Reading: Pedophilic Disorder -

Pedophilia is termed pedophilic disorder in the DSM-5, and the manual defines it as a paraphilia involving intense and recurrent sexual urges towards and fantasies about prepubescent children that have either been acted upon or that cause the person with the attraction distress or interpersonal difficulty.

The word pedophilia is derived from the Greek words “paidos” (child) and “philia” (love). An estimated 20% of American children have been sexually molested, making pedophilia a common paraphilia. Offenders are usually family friends or relatives. Types of activities vary and may include just looking at a child or undressing and touching a child. However, acts often involve oral sex or touching of genitals of the child or the offender. Studies suggest that children who feel uncared for or lonely may be at higher risk for sexual abuse.

The key feature of this disorder is that the individual experiences sexual arousal when with children that may be equal to, if not greater than, that which they experience with individuals who are physically mature. In other words, an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children. Although girls typically begin the process of puberty at age 10 or 11 and boys at age 11 or 12, criteria for pedophilia extend the cut-off point for prepubescence to age 13. A person must be at least 16 years old, and at least five years older than the prepubescent child, for the attraction to be diagnosed as pedophilia. If an individual is 16 years old and exhibits these behaviors with someone that is at least 5 years younger, he or she would be considered for this disorder.

Another feature involves recurring sexual dreams, behaviors, or urges concerning children that are 13 years old or younger. These urges may be directed toward children of the same sex as the pedophiles, or the other sex. Some pedophiles are attracted to both boys and girls. Some are attracted to only children while others are attracted to children as well as adults. These issues must be persistent for at least six months and must cause impairment to everyday functioning to be considered symptoms.

Pedophilia emerges before or during puberty and is stable over time, although some individuals with pedophilia report that they did not become sexually aroused by children until middle adulthood. It is said to be self-discovered, not chosen.^[1] For these reasons, pedophilia has been described as a disorder of sexual preference, phenomenologically similar to a heterosexual or homosexual orientation. This description led to some misunderstandings about wording in the DSM-5, prompting the APA to comment that “APA considers pedophilic disorder a ‘paraphilia,’ not a ‘sexual orientation.'” They said they strongly support efforts to criminally prosecute those who sexually abuse and exploit children and adolescents, and “also support continued efforts to develop treatments for those with pedophilic disorder with the goal of preventing future acts of abuse.”^[2]

Pedophiles may limit their activity to exposing themselves to a child (sometimes known as flashing), touching and fondling the child gently, undressing the child and looking at them, or masturbating in front of the child. Consumption of child pornography appears to be a more reliable indicator of pedophilia than molesting a child, although some non-pedophiles also view child pornography. Child pornography may be used for a variety of purposes, ranging from private sexual gratification or trading with other collectors, to preparing children for sexual abuse as part of the child grooming process. 

Pedophilic viewers of child pornography are often obsessive about collecting, organizing, categorizing, and labeling their child pornography collection according to age, gender, sex act, and fantasy. When it comes to child sexual exploitation material (CSEM), those whose usage appears to be confined to engagement with the images themselves (e.g., as a facilitator of sexual fantasy or collecting behavior) are labeled as contact-driven, and those whose CSEM usage is functionally and directly related to contact sex offending (e.g., as a behavioral substitute, facilitatory factor, or product of a contact offense) are labeled as fantasy-driven, utilizing terminology introduced by Merdian, Curtis, Thakker, Wilson, and Boer (2013)^[3]. 

Figure 1. The internet has made it easier for predators to gain access to child pornography or solicit contact with minors.

Researchers Taylor and Quayle reported that pedophilic collectors of child pornography are often involved in anonymous internet communities dedicated to extending their collections. Children are particularly vulnerable to sexual predators, such as pedophiles, on the internet. Forensic science research reveals two models of pedophilia on the internet: a trust-based seductive model, in which a pedophile will use the internet to build a relationship of trust with a child, with the end goal of an in-person meeting, and a direct sexual model, which is generally a shorter relationship in which the pedophile will bring up sexual activities and solicit images with the minor ^[4]

Neither the DSM nor the ICD-11 diagnostic criteria require actual sexual activity with a prepubescent youth. The diagnosis can therefore be made based on the presence of fantasies or sexual urges even if they have never been acted upon. On the other hand, a person who acts upon these urges yet experiences no distress about their fantasies or urges can also qualify for the diagnosis. Acting on sexual urges is not limited to overt sex acts for purposes of this diagnosis.

Gender and Cultural Differences in Presentation

Until recently, pedophilic individuals had found it relatively easy to gain access to unattended children. Awareness of pedophilia has been raised in the past two decades, and it has become more difficult for these individuals to find children with whom to act out their fantasies. In response to the scarcity of vulnerable children, many pedophiles have turned to chatrooms and child pornography.

Males are more often diagnosed with this disorder than women. Pedophilia is more prevalent among Caucasians than among other ethnicities. It is also known that if a male prefers males, it is more likely that he will repeat his pedophilic actions. This has led certain religious or otherwise radical activists to suggest that pedophilia and homosexuality are “one and the same,” resulting in further media attention to an already well-covered topic.

CULTURAL PRACTICES AND PEDOPHILIA

One of the biggest issues in assessing behavior as pedophilic or normal is the criteria for pedophilia. E. E. Evans- Pritchard recorded that male Azande warriors (in the northern Congo) routinely took on boy-wives between the ages of twelve and twenty, who helped with household tasks and participated in intercrural (non-penetrative) sex with their older husbands. The practice had died out by the early 20th century, after Europeans had gained control of African countries, but was recounted to Evans-Pritchard by the elders he spoke to.

Figure 2. Ethiopia is one of the countries where child marriage is more prevalent.

By Western standards, certain cultures would have a higher prevalence of pedophilia because these cultures allow child weddings, or unions between mature males and prepubescent females. Clearly, it is important to note any religious or cultural backgrounds in individuals being examined as having pedophilia. This is a very difficult situation, as some groups have voiced the concern that any pedophile can simply convert to a belief system that accommodates and excuses his behaviors. UNICEF has stated that child marriage “represents perhaps the most prevalent form of sexual abuse and exploitation of girls.” The effects of child sexual abuse can include depression, post-traumatic stress disorder, anxiety, a propensity to further victimization in adulthood, and physical injury to the child, among other problems. Sexual abuse by a family member is a form of incest and can result in more serious and long-term psychological trauma, especially in the case of parental incest.

Pedophilia and the Law

As we discuss further in this section, under the law, child sexual abuse is often used as an umbrella term describing criminal and civil offenses in which an adult engages in sexual activity with a minor or exploits a minor for the purpose of sexual gratification. The American Psychological Association states that “children cannot consent to sexual activity with adults,” and condemns any such action by an adult: “an adult who engages in sexual activity with a child is performing a criminal and immoral act which never can be considered normal or socially acceptable behavior.” ^[5]

Several terms have been used to distinguish “true pedophiles” from non-pedophilic and non-exclusive offenders, or to distinguish among types of offenders on a continuum according to strength and exclusivity of pedophilic interest, and motivation for the offense. Exclusive pedophiles are sometimes referred to as true pedophiles. They are sexually attracted to prepubescent children, and only prepubescent children. Showing no erotic interest in adults, they can only become sexually aroused while fantasizing about or being in the presence of prepubescent children, or both. Non-exclusive offenders—or “non-exclusive pedophiles”—may at times be referred to as non-pedophilic offenders, but the two terms are not always synonymous. Non-exclusive offenders are sexually attracted to both children and adults, and can be sexually aroused by both, though a sexual preference for one over the other in this case may also exist. If the attraction is a sexual preference for prepubescent children, such offenders are considered pedophiles in the same vein as exclusive offenders.

Epidemiology

The most commonly asked question about pedophilia is how frequently it occurs. Obtaining reliable incidence numbers of pedophilia as a preference disorder is difficult as individuals are typically unwilling to admit pedophilic preferences, particularly when offenses have been committed. The prevalence of pedophilia in the general population is not known. The prevalence of a true pedophilic sexual preference is approximately 1%, but when general fantasies are investigated, that prevalence can reach up to 5% among men in the general population.

Some studies suggest that the prevalence of pedophilia may be between 3%-5% in the general population (as reviewed by Seto, 2009). In penile plethysmography, studies of men with sexual offense histories against children, these prevalences can jump from 30% for men with one offense to 61% for men with three or more sexual offenses against children (Blanchard, 2010; Seto, 2009). The most well-known objective method of measuring pedophilic interest is penile plethysmography (PPG) or phallometry. This method measures genital sexual arousal through sexual stimuli and is based on the relative change in penile response. Sexual preference can be determined as the relative change in penile response to various classes of sexual stimuli (according to Tanner scales), such as prepubescent, pubescent, or adult female or male targets. ^[6]

Less is known about the prevalence of pedophilia in women, but there are case reports of women with strong sexual fantasies and urges towards children. Frequently, the abuse against a child is carried out in collaboration with a male partner or victims are seen as surrogates to replace less than desirable relationships. The 2009 Plymouth child abuse case was a child abuse and pedophile ring involving at least five adults from different parts of England who all met on Facebook. The case centered on photographs taken of up to 64 children aged two to five years old by Vanessa George, a nursery (pre-school) worker in Plymouth. It highlighted the issue of child molestation by women, as all but one of the members of the ring were female. The case prompted an increased recognition of the problem of female pedophiles, sex offenders, and the scale of their offending, with one estimate suggesting that at least 10% of sex offenders are female. 

Currently, there is no reliable estimate of pedophilia in women and the question remains whether pedophilia, as currently defined, even exists in women^[7].The true number of female child molesters may be underrepresented by available estimates, for reasons including a “societal tendency to dismiss the negative impact of sexual relationships between young boys and adult women, as well as women’s greater access to very young children who cannot report their abuse,” among other explanations (e.g., Vanessa George who worked with children under the age of 5).

The reason that there is very little known about the prevalence of pedophilia at this time may be because of the severely negative stigma associated with having pedophilia, and therefore, many people with pedophilia only rarely seek help from a mental health professional. Also, abnormal psychology has studied egosyntonic and egodystonic concepts in some detail. Egosyntonic refers to the behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one’s ideal self-image. Egodystonic (or ego alien) is the opposite, referring to thoughts and behaviors (dreams, compulsions, desires, etc.) that are in conflict, or dissonant, with the needs and goals of the ego, or, further, in conflict with a person’s ideal self-image. Many mental disorders, including pedophilic disorder, are egosyntonic, which makes their treatment difficult as the patients may not perceive anything wrong and view their perceptions and behavior as reasonable and appropriate. This corresponds to the general concept in psychiatry of poor insight. 

Ego-dystonic sexual orientation includes people who acknowledge that they have a sexual preference for prepubertal children, but wish to change it due to the associated psychological or behavioral problems (or both).

Etiology

Some researchers feel that it is due to biological factors, that one of the male sex hormones predisposes men to be more sexually deviant; however, according to a 2002 study there is no evidence of any link between genetics and pedophilia.

Although what causes pedophilia is not yet known, researchers began reporting a series of findings linking pedophilia with brain structure and function, beginning in 2002. Testing individuals from a variety of referral sources inside and outside the criminal justice system as well as controls, these studies found associations between pedophilia and lower IQs, poorer scores on memory tests, greater rates of non-right-handedness, greater rates of school grade failure over and above the IQ differences, lesser physical height, greater probability of having suffered childhood head injuries resulting in unconsciousness, and several differences in MRI-detected brain structures.

Figure 3. Overview of neuropsychological findings in pedophilia and child sexual offending.

Such studies suggest that there are one or more neurological characteristics present at birth that cause or increase the likelihood of being pedophilic. Some studies have found that pedophiles are less cognitively impaired than non-pedophilic child molesters. A 2011 study reported that pedophilic child molesters had deficits in response inhibition, but no deficits in memory or cognitive flexibility. Evidence of familial transmittability “suggests, but does not prove that genetic factors are responsible” for the development of pedophilia. A 2015 study indicated that pedophilic offenders have a normal IQ.

Another study, using structural MRI, indicated that male pedophiles have a lower volume of white matter than a control group. Functional magnetic resonance imaging (fMRI) has indicated that child molesters diagnosed with pedophilia have reduced activation of the hypothalamus as compared with non-pedophilic persons when viewing sexually arousing pictures of adults. A 2008 functional neuroimaging study notes that central processing of sexual stimuli in heterosexual “pedophile forensic inpatients” may be altered by a disturbance in the prefrontal networks, which “may be associated with stimulus-controlled behaviors, such as sexual compulsive behaviors.” The findings may also suggest “a dysfunction at the cognitive stage of sexual arousal processing.”

Blanchard, Cantor, and Robichaud (2006) reviewed the research that attempted to identify hormonal aspects of pedophiles. They concluded that there is some evidence that pedophilic men have less testosterone than controls, but that the research is of poor quality and that it is difficult to draw any firm conclusion from it.

While not causes of pedophilia themselves, childhood abuse by adults or comorbid psychiatric illnesses—such as personality disorders and substance abuse—are risk factors for acting on pedophilic urges. Blanchard, Cantor, and Robichaud addressed comorbid psychiatric illnesses; “The theoretical implications are not so clear. Do particular genes or noxious factors in the prenatal environment predispose a male to develop both affective disorders and pedophilia, or do the frustration, danger, and isolation engendered by unacceptable sexual desires—or their occasional furtive satisfaction—lead to anxiety and despair?” They indicated that, because they previously found mothers of pedophiles to be more likely to have undergone psychiatric treatment, the genetic possibility is more likely.

A study analyzing the sexual fantasies of 200 heterosexual men by using the Wilson Sex Fantasy Questionnaire exam determined that males with a pronounced degree of paraphilic interest (including pedophilia) had a greater number of older brothers, a high 2D:4D digit ratio (which would indicate low prenatal androgen exposure), and an elevated probability of being left-handed, suggesting that disturbed hemispheric brain lateralization may play a role in deviant attractions.

Other research suggests that pedophilia results from certain psychosocial factors (e.g., being sexually abused as a child, or the nature of one’s familial interactions). Studies of pedophilia in child sex offenders often report that it co-occurs with other psychopathologies, such as low self-esteem, depression, anxiety, and personality problems. Still others invoke factors such as the following: anomalies in psychological development, the desire to overpower sexual partners, and the belief that sex is a necessary requisite for affection.^[8]

Treatment

Current therapeutic approaches to treat pedophilia include psychotherapy as well as pharmacological treatment, among which includes androgen-lowering therapy. CBT aims to reduce attitudes, beliefs, and behaviors that may increase the likelihood of sexual offenses against children. Its content varies widely between therapists, but a typical program might involve training in self-control, social competence and empathy, and use cognitive restructuring to change views on sex with children. The most common form of this therapy is relapse prevention, where the patient is taught to identify and respond to potentially risky situations based on principles used for treating addictions.

Antiandrogen drugs (ADT) are used to drastically decrease the testosterone concentration in patients. Antiandrogen drugs (ADT) are also known as chemical castration due to the fact that serum testosterone concentration can drop rapidly and even reach castration levels after several weeks. The aim of the treatment is a reduction in sexual drive and, in consequence, a reduced risk of recidivism in paraphilic patients and sexual offenders. Despite a large number of studies, the efficiency of ADT aiming at a reduction of the sex drive and a reduced risk of recidivism is still under debate^[9]

However, chemical castration therapy reduces an individual’s libido, which then makes some offenders more responsive to the introduction of psychotherapy. This combination therapy is most often utilized in those who are at a high risk of offending. Unlike surgical castration, where the gonads are removed through an incision in the body, chemical castration is not as radical and does not remove organs, nor is it a form of sterilization.

As of 2008, most doctors believe that pedophilia cannot be cured. The current approach to deal with pedophiles who have been convicted of sexual abuse is to try to change their behavior. It does not change their sexual attraction. Using this treatment, it is believed that some sex offenders can be prevented from offending again.

Controversies and Complications Surrounding the Diagnosis of Paraphilic Disorders

Many complications of paraphilia and paraphilic disorders can arise. Living with these intense and abnormal desires and behaviors can be troublesome and cause much turmoil to those individuals suffering from them. When the paraphilia becomes a paraphilic disorder, individuals suffer harm, distress, and functional impairment. Furthermore, legal ramifications often ensue, leading to a life of incarceration and/or probation, and forensic psychiatric hospital confinement as well as permanent induction onto the sexual offender registry. Dependent on jurisdiction, the requirements of being on the sex offender registry include address notification; making living location public knowledge; housing limitations; and restrictions on being in the presence of underage persons, living in proximity to a school or daycare center, internet use, or even owning toys or other items that may suggest involvement with children.

Overall, the majority of patients suffering from paraphilic disorders rarely seek treatment voluntarily, as many individuals feel indignity, culpability, or discomfiture while others focus on the difficulty and lack of desire to halt efforts of achieving intense sexual pleasure and ultimate satisfaction. Furthermore, the very nature of paraphilic disorders in many individuals leads to victimization and often legal repercussions. These consequences will only further deter patients from seeking treatment. Those patients actually involved in treatment plans are most often either mandated legally or convinced by family, friends, or sexual partners.

Despite the medications used in the management of paraphilic disorders, better preventative measures are deemed necessary to reduce victimization, as many of those with paraphilic disorders will only be under evaluation upon incarceration after the harm has been inflicted. 

Childhood sexual abuse is considered to be a leading cause of pedophilia, among other paraphilias and resultant paraphilic disorders. Maybe preventative measures should start here. Many psychiatrists and mental healthcare providers feel that the only cure for pedophilic disorder is incarceration. As paraphilias and paraphilic disorders are deeply engrained thoughts and irresistible behaviors of the individual, whether viewed as right or wrong, it is currently deemed as merely impossible to fix.[footnote]Fisher KA, Marwaha R. Paraphilia. [Updated 2020 Mar 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554425/[/footnote]

Lastly, sexual preference itself cannot be considered a mental disorder similar to how a homosexual orientation was considered in the 1970s in the United States of America (Green, 2002). Separating sexual preference from psychosocial impairment, thus allowing for the practice of various sexual behaviors with consenting partners, has been applied within the new DSM-5 with the other paraphilias as well, including fetishism, bondage/dominance-sadism/masochism, and is therefore not specific to pedophilia (Wright, 2010, 2014).^[12]