Pedophilia is defined as an ongoing sexual attraction to pre-pubertal children.
Pedophilia 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 the fantasy or act of sexual activity with children who are generally age 13 years or younger. Pedophiles are usually men and can be attracted to either or both sexes. How well they relate to adults of the 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, despite objective evidence of pedophilia. For the condition to be diagnosed, an individual must either act on their sexual urges or experience significant distress 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 approximately 3-5 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 do involve oral sex or touching of genitals of the child or offender. Studies suggest that children who feel uncared for or lonely may be at higher risk for sexual abuse.
For pedophilic disorder to be diagnosed, the following criteria must be met:
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 difficulties 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 can 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.
Paraphilias as a group have a high rate of comorbidity with one another and an equally high rate of comorbidity with anxiety, major depression or mood disorders, and substance abuse disorders.
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.
Other factors, such as abnormalities in male sexual hormones or the brain chemical serotonin, have not been proven as factors in the development of paraphilias or pedophilia. A history of childhood sexual abuse is also a potential factor in the development of pedophilias but this, too, has not been proven.
Behavioral learning models suggest that a child who is the victim or observer of inappropriate sexual behaviors learns to imitate and is later reinforced for these same behaviors. These individuals are deprived of normal social and sexual contacts and thus seek gratification through less socially acceptable means. Physiological models focus on the relationship between hormones, behavior, and the central nervous system with a particular interest in the role of aggression and male sexual hormones.
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 may change over time (distress, psychosocial impairment, tendency to act on urges).
Medications may be used in conjunction with psychotherapy to treat pedophilic disorder. Such medications include antiandrogens to lower sex drive, medroxyprogesterone acetate (Provera) and leuprolide acetate (Lupron). Selective serotonin reuptake inhibitors (SSRIs) may be prescribed to treat associated compulsive sexual disorders and/or to gain benefit from libido-lowering sexual side effects. Higher doses than are typically administered for depression are usually used. These include sertraline (Zoloft), fluoxetine (Prozac), fluvoxamine (Luvox), citalopram (Celexa), and paroxetine (Paxil).
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, thereby reducing sex drive and aggression. These hormones reduce the frequency of erections, sexual fantasies, and initiation of sexual behaviors, including masturbation and intercourse. Hormones are typically used in tandem with behavioral and cognitive treatments. Antidepressants such as fluoxetine have also successfully decreased sex drive but have not effectively targeted sexual fantasies.
Research suggests that cognitive-behavioral models are effective in treating people with pedophilic disorder. Such models may include aversive conditioning, confrontation of cognitive distortions, victim empathy (show 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.
Aversive conditioning involves using negative stimuli to reduce or eliminate a behavior. One such therapy is covert sensitization, which involves the patient relaxing and visualizing scenes of deviant behavior followed by a negative event such as getting his penis stuck in the zipper of his pants. Assisted aversive conditioning is similar to covert sensitization except the negative event is real, such as in the form of a foul odor pumped in the air by the therapist. The goal is for the patient to associate the deviant behavior with the foul odor. Aversive behavioral reversal has the goal of humiliating the offender into ceasing the deviant behavior. For example, the offender might watch videotapes of their crime with the goal that the experience will be distasteful and offensive to the offender.
There are positive conditioning approaches that center on social skills training and alternative, more appropriate behaviors. Reconditioning, for example, is giving the patient immediate feedback, which may help him change his behavior. For instance, a person might be connected to a biofeedback machine connected to a light, and he is taught to keep the light within a specific range of color while he is exposed to sexually stimulating material.
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. A pedophile observing a young girl wearing shorts may erroneously think, "she wants me." Empathy training involves helping the offender take on the perspective of the victim and to identify with the victim and understand the harm they are inflicting.
The prognosis for pedophilia is difficult to determine. For pedophiles, these longstanding sexual fantasies about children can be very difficult to change. The practitioner can attempt to reduce the intensity of pedophiliac fantasies and develop coping strategies for the patient, but the individual must be willing to recognize that a problem exists and be willing to participate in treatment for it to succeed. Dynamic psychotherapy, behavioral techniques, chemical approaches, and surgical interventions yield mixed results. Lifelong maintenance may be a pragmatic and realistic approach.