9824_Evaluating Stigmatizing Attitudes among Clinicians Toward People with ABDL and Pedophilic Interests

Minnesota State University, Mankato
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Theses, Dissertations, and Other Capstone Projects
2018
Evaluating Stigmatizing Attitudes among Clinicians
Toward People with ABDL and Pedophilic
Interests
Katlyn Hanson
Minnesota State University, Mankato
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Hanson, Katlyn, “Evaluating Stigmatizing Attitudes among Clinicians Toward People with ABDL and Pedophilic Interests” (2018). All
Theses, Dissertations, and Other Capstone Projects. 807.
https://cornerstone.lib.mnsu.edu/etds/807
Running head: STIGMA, CLINICIANS, ABDL, PEDOPHILIA
1

Evaluating Stigmatizing Attitudes among Clinicians Toward People with ABDL and Pedophilic
Interests

By:
Katlyn M. Hanson

A Thesis Submitted in Partial Fulfillment of the
Requirements for Degree of
Masters of Arts
In
Clinical Psychology

Minnesota State University – Mankato
Mankato, Minnesota
May 2018

STIGMA, CLINICIANS, ABDL, PEDOPHILIA
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April 10, 2018

Evaluating Stigmatizing Attitudes among Clinicians Toward People with ABDL and Pedophilic
Interests

Katlyn M. Hanson

This thesis has been examined and approved by the following members of the student’s
committee.

____________________________________
Dr. Eric Sprankle, Adviser

____________________________________
Dr. Jeffrey Buchanan, Committee Member

____________________________________
Dr. Dennis Waskul, Committee Member

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Table of Contents
Abstract ………………………………………………………………………………………………………………………… 4
Introduction
……………………………………………………………………………………………………………………. 5
Literature Review………………………………………………………………………………………………………..5-13
Review of Pedohpilia Literature …………………………………………………………………………………… 7
Review of Fetish/Paraphilia Literature ………………………………………………………………………….. 9
Review of Stigma Lilterature
……………………………………………………………………………………… 11
Aims of Current Study ………………………………………………………………………………………………. 12
Methods…………………………………………………………………………………………………………………… 13-16
Participants
………………………………………………………………………………………………………………. 13
Measures …………………………………………………………………………………………………………………. 14
Procedure ……………………………………………………………………………………………………………….. 16
Results
…………………………………………………………………………………………………………………….. 16-21
Discussion ……………………………………………………………………………………………………………….. 22-24
Limitations ………………………………………………………………………………………………………………. 23
Future Research and Conclusion ………………………………………………………………………………… 24
References
……………………………………………………………………………………………………………………. 25
Appendix A – Tables …………………………………………………………………………………………………….. 28
Appendix B – Figures ……………………………………………………………………………………………………. 30
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Abstract
Because child sexual abuse continues to be covered by mainstream media, the public has
become more aware of the paraphilic interest pedophilia. While there is no definitive correlation
between an individual with pedophilic interests and offenses against a child, strong public
stigmatization toward these individuals remain. Additionally, stigmatizing attitudes have been
found toward other paraphilic interests such as fetishes. This is the first study to evaluate and
compare clinicians’ attitudes toward the paraphilic interest pedophilia and the fetish interest
community of Adult Baby/Diaper Lovers (ABDL). Clinicians were randomly assigned to one of
three survey conditions assessing their attitudes toward people with pedophilia, people with
depression, or people with an interest in ABDL. Results indicated that current clinical
psychology pre-doctoral interns hold stigmatizing attitudes toward people with pedophilia
compared to clinicians’ attitudes toward depression across multiple measures. Significant
findings were found toward people with an interest in ABDL compared to pedophilic interests
and depression. Furthermore, sympathy and anger were found to significantly predict clinicians’
motivations to work with people with pedophilic interests. These results indicate the need to
revisit ethical considerations when working with people with paraphilic interests. Further
implications of these findings are discussed.

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Introduction
A general population survey of the United States found that sexually abused children rose
125% from the year 1986 to 1993 (133,600 to 300,200). This same survey revealed that 12% of
men and 17% of women reported being sexually touched by an adult as a child (Fagan, Wise,
Schmidt, Jr., & Berlin, 2002). Women and girls were found to be three times more likely to be
sexually abused then men and boys, and children in low socioeconomic housing were 18 times
more likely to be sexually abused than other economic backgrounds. Biological parents
accounted for 29% of the sexual offenses against children while other parents accounted for 25%
and other caretakers made up 46%. Eighty-nine percent of these offenses were conducted by men
while 12% were performed by women (Fagan et al. 2002). Victims of child sexual abuse tend to
display behavioral problems, substance abuse, and suicidal ideation during adolescence and are
at a higher risk of anxiety, mood, and substance abuse disorders as well as suicide attempts upon
adulthood (Fagan et al. 2002).
Pedophilia is defined in the Diagnostic and Statistical Manual, 5th Editions (DSM-5), as
recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual
activity with a prepubescent child or children (American Psychiatric Association [APA], 2013).
For an individual to be diagnosed with pedophilic disorder, they must experience marked
distress or impairment from their sexual interest. Additionally, an individual can be diagnosed
with pedophilic disorder if they commit a sexual offense on someone who did not consent (APA,
2013). This distinction between pedophilia and pedophilic disorder means that one can have
pedophilic interests without meeting criteria for a pedophilic disorder. Because of this
distinction, researchers like Seto have conceptualized pedophilic interests as a sexual orientation
toward prepubescent children.
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Sexual orientation can be more than just attraction to males or females. Sexual orientation
can be attraction to specific characteristics like muscularity and age. Seto (2012), explained that
there are three aspects of sexual orientation: 1) age of onset, 2) sexual and romantic behavior,
and 3) stability overtime. Individuals reporting pedophilic interests acknowledged early onset of
sexual interest in children with 25% of self-identified pedophiles reporting being aware of their
sexual interests by the age of 15. While pedophiles are sexually aroused by prepubescent
children, some seek romantic relationships with children and engage in sexual relationships with
them to fulfill emotional needs. Finally, efforts to change orientation have continuously failed to
show evidence of decreased sexual thoughts, fantasies, urges or arousal toward prepubescent
children supporting the idea that pedophilia is a lifelong course (Seto, 2012). This information is
important for clinicians who would potentially work with someone with this sexual orientation.
The purpose of treatment with a client who has pedophilic interests should be to prevent
sexual abuse of children and to help the client control their sexual desires and urges. It is also
important for clinicians to remember that the client is not at fault for having an atypical sexual
orientation, but they are responsible for how they act on those urges. Treatments often focus on
building interpersonal skills, assertiveness, and empathy to enhance relations with adults. A
study conducted by Raymond et al. (1999) found that 93% of the participants with a diagnosis of
pedophilic disorder also met criteria for another disorder. Sixty-seven percent of the subjects
were diagnosed with a mood disorder, 64% with an anxiety disorder, and 60% reported a history
of substance abuse. Additionally, Blanchard (2010), pointed out that attraction to pubescent
children is more prevalent than prepubescent children which is known as ephebophilia.
Furthermore, there is ambivalence among mental health professionals when it comes to helping
individuals with pedophilia. There is weak and insubstantial evidence to support the
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effectiveness of treatments, and clinicians who work with pedophiles are often viewed as
supporting the act of child sexual abuse rather than as treating a mental illness (Repique, 1999).
Review of the Pedophilia Literature
A study conducted by Imhoff in 2015, looked at how the addition of the label pedophile
influenced participants’ attitudes toward individuals with sexual interests in prepubescent
children. The participants for this study were German individuals recruited online via email and
sorted into one of two survey conditions. Both conditions assessed their attitudes towards people
with pedophilic interests, however, one condition used the label pedophile, while the other used
people with sexual interests in children. Imhoff used three scales (dangerousness, deviance,
intentionality) to measure how the German public viewed people with sexual interests in
prepubescent children with or without the label of pedophilia and also assessed social desirability
(how willing they were to allow people with pedophilic interests into their community). Imhoff
discussed how there are negative feelings towards individuals with this type of sexual orientation
because there is no legal or socially acceptable way to act out their sexual interests. The
dangerousness scale assessed the perceived link between sexual interest and the likelihood of an
action being taken based on that interest. The deviance scale measured the degree to which
participants thought that the sexual interest was a psychological disease. The intentionality scale
assessed whether participants thought an individual was in control of their sexual interests.
Imhoff discovered that it was socially desirable for participants to respond with greater punitive
attitudes toward individuals with pedophilic interests (regardless if they had ever committed a
crime) and that punitive attitudes increased with the label of pedophile.
In follow-up studies, surveys were distributed in Germany and the United Stated in a
study conducted by Janke, Imhoff, and Hoyer (2015). In the German sample, participants were
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recruited from public areas in Dreaden and Stuttgart. In the United States sample, participants
were recruited using the Amazon Mechanical Turk (MTurk), which is a crowdsourcing service.
Janke et al. (2015a) found that the public reacted to people with pedophilia with negative
emotions, social distance, and stigmatizing assumptions when compared with people who
consumed and abused alcohol. The majority of individuals believed that people with pedophilia
were in control of their sexual interests. Eighty percent of the participants reacted angrily toward
people with pedophilia and showed little pity for them. Furthermore, 14% of the participants in
Germany and 28% of the participants in the United States stated that people with pedophilia
should be dead. In the United States survey, 39% of the participants recommended that people
with pedophilic interests be imprisoned even though they had never committed a crime against a
child. Janke continued her research on pedophilia to include self-identified pedophiles’ thoughts
on the stigmatization against them.
Because it is socially unacceptable for people with pedophilic interests to engage in their
urges or sexual fantasies, it is unknown how many people with pedophilic interests exist and
what are their motives for seeking treatment. Patients seeking treatment can range from having
engaged in sexual interactions with children to never succumbing to their urges. Janke, Schmidt,
Geradt, & Hoyer (2015) examined pedophiles’ fears of seeking treatment for their disorder.
Janke et al. (2015c) surveyed 104 self-identified pedophiles from online pedophilia forums and
discovered there were significant discrepancies between their perceived stigma toward
pedophiles compared to the results collected in the German and United States surveys.
Researchers found that 64% of the self-identified pedophiles reportedly believed that more than
half of the population wished they were dead based on their sexual orientation alone, without any
criminal act behind it. However, only 14% of the German population and 28% of the United
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States population reported having those feelings. These results supported the hypothesis
presented by Janke et al. (2015c), that pedophiles are not seeking professional help due to the
perceived public stigma against them and fear of discovery.
Continuing their research regarding stigma toward individuals with pedophilia, Janke,
Philipp, and Hoyer (2015) evaluated psychotherapists from German cognitive behavior therapy
institutes for their attitudes toward people with pedophilia. The researchers found that the sample
of psychotherapists held considerably less stigmatizing views toward people with pedophilia
when compared to the responses from the general public. Of those surveyed, less than 3% agreed
that sexual interest in children is something that one can choose and 40% reported feeling angry
when thinking of a person with pedophilia. Additionally, Janke et al. implemented an anti-stigma
program. The results demonstrated that the program was successful at affecting the
psychotherapists’ opinions toward people with pedophilia, indicating that there is room for
improvement among clinicians’ attitudes toward paraphilic interests. However, pedophilia is not
the only paraphilia that is stigmatized.
Review of Fetish/Paraphilia Literature
In an attempt to understand and provide treatment to individuals displaying atypical
sexual preferences, health care professionals have organized certain sexual deviations as mental
disorders known as paraphilias. Fetishistic disorder is a paraphilic disorder that is characterized
by a distressing and/or impairing period of at least 6 months during which recurrent, intense
sexually arousing fantasies, sexual urges, or behaviors involving the use of nonliving objects
occur (APA, 2013). Moser (2006) has argued that the entire category of paraphilias be removed
from the DSM due to clinicians overpathologizing certain sexual behaviors. Wright (2010) called
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for clinicians to stop overpathologizing various forms of paraphilias and provided some
unforeseen consequences of it.
Wright (2010) described a situation where a mother was involved in a child custody case
with the Department of Social Services (DSS) Children’s Division. The mother underwent a
psychological evaluation which concluded there was no mental illness. The mother ran a blog
and website that portrayed elements of bondage, discipline, and sexual sadism and masochism,
often referred to as BDSM. Sexual sadism is characterized by being aroused by inflicting
suffering on another person, whereas sexual masochism is characterized by being aroused by
being humiliated, beaten or bound by another person. Similar to pedophilia, these sexual interests
should not be diagnosed as a disorder unless the individual experiences significant impairment or
distress or have acted on their urges with a nonconsenting individual (APA, 2013). The case
worker from DSS wrote a letter to the appointed psychologist to re-evaluate her mental state
because sexual sadism can be diagnosed as a mental disorder. Issues like this are common due to
overpathologizing and misunderstanding of these atypical sexual behaviors. Almost 500 people
contact the National Coalition for Sexual Freedom (NCSF) each year for help because of
discrimination or persecution due to their alternative sexual practices (Wright, 2010).
While there are many subtypes of fetishism, this study primarily examined individuals
who wear diapers voluntarily and/or participate in infant-like role play. An exploratory study
conducted by Hawkinson and Zamboni in 2014 was one of the most recently published research
articles addressing individuals who wear diapers voluntarily and/or participate in infant like role
play. The researchers found that there is an online presence for members of this community and
they tend to refer to themselves as adult babies (AB), who enjoy role-playing as infants, and
diaper lovers (DL), who wear diapers voluntarily but may not engage in other baby-like
STIGMA, CLINICIANS, ABDL, PEDOPHILIA
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behaviors. For the remainder of this paper, this community will be referred to as Adult
Baby/Diaper Lovers (ABDL).
Over the past sixty years, only a few clinical case studies examining ABDL have
emerged (Croarkin, Nam, & Waldrep, 2004; Dinello, 1967; Evcimen & Gratz, 2006; Kise &
Nguyen, 2011; Malitz, 1966; Pandita-Gunawardena, 1990; Sanders, 1997). Several different
explanations for why someone engaged in ABDL emerged: A maladaptive behavior for parental
relationships (Dinello, 1967; Malitz, 1966), a fixation on being a baby (Pandita-Gunawardena,
1990), and having components of depression or obsessive-compulsive disorder (Croarkin et al.,
2004; Evcimen & Gratz, 2006; Kise & Nguyen, 2011). It is important to note that individuals
with ABDL interests should not be diagnosed with a paraphilic disorder unless, similar to
pedophilic interests, they are experiencing impairment or distress related to their sexual interests.
While it is unknown how many people have interests in ABDL, there is expected stigma toward
this population due to the tendency for fetishes or paraphilic interests being overpathologized.
Review of Stigma Literature
Decades of stigma related research has found that mental illness stigma is an enormous
obstacle for people to seek treatment (Fox, Ernshaw, Taverna, & Vogt, 2017). Stigma has been
defined by Goffman (1963, p. 3) as an “attribute that is deeply discrediting” and that changes the
individual “from a whole and usual person to a tainted, discounted one.” Crocker, Major, and
Steele (1998, p. 505) elaborated on this definition to explain that “stigmatized individuals
possess (or are believed to possess) some attribute, or characteristic, that conveys a social
identity that is devalued in a particular social context.” Some examples of stigmatized groups
include people with mental disorders (Angermeyer & Dietrich, 2006), and the LGBTQ+
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community (Pachankis, 2007). Janke et. al (2015c) provided an outline to describe how stigma
affects minority populations.
Janke et. al (2015c) hypothesized that public stigma such as negative stereotypes and
social distance caused stigma-related stress among people with pedophilia. Stigma-related stress
can be perceiving that the public will judge them or actual experiences of discrimination. This
stress, in turn, can lead to impairment in a number of domains such as emotional functioning,
social functioning, and cognitive distortions. These may then lead to an increase risk for the
individual to commit a sexual offense. This model can be applied to stigma related stress for both
people with pedophilic interests and people with ABDL interests. For an overview of the
framework developed by Janke et. al (2015) refer to Figure 1 in Appendix B.
Aims of Current Study
The purpose of this study was to further the literature surrounding the stigma associated
with paraphilic interests. This is the first study to evaluate how clinicians perceive individuals
with paraphilic interests. The goal was to determine if stigmatization of pedophilia found in the
general population could be replicated in a clinician population. Additionally, this study sought
to determine to what extent those attitudes were similar to an under-researched fetishistic interest
(ABDL). It was hypothesized that clinicians would hold stigmatizing attitudes towards
individuals with pedophilic interests across all dependent variables when compared to clinicians’
attitudes towards individuals with depression. It was also hypothesized that clinicians would
express stigmatizing attitudes towards individuals with an interest in AB/DL when compared to
clinicians’ opinions towards individuals with depression. Additionally, it was hypothesized that
clinician’s attitudes towards pedophilic interests and AB/DL interests would not produce a
significant difference. Lastly, it was hypothesized that dependent variables such as
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dangerousness, anger, and sympathy would predict the extent to which clinicians have social
distance and motivations to work with individuals with pedophilic interests and AB/DL interests.
Methods
Participants

Participants for this study were recruited by utilizing the Association of Psychology
Postdoctoral and Internship Centers (APPIC) directory. Pre-doctoral interns were selected as the
targeted population to be sampled in order to evaluate the attitudes of clinicians getting ready to
enter the field. Emails with a brief explanation of the study and a link to a Qualtrics survey were
sent to program directors at a total of 235 sites, asking to be forwarded to current interns. The
235 internship sites were pulled from the 2016-2017 list of pre-doctoral internship programs.
There were no inclusion criteria for which sites were selected, the researcher went through the
directory alphabetically and recorded program director contact information. Only time
constraints restricted more sites being contacted. Programs contacted were located in the United
States and Canada.
Over the course of 6 months, a total of 138 interns initiated the Qualtrics survey
(Qualtrics is a secure, web-based survey tool used to conducted survey research). Participants
were eliminated if they did not complete more than half of the survey (n = 30). Of the 108
participants included in the analysis (78.3%), the majority of participants in the study identified
as female (n = 89; 82.4%), white (n = 83; 76.9%), non-parent (n = 84; 77.8%), and interested in
the field of forensics (n = 19; 17.6%) and sexual health (n = 16; 14.8%). Age of the participants
ranged from 25-53 (M = 30.06, SD = 4.31). For a full description of participant demographics,
refer to Table 2 in the Appendix A.

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Measures
Dependent measures were adopted and modified based on previous literature evaluating
the public’s and clinicians’ attitudes toward individuals with pedophilia (Imhoff, 2015; Jahnke et
al., 2015a; Jahnke et al., 2015b). All measures were rated on a 7-point Likert scale, with 0
indicating strongly disagree and 6 indicating strongly agree. Each survey was manipulated by
changing the target of evaluation. People with pedophilia were described as people with a
primary sexual interest in children, due to the literature suggesting that the label pedophile itself
may produce punitive attitudes. People with ABDL interests were described as people with a
primary sexual interest in wearing diapers/engaging in infant-like role playing. Finally, people
with depression were described as people with depression. See Table 1 in Appendix A for a
complete list of items that composed these scales.
Controllability

Controllability refers to the degree to which an individual has control of their behavior or
is the result of a disorder. This scale was comprised of four items and higher scores on this scale
indicated that the clinician reported the presented interest has control over their behavior.
Previous studies reported reliability for this measure to range from, α = 0.71-0.87, (Imhoff, 2015;
Jahnke et al., 2015a; Jahnke et al., 2015b) depending on the modification of the scale. In the
current study, reliability ranged from good to excellent (α = 0.93 for people with pedophilic
interests, 0.80 for people with ABDL interests, and 0.73 for people with depression).
Dangerousness

Dangerousness refers to the degree to which an individual perceives a connection
between someone with pedophilic interests and their likelihood of committing a sexual crime
against a child. The dangerousness scale was comprised of 8 items with higher scores on the
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dangerousness scale indicating higher perceived dangerousness. Previous studies reported
reliability for this measure to range from, α = 0.69-0.82, (Imhoff, 2015; Jahnke et al., 2015a;
Jahnke et al., 2015b). The current study produced good reliability scores (α = 0.72 for people
with pedophilic interests, 0.81 for people with ABDL interests, and 0.79 for people with
depression).
Affective Reactions

Clinicians were asked to rate their reaction towards individuals with atypical sexual
interests on three emotions: Anger, pity, and sympathy. These reactions were one item each and
rated on a 7-point Likert scale, with 0 being strongly disagree and 6 being strongly agree.
Social Distance

Social distance, previously referred to as discriminatory behavior intentions, is a measure
evaluating the clinician’s willingness to interact with an individual with pedophilic interests
across a range of social contexts. The social distance scale was comprised of 8 items with higher
scores on the social distance measure indicated more acceptability of these individuals in various
social settings. Previous studies reported good reliability for social distance, α = 0.77-0.82
(Imhoff, 2015; Jahnke et al., 2015a; Jahnke et al., 2015b). In the current study, reliability for
social distance ranged from good to excellent (α = 0.91 for people with pedophilic interests, 0.79
for people with ABDL interests, and 0.82 for people with depression).
Motivation to Work

The motivation to work scale was used to determine how willing a clinician was to work
with individuals with different presenting problems. This measure was comprised of five items
with only four being evaluated for internal reliability. The first item evaluated clinicians’
opinions on whether the presenting interest was a mental disorder. The remaining four items
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evaluated their motivations to work with the individual. Higher scores on this scale indicated a
greater interest in working with the given individuals. Previous literature reported high
reliability, α = 0.83-0.85, (Imhoff, 2015; Jahnke et al., 2015a; Jahnke et al., 2015b). The current
study produced reliability scores ranging from poor to excellent (α = 0.89 for people with
pedophilic interests, 0.61 for people with ABDL interests, and 0.36 for people with depression.
Procedure

Program directors at pre-doctoral internship sites were contacted and asked to forward the
link to the Qualtrics survey to their current interns. Because program directors did not respond
whether they forwarded the email to current interns or not, there was no way to determine
response rates. Interns that followed the link to the Qualtrics survey were presented with a
consent form. The consent form informed clinicians that the purpose of the study would be to
assess predoctoral intern’s attitudes about people with atypical sexual interests using an
anonymous online survey. Once participants read the consent form and confirmed that they were
18 years of age, they were randomly assigned to one of three survey conditions (pedophilic
interest, ABDL interest, depression). All surveys evaluated clinician’s opinions across the
dependent variables. The only manipulation between surveys was the presenting problem
described. The survey took an average of 6 minutes to complete.
Results
MANOVA/ANOVA
It was hypothesized that participants would respond to the dependent measures
differently depending on which survey they were presented. Specifically, clinicians would report
more stigmatizing attitudes in the pedophilic and ABDL interest surveys when compared to the
depression survey. A three-way multivariate analysis of variance (MANOVA), was conducted to
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evaluate differences between clinician’s opinions on people with pedophilic interests, ABDL
interests, and depression on four dependent variables measuring controllability, dangerousness,
social distance, and motivation. The results indicated that the overall model was significant
F(8,184)=19.44, p<0.001, Wilks’ Λ=0.29, ηp2=0.46, indicating that significant differences were found within all four dependent measures. Controllability was found to be significant F(2,95)=12.65, p<0.001, ηp2=0.21; dangerousness, F(2,95)=46.57, p<0.001, ηp2=0.50; social distance, F(2,95)=55.44, p<0.001, ηp2=0.54; and finally, motivation, F(2,95)=18.30, p<0.001, ηp2=0.28. Individual analyses examined the significant differences between the dependent variables. Controllability When assessing for differences within the controllability measure, a one-way analysis of variance (ANOVA) indicated overall significant results, F(2,104)=15.52, p<0.001. A Bonferroni post-hoc evaluation concluded that there were significant differences between clinician’s opinions toward people with pedophilia and clinicians’ opinions toward people with depression (p<0.001), but not between clinicians’ opinions on pedophilic interests and ABDL interests (p=1.00). Additionally, clinicians’ opinions towards people with ABDL interests were found to be significantly different than clinicians’ opinions toward people with depression (p<0.001). Clinicians reported that people with pedophilic interests (M=2.20, SD=1.47) and ABDL interests (M=2.13, SD=1.22), were in more control of their behavior when compared to people with depression (M=0.87, SD=0.80). Dangerousness A one-way ANOVA was conducted to examine significant differences on perceived dangerousness of a client. People with pedophilic interests (M=3.02, SD=0.84) were rated STIGMA, CLINICIANS, ABDL, PEDOPHILIA 18 significantly more dangerous than both people with ABDL interests (M=1.29, SD=0.79, p<0.001) and people with depression (M=1.28, SD=0.87, p<0.001). Furthermore, people with ABDL interests were rated similarly to people with depression resulting in no significant difference found (p=1.00). Affective Reactions Responses to the three affective reactions questions were not included in the original MANOVA. One-way ANOVAs were conducted to determine if significant differences were found at each affective reaction. For the first question, evaluating whether clinicians experience sympathy towards individuals with atypical interests, overall significance was found F(2,103)=26.37, p<0.001. Clinicians reported feeling significantly less sympathetic toward people with pedophilic interests (M=2.42, SD=0.24) and ABDL interests (M=2.97, SD=0.24) than people with depression (M=4.67, SD=0.22, p<0.001). No significant difference was found between clinicians’ attitudes toward people with pedophilic interests and people with ABDL interests (p=1.00). The second question, assessing if clinicians feel anger toward individuals with atypical sexual interests found overall significance, F(2,103)=56.82, p<0.001. On this measure, clinicians reported significantly higher levels of anger toward people with pedophilic interests (M=3.70, SD= 1.49) than both people with ABDL interests (M=1.06, SD=0.92, p<0.001) and people with depression (M=1.00, SD=1.12, p<0.001). Clinicians’ attitudes toward people with ABDL interests were not significantly different than people with depression (p=1.00). The third question, evaluating if clinicians feel pity towards individuals with atypical sexual interests, also produced overall significance F(2,103)=5.15, p<0.01. At this measure, clinicians reported the highest levels of pity toward people with pedophilic interests (M=3.06, STIGMA, CLINICIANS, ABDL, PEDOPHILIA 19 SD=1.75), followed by people with depression (M=2.41, SD=1.55), then people with ABDL interests (M=1.79, SD=1.55). Clinicians’ attitudes toward people with pedophilia were significantly different than clinicians’ attitudes toward people with ABDL interests (p<0.01) but were not significantly different than clinician’s attitudes toward people with depression (p=0.28). Finally, clinicians’ attitudes toward people with depression were not significantly different than clinicians’ attitudes toward people with ABDL interests (p=0.32). Social Distance A one-way ANOVA indicated a significant difference among clinicians’ responses on the social distance scale F(2,95)=55.44, p<0.001. People with pedophilic interests received the lowest scores (M=2.51, SD=1.17), followed by people with depression (M=4.59, SD=0.87), then people with ABDL interests (M=4.64, SD=0.70). The lower scores indicate a higher level of discrimination, while higher scores indicate more acceptability. Bonferroni post-hoc examination determined that there was a significant difference between clinicians’ attitudes toward people with pedophilic interests and both people with ABDL interests (p<0.001) and people with depression (p<0.001). No significant difference was found between clinicians’ attitudes towards people with ABDL interests and people with depression (p=1.00) on the measure of social distance. When looking at clinicians’ opinions on whether or not individuals with pedophilic interests should be dead, 12% of the clinicians surveyed reported somewhat to strongly agreeing. Furthermore, 24% of clinicians reported somewhat to strongly agreeing that people with pedophilic interests should be incarcerated. Motivations to Work A one-way ANOVA was conducted in order to determine if clinicians’ reported significant differences in willingness to work with individuals depending on their presented STIGMA, CLINICIANS, ABDL, PEDOPHILIA 20 interest. The overall model was found to be significant F(2,97)=19.93, p<0.001. Overall, people with pedophilic interests were rated with the lowest scores to work with them (M=3.48, SD=1.70), followed by people with ABDL interests (M=4.23, SD=1.04), then people with depression (M=5.27, SD=0.53). Lower scores indicate high resistance to work with the stated population. Further examination determined that clinicians significantly reported lower desires to work with people with pedophilic interests when compared to both people with ABDL interests (p<0.05), and people with depression (p<0.001). Additionally, clinicians reported less motivation to work with people with ABDL interests than people with depression (p<0.01). See Table 3 in Appendix A for a complete list of means for each dependent measure. Regressions It was hypothesized that the way a clinician rated the interest across the dependent measures would predict how willing they were to work with that given population. A step-wise linear regression was used to determine if there were any measures that would predict the likelihood that clinicians would want to work with someone with atypical interests. A step-wise regression was used because there were not specific hypotheses about which measure would predict clinicians’ motivations and served exploratory for this study. The overall model was found to be significant (R2=.48, F(1,96)=53.21, p<0.001). Sympathy (p<0.001) and Dangerousness (p<0.05) were found to be significant predictors of a clinician’s motivations to work with a specific population. Higher rates of dangerousness decreased a clinician’s likelihood to want to work with that population and higher rates of sympathy increased a clinician’s likelihood to want to work with them. Further analyses were conducted by only selecting clinicians that responded to a specific survey to determine if specific dependent measures predicted motivations to work with a specific atypical interest. STIGMA, CLINICIANS, ABDL, PEDOPHILIA 21 People with Pedophilic Interests Another step-wise linear regression was conducted only using responses from participants randomly assigned to the people with pedophilic interest survey. Dangerousness, sympathy, and anger were used to predict motivations and the model was found to be significant (R2=0.46, F(2,329)=8.28, p<0.001). Sympathy (p<0.05) and anger (p<0.05) were both found to be significant predictors on the likelihood of a clinician wanting to work with individuals with pedophilic interests. Increased ratings of sympathy increase the likelihood that a clinician was willing to work with someone with pedophilic interests while anger decreased the likelihood. People with ABDL Interests A step-wise linear regression using social distance as a predictor for motivations to work with people with ABDL interests was found to be significant (R2=0.47, F(1,32)=28.70, p<0.001). This means that higher acceptance in various social settings increased the likelihood that a clinician would be willing to work with people with ABDL interests. People with Depression Dangerousness was used as a predictor for motivations to work with people with depression in a linear regression. The model was found to be significant (R2=0.13, F(1,30)=4.43, p<0.05). This means that increased ratings of perceived dangerousness decreased a clinician’s willingness to work with individuals with depression. STIGMA, CLINICIANS, ABDL, PEDOPHILIA 22 Discussion The purpose of this study was to evaluate if stigmatizing attitudes were present in a clinician population in North America toward individuals with pedophilic and ABDL interests, and determine if there were factors that would increase a clinician’s willingness to work with these populations. This study sought to examine emerging clinicians’ attitudes in order to assess the immediate future’s clinical attitudes toward individuals with atypical sexual interests in the United States and Canada. Building off of pedophilia and stigma research, it was hypothesized that some stigmatizing attitudes would be present toward people with pedophilic and ABDL interests. The sample did exhibit significantly different opinions of people with pedophilic interests when compared to the control group depression. There was a range of significant differences between people with pedophilic interests and people with ABDL interests. It was hypothesized that people with pedophilic interests would be rated similarly to people with ABDL interests due to the literature surrounding stigma associated with paraphilic interests. However, people with pedophilic interests were only rated similarly to ABDL on the measures of controllability and sympathy. Clinicians viewed people with both interests as being able to control their interests and this may have lead them to not feeling sympathy for these populations. Additionally, clinicians rated people with pedophilic interests significantly different than people with ABDL interests on measures of dangerousness, pity, anger, social distance, and motivations. This could mean that clinicians were able to make the distinction between someone who has a sexual interest in prepubescent children and someone who has a sexual interest in involving aspects of being a baby. STIGMA, CLINICIANS, ABDL, PEDOPHILIA 23 Limitations One of the limitations to this study was that there was no way of knowing the response rate. Because program directors were contacted and asked to forward the Qualtrics link to the interns at their site, there was no way of knowing how many program directors forwarded the email, and of those that did, how many interns were at that particular site and read the email. Additionally, this study only looked at clinicians who were just completing their formal education. There could be a problem of generalizability in that clinicians who have been in the field longer have different attitudes towards individuals with these atypical interests. Furthermore, specific clinical interests may have influenced the results. There were several clinicians who had an interest in forensics or sexual health. These individuals may have more exposure to individuals with atypical sexual interests. Another limitation to this study may have been the use of depression as a control condition. While depression was used as a control because there should be no stigmatization associated with this mental health issue, it did not have a sexual component. A few participants expressed concern by emailing the researcher after being randomly assigned the depression survey. They expressed confusion because the consent stated that the study was looking at atypical sexual interests and they were questioned about their opinions on depression. Additionally, internal consistency was lowest for the depression group. This could have been due to the questions still asking about how depression would influence someone to engage in sexual activities. A final limitation to this study could be from participants responding in a socially desirable manner. Imhoff (2015) found that it was socially desirable for the public to have punitive attitudes toward individuals with pedophilic interests. However, one would hope that it STIGMA, CLINICIANS, ABDL, PEDOPHILIA 24 would not be socially desirable for clinicians to hold punitive attitudes toward any clinical population. Furthermore, there is potential that clinicians wanted to appear more accepting of people with ABDL interests and people with depression. Future Research and Conclusion This study increased the literature surrounding evidence of stigmatization toward people with pedophilic interests. Because these stigmatizing attitudes were found in a clinician population, these findings should caution clinicians and researchers who work with these individuals to be aware of potential biases in order to provide ethical treatment. Results from the regression using the clinicians who responded to the pedophilia survey examines areas to focus education training on for clinicians who will work with people with pedophilic interests. This study also added to the literature surrounding the under-researched ABDL population. Fortunately, this study appears to support the idea that clinicians are able to make the distinction between people who are sexually attracted to prepubescent children and those who role play as babies or wear diapers for sexual pleasure. Future studies should examine ABDL versus people with pedophilic interests in the general population to see if they can make the same distinction. This would be especially helpful given the growing number of people who contact the National Coalition for Sexual Freedom (NCSF).