Pedophilic disorder is characterized by recurrent, intense sexually arousing fantasies, urges, or behaviors involving sexual activity with prepubescent children (generally 13 years); based on clinical criteria, it is diagnosed only when the patient is 16 years and 5 years older than the child who is the target of the fantasies or behaviors.
Pedophilia is a form of paraphilia that causes harm to others and is thus considered a paraphilic disorder. Multiple studies suggest that there are both structural and functional differences in the brains of pedophiles compared to those of controls, in both cortical and subcortical areas (eg, limbic system, frontostriatal region) (1).
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, as DSM criteria stipulate the offender must be over 16 years of age and the age differential with the individual who has been engaged in sexual activity must be at least 5 years. 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 may not apply to all cultures. Many cultures accept sexual activity, marriage, and childbearing at younger ages and accept much greater age differences between sex partners.
Most pedophiles are male. The prevalence is unknown but estimated to be up to 3% of the adult male population and substantially lower in women (2). Attraction may be to children or adolescents of one or more than one gender. But pedophiles prefer opposite-sex to same-sex children 2:1 (3). 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, clergy, a coach). Looking at children undressed and fondling their genitals seems more prevalent than intercourse for non-incest cases of pedophilia (4).
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. When both antisocial personality disorder and pedophilia are simultaneously present, treatments have been shown to be of limited value compared to those with pedophilia alone as measured by increased dropout rates from treatment and increased recidivism rates for individuals with both conditions (4, 5).
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.
General references
1. Kirk-Provencher KT, Rebecca J Nelson-Aguiar RJ, Spillane NS: Neuroanatomical differences among sexual offenders: A targeted review with limitations and implications for future directions. Violence Gend 7(3):86-97, 2020. doi: 10.1089/vio.2019.0051
2. Seto MC, Kingston DA, Bourget D: Assessment of the paraphilias. Psychiatr Clin North Am 37(2):149-161 2014. doi: 10.1016/j.psc.2014.03.001
3. Freund K, Watson RJ: The proportions of heterosexual and homosexual pedophiles among sex offenders against children: An exploratory study. J Sex Marital Ther 18(1):34-43, 1992. doi: 10.1080/00926239208404356
4. Hall RC, Hall RCW: A profile of pedophilia: Definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues. Mayo Clin Proc 82(4):457-471, 2007. doi: 10.4065/82.4.457
5. Cohen LJ, Galynker II: Clinical features of pedophilia and implications for treatment. J Psychiatr Pract 8(5):276-289, 2002. DOI: 10.1097/00131746-200209000-00004
Diagnosis of Pedophilic Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
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 (typically in the context of legal involvement) 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, Text Revision [DSM-5-TR]) of pedophilic disorder follow (1):
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, as many with this condition deny any distress or impairment.
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).
The clinician must specify whether
The patient has an exclusive attraction to prepubescent children (exclusive type) or attraction to both children and adults (nonexclusive type).
The patient is sexually attracted to males, females, or both.
The behaviors/urges/fantasies are limited to incest.
Identifying a patient as a potential pedophile sometimes poses an ethical crisis for clinicians. However, clinicians have a responsibility to protect the community of children. Clinicians should know the reporting requirements in their state. If clinicians 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).
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC.
Treatment of Pedophilic Disorder
Individual and/or group psychotherapy
Treatment of comorbid disorders
Pharmacologic therapy (eg, antiandrogens, selective serotonin reuptake inhibitors [SSRIs])
Long-term individual or group psychotherapy, particularly cognitive-behavioral therapy, 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 psychiatric disorders, and pharmacologic therapy.
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 clinics that have treated self-referred and court-ordered patients have accumulated long-term follow-up studies using phallometric monitoring. They have reported substantial improvements with treatment over the long term with low recidivism rates (1).
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.
Medications
In the United States, the treatment of choice for pedophilia is
testosterone production and thus reduces libido.
testosterone2). 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 pedophilic fantasies usually recur weeks to months after treatment is stopped. Liver 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, limited data suggest that SSRIs may be useful (2).
Medications are most effective when used as part of a multimodal treatment program that involves cognitive-behavioral therapy.
Treatment references
1. Federoff JP: Pedophilia: Interventions that work. Psychiatric Times 33(7): 2016.
2. Hall RCW, Hall RCW: A profile of pedophilia: Definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues. Mayo Clin Proc 82(4):457-471, 2007. doi: 10.4065/82.4.457
