Pedophilia

Pedophilia (or paedophilia) is a psychiatric disorder in adults or late adolescents (persons age 16 and older) for whom prepubescent children are the primary or exclusive sexual object of their sex drive. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), pedophilia is a paraphilia in which a person has intense and recurrent sexual urges towards and fantasies about children they have either acted on or cause distress or interpersonal difficulty.

The disorder is common among people who commit child sexual abuse; however, some offenders do not meet the clinical diagnosis standards for pedophilia. In strictly behavioral contexts, the word "pedophilia" has been used to refer to child sexual abuse itself, also called "pedophilic behavior". In law enforcement, the term "pedophile" is loosely used without formal definition to describe those convicted of child sexual abuse or the sexual abuse of a minor, including both prepubescent children and pubescent or post-pubescent adolescents. An example of this use can be seen in various forensic training manuals. Researchers recommend that this imprecise use be avoided. In common usage, the term refers to any adult who is sexually attracted to young children or who sexually abuses a child or adolescent minor.

The causes of pedophilia are not known; research is ongoing. Most pedophiles are men, though there are also women who are pedophiles. Studies in the United Kingdom and United States suggest that a range of 5% to 20% of child sexual abuse offenses are perpetrated by women.

In forensic psychology and law enforcement, there have been a variety of typologies suggested to categorize pedophiles according to behavior and motivations. No significant curative treatment for pedophilia has yet been found. There are, however, certain therapies that can reduce the incidence of pedophilic behaviors that result in child sexual abuse.

Etymology and history
The word comes from the παιδοφιλία (paidophilia):  (pais), "child" and φιλία (philia), "friendship". Paidophilia was coined by Greek poets either as a substitute for "paiderastia" (pederasty), or vice versa.

The term paedophilia erotica was coined in 1886 by the Viennese psychiatrist Richard von Krafft-Ebing in his writing Psychopathia Sexualis. The term appears in a section titled "Violation of Individuals Under the Age of Fourteen," which focuses on the forensic psychiatry aspect of child sexual offenders in general. Krafft-Ebing describes several typologies of offender, dividing them into psychopathological and non-psychopathological origins, and hypothesizes several apparent causal factors that may lead to the sexual abuse of children.

After listing several typologies of sexual offender, Krafft-Ebing then mentioned one final typology, which he refers to as a "psycho-sexual perversion": paedophilia erotica. He noted that he had only encountered it four times in his career and gave brief descriptions of each case, as well as noting they all have three traits in common:
 * 1) Their attraction is persistent (Krafft-Ebing refers to this as being "tainted")
 * 2) The subject's primary attraction is to children, rather than adults.
 * 3) The acts committed by the subject are typically not intercourse, but rather involve inappropriate touching or manipulating the child into performing an act on the subject.

It is notable that this work also indicates several cases of pedophilia among adult women (provided by another physician), and also considered the abuse of boys by homosexual men to be extremely rare. Further clarifying this point, he indicated that cases of adult men who have some medical or neurological disorder and abuse a male child are not true pedophilia, and that in his observation victims of such men tended to be older and pubescent. He also lists "Pseudopaedophilia" as a related condition wherein "individuals who have lost libido for the adult through masturbation and subsequently turn to children for the gratification of their sexual appetite" and claimed this is much more common.

In 1908, Swiss neuroanatomist and psychiatrist Auguste Forel wrote of the phenomenon, proposing that it be referred to it as "Pederosis," the "Sexual Appetite for Children." Similar to Krafft-Ebing's work, Forel made the distinction between incidental sexual abuse by person's with dementia and other organic brain conditions, and the truly preferential and sometimes exclusive sexual desire for children. However, he disagreed with Krafft-Ebing in that he felt the condition of the latter was largely ingrained and unchangeable.

The term "Pedophilia" became the generally accepted term for the condition and saw widespread adoption in the early 20th century, appearing in many popular medical dictionaries such as the 5th Edition of Stedman's. In 1952, it was included in the first edition of the Diagnostic and Statistical Manual of Mental Disorders This edition and the subsequent DSM-II listed the disorder as one subtype of the classification "Sexual Deviation," but no diagnostic criteria were provided. The DSM-III, published in 1980, contained a full description of the disorder and provided a set of guidelines for diagnosis. The revision in 1987, the DSM-III-R, kept the description largely the same, but updated and expanded the diagnostic criteria.

Diagnosis
The ICD (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." Under this system's criteria, a person 16 years of age or older meets the definition if they have a persistent or predominant sexual preference for prepubescent children at least five years younger than them.

The Diagnostic and Statistical Manual of Mental Disorders 4th edition Text Revision (DSM-IV-TR) 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 (often aged 13 or younger) for six months or more, and that the subject has acted on these urges or suffers from distress as a result of having these feelings. The criteria also indicate that the subject should be 16 or older and that child or children they fantasize about are at least five years younger than them, though ongoing sexual relationships between a 12-13 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".

Many 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 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. Non-exclusive pedophiles may at times be referred to as non-pedophilic offenders, but the two terms are not always synonymous. Non-exclusive pedophiles are 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.

Neither the ICD nor the DSM 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, or masturbating to child pornography. Often these behaviors need to be considered in-context with an element of clinical judgment before a diagnosis is made. Likewise, when the patient is in late adolescence, the age difference is not specified in hard numbers and instead requires careful consideration of the situation.

Nepiophilia, also called infantophilia, is used to refer to a sexual preference for toddlers and infants (usually ages 0–3).

Ego-dystonic sexual orientation includes people who do not doubt that they have a prepubertal sexual preference, but wish it were different because of associated psychological and behavioral disorders. The WHO allows for the patient to seek treatment to change their sexual orientation.

Biological associations
Beginning in 2002, researchers began reporting a series of findings linking pedophilia with brain structure and function: Pedophilic (and hebephilic) men have lower IQs,  poorer scores on memory tests, greater rates of non-right-handedness,   greater rates of school grade failure over and above the IQ differences, lesser physical height, greater probability of having suffered childhood head injuries resulting in unconsciousness, and several differences in MRI-detected brain structures. 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.

Another study, using structural MRI, shows that male pedophiles have a lower volume of white matter than a control group.

Functional magnetic resonance imaging (fMRI) has shown 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. 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."

Blanchard, Cantor, and Robichaud (2006) reviewed the research that attempted to identify hormonal aspects of pedophiles. 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, comorbid psychiatric illnesses &mdash; such as personality disorders and substance abuse &mdash; are risk factors for acting on pedophilic urges. 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?" 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.

Psychopathology and personality traits
Several researchers have reported correlations between pedophilia and certain psychological characteristics, such as low self-esteem and poor social skills. 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.

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).

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. Other cognitive distortions include the idea of "children as sexual beings," "uncontrollability of sexuality," and "sexual entitlement-bias."

One review of the literature concludes 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. 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.

Prevalence and child molestation
The prevalence of pedophilia in the general population is not known, and research is highly variable owing 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. Some researchers, such as Howard E. Barbaree, 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 (such as stress, marital problems, or the unavailability of an adult partner). Child sexual abuse may or may not be an indicator that its perpetrator is a pedophile. Offenders may be separated into two types: Exclusive (i.e., "true pedophiles") and non-exclusive (or, in some cases, "non-pedophilic"). According to a U.S. study on 2429 adult male pedophile sex offenders, only 7% identified themselves as exclusive; indicating that many or most offenders fall into the non-exclusive category. However, the Mayo Clinic reports perpetrators who meet the diagnostic criteria for pedophilia offend more often than non-pedophile perpetrators, and with a greater number of victims. They state that approximately 95% of child sexual abuse incidents are committed by the 88% of child molestation offenders who meet the diagnostic criteria for pedophilia. 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)."

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.

As noted by Abel, Mittleman, and Becker (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.

Some child molesters &mdash; pedophiles or not &mdash; threaten their victims to stop them from reporting their actions. 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, infrequently, get foster children from non-industrialized nations or abduct child victims from strangers. 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 abuse.

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

Cognitive behavioral therapy ("relapse prevention")
Cognitive behavioral therapy has been shown to reduce recidivism in contact sex offenders.

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. The techniques of relapse prevention are based on principles used for treating addictions. Other scientists have also done some research that indicates that recidivism rates of pedophiles in therapy are lower than pedophiles who eschew therapy, says Dr. Zonana.

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. 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.

Applied behavior analysis has been applied with sex offenders with mental disabilities.

Pharmacological interventions
Medications are used to lower sex drive in pedophiles by interfering with the activity of testosterone, such as with Depo-Provera (medroxyprogesterone acetate), Androcur (cyproterone acetate), and Lupron (leuprolide acetate).

Gonadotropin-releasing hormone analogues, which last longer and have fewer side-effects, are also effective in reducing libido and may be used.

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."

In a controlled Depo-Provera treatment study of 40 sex offenders &mdash; including 23 pedophiles &mdash; who received Depo-Provera, and 21 sex offenders who received psychotherapy alone, the outcome follow-up of the treated group as compared to the untreated group demonstrated that the reoffense rate for the Depo-Provera-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.

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 prepubescent youth's view.

Limitations of treatment
Although these results are relevant to the prevention of reoffending 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, believes that pedophilia could be successfully treated if the medical community would give it more attention. Castration, either physical or chemical, appears to be highly effective in removing such sexual impulses when offending is driven by the libido, but this method is not recommended when the drive is an expression of anger or the need for power and control (e.g., violent/sadistic offenders). Chemical and surgical castration has been used in several European countries since the second world war, although not to the extent it was employed under National Socialism. The program in Hamburg was terminated after 2000, while Poland is now seeking to introduce chemical castration. The Council of Europe works to bring the practice to an end in Eastern European countries where it is still applied through the courts.

Misuse of terminology
The words "pedophile" and "pedophilia" are frequently misused to refer to situations in which an older person has sexual relations with a person  who is below the legal age of consent, but is pubescent or post-pubescent. The terms "hebephilia" or "ephebophilia" may be more accurate in these cases, but even then may be erroneously used to refer to the actus reus itself, rather than the correct meaning, which is a preference for that age group on the part of the older individual. Even more problematic are situations where the terms are misused to refer to relationships where the younger person is an adult of legal age, but is either perceived socially as being too young in comparison to their older partner, or the older partner occupies a position of authority over them.

During the late 1950s to early 1990s, several pedophile membership organizations advocated age of consent reform to lower or abolish age of consent laws,  and for the acceptance of pedophilia as a sexual orientation rather than a psychological disorder, and the legalization of child pornography. The efforts of pedophile advocacy groups did not gain any public support   and today those few groups that have not dissolved have only minimal membership and have ceased their activities other than through a few websites.

Anti-pedophile activism
Anti-pedophile activism encompasses opposition against pedophiles, against pedophile advocacy groups, and against other phenomena that are seen as related to pedophilia, such as child pornography and child sexual abuse. Much of the direct action classified as anti-pedophile involves demonstrations against sex offenders, groups advocating legalization of sexual activity between adults and children, and internet users who solicit sex from teens.

Moral panic and vigilantism
In the 1990s and 2000s, there have been several moral panics related to misuse of the term "pedophile" with regards to unusual crimes of abuse such as high-profile cases of child abduction and murder, and popular press reports of ideas such as stranger danger, satanic ritual abuse and the day care sex abuse hysteria. Vigilantes have acted against convicted or publicly suspected child sex offenders; for example, the mob violence that followed the News of the World "naming and shaming" campaign in the UK in the early 2000s.