treatment programmes, internationally, that have demonstrated a measure of success in reducing recidivism rates (Hanson et al., 2009). The emphasis on skill-building and cognitive restructuring renders CBT highly suitable for the management of deviant sexual interests. CBT’s structured focus on self-monitoring and behavioural accountability also aligns well with South Africa’s statutory emphasis on offender rehabilitation.
Solution-focused brief therapy (SFBT)
SFBT is a goal-oriented approach that focuses on solutions, rather than problems (De Shazer et al., 2021). It emphasises identifying the client’s existing strengths and resources and constructing future-oriented solutions. While not a primary, standalone treatment for paedophilic disorder, SFBT principles can be integrated, particularly in addressing the client’s motivation for change and identifying preferred future states (Takagi et al., 2022). Within highly stigmatised presentations, these techniques cultivate hope and agency, complementing more directive or risk-focused approaches. Key techniques include the following:
Miracle question: ‘If a miracle happened overnight and your problem was solved, what would be different?’ This assists clients to envision a life free from their urges and identifies specific behavioural changes;
Scaling questions: ‘On a scale of 1 to 10, where are you now in terms of managing your urges, and where would you like to be?’ This tracks progress and identifies small, achievable steps; and
Coping questions: ‘How have you managed to cope with these urges so far?’ This highlights existing strengths and resilience.
SFBT’s utility lies in fostering hope, motivation, and a positive outlook, which can be crucial for individuals engaging in long-term treatment for a stigmatised condition. It can complement other approaches by reinforcing positive coping mechanisms (Takagi et al., 2022).
Psychoanalytic theory
Psychoanalytic approaches, rooted in the work of Freud, Jung, and subsequent theorists, explore unconscious conflicts, early childhood experiences, and interpersonal dynamics as contributors to psychological distress (Tarzian et al., 2023). In the context of paedophilic disorder, a psychoanalytic perspective might explore:
Developmental traumas: Investigating unresolved childhood conflicts, attachment issues, or traumatic experiences that may contribute to the development of paraphilic interests. This aligns with local research on child sex offending trajectories, which often highlights a history of victimisation as a factor in perpetration (Naidoo & Van Hout, 2021):
Unconscious motivations: Exploring the symbolic meaning of the sexual attraction to children, which may represent unresolved needs, power dynamics, or a regression to an earlier developmental stage; and
Defence mechanisms: Identifying and working through defence mechanisms that individuals may employ to avoid confronting their urges or associated guilt. Integrating psychodynamic case formulations within structured behavioural programmes may therefore enhance empathy and relapse prevention.
Whereas traditional psychoanalysis is a long-term, intensive therapy, psychodynamic principles can inform a deeper understanding of the origins and functions of paedophilic urges, complementing more symptom-focused interventions. Its efficacy is more challenging to quantify empirically with regard to this specific disorder; however, it offers a framework for understanding complex underlying psychological processes.
Positive psychology
Positive psychology focuses on building strengths, fostering well-being, and promoting flourishing, rather than solely focusing on pathology (Seligman & Csikszentmihalyi, 2000). Although not a primary treatment for paedophilic disorder, positive psychology interventions can support overall psychological health and resilience in individuals undergoing treatment. Aspects that may be integrated include identifying strengths by helping clients recognise and utilise their personal strengths and virtues; exploring sources of meaning and purpose in life, beyond the paraphilic interest; and cultivating positive emotions to counterbalance distress and improve overall mood.
Integrating positive psychology can enhance treatment adherence and promote a more holistic approach to rehabilitation by focusing on what is healthy and adaptive within the individual.
Eclectic approaches and combination therapies
Given the complexity of paedophilic disorder, many clinicians use an eclectic or integrative approach, combining elements from various therapeutic modalities to create a tailored treatment plan. This flexibility allows therapists to address diverse needs, including managing urges, developing prosocial behaviours, and addressing underlying psychological issues or comorbidities. Combination therapies often include the following:
Pharmacological interventions: In conjunction with psychotherapy, certain medications, for example, antiandrogens and SSRIs, may be used to reduce sexual drive or manage co-occurring mental health conditions, such as depression or anxiety, that can exacerbate paraphilic urges (Fedoroff, 2018). Recent reviews confirmed the role of pharmacological treatments in multimodal treatment plans for paedophilic disorder (Landgren et al., 2022). Beyond the mechanism of action, qualitative studies, such as that by Boons et al. (2021), highlighted the lived experiences of patients undergoing pharmacological intervention, detailing their physical, psychological, and sexual perceptions of this treatment;
Risk-need-responsivity (RNR) model: This highly influential model, originating from Canadian research, guides the assessment and treatment of offenders. It posits that treatment intensity should match the offender’s risk of re-offending (risk principle), target criminogenic needs (need principle), and be delivered in a way that is responsive to the offender’s learning style and motivation (responsivity principle; Andrews & Bonta, 2010). Applicable primarily to forensic populations, its principles are highly relevant to clinical treatment aimed at risk reduction (De Tribolet-Hardy et al., 2025). Its structured assessment approach aids South African practitioners in balancing therapeutic confidentiality with mandatory-reporting expectations. In the South African context, the development of holistic conceptual frameworks for sex offending (Coetzee, 2023) further supports the need for comprehensive and tailored approaches; and
Good Lives Model (GLM): This strengths-based approach, also originating from Canadian scholarship, shifts the focus from solely reducing risk to helping individuals build a fulfilling life through legitimate means (Ward & Brown, 2004). The GLM identifies ‘primary human goods’, for example, knowledge, inner peace, mastery and relatedness that individuals seek, and posits that problematic behaviour arises from attempting to achieve these goods through maladaptive or harmful means. Treatment involves assisting individuals to develop prosocial strategies, so as to achieve these goods. For example, a desire for intimacy – a primary good – might be pursued through healthy adult relationships, instead of through harmful sexual contact with children. This model provides a positive framework for rehabilitation, focusing on building a meaningful life, rather than just preventing harm (De Tribolet-Hardy et al., 2025). The GLM’s humanistic emphasis resonates with restorative justice principles, gaining traction in South African offender rehabilitation (Coetzee, 2023).
The integration of these various approaches highlights the dynamic and client-centred nature of treating paedophilic disorder, aiming to address both the overt symptoms and underlying complexities. It demonstrates that effective intervention must address both the behavioural risk and the moral–emotional context of clients’ lives. For South African practitioners, the absence of national treatment protocols reinforces dependence on international evidence while underscoring the urgent need for culturally grounded models.
Methods
This exploratory study adopted a qualitative research design, utilising semi-structured online interviews on the Zoom platform and face-to-face interviews to gather in-depth insights into the psychotherapeutic approaches and theoretical models currently used by South African psychologists treating individuals with paedophilic disorder. A qualitative design was selected for its capacity to capture subjective meanings, contextual influences, and clinical reasoning that would be inaccessible through quantitative methods.
Participant sampling and recruitment
A purposive sampling strategy was used to recruit six clinical and counselling psychologists registered with the Health Professions Council of South Africa (HPCSA), practising in South Africa, who self-reported their experience treating individuals with paedophilic disorder. Participants were recruited through advertisements on social media platforms frequented by South African psychologists, for example, professional psychology groups on Facebook and LinkedIn. This recruitment approach allowed for confidentiality while reaching a niche professional population unlikely to be identifiable through institutional listings.
Participant biographical details
The participant group comprised three males and three females, ranging in age from 30 to 70 years. Four participants identified as White, one as Black, and one as Indian. These demographic details were collected to provide context for the sample, acknowledging that, while not directly linked to the study’s primary aims, they offered a demographic overview of the clinicians contributing to the data. No attempt was made to infer correlations between demographic characteristics and clinical attitudes, given the small sample size and ethical sensitivities of the topic.
Data collection
Data were collected through semi-structured interviews, allowing for flexibility to explore emergent themes, while ensuring coverage of key research areas. Interviews lasted approximately 60–90 min. The interview protocol was designed to elicit information on specific theoretical approaches and models used in practice; the clinician’s experiences working with individuals with paedophilic disorder, perceptions of the adequacy of professional training received in South Africa; reliance on and knowledge of international guidelines, organisations, and models, such as the RNR model and the GLM; and challenges and ethical considerations encountered in treatment.
A key question included, ‘Could you describe your professional experience engaging with and/or treating clients with paedophilic disorder? For instance, how many clients have you worked with in this context over your career?’ This open-ended phrasing avoided pathologising the client population while situating the participant’s experience within a professional context.
Interviews were conducted either online, via Zoom’s video conferencing platforms, or in-person, depending on participants’ preferences and geographical locations. Although both modalities were used, no systematic differences were observed in the richness or depth of discussions when comparing the online and in-person interviews. All interviews were audio-recorded with explicit consent and subsequently transcribed verbatim.
Data analysis
The transcribed interview data were analysed using thematic analysis, following the systematic approach outlined by Braun and Clarke (2006, 2012, 2023). This method was selected for its flexibility and its capacity to identify, analyse, and report patterns (themes) within qualitative data, thereby providing a rich and detailed account of the data set. Both inductive and deductive approaches were used to ensure an in-depth understanding of insights from the data and validation of these against existing theory. An inductive approach was necessary, as this was exploratory research; thus, the researchers had to analyse the data for patterns. In addition, the researchers adopted a critical realist perspective, acknowledging that themes are not simply ‘found’, but are actively constructed through the researchers’ interpretative engagement with the data, informed by both participant accounts and existing theoretical knowledge.
The analysis proceeded through the following six phases:
Familiarisation with transcripts through repeated reading.
Generating initial codes capturing meaningful data features.
Grouping codes into potential themes and subthemes.
Reviewing and refining themes for coherence and distinctiveness. As Ahmed et al. (2025) stated, the themes emerge from the data.
Defining and naming each theme to capture its analytic essence. This stage refined the themes’ focus to ensure they captured an aspect of the data (Ahmed et al., 2025).
Producing the report, using data extracts to illustrate each theme and linking them to existing literature.
NVivo software was used for data management to enhance rigour and auditability.
Ethical considerations
Ethical approval was obtained before data collection, in accordance with the HPCSA’s requirements, to ensure participant protection from harm or misconduct.
Participants were anonymised via the allocation of numeric identifiers P1 through to P6 to distinguish inputs. They were requested to use pseudonyms for clients, ensuring privacy. In addition, the two transcribers signed a non-disclosure agreement, protecting participants and data. Data voice recorded on the Zoom platform and transcribed, as well as any notes that were taken, were locked in a personal safe and stored on a laptop computer with a security access code, in a secure folder, ensuring its protection. As an extension of their autonomy, each participant in this study was supplied with a consent form and an information sheet. The participation form, in conjunction with the information sheet, explained the purpose of this study and described the right of participants to withdraw from the research study before its publication. The participants received information explaining the purpose of this study, the role of the interviewee, and the benefits of participating. Each participant was allowed to ask questions before and after the interview, and it was explained to the participants that there were no anticipated risks to any participant in this research study. Given the sensitive topic and potential intersection with legal obligations concerning child-protection laws, participants were reminded of their ethical duty to report current risk while discussing historical or hypothetical cases freely. Notably, all participants provided explicit consent for the use of their data in this article.
Reflexivity
The research team comprised individuals with varying levels of experience in qualitative research and clinical work with complex populations. Acknowledging positionality was crucial throughout the research process. During regular debriefing sessions, research team members discussed emerging interpretations and potential biases, challenging one another’s assumptions. This reflexive practice ensured that personal beliefs and experiences did not unduly influence the data analysis and interpretation. To this end, the researchers consciously sought to remain receptive to participants’ perspectives, aiming to represent their experiences authentically. In this regard, initial predispositions towards certain therapeutic models were set aside during the coding and theme development phases to allow for a broader understanding of participants’ diverse practices. This ongoing critical self-reflection enhanced the trustworthiness and rigour of the qualitative inquiry. Memo writing and peer review of theme definitions further enhanced credibility and transparency. By explicitly engaging in reflexivity, the researchers recognised their interpretive role in constructing knowledge about an ethically complex clinical population.
Findings and discussion
The thematic analysis produced a nuanced understanding of the psychotherapeutic approaches to paedophilic disorder in South Africa. One overarching theme ‘therapeutic approaches and models’ emerged, supported by subthemes on ‘training deficits’ and ‘International Models and Organisations’. Additional cross-cutting insights concerned practitioner ethics, emotional burden, and the impact of legal and societal frameworks on therapeutic engagement.
Main theme: therapeutic approaches and models
Eclectic approach
An emerging subtheme within therapeutic approaches and models was that some participants demonstrated a broad spectrum of psychotherapeutic approaches in their work with individuals presenting with paedophilic disorder. Three participants reported a more eclectic or integrative practice. Zarbo et al. (2021) pointed out that there is more agreement that no single approach is effective for all clients and their problems. An eclectic approach is multimodal, adapting to the individual client’s specific needs. Participant 1 said that individuals with paedophilic disorder presented with obsessive–compulsive disorder; thus, an eclectic approach was suitable. Participant 3 said, ‘I find myself drawing from various schools of thought, primarily cognitive behavioural therapy for managing the urges, but also some psychodynamic insights to understand the underlying issues’. The integration of approaches, at times, involved a combination of psychotherapy with other interventions, such as the use of medication (e.g., antiandrogens) to reduce sexual drive where appropriate and in collaboration with psychiatrists. Participant 6 said, ‘So, in my opinion, the most effective would be pharmacotherapy . . . paired with ongoing psychotherapy for the rest of the lives’. This was reinforced by Participant 1 explaining their experience with a client under house arrest, where pharmacotherapy was combined with regular individual therapy, group therapeutic process, and also taking responsibility for the harm they caused to their victims.
These participants reflect a pragmatic responsiveness to client needs and contextual realities. The diversity of approaches also revealed a tension between evidence-based structure and the relational depth required in high-stigma work.
Cognitive behavioural therapy (CBT)
Several participants reported utilising CBT techniques, particularly for managing deviant sexual urges and challenging cognitive distortions. Participant 4 highlighted the utility of ‘identifying and restructuring the thought patterns that precede the urges, helping clients develop alternative coping strategies’. In contrast, Participant 3 said that while ‘CBT can be effective . . . it’s very difficult to access those cognitions because the perpetrators are so ashamed . . . because of the stigma attached to it’. Participant 5 also found CBT to be useful: ‘I do see improvement, some shift in their cognitions’. However, they added that for CBT to be effective, the individual’s cognitive distortions need to be reduced, and for this to occur, the individual needs to talk about their behaviour. An example of a cognitive distortion would be denying or minimising their actions. According to Schneider and Wright (2004), ‘denial may be best understood as the acceptance of explanations that reduce accountability and are reinforced by distorted beliefs and self-deceptive thinking processes’ (p. 3).
These findings align with the evidence base for CBT in addressing problematic sexual behaviours by targeting thought-action links. Furthermore, local South African studies have historically investigated the assessment of sexual arousal in individuals with paedophilia, providing a foundation for such behavioural interventions (Conradie, 2007). Participants emphasised the model’s clarity and accountability, which also aided compliance with ethical and medico-legal expectations around risk documentation.
Psychoanalytic/psychodynamic approaches
Some participants with extensive experience incorporated psychodynamic principles to explore the deeper, often unconscious, roots of the disorder. As Participant 1 articulated, ‘It’s about understanding the developmental history, early attachments, and how past experiences might manifest in these present urges. It’s not just about stopping the behaviour, but understanding its psychological function’. This suggested a recognition that symptom management alone may be insufficient, when neglecting to address underlying psychological vulnerabilities. Participant 2 delved into fantasies saying, ‘But then you must work with fantasy, okay, what is the fantasy, how do we break the fantasy’. Similarly, Participant 4 emphasised, ‘You know that’s what I want patients to realise how constrained he is by his fantasies’. In contrast, Participant 3 said, ‘You kind of just want to get the gist of the fantasy . . . an idea of what the fantasies are, but you don’t want to know the step-by-step of the fantasies’.
Participants highlighted that such in-depth work helps sustain empathy and reduce burnout, countering the moral distancing often triggered by the subject matter. As Participant 6 said, ‘You have a level of empathy for them, what they’ve been through, what they’ve endured, what they still fighting at the moment’.
Solution-focused brief therapy (SFBT) and positive psychology
Although not primary modalities, elements of SFBT and positive psychology were reportedly integrated to build client motivation, identify existing strengths, and foster a sense of hope and future-orientation. Participant 3 stated, ‘So I work from a positive psychology framework, and I use solution-focused therapy a lot’. Participant 4 noted, ‘Sometimes, just asking what a life free from these urges would look like, opens up new possibilities for the client, shifting focus from pathology to potential’, thus illustrating how these approaches could complement the more challenging and confrontational aspects of therapy. Although Participant 6 was a CBT-trained therapist, they said that because CBT is a confrontational and direct approach, it negatively impacts this population of clients who are already highly stigmatised. Thus, in their assessment, CBT’s prognosis for treating paedophilic disorder was poor. Therefore, they focused on skills associated with the symptomatic presentation of each client in therapy. These were social skills such as training, sexual awareness, healthy sexual relationships, communication skills, and fantasy management. These helped clients envision adaptive futures and supported motivation within longer-term CBT or psychodynamic work (De Shazer et al., 2021; Takagi et al., 2022). In a context marked by shame and secrecy, fostering positive identity reconstruction through skill development is central to therapeutic alliance.
Subtheme: training deficits
A striking and unanimous finding was the participants’ consensus regarding the inadequacy of specialised training on paedophilic disorder within South African psychology master’s programmes. Participants expressed significant concerns regarding the lack of dedicated modules, clinical placements, or supervisory opportunities focusing on paraphilic disorders, as a whole. Participant 1 stated, ‘My master’s degree barely touched on paraphilias, let alone paedophilic disorder. Most of what I’ve learned has been through self-study, workshops, or international resources’. Participant 6 agreed, ‘We are expected to treat these complex conditions, yet our foundational training is severely lacking in this area’. As did Participant 4, ‘There is no training you learn from your own studying further, internationally, not South African-based’. This perceived deficit in local training compels clinicians to seek knowledge and guidance from external sources, highlighting a significant gap in South Africa’s mental health education system. The unanimous concerns regarding specialised training resonated with broader observations concerning the significant mental health treatment gap and limited resources available to mental health professionals in sub-Saharan Africa (Owen et al., 2016).
Participants’ responses gave a negative impression of the state of training in South Africa as well as of the treatment of individuals with paedophilic disorder. The implication was that many psychologists may regard themselves ill-equipped to handle such cases, potentially leading to suboptimal care or a reluctance to accept clients with paedophilic disorder, further limiting access to treatment. Consequently, some avoid treating this population altogether, further limiting access to care. Participants argued for curriculum reform and supervision frameworks addressing sexual deviance work within an ethics-of-care paradigm rather than a punitive lens.
Subtheme: international models and organisations
Given the lack of local training and established protocols, participants heavily relied on international models, organisations, and literature to inform their practice. Prominently mentioned were the RNR model and the GLM, and organisations such as the Association for the Treatment of Sexual Abusers (ATSA) and the European Association for the Treatment of Sexual Offenders (EATSO). Participant 4 indicated a lack of literature on the topic of paedophilic disorder and that there were no assessments for paedophilic disorder within the South African context. Thus, the reliance on international models, organisations, and literature.
Clinicians valued the RNR model (Andrews & Bonta, 2010) for its structured approach to assessment and treatment planning, particularly in managing risk. Participant 2 explained, ‘One basic model that we work with called the risk-need-responsivity model, identify criminogenic needs and then those who have the highest motivation because that’s your best chance for success’. The RNR model seemed to align with South Africa’s statutory emphasis on rehabilitation within correctional and community settings, providing a defensible structure in legally sensitive work.
In contrast, the GLM (Ward & Brown, 2004) resonated with several participants for its strengths-based, rehabilitative focus. Participant 3 said, ‘It has these 10 life goals that they say all of us wants to reach these life goals, but some of us just go about it in maladaptive ways’ adding that, ‘It’s not just about preventing harm; it’s about helping individuals find legitimate ways to achieve their good lives’. Participant 3 combined training from the Canadian organisation with the standard sex offender treatment model to create a self-formulated model for paedophilic disorder. The GLM builds on personal strengths and respect for the individual to help patients self-actualise, reducing their desire to harm others (Ward & Brown, 2004). This perspective offers a more hopeful and comprehensive pathway to change.
Participant 6 also spoke about programmes adapted from Canada and New Zealand, such as the Sex Offender Treatment Programme (STOP) but was wary of models in general, saying it provided a space for members to feed off each other’s fantasies. The RNR model and GLM were viewed as culturally resonant with South Africa’s restorative justice ideals, promoting reintegration rather than exclusion. This highlighted a shift towards a more holistic understanding of rehabilitation that integrates the prevention of problematic behaviour with the promotion of well-being.
Subtheme: international organisations and literature
Participants frequently referred to literature and guidance from organisations, such as ATSA and EATSO, as these bodies provide frameworks, research, and best practices that are largely unavailable locally. Managing treatment, including the use of assessments before treatment began, was raised by participants. Participants talked about different types of assessments they used and the lack of an appropriate assessment for paedophilic disorder specific to a South African population. This is an important area regarding the law concerning reporting sexual offences and the grey area that sometimes occurs in the therapeutic context. Assessments for paedophilic disorder in South Africa were a problem area. Participant 1 explained, ‘I know a very prominent colleague uses the Rorschach quite a lot . . . the South African Sexual Functioning and Adaption Test . . . it’s quite defunct now . . . I can look at what else I’ve used in the past, but they are based on norms that are so difficult to apply in South Africa’. Participant 6 added, ‘We don’t have psychometric assessments . . . that I’m aware of that’s norm for the South African population’.
Regarding the ethical obligation to report clients, Participant 1 said, ‘Sometimes the reporting does more harm in the actual act’. Participant 1 explained a scenario whereby psychologists are often led into a grey area of reporting a client who then never receives treatment. Instead, the trauma of the legal system ensues. This then leads the therapist, in this case, to cautiously contravene HPCSA regulations and legislation. Participant 2 agreed with Participant 1 in this regard, stating that as long as the psychologist sets specific boundaries, therapy can continue. According to the law and HPCSA regulations, therapists must report sexual activity concerning children and adults (Hendricks, 2014; Hunter, 2006; Republic of South Africa, 2020). It is an ethical practice to inform one’s client that one is legally required to report suspected sexual abuse of children, which must be part of the informed verbal and written consent process (Hendricks, 2014; South African Human Rights Commission, 2003).
The reliance on international guidelines underscored a significant need for the development of contextually relevant South African guidelines, assessments, and training initiatives. The finding regarding the reliance on international guidelines is consistent with other local observations, which also noted the adaptation of international therapeutic approaches, on account of the absence of standardised local assessments and training (Pienaar, 2023). The ongoing efforts to propose holistic conceptual frameworks for sex offending in South Africa (Coetzee, 2023) further emphasise this local need. While international models provide a valuable foundation, its direct applicability must be carefully assessed in terms of South Africa’s unique cultural, societal, and legal milieu.
Limitations of international models
Counselling individuals with paedophilic disorder presents unique challenges, beyond the theoretical application of therapeutic models. Participants frequently discussed the emotional burden, the potential for countertransference, and the ethical dilemmas inherent in balancing client confidentiality with child-protection concerns.
Emotional burden and countertransference
Participants described the emotional toll of working with this population, acknowledging the potential for feelings of disgust, anger, or fear. Participant 5 said, ‘It’s incredibly challenging to maintain objectivity. I have to focus on treating them’. Participants noted that countertransference can distort clinical judgement if unsupported, underscoring the need for dedicated supervision and access to personal therapy. This highlights the critical need for robust clinical supervision and personal therapy for clinicians in this field, so as to manage countertransference reactions effectively.
Ethical dilemmas
The most pressing ethical concern for participants revolved around the tension between maintaining client confidentiality and fulfilling the duty to protect children. Therapists operate under strict ethical codes requiring confidentiality, but also mandatory-reporting laws concerning child abuse. This necessitates careful navigation of when and how to breach confidentiality, to ensure child safety. Participants expressed fear that misjudging the threshold for disclosure could either endanger a child or breach confidentiality, eroding client trust. For example, Participant 1 shared, ‘Every session, I’m thinking about the safety of children. It’s a constant ethical tightrope walk’. This ethical complexity is further exacerbated by the intricacies of South African criminal law concerning paraphilia and sex offending (Carstens & Stevens, 2016) and the broader legal mechanisms for handling child sexual abuse and offenders (Mphatheni, 2022). This underscored the need for establishing clear ethical guidelines and legal frameworks that support clinicians in this complex area.
Societal stigma and client engagement
The pervasive societal stigma associated with paedophilic disorder often renders it difficult for individuals to seek and maintain treatment. Participants noted that clients might present with co-occurring mental health issues, such as depression or anxiety, and only gradually disclose their paraphilic urges, owing to fear of judgement or legal repercussions. This fear can lead to delayed presentation, poor treatment adherence, and difficulty building trust in the therapeutic relationship. Despite the pervasive stigma, individuals with paedophilic disorder do seek help, and understanding risk factors among these self-referred individuals is crucial for effective intervention (Wittström et al., 2020). However, therapists reported that fear of public exposure or punitive consequences led many potential clients to abandon therapy prematurely. Insights into the mindsets and grooming strategies of offenders in South Africa (Naidoo & Sewpaul, 2014) and analyses of adult-child sex offenders in correctional facilities (Mphatheni, 2024) provide further context to these challenges in client engagement. Further stigma was associated with only men being labelled as paedophiles – a social construction that has led to the exclusion of women, who also engage in sexual acts with minors. This specific area of research highlights a major gap in existing research and, by default, a gap in developing an understanding of this population (Kramer & Bowman, 2011; Papakyriakou, 2017). This gender invisibility was seen as a major research and service-delivery gap, reflecting broader patriarchal narratives within South African criminology and psychology. It can be deduced that this population – of females with paedophilic disorder – not only goes unrecognised but, by extension, untreated (Kramer & Bowman, 2011).
Conclusion
Overall, there is a paucity of research in this field. This exploratory study thus provides crucial insights into the psychotherapeutic landscape for paedophilic disorder in South Africa, specifically, with its complex socio-legal and cultural climate. The findings reveal how psychologists navigate entrenched stigma, scarce training resources, dependence on international models, and an over-reliance on mainstream psychology practices when treating a profoundly marginalised client group. Whereas research participants demonstrated adaptability in their use of diverse theoretical models, the findings underscore a pressing need for systemic reform in professional training, ethical guidance, and multidisciplinary collaboration.
Recommendations include a call for the enhancement of professional training programmes in South Africa. Comprehensive, dedicated modules on paraphilic disorders, including paedophilic disorder that integrate theoretical knowledge, supervised clinical exposure, and discussion of ethical-legal duties are much needed. Training should include simulated scenarios, guidance on confidentiality and mandatory reporting, and explicit instruction on self-care and countertransference management, given the emotional burden associated with this work. National professional bodies (e.g., HPCSA, Psychological Society of South Africa) could partner with universities to develop accredited continuing-education workshops addressing sexual deviance assessment and intervention.
There is also an urgent need to establish South African-specific clinical guidelines for assessment and treatment that are culturally attuned and legally compliant while drawing on global evidence. Such guidelines should clarify reporting thresholds, ethical boundaries, and interdisciplinary referral pathways between psychologists, psychiatrists, and legal authorities. Ongoing efforts to conceptualise holistic frameworks for sex offending (Coetzee, 2023) provide a valuable starting point.
Further empirical and practice-based research is required to strengthen the local evidence base. This should include outcome studies on the efficacy of various interventions, qualitative studies capturing client experiences and barriers to care, and applied research on adapting international models such as RNR and GLM to South African sociocultural conditions. Collaboration among universities, correctional-service psychologists, community organisations, and justice departments will be critical for scalable, ethical intervention frameworks. Continuous analysis of sex offending in South African contexts, such as the studies by Mphatheni (2024) and Naidoo and Sewpaul (2014), is critical to inform these research efforts.
Finally, efforts to reduce the pervasive stigma associated with paedophilic disorder are crucial. Public education campaigns can help differentiate the disorder from criminal behaviour, fostering a more nuanced understanding that encourages individuals to seek treatment, rather than operate in secrecy. This contributes to public safety by promoting therapeutic engagement and risk reduction. Understanding the South African criminal justice system’s handling of child sexual abuse and sex offenders (Carstens & Stevens, 2016; Mphatheni, 2022) is integral to effective public education and advocacy.
By addressing these recommendations, South African healthcare providers, particularly psychologists, can move towards a more informed, ethical, and effective approach to treating paedophilic disorder. In sum, this exploratory study offers a foundational evidence base for shaping ethical, culturally responsive, and therapeutically sound approaches to paedophilic disorder in South Africa with due consideration to its human rights framework. Implementing these recommendations can strengthen clinician competence, promote client accountability, and ultimately enhance both individual recovery and community safety.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.