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Pedophilia

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This article is about sexual attraction towards prepubescent children. For sexual attraction towards young adolescents, see hebephilia. For sexual attraction towards older adolescents and young adults, see ephebophilia. Not to be confused with podophilia, also known as foot fetishism.

Pedophilia (alternatively spelled paedophilia) is a psychiatric disorder in which an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children.[1][2]: vii  Although girls typically begin the process of puberty at age 10 or 11, and boys at age 11 or 12,[3] psychiatric diagnostic criteria for pedophilia often extend the cut-off point for prepubescence to age 13.[4] People with the disorder are often referred to as pedophiles (or paedophiles).
Pedophilia
Specialty
	Psychiatry, clinical psychology, forensic psychology
Symptoms
	Primary or exclusive sexual attraction to prepubescent children
Risk factors
	Childhood abuse by adults, substance abuse, personality disorders, family history
Treatment
	Cognitive behavioral therapy, chemical castration

Pedophilia is a paraphilia. In recent versions of formal diagnostic coding systems such as the DSM-5 and ICD-11, "pedophilia" is distinguished from "pedophilic disorder", which is considered the corresponding paraphilic disorder. Pedophilic disorder is defined as a pattern of pedophilic arousal accompanied by either subjective distress or interpersonal difficulty, or having acted on that arousal. The DSM-5 requires that a person must be at least 16 years old, and at least five years older than the prepubescent child or children they are aroused by, for the attraction to be diagnosed as pedophilic disorder. Similarly, the ICD-11 excludes sexual behavior among post-pubertal children who are close in age. The DSM requires the arousal pattern must be present for 6 months or longer, while the ICD lacks this requirement. The ICD criteria also refrain from specifying chronological ages.[5]

In popular usage, the word pedophilia is often applied to any sexual interest in children or the act of child sexual abuse, including any sexual interest in minors below the local age of consent or age of adulthood, regardless of their level of physical or mental development.[1][2]: vii [6] This use conflates the sexual attraction to prepubescent children with the act of child sexual abuse and fails to distinguish between attraction to prepubescent and pubescent or post-pubescent minors.[7][8] Although some people who commit child sexual abuse are pedophiles,[6][9] child sexual abuse offenders are not pedophiles unless they have a primary or exclusive sexual interest in prepubescent children,[7][10][11] and many pedophiles do not molest children.[12]

Pedophilia was first formally recognized and named in the late 19th century. A significant amount of research in the area has taken place since the 1980s. Although mostly documented in men, there are also women who exhibit the disorder,[2]: 72–74 [13] and researchers assume available estimates underrepresent the true number of female pedophiles.[14] No cure for pedophilia has been developed, but there are therapies that can reduce the incidence of a person committing child sexual abuse.[6] The exact causes of pedophilia have not been conclusively established.[2]: 101  Some studies of pedophilia in child sex offenders have correlated it with various neurological abnormalities and psychological pathologies.[15]
Etymology and definitions
Title page of the tenth edition of Psychopathia Sexualis (1899, translated)

The word pedophilia comes from the Greek παῖς, παιδός (paîs, paidós), meaning 'child', and φιλία (philía), 'friendly love' or 'friendship'.[16] The term paedophilie (in German) started being used in the 1830s among researchers of pederasty in Ancient Greece. It was further used in the field of forensics after the 1890's, following Richard von Krafft-Ebing's coinage of the term paedophilia erotica in the 1896 edition of Psychopathia Sexualis. Krafft-Ebing was the first researcher to use the term pedophilia to refer to a pattern of sexual attraction toward children who had not yet reached puberty, excluding pubescent minors from the pedophilic age range. In 1895, the English word pedophily was used as a translation of the German word pädophilie.[17]

The term pedophilia was hardly used by 1945, but started appearing in medical records after 1950. By the 1950s and throughout the 1980s, the word pedophilia started being increasingly used by the popular media.[17]

Infantophilia (or nepiophilia) is a sub-type of pedophilia; it is used to refer to a sexual preference for children under the age of 5 (especially infants and toddlers).[18][9] This is sometimes referred to as nepiophilia (from the Greek νήπιος (népios) meaning 'infant' or 'child', which in turn derives from ne- and epos meaning 'not speaking'), though this term is rarely used in academic sources.[19][20] Hebephilia is defined as individuals with a primary or exclusive sexual interest in 11- to 14-year-old pubescents.[21] The DSM-5 does not list hebephilia among the diagnoses. While evidence suggests that hebephilia is separate from pedophilia, the ICD-10 includes early pubertal age (an aspect of hebephilia) in its pedophilia definition, covering the physical development overlap between the two philias.[22] In addition to hebephilia, some clinicians have proposed other categories that are somewhat or completely distinguished from pedophilia; these include pedohebephilia (a combination of pedophilia and hebephilia) and ephebophilia (though ephebophilia is not considered pathological).[23][24]
Signs and symptoms
Development

Pedophilia emerges before or during puberty, and is stable over time.[25] It is self-discovered, not chosen.[6] For these reasons, pedophilia has been described as a disorder of sexual preference, phenomenologically similar to a heterosexual or homosexual orientation.[25] These observations, however, do not exclude pedophilia from being classified as a mental disorder since pedophilic acts cause harm, and mental health professionals can sometimes help pedophiles to refrain from harming children.[26]

In response to misinterpretations that the American Psychiatric Association considers pedophilia a sexual orientation because of wording in its printed DSM-5 manual, which distinguishes between paraphilia and what it calls "paraphilic disorder", subsequently forming a division of "pedophilia" and "pedophilic disorder", the association commented: "'[S]exual orientation' is not a term used in the diagnostic criteria for pedophilic disorder and its use in the DSM-5 text discussion is an error and should read 'sexual interest.'" They added, "In fact, APA considers pedophilic disorder a 'paraphilia,' not a 'sexual orientation.' This error will be corrected in the electronic version of DSM-5 and the next printing of the manual." 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."[27]
Comorbidity and personality traits

Studies of pedophilia in child sex offenders often report that it co-occurs with other psychopathologies, such as low self-esteem,[28] depression, anxiety, and personality problems. It is not clear whether these are features of the disorder itself, artifacts of sampling bias, or consequences of being identified as a sex offender.[15] One review of the literature concluded that research on personality correlates and psychopathology in pedophiles is rarely methodologically correct, in part owing to confusion between pedophiles and child sex offenders, as well as the difficulty of obtaining a representative, community sample of pedophiles.[29] Seto (2004) points out that pedophiles who are available from a clinical setting are likely there because of distress over their sexual preference or pressure from others. This increases the likelihood that they will show psychological problems. Similarly, pedophiles recruited from a correctional setting have been convicted of a crime, making it more likely that they will show anti-social characteristics.[30]

Impaired self-concept and interpersonal functioning were reported in a sample of child sex offenders who met the diagnostic criteria for pedophilia by Cohen et al. (2002), which the authors suggested could contribute to motivation for pedophilic acts. The pedophilic offenders in the study had elevated psychopathy and cognitive distortions compared to healthy community controls. This was interpreted as underlying their failure to inhibit their criminal behavior.[31] Studies in 2009 and 2012 found that non-pedophilic child sex offenders exhibited psychopathy, but pedophiles did not.[32][33]

Wilson and Cox (1983) studied the characteristics of a group of pedophile club members. The most marked differences between pedophiles and controls were on the introversion scale, with pedophiles showing elevated shyness, sensitivity and depression. The pedophiles scored higher on neuroticism and psychoticism, but not enough to be considered pathological as a group. The authors caution that "there is a difficulty in untangling cause and effect. We cannot tell whether paedophiles gravitate towards children because, being highly introverted, they find the company of children less threatening than that of adults, or whether the social withdrawal implied by their introversion is a result of the isolation engendered by their preference i.e., awareness of the social [dis]approbation and hostility that it evokes" (p. 324).[34] In a non-clinical survey, 46% of pedophiles reported that they had seriously considered suicide for reasons related to their sexual interest, 32% planned to carry it out, and 13% had already attempted it.[35]

A review of qualitative research studies published between 1982 and 2001 concluded that child sexual abusers use cognitive distortions to meet personal needs, justifying abuse by making excuses, redefining their actions as love and mutuality, and exploiting the power imbalance inherent in all adult–child relationships.[36] Other cognitive distortions include the idea of "children as sexual beings", uncontrollability of sexual behavior, and "sexual entitlement-bias".[37]
Child pornography

Consumption of child pornography is a more reliable indicator of pedophilia than molesting a child,[38] although some non-pedophiles also view child pornography.[39] 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.[40][41][42]

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.[43] According to FBI agent Ken Lanning, "collecting" pornography does not mean that they merely view pornography, but that they save it, and "it comes to define, fuel, and validate their most cherished sexual fantasies".[39] Lanning states that the collection is the single best indicator of what the offender wants to do, but not necessarily of what has been or will be done.[44] Researchers Taylor and Quayle reported that pedophilic collectors of child pornography are often involved in anonymous internet communities dedicated to extending their collections.[45]
Causes

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,[46][47][48] poorer scores on memory tests,[47] greater rates of non-right-handedness,[46][47][49][50] greater rates of school grade failure over and above the IQ differences,[51] being below average height,[52][53] greater probability of having had childhood head injuries resulting in unconsciousness,[54][55] and several differences in MRI-detected brain structures.[56][57][58]

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.[59] A 2011 study reported that pedophilic child molesters had deficits in response inhibition, but no deficits in memory or cognitive flexibility.[60] Evidence of familial transmittability "suggests, but does not prove that genetic factors are responsible" for the development of pedophilia.[61] A 2015 study indicated that pedophilic offenders have a normal IQ.[62]

Another study, using structural MRI, indicated that male pedophiles have a lower volume of white matter than a control group.[56] 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.[63] A 2008 functional neuroimaging study notes that central processing of sexual stimuli in heterosexual "paedophile forensic inpatients" may be altered by a disturbance in the prefrontal networks, which "may be associated with stimulus-controlled behaviours, such as sexual compulsive behaviours". The findings may also suggest "a dysfunction at the cognitive stage of sexual arousal processing".[64]

Blanchard, Cantor, and Robichaud (2006) reviewed the research that attempted to identify hormonal aspects of pedophiles.[65] 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.[6] Blanchard, Cantor, and Robichaud addressed comorbid psychiatric illnesses that, "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?"[65] 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.[54]

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.[66]
Diagnosis
DSM and ICD-11

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) states, "The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who freely disclose this paraphilia and to individuals who deny any sexual attraction to prepubertal children (generally age 13 years or younger), despite substantial objective evidence to the contrary."[4] The manual outlines specific criteria for use in the diagnosis of this disorder. These include the presence of sexually arousing fantasies, behaviors or urges that involve some kind of sexual activity with a prepubescent child (with the diagnostic criteria for the disorder extending the cut-off point for prepubescence to age 13) for six months or more, or that the subject has acted on these urges or is distressed as a result of having these feelings. The criteria also indicate that the subject should be 16 or older and that the child or children they fantasize about are at least five years younger than them, though ongoing sexual relationships between a 12- to 13-year-old and a late adolescent are advised to be excluded. A diagnosis is further specified by the sex of the children the person is attracted to, if the impulses or acts are limited to incest, and if the attraction is "exclusive" or "nonexclusive".[4]

The ICD-11 defines pedophilic disorder as a "sustained, focused, and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—involving pre-pubertal children."[5] It also states that for a diagnosis of pedophilic disorder, "the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. This diagnosis does not apply to sexual behaviours among pre- or post-pubertal children with peers who are close in age."[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 (see child sexual offender types). 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.[14] 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.[14]

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, and can sometimes include indecent exposure, voyeuristic or frotteuristic behaviors.[4] The ICD-11 also considers planning or seeking to engage in these behaviors, as well as the use of child pornography, to be evidence of the diagnosis.[5] However the DSM-5-TR, in a change from the prior edition, excludes the use of child pornography alone as meeting the criteria for "acting on sexual urges."[4] This change is controversial due to being made for legal reasons rather than scientific. According to forensic psychologist Michael C. Seto, who was part of the DSM-5-TR workgroup, the removal of child pornography use alone was to avoid diagnosing criminal defendants convicted of child pornography offenses, but no in-person offenses, with pedophilic disorder, as this could potentially lead to such defendants being committed to mental institutions under sexually violent predator laws. Seto, who has published several research studies on pedophilia and its relationship with child pornography, objected to this reasoning by the APA, as it would only apply to a tiny minority of commit