Pedophilia is a form of paraphilia that causes harm to others and is thus considered a paraphilic disorder.
Sexual offenses against children constitute a significant proportion of reported criminal sexual acts. For older adolescents (ie, 17 to 18 years old), ongoing sexual interest or involvement with a 12- or 13-year-old may not meet the clinical criteria for a disorder. However, legal criteria may be different from psychiatric criteria. For example, sexual activity between a 19-year-old and a 16-year-old may be a crime and not a pedophilic disorder, depending on the jurisdiction. Diagnostic age guidelines apply to Western cultures and not to the many cultures that accept sexual activity, marriage, and childbearing at much younger ages and accept much greater age differences between sex partners than Western cultures do.
Most pedophiles are male. Attraction may be to young boys, girls, or both. But pedophiles prefer opposite-sex to same-sex children 2:1. In most cases, the adult is known to the child and may be a family member, stepparent, or a person with authority (eg, a teacher, a coach). Looking or touching seems more prevalent than genital contact. Pedophiles may be attracted only to children (exclusive form) or also adults (nonexclusive form); some are attracted only to children who are related to them (incest).
Predatory pedophiles, many of whom have antisocial personality disorder, may use force and threaten to physically harm the child or the child’s pets if the abuse is disclosed.
The course of pedophilia is chronic, and perpetrators often have or develop substance use disorders or dependence and depression. Pervasive family dysfunction, a personal history of sexual abuse, and marital conflict are common. Other comorbid disorders include attention-deficit/hyperactivity disorder, anxiety disorders, and posttraumatic stress disorder.
Extensive use of child pornography is a reliable marker of sexual attraction to children and may be the only indicator of the disorder. However, use of child pornography by itself does not meet criteria for pedophilic disorder, although it is typically illegal.
If a patient denies sexual attraction to children but circumstances suggest otherwise, certain diagnostic tools can help confirm such attraction. Tools include penile plethysmography (men), vaginal photoplethysmography (women), and viewing time of standardized erotic materials; however, possession of such material, even for diagnostic purposes, may be illegal in certain jurisdictions.
Clinical criteria for diagnosis (based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) of pedophilic disorder are
Recurrent, intense sexually arousing fantasies, urges, or behaviors involving a prepubescent child or children (usually ≤ 13 years) have been present for ≥ 6 months.
The person has acted on the urges or is greatly distressed or impaired by the urges and fantasies. The experience of distress about these urges or behaviors is not a requirement for the diagnosis.
The person is ≥ 16 years and ≥ 5 years older than the child who is the target of the fantasies or behaviors (but excluding an older adolescent who is in an ongoing relationship with a 12- or 13-year-old).
Identifying a patient as a potential pedophile sometimes poses an ethical crisis for health care practitioners. However, health care practitioners have a responsibility to protect the community of children. Practitioners should know the reporting requirements in their state. If practitioners have reasonable suspicion of child sexual or physical abuse, the law requires that it be reported to authorities. Reporting requirements vary by state (see Child Welfare Information Gateway).
Long-term individual or group psychotherapy is usually necessary and may be especially helpful when it is part of multimodal treatment that includes social skills training, treatment of comorbid physical and mental disorders, and drug treatment.
Treatment of pedophilia is less effective when court ordered, although many adjudicated sex offenders have benefited from treatments, such as group psychotherapy plus antiandrogens.
Some pedophiles who are committed to treatment and monitoring can refrain from pedophilic activity and can be reintegrated into society. These results are more likely when no other psychiatric disorders, particularly personality disorders, are present.
In the US, the treatment of choice for pedophilia is
By blocking pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), medroxyprogesterone reduces testosterone production and thus reduces libido. Typical doses are medroxyprogesterone 200 mg IM 2 to 3 times a week for 2 weeks, followed by 200 mg 1 to 2 times a week for 4 weeks, then 200 mg every 2 to 4 weeks.
The gonadotropin-releasing hormone (GnRH) agonist leuprolide, which reduces pituitary production of LH and FSH and thus reduces testosterone production, is also an option and requires less frequent IM injections (at 1- to 6 month- intervals) than medroxyprogesterone. However, the cost is usually considerably higher. Cyproterone acetate, which blocks testosterone receptors, is used in Europe. Serum testosterone should be monitored and maintained in the normal female range (< 62 ng/dL [2.15 nmol/L]) in male patients. Treatment is usually long-term because deviant fantasies usually recur weeks to months after treatment is stopped. Liver function tests should be done, and blood pressure, bone mineral density, and complete blood count should be monitored as required.
The usefulness of antiandrogens in female pedophiles is less well established.
In addition to antiandrogens, SSRIs (eg, high-dose fluoxetine 60 to 80 mg once a day or fluvoxamine 200 to 300 mg orally once a day) may be useful.
Drugs are most effective when used as part of a multimodal treatment program.