FULL TEXT REVIEW : Pedophilia

Pedophilia

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The term pedophilia or paedophilia has a range of definitions as found in psychology, law enforcement, and the popular vernacular. As a medical diagnosis, it is defined as a psychological disorder in which an adult experiences a sexual preference for prepubescent children.[1][2][3] According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), pedophilia is specified as a form of paraphilia in which a person either has acted on intense sexual urges towards children, or experiences recurrent sexual urges towards and fantasies about children that cause distress or interpersonal difficulty.[4] The disorder is frequently a feature of persons who commit child sexual abuse;[5][6][7] however, some offenders do not meet the clinical diagnosis standards for pedophilia.[8] In strictly behavioral contexts, the word "pedophilia" can also be applied to the act of child sexual abuse itself, also called "pedophilic behavior".[9][10][6][11][9][12]
In law enforcement, the term "pedophile" is generally used to describe those accused or convicted of the sexual abuse of a minor (including both prepubescent children and adolescent minors younger than the local age of consent).[13] An example of this use can be seen for example in the name of the United Kingdom police agency, the Paedophile Unit and in various forensic trainings manuals. Some researchers have described this usage as improper and suggested it can confound two separate types of offenders.[13]
In common usage, the term refers to any adult who is sexually attracted to children or who sexually abuses a child.[14][12]
The causes of pedophilia are not known; research is ongoing.[15] Most pedophiles are men, though pedophilia occurs in women as well.[11][16][17] In forensic psychology and law enforcement, there have been a variety of typologies suggested to categorize pedophiles according to behavior and motivations.[18] No significant curative treatment for pedophilia has been found at this time. There are, however, certain therapies that can reduce the incidence of pedophilic behaviors that result in child sexual abuse.[19][6]

History of the term
The word comes from the Greek paidophilia (παιδοφιλία): pais (παις, "boy") and philia (φιλία, "love, friendship"). Paidophilia was coined by Greek poets either as a substitute for "paiderastia" (pederasty),[20] or vice versa.
The term paedophilia erotica was coined in 1886 by the Viennese psychiatrist Richard von Krafft-Ebing in his writing Psychopathia Sexualis.[21] He gave the following characteristics:
The sexual interest is toward pre-pubescent youth only. This interest does not extend to the first signs of pubic hair.
The sexual interest is toward pre-pubescent youths only and does not include teenagers.
The sexual interest remains over time.
Adults sexually attracted to pre-pubescent youths were placed into three categories by Krafft-Ebing:
a.) pedophile
b.) surrogate (that is, the pre-pubescent youths are regarded as a substitute object for a preferred, non-available adult object)
c.) sadistic
These types have been expanded upon and updated over the years into a variety of typologies

Diagnosis
The International Statistical Classification of Diseases and Related Health Problems (F65.4) defines pedophilia as "a sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age."[1]

The APA's Diagnostic and Statistical Manual of Mental Disorders 4th edition, Text Revision gives the following as its "Diagnostic criteria for 302.2 Pedophilia":[22][23]

• A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger);
• B. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty;
• C. The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.

The diagnosis is further specified by the sex of the children the person is attracted to, and if the impulses or acts are limited to incest. It is also sometimes split further into two categories: exclusive type (attracted only to children) and nonexclusive type.
Exclusive pedophiles are attracted to children, and children only. They show little erotic interest in adults their own age and in some cases, can only become aroused while fantasizing or being in the presence of prepubescent children. Nonexclusive pedophiles are attracted to both children and adults, and can be sexually aroused by both. According to a U.S. study on 2429 adult male pedophile sex offenders, only 7% identified themselves as exclusive; indicating that many or most pedophiles fall into the nonexclusive category.[7] Some systems further differentiate types of offender in more specific categories.
Neither the ICD or the APA 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 alone, provided the subject meets the remaining criteria. "For individuals in late adolescence with pedophilia, no precise age difference is specified, and clinical judgment must be used" (p. 527 DSM).[23]
Nepiophilia, also called infantophilia, is used to refer to a sexual preference for toddlers and infants (usually ages 0–3).[24]

Causes
The cause or causes of pedophilia are not known.[15] The experience of sexual abuse as a child was previously thought to be a strong risk factor, but research does not show a causal relationship, as the vast majority of sexually abused children do not grow up to be adult offenders, nor do the majority of adult offenders report childhood sexual abuse. The US Government Accountability Office concluded, "the existence of a cycle of sexual abuse was not established." Prior to 1996, there was greater belief in the theory of a "cycle of violence," because most of the research done was retrospective—abusers were asked if they had experienced past abuse. Even the majority of studies found that most adult sex offenders said they had not been sexually abused during childhood, but studies varied in terms of their estimates of the percentage of such offenders who had been abused, from 0 to 79 percent. More recent prospective longitudinal research—studying children with documented cases of sexual abuse over time to determine what percentage become adult offenders—has demonstrated that the cycle of violence theory is not an adequate explanation for why people molest children.[25]

Biological correlations
Several researchers have reported correlations between pedophilia and certain psychological characteristics, such as low self-esteem[26][27] and poor social skills.[28] Until recently, many pedophilia researchers believed that pedophilia was actually caused by those characteristics. Beginning in 2002, other researchers, most notably Canadian sexologists James Cantor and Ray Blanchard and their colleagues, began reporting a series of findings linking pedophilia with brain structure and function: Pedophilic (and hebephilic) men have lower IQs,[29][30][3] poorer scores on memory tests,[29] greater rates of non-right-handedness,[29][3][31][32] greater rates of school grade failure over and above the IQ differences,[33] lesser physical height,[34] greater probability of having suffered childhood head injuries resulting in unconsciousness,[35][36] and several differences in MRI-detected brain structures.[37][38][39] They report that their findings suggest that there are one or more neurological characteristics present at birth that cause or increase the likelihood of being pedophilic. Evidence of familial transmittability "suggests, but does not prove that genetic factors are responsible" for the development of pedophilia.[40]

Another study, using structural MRI, shows that pedophilic men have a lower volume of white matter than non-sexual criminals.[37]
Functional magnetic resonance imaging (fMRI) has shown that child molesters diagnosed with pedophilia have reduced activation of the hypothalamus as compared with non-pedophilic individuals when viewing sexually arousing pictures of adults.[41] 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."[42]
Blanchard, Cantor, and Robichaud (2006) reviewed the research that attempted to identify hormonal aspects of pedophiles.[43] 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 itself, comorbid psychiatric illness—such as personality disorders and substance abuse—are risk factors for acting on pedophilic urges.[6] Blanchard, Cantor, and Robichaud (2006) noted about 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?"[43] They indicated that, because they previously found mothers of pedophiles to be more likely to have undergone psychiatric treatment,[35] the genetic possibility is more likely.

Psychopathology and personality traits
Cohen et al. (2002), studying child sex offenders, states that pedophiles have impaired interpersonal functioning and elevated passive-aggressiveness, as well as impaired self-concept. Regarding disinhibitory traits, pedophiles demonstrate elevated sociopathy and propensity for cognitive distortions. According to the authors, pathologic personality traits in pedophiles lend support to a hypothesis that such pathology is related to both motivation for and failure to inhibit pedophilic behavior.[44]

According to Wilson and Cox (1983), "The paedophiles emerge as significantly higher on Psychoticism, Introversion and Neurotocism than age-matched controls. [But] 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 isloation engendered by their preference (i.e., awareness of the social approbation and hostility that it evokes" (p. 324).[45]

Studying child sex offenders, a review of qualitative research studies published between 1982 and 2001 concluded that pedophiles 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.[46] Other cognitive distortions include the idea of "children as sexual beings," "uncontrollability of sexuality," and "sexual entitlement-bias."[47]

One review of the literature concludes that research on personality correlates and psychopathology in pedophiles is rarely methodologically correct, in part due to confusion between pedophiles and child sex offenders, as well as the difficulty of obtaining a representative, community sample of pedophiles.[48] 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.[49]
Some people with pedophilia threaten children to stop them from reporting their actions.[4] Others, like those that often victimize children, can develop complex ways of getting access to children, like gaining the trust of a child's parent, trading children with other pedophiles or on infrequent occasions, get foster children from nonindustrialized nations or abduct child victims from strangers.[4] Pedophiles may often act interested in the child, to gain the child's interest, loyalty and affection to keep the child from letting others know about the sexual activity.[4]

Prevalence
The prevalence of pedophilia in the general population is not known,[49] and research is highly variable due to varying definitions and criteria. The term pedophile is commonly used to describe all child sexual abuse offenders, including those who do not meet the clinical diagnosis standards. This use is seen as problematic by some people.[8] Some researchers, such as Howard E. Barbaree,[50] have endorsed the use of actions as a sole criterion for the diagnosis of pedophilia as a means of taxonomic simplification, rebuking the American Psychiatric Association's standards as "unsatisfactory".

A perpetrator of child sexual abuse is commonly assumed to be and referred to as a pedophile; however, there may be other motivations for the crime[50] (such as stress, marital problems, or the unavailability of an adult partner).[51] Child sexual abuse may or may not be an indicator that its perpetrator is a pedophile. Many terms have been used to distinguish "true pedophiles" from nonpedophilic 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).

Perpetrators who meet the diagnostic criteria for pedophilia offend more often than non-pedophile perpetrators, and with a greater number of victims. According to the Mayo Clinic, approximately 95% of child sexual abuse incidents are committed by the 88% of child molestation offenders who meet the diagnostic criteria for pedophilia.[7] A behavioral analysis report by the FBI states that a "high percentage of acquaintance child molesters are preferential sex offenders who have a true sexual preference for children (i.e., pedophiles)."[18]

A review article in the British Journal of Psychiatry notes the overlap between extrafamilial and intrafamilial offenders. One study found that around half of the fathers and stepfathers in its sample who were referred for committing extrafamilial abuse had also been abusing their own children.[52]

As noted by Abel, Mittleman, and Becker[53] (1985) and Ward et al. (1995), there are generally large distinctions between the two types of offenders' characteristics. Situational offenders tend to offend at times of stress; have a later onset of offending; have fewer, often familial victims; and have a general preference for adult partners. Pedophilic offenders, however, often start offending at an early age; often have a large number of victims who are frequently extrafamilial; are more inwardly driven to offend; and have values or beliefs that strongly support an offense lifestyle. Research suggests that incest offenders recidivate at approximately half the rate of extrafamilial child molesters, and one study estimated that by the time of entry to treatment, nonincestuous pedophiles who molest boys had committed an average of 282 offenses against 150 victims.[54]

Treatment
Although pedophilia has no cure at this time, various treatments are available that are aimed at reducing or preventing the expression of pedophilic behavior, reducing the prevalence of child sexual abuse.[55][19] Treatment of pedophilia often requires collaboration between law enforcement and health care professionals.[19][6] A number of proposed treatment techniques for pedophilia have been developed, though the success rate of these therapies has been very low.[56]

Cognitive behavioral therapy ("relapse prevention")
Cognitive behavioral therapy has been shown to reduce recidivism in contact sex offenders.[57]
According to Canadian sexologist Michael Seto, cognitive-behavioral treatments target attitudes, beliefs, and behaviors that are believed to increase the likelihood of sexual offenses against children, and "relapse prevention" is the most common type of cognitive-behavioral treatment.[58] The techniques of relapse prevention are based on principles used for treating addictions.

Behavioral interventions
Behavioral treatments target sexual arousal to children, using satiation and aversion techniques to suppress sexual arousal to children and covert sensitization (or masturbatory reconditioning) to increase sexual arousal to adults.[58] Behavioral treatments appear to have an effect on sexual arousal patterns on phallometric testing, but it is not known whether the test changes represent changes in sexual interests or changes in the ability to control genital arousal during testing.[59][60]
Applied behavior analysis is used with mentally disabled sex offenders.[61] This method is rarely used on pedophiles who have not offended.

Pharmacological interventions
Medications are used to lower sex drive in pedophiles by interfering with the activity of testosterone, such as with Provera (medroxyprogesterone acetate), Androcur (cyproterone acetate), and Lupron (leuprolide acetate).
Gonadotropin-releasing hormone analogues, which last longer and have less side effects, are also effective in reducing libido and may be used.[62]
These treatments, commonly referred to as "chemical castration," are often used in conjunction with the non-medical approaches noted above. According the Association for the Treatment of Sexual Abusers, "Anti-androgen treatment should be coupled with appropriate monitoring and counseling within a comprehensive treatment plan."[63]
In a controlled Depo-Provera treatment study of forty sex offenders – including 23 pedophiles – who received Depo, and 21 sex offenders who received psychotherapy alone, outcome follow-up of the treated group v. the untreated group demonstrated that the reoffense rate for the Depo-treated group was significantly lower. Eighteen percent reoffended while receiving medication; 35 percent reoffended after stopping medication. In contrast, 58 percent of the control patients, who received psychotherapy alone reoffended. Patients defined as regressed were much more likely to reoffend off therapy than the patients defined as fixated.[64]

Other therapies
Klaus M. Beier of the Institute of Sexology and Sexual Medicine at Charité, a university hospital in Berlin, reported success in a preliminary study using role-play therapy and "impulse-curbing drugs" to help pedophiles avoid sexually assaulting a child. According to researchers, contact child sex offenders were better able to control their urges once they understood the pre-pubescent youth's view.[65][66]

Limitations of treatment
Although these results are relevant to the prevention of re-offending in contact child sex offenders, there is no empirical suggestion that such therapy is a cure for pedophilia. Dr. Fred Berlin, founder of the Johns Hopkins Sexual Disorders Clinic has stated that pedophilia could be successfully treated if the medical community would give it more attention.[67]


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