Help-seeking pedophilic disorder with occupational access risk (MEQ)

(i) Formulation. Working diagnosis: pedophilic disorder (preferential interest in prepubescent children with acted-on component via illegal material and/or marked distress — apply local manual wording carefully) with comorbid depression and hazardous alcohol use. High dynamic risk: occupational access to children, online illegal material, alcohol as facilitator, fear of escalation. Differentials: CSBD (control failure without atypical target — not primary here because target is atypical), OCD sexual obsessions (ego-dystonic non-preferred thoughts — less fitting if preference is clear), substance-only disinhibition, personality facilitation. Motivation–facilitation framing: motivation = pedophilic interest; facilitators = access, alcohol, possible self-regulation failure.[1][2][5][7]

(ii) Assessment priorities. Immediate child-protection and public-interest duties given swimming-coach access and disclosed illegal material — act under jurisdiction-specific mandatory reporting; do not book a delayed elective review only. Assess contact offences history, grooming, escalation, devices, living situation, and partner-child access. Suicide risk (passive death wishes after legal threat) — same-day safety plan. Permission-based sexual history, substances, MSE for insight/minimisation, collateral and multiagency liaison. Explain limits of confidentiality early. Document carefully.[2][3]

(iii) Management. Protect children first (remove/restrict occupational access via appropriate agencies; multiagency plan). Treat depression and alcohol. Psychological therapy: CBT/self-management, relapse prevention, opportunity control, motivational work. Pharmacotherapy per WFSBP: consider SSRI at antidepressant-class dosing for drive/compulsivity and depression (e.g. sertraline titrated in usual adult ranges such as 50–200 mg oral daily with early suicide monitoring); escalate to specialist antiandrogen or GnRH pathways only if high residual risk after specialist assessment, with full medical monitoring (metabolic, bone, mood, drive logs) and informed consent — not as punishment.[3][4][6][8]

(iv) Goals and prognosis. Goals: no harm to children, cessation of illegal material use, reduced drive and distress, alcohol recovery, mood recovery, sustainable monitoring. Interests may persist; success is risk and function, not guaranteed erasure of preference.[2][3]

(v) Evidence links. ICD-11/DSM threshold teaching separates interest from disorder and centres consent/harm.[1] Seto reviews pedophilia science and motivation–facilitation risk thinking.[2][5] WFSBP 2010/2020 and pharmacologic reviews structure stepped intensity including LHRH agonists in selected high-risk men.[3][4][6][8]