Pedophilia is an ongoing sexual attraction to pre-pubertal children. It is considered a paraphilia, a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in sexual behavior that is atypical and extreme. Pedophilia is defined as recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children—generally age 13 years or younger—over a period of at least six months. Pedophiles are more often men and can be attracted to either or both sexes. How well they relate to adults of the same or opposite sex varies.
Pedophilic disorder can be diagnosed in people who are willing to disclose this paraphilia, as well as in people who deny any sexual attraction to children but demonstrate objective evidence of pedophilia. For the condition to be diagnosed, an individual must either act on their sexual urges or experience significant distress or interpersonal difficulty as a result of their urges or fantasies. Without these two criteria, a person may have a pedophilic sexual orientation but not pedophilic disorder.
The prevalence of pedophilic disorder is unknown, but the highest possible prevalence in the male population is theorized to be approximately three to five percent. The prevalence in the female population is thought to be a small fraction of the prevalence in males.
An estimated 20 percent 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.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), in order for pedophilic disorder to be diagnosed, the following criteria must be met:
- Recurrent, intense sexual fantasies, urges, or behaviors involving sexual activity with a prepubescent child (generally age 13 years or younger) for a period of at least 6 months.
- These sexual urges have been acted on or have caused significant distress or impairment in social, occupational, or other important areas of functioning.
- The person is at least 16 years old, and at least 5 years older than the child in the first category. However, this does not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.
Additionally, a diagnosis of pedophilic disorder should specify whether the individual is exclusively attracted to children or not, the gender that the individual is attracted to, and whether the sexual urges are limited to incest.
There are a number of challenges with the diagnosis of pedophilia. People who have this condition rarely seek help voluntarily—counseling and treatment are often the result of a court order. Interviews, surveillance, or internet records obtained through a criminal investigation may be helpful evidence in diagnosing the disorder. Extensive use of child pornography is a useful diagnostic indicator of pedophilic disorder. Additionally, genital sexual arousal can be measured in a laboratory setting through sexual stimuli and is based on the relative change in penile response.
The causes of pedophilia (and other paraphilias) are not known. There is some evidence that pedophilia may run in families, though it is unclear whether this stems from genetics or learned behavior.
A history of childhood sexual abuse is another potential factor in the development of pedophilias, although this has not been proven. Behavioral learning models suggest that a child who is the victim or observer of inappropriate sexual behaviors may become conditioned to imitate these same behaviors. These individuals, deprived of normal social and sexual contacts, may seek gratification through less socially acceptable means.
Physiological models are investigating the potential relationship between hormones and behavior, particularly the role of aggression and male sexual hormones. Pedophiles have been shown to be shorter on average and are more likely to be left-handed, as well as to have lower IQs than the general population. Brain scans indicate that they have less white matter—the connective circuitry in the brain—and at least one study has shown they are more likely to have suffered childhood head injuries than non-pedophiles.
Individuals may become aware of their sexual interest in children around the time of puberty. Pedophilia may be a lifelong condition, but pedophilic disorder includes elements that can change over time, including distress, psychosocial impairment, and an individual's tendency to act on urges.
Research has disproven the perception that sex offenders are especially prone to recidivism. In reality, recidivism rates for sex offenses are lower than for all other major types of crime, and the U.S. Department of Justice has found that only about 3 percent of child molesters commit another sex crime within three years of being released from prison. Meta-analysis of hundreds of studies confirms that once they are detected, most convicted offenders never sexually reoffend. (Not all sex offenders who victimize children are pedophiles; only about 40 percent of convicted sex offenders meet the diagnostic criteria for the disorder.)
While treatment may help pedophiles resist acting on their attraction to children, many do not seek clinical help because of the risk of legal consequences due to mandatory reporting laws for licensed professionals, including therapists.
For people with pedophilic disorder who do seek help, research suggests that cognitive-behavioral treatment models may be effective. Such models may include aversive conditioning, confrontation of cognitive distortions, building victim empathy (such as by showing videos of consequences to victims), assertiveness training (social skills training, time management, structure), relapse prevention (identifying antecedents to the behavior [high-risk situations] and how to disrupt antecedents), surveillance systems (family associates who help monitor patient behavior), and lifelong maintenance.
Medications may be used in conjunction with psychotherapy to treat pedophilic disorder. Such medications include medroxyprogesterone acetate (Provera) and leuprolide acetate (Lupron), antiandrogens to lower sex drive. Intensity of sex drive is not consistently related to the behavior of paraphiliacs and high levels of circulating testosterone do not predispose a male to paraphilias. Hormones such as medroxyprogesterone acetate and cyproterone acetate decrease the level of circulating testosterone, potentially reducing sex drive and aggression. These hormones, typically used in tandem with behavioral and cognitive treatments, may reduce the frequency of erections, sexual fantasies, and initiation of sexual behaviors, including masturbation and intercourse. Antidepressants such as fluoxetine have also been found to decrease sex drive but have not effectively targeted sexual fantasies.
Cognitive therapies include restructuring cognitive distortions and empathy training. Restructuring cognitive distortions involves correcting a pedophile's thoughts that the child wishes to be involved in the activity. Empathy training involves helping the offender take on the perspective of the victim, identify with the victim, and understand the harm they are inflicting. Positive conditioning approaches center on social skills training and alternative, more appropriate behaviors. Reconditioning, for example, involves giving the patient immediate feedback, which may help him change his behavior.
The Prevention Project Dunkelfeld clinics in Germany, which use cognitive behavioral methodology to teach clients how to control their sexual impulses, have treated more than 5,000 people who have voluntarily come forward seeking services. (Germany does not have mandatory reporting laws comparable to those in the United States.) The clinic also offers psychopharmaceutical interventions, including, when needed, testosterone-lowering medication to dampen sexual appetite. The project’s initial results, while based on small samples, appear encouraging: Participants have been shown to experience improvements in their self-regulation abilities and decreases in attitudes that support sexual contact with children.
The prognosis for reducing pedophilic desire is difficult to determine, as longstanding sexual fantasies about children can be difficult to change. A practitioner can attempt to reduce the intensity of fantasies and help a patient develop coping strategies, but the individual must be willing to recognize that a problem exists and be willing to participate in treatment for it to have a chance to succeed. Dynamic psychotherapy, behavioral techniques, chemical approaches, and even surgical interventions deliver mixed results. Lifelong maintenance may be the most pragmatic and realistic approach.