“Pedophilia” is a combination of two Greek words meaning children (pedo) and love or attraction (philia). The love or attraction involved in this word refers to an adult's sexual or erotic attraction as opposed to an adult's normal attraction or love of children in which the adult regards children are “cute” and perhaps wants to be around them based on this feeling, nurture them, and make sure they are safe and healthy. Pedophilia belongs to a larger class of mental disorders in the Diagnostic and Statistical Manual of the American Psychiatric Association (American Psychiatric Association [APA], 2013) called paraphilic disorders. Para means outside and again philia means love or attraction. The basic idea is that individuals suffering from this group of disorders have a sexual attraction or orientation that is outside the norm.
In pedophilia the adult finds children sexually arousing and usually has sexual fantasies about children and, in the typical case, desires to have some sort of sexual contact with the child. Pedophilia, unsurprisingly, is considered a mental disorder in the DSM-5 (APA, 2013). (It is also important to note that there is another technical term, hebephilia, which indicates an attraction to individuals—early adolescents—that are still regarded as too young for an adult to be attracted to them—say 14- or 15-year-olds. Hebephilia is an attraction to postpubescent adolescents who are still below the legal age of consent in the state, which admittedly varies tremendously across states. Despite the efforts of some, hebephilia currently is not considered a mental disorder in the DSM-5 and thus hebephiles are regarded as pedophiles.)
It is useful to actually examine the DSM-5 diagnostic criteria for pedophilia (APA, 2013, pp. 697–698). Basically, the diagnosis of pedophilia involves four specific criteria:
It is important to note that the DSM-5 also makes a distinction between a pedophilic sexual orientation and a pedophilic disorder. Basically, if the adult is sexually attracted to children but is not distressed by these feelings, is not functionally impaired by these feelings, and has never acted on these urges then, according to the DSM-5, the adult simply has a pedophilic sexual orientation. This is not regarded as a mental disorder or a pathology in the DSM. (This may be a weakness of the current DSM.) However, if the adult is sexually attracted to children and is distressed, or functionally impaired, or has acted on these urges then the adult, according to the DSM-5, suffers from a pedophilic disorder. O'Donohue (2010) has argued that this distinction between a pedophilic orientation and a pedophilic disorder is not useful and not valid. He argued that a sexual orientation toward children in itself is disordered and the additional criteria needed to be met in the DSM-5 are superfluous—for example, if someone is not distressed by being attracted to children, this in fact is just a further abnormality rather than something that somehow overrides the pathological orientation. According to O'Donohue (2010), the notion of a “contented pedophile”—an adult who is happy with their sexual attraction to children—is still to be regarded as disordered.
Five Interesting Facts About Pedophilia According to DSM-5
Other Information Known About Pedophiles
It also may be useful to take a look at what other kinds of problems the DSM-5 classifies as a paraphilia. This can be important as there is some evidence that in some cases substantial comorbidity exists between the paraphilias (Abel, Becker, Cunningham, Mittelman, & Rouleau, 1988). That is, many individuals suffer from more than one paraphilia:
It should be apparent that these are para (outside) philias (attractions). More commonly these are often called perversions. Although many people may “play” with some of these behaviors, the important differences are related to consent and severity.
Now that there has been a bit of an overview of pedophilia, we examine some diagnostic issues in a bit more detail.
O'Donohue (2010) has argued that the diagnostic criteria in the DSM have at least two problems. For example:
As one can see, there are a number of terms that are not perfectly clear and may result in diagnostic unreliability.
The DSM diagnostic criteria refer rather vaguely to age—remember these state “generally age 13 years or younger” and there is also reference to a developmental stage “prepubescent.” Basically the idea is that normal sexual attraction meets one of two conditions:
Sometimes scholars have tried to add a bit more precision by using a developmental scale called the Tanner scale. There are five Tanner stages of physical development for both males and females, with Tanner Stage 1 indicating prepuberty and Tanner Stage 5 indicating full maturation (Tanner, 1978). Tanner stages focus on breast development and pubic hair growth in females, and on genital development and pubic hair growth in males. The first three stages (Stages 1 to 3), representing physical immaturity and thus relevant to the diagnosis of pedophilia, are:
Again, basically the idea is that these boys and girls have not developed physically into adult bodies and it is abnormal for an adult to be sexually attracted to them.
It is also important to note that we do not know all that the individual suffering from pedophilia is attracted to—certainly it seems that the attraction is to the physically immature body, but others have hypothesized that individual suffering from pedophila may also be attracted to the powerlessness of the child, the obedience of a typical child, and even their immature voices, and simplicity.
This can be an important question, partly because there are some that have argued that viewing adult-child (or what they often call intergenerational) sexual attraction wrong is simply a prejudice or sexual hang-up. There are actually a few organizations that are trying to instigate social movements to correct what they see as this societal wrong or prejudice. Two of the most prominent of these are the Rene Guyon Society and the North American Man-Boy Love Association (NAMBLA). Their view is that sexuality throughout history has often been harshly and inappropriately judged and that there has been a series of successful sexual revolutions in the past century. For example, in their literature they claim the first sexual revolution was realizing that women's sexuality was often inappropriately judged—women were not supposed to enjoy sex; to be sexual was to be unladylike, it was worse for a woman to engage in premarital sex (they were labeled a “slut”) than for a man to do the same thing (men would be “studs”), and so on. Individuals in these organizations then state that there was a sexual revolution for women around the turn of the 20th century in which women's sexuality was viewed as more equal to males and as acceptable and healthy. The second sexual revolution for them occurred when gay rights were recognized and homosexuality was taken out of the Diagnostic and Statistic Manual in the latter half of the 20th century. They argue that now a further revolution is needed in which societal prejudices against “man-boy love” (NAMBLA is oriented toward only this) and intergenerational sex are overcome. They argue that an older person can sexually “mentor” a younger person and this is a good, healthy way to learn about sex. One of their mottos is something along the lines “Sex before 8 or else it is too late.”
O'Donohue (1987) and others (de Young, 1987) have argued against this line of reasoning. De Young has astutely analyzed the rhetoric (basically attempts at persuasion) of this movement and has suggested that they use a number of tropes (rhetorical strategies) in which members of these organizations illegitimately take on the role of victim (they are being discriminated against); they ally themselves with past positive social movements (women's rights and suffrage movements); and speak in philanthropic and amelioristic terms (they are about helping children). Thus, their rhetoric may be shrewd but this does not mean the substance of their argument or their goals are sound.
O'Donohue (2010) has argued that the core reason that adult-child sexual contact is wrong (morally and legally) is that children, by virtue of their being children, are not capable of consenting to sexual interactions with an adult because they are developmentally incapable of the relatively complex cognitive tasks associated with this. Basically, the idea is that when two adults decide to have sex, they are both more or less capable of making an informed decision and thus giving consent to the sexual contact. Two adults can consider factors like: Do they actually like this person; what is the risk of venereal disease or pregnancy; what impact might this have on them socially; is this consistent with their morals; will the person treat them well. The key problem is that children are immature not only physically but also cognitively and intellectually and thus cannot appraise these factors because they do not have all the information or the abilities to process this information rationally. Thus, it would be a very unequal negotiation between the adult and the child. For the same reasons, all states have laws that prohibit children entering into contracts: Due to their cognitive unsophistication they might think incorrectly that a fair trade may be to sell a house for three Barbie dolls. Thus, because sex can be very consequential (on self-image, health, and social variables) and because informed consent is critical and because children are cognitively incapable of the information and processing needed to consent to sex, then sex with children is properly considered to be both morally and legally wrong. Thus, the idea is that an attraction to do this is a mental disorder because it inclines one toward this immoral and illegal act.
This is an important distinction. Remember that a pedophile is someone who has an abnormal attraction to a child. A child sexual abuser is someone who has actually sexually abused a child. These are not identical terms because their extensions are not the same:
Sometimes an individual suffering from pedophilia will act just like everyone else. Again, there is not a typical profile of a pedophile. However, compared to individuals who do not suffer from pedophilia they will tend to:
A simple and true answer is that we do not know what causes pedophilia. This is an important question but a difficult one. Special research methodologies must be used in order that a causal inference can be made (i.e., “This caused that”). Remember the old saying, “correlation is not causation.” Thus, it is not enough to show that some higher than expected percentage of child abusers (again, remember this is not the same construct as “pedophile”) have been abused as children. This shows a correlation—perhaps a very interesting one—but it does not show causation. It does not prove that undergoing abuse as a child will cause a person to become an abuser.
In general, behavioral science looks to both nature (genetics) and nurture (environment) in order to understand causes of behavioral conditions (e.g., schizophrenia, extraversion). In general, we find that both kinds of causal factors are important. That is, conditions have a heritable, genetic component (we are physiologically predisposed toward a specific behavior by our genes) but that the environment also plays a role (we are more likely to engage the behavior in some contexts). That is, our life experiences impact this inborn potentiality. Take a simple example. Genetics clearly play a role in determining your adult height. If both your parents are unusually tall, you will generally have the genes to also be tall (generally less unusually tall than your parents—this is called regression toward the mean). However, say that during your gestation (when you were in the womb) and even during your childhood you were very poor and did not consume much protein. This lack of proper diet is an environmental factor. In general, severe protein deprivation will reduce your adult height—even though you had the genetic potential to be a few inches taller, because you did not get the right nourishment from your environment, this genetic potential was not fully actualized. This general phenomenon is called a genetic-by-environment interaction—it shows the important role of both kinds of factors.
What do we know about sexual orientation in general? J. Michael Bailey of Northwestern University has done some important studies. In 1993, along with Richard Pillard, he published some twin studies investigating the role of genetics and environment in determining sexual orientation. Studying twins is generally thought of as the “gold standard” method for understanding the roles of nature versus nurture. The logic of these twin studies is as follows. Both monozygotic (identical) and dizygotic (fraternal) twins are studied. We know by definition that identical twins have 100% of the same genetic makeup. We know also by definition that dizygotic twins have exactly half of this—that is, their genetic makeup is only 50% the same. Thus, if we find that the same ratio is found in some trait (this is called by a technical term concordance) we can infer that there is a genetic component to the trait. In addition, if we find that the concordance rate is less than 100% in identical twins, this generally means that the trait is not completely due to genetics—that the environment also plays a role. (The astute reader might also notice that another factor plays a role here—how the environment may treat identical twins more similarly [after all they are identical] than fraternal twins. The best twin studies also examine adopted identical and fraternal twins as this adoption can control for environment—if they are adopted to different families then they no longer share the same environments.)
Bailey has not studied pedophilia with the twin study methodology—unfortunately, no one has. Instead, he studied sexual orientation and more specifically homosexual orientation. However, their conclusions can possibly shed some light onto this question. In their first study they found the concordance rate of monozygotic gay twins at 52% and with dizygotic twins at 22% (i.e., roughly one half the rate). That is, if one identical twin was gay there was a 52% likelihood that the other identical twin was gay; but if a fraternal twin was gay there was only a 22% likelihood that the other fraternal twin was gay. Also, for the adoptive siblings of the same sex who are not twins the concordance rate was 11%. However, subsequent research by Bailey and his colleagues did not replicate these high concordance rates. In monozygotic twins he found a concordance rate of 20% for males and 24% for women, suggesting a much smaller role for genetics. Bailey suggests that the first study might have had a biased sample as he advertised for gay twins, and he thinks twins might have considered the sexual orientation of their twin before deciding to participate.
These data suggest that sexual orientation is at least partially genetically determined. These data also show an important role of the environment (the concordance rates for identical twins were not 100%). Also, fraternal twins and brothers are similar genetically yet fraternal twins have nearly twice the concordance rate of brothers who were adopted—this points to the role of environmental factors. To be sure, we would have to extrapolate these findings to pedophilia and this must be done with caution. We need to return to our previous statement: We as a field do not know what causes pedophilia, but there are some data to show that sexual orientation has a moderate genetic component. However, there are still environmental factors that have a role and we do not know what these are.
Typically, the clinician uses several assessment procedures to arrive at this diagnosis. These include a record review, clinical interview, paper and pencil testing, collateral contacts, and sometimes even physiological testing called the penile plethysmograph. The clinician then takes all this information and determines the extent to which reasonable conclusions can be made regarding whether the diagnostic criteria set forth in the DSM-5 (APA, 2013) are met. Typically, though, the clinician is also assessing a few other important issues:
Thus, assessment is often complex and may take several sessions. Again, assessment is complicated if the person is not maximally cooperative or if they are lying, denying, or minimizing.
This is a formal name for asking questions to find out more about the person and their past. The clinician may get a history from the clients finding out about their childhood, past sexual experiences, previous contacts with mental health professionals or law enforcement, work history, marital history, and so on. The interview may cover the extent to which the person is motivated for treatment and what past abuse they will admit to. The interview may also question the clients about their willingness to participate in therapy, which may take years. Finally, the clinician may ask questions about topics covered earlier—that is, comorbid problems—and topics such as victim empathy, emotional regulation, and lifestyle balance.
Because individuals with these problems are often reluctant to be perfectly honest, it is important to examine records. Of particular importance are the statements of past victims (these are usually gathered by police as part of routine evidence gathering). The clinician typically sees the extent to which the client's self-report in the assessment session matches the victim's statements. For example, if the victim says the abuse happened 10 times over 1 year and the client says it happened only twice, the victim statement is viewed as more accurate and the client then is viewed as minimizing. The client may be confronted with this discrepancy to see how he reacts. Records are also reviewed for past arrests, past statements from spouses or partners, and past mental health treatment.
“Collateral” literally means “on the side.” Given consent the clinician may deem it useful to speak with certain key individuals to gain more information on the client. They may interview current or past spouses, current or past employers, current or past therapists, and even past victims. Clinicians want to both check up on what the client tells them about these situations and to get impressions of these individuals who know the person well. The clinician may ask questions such as: How well did they control their emotions? What did you observe about their substance use? Did they ever behave in ways that you thought were strange or inappropriate? How well did they function as a spouse, parent, or employee?
There are a variety of tests that can be given. The clinician may routinely give common tests such as the Minnesota Multiphasic Personality Inventory-2. This test is commonly used as a broad screen for psychopathology and it has scales both for antisocial tendencies as well as lying or faking validity scales, which can be of interest to the clinician. Some clinicians then will give other tests depending on the view of the client (depression scales such as the Beck Depression Inventory; or Empathy Scales; or Cognitive Distortion Scales).
Most clinicians do not have the equipment or the skills to administer this test, and thus if they think it critical they will refer the client to someone to administer this. This is fairly specialized testing and a referral can be difficult. This test is also controversial. In this test a client places what is called a strain gauge on his penis—this gauge is used to measure the physical circumference of his penis. Obviously when the circumference changes, this means that the person is becoming physiologically aroused. The client is then shown a variety of stimuli (e.g., slides of nudes of various ages). The basic idea is that if a person shows a physiological response (penile engorgement—an erection) to a certain kind of stimuli, then they are attracted sexually to this kind of stimuli. Typically the data are recorded by a computer and then a printout of circumference changes by type of stimuli is then available to the clinician. Certainly, this measure is not perfect and there are ways around it (not viewing the stimuli, masturbating before the test so that they are not aroused by anything, pinching themselves) but in general the reliability and validity of this procedure has been well studied and is quite good (O'Donohue & Letourneau, 1992).
The clinicians look at all the data—from their review of records, from their clinical interview, from their paper and pencil testing, and from the specialized testing—and arrive at some diagnostic conclusions as well as some treatment recommendations.
All mental health professionals are what is called mandated reporters. That is, if they have reason to suspect that a child has been abused they must report these suspicions to either the police or to the department of child welfare. It is important to note that clinicians do not have to do an investigation to become absolutely convinced that a child has been abused, they just have to form a reasonable suspicion. This is relevant because sometimes during this assessment phase, an offender will disclose new victims or new incidents of abuse. These trigger mandated reporting requirements and the clinician must inform either the police or the department of child welfare. The basic rationale for this rule is that society was to be maximally vigilant and to discover and help all children who have been abused, particularly when their abuser has not been identified and thus may abuse them or others again. Chapter 12 in this book is specifically dedicated to mandated reporting laws.
In some important sense pedophilia is not treated—it is viewed as a sexual orientation that has not been shown to be able to be changed. Perhaps much like your sexual orientation, you cannot imagine that going into therapy could suddenly cause you to switch these—from say being straight to being gay. Instead, more research in this area has focused on taking child abusers and attempting to help them learn how to not abuse any additional children in the future. The idea has been that their attraction to children may remain, but can we as therapists give them enough tools so they will never act on this deviant attraction? You might think that this is not an easy task. You would be right. The outcome data from these sorts of interventions are often disappointing—there are too many relapses despite years of therapy. However, we review the most common model used—called relapse prevention—and also briefly review some of the best designed outcome research investigating this model's effectiveness.
An important professional association related to the assessment and treatment of pedophilia is called the Association for the Treatment of Sexual Abuse (ATSA; www.atsa.com). This organization has made a statement regarding what is commonly called chemical castration, that is, treating individuals with sexual offending problems by essentially giving them chemicals to wipe out their sex drive. These chemicals are also called antiandrogens. Androgens are the male sex hormones such as testosterone. Both males and females manufacture testosterone (although males have more of it) and these androgens are most responsible for a sex drive in both genders. Here are some of the most important of ATSA's conclusions:
Findings from a meta-analysis examining the effectiveness of various treatment interventions for adult sex offenders indicated that, when used in combination with other treatment approaches, biological interventions like testosterone-lowering hormonal treatments may be linked to greater reductions in recidivism for some offenders than the use of psychosocial treatments alone. (Losel & Schmucker, 2005)
Other data, described later, suggest that nonhormonal psychotropic medications can also be effective supplements to standard therapeutic interventions for sex offenders.
A number of hormonal agents have been introduced as pharmacological treatments for reducing testosterone and sexual drive in individuals with paraphilias and/or who have engaged in sexually abusive behaviors. Primary examples include medroxyprogesterone acetate (MPA—Depo-Provera), leuprolide acetate, cyproterone acetate, and gonadotropin-releasing hormone analog. These chemical agents, referred to as antiandrogens, act by breaking down and eliminating testosterone and inhibiting the production of luteinizing hormone through the pituitary gland, which in turn inhibits or prevents the production of testosterone. Because testosterone is associated with sexual arousal, the use of these agents generally results in a reduction of sexual arousal. This reduction in sexual arousal is assumed to also reduce the motivation for sexually offending in individuals predisposed to such behaviors.
As of 2010 approximately 20 states (Arizona, California, Florida, Illinois, Iowa, Kansas, Massachusetts, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Pennsylvania, South Carolina, Texas, Virginia, Washington, and Wisconsin) and the District of Columbia have passed laws permitting the civil commitment of sexual offenders. In addition, the federal government passed legislation allowing civil commitment for federal sex offenders. The term “civil commitment” means that even after a convicted sex offender (this term applies to both rapists and child molesters) has fully served their prison term, they can, after certain legal proceedings showing their continued high risk of reoffending, be confined to a secure treatment facility for future treatment and in order to further protect the public. This civil commitment (civil because no additional crime has been committed) can last for many years—until treatment providers believe that the risk of reoffending has been reduced to a level in which it is safe to release the person. This law was passed partly based on past incidences in which offenders served their complete terms and treatment providers had good evidence that they would hurt other children if released, and these predictions turned out to be true. For example, in California a child molester who sexually violated and physically harmed children served his full prison term. While in treatment he stated that if released he would harm another child. He was released once he served his full term and immediately kidnapped a child and even bit off his penis. Officials wanted a legal mechanism to prevent this sort of occurrence so fairly predictable future incidences of abuse could be prevented.
This kind of law has been controversial. There have been criticisms along three major lines: (1) the field is not all that accurate at predicting future risk and thus due to this error rate, some individuals will be incorrectly committed; (2) relatedly, the field is not all that effective at reducing risk, that is, our treatments are somewhat weak and thus is it only to require someone to receive a relatively weak treatment until they are substantially changed by this; and (3) is it constitutional to confine someone based on the (flawed) prediction of a future crime. In general our system confines based on past crimes after due process. There are, however, exceptions to this—for instance, a person may be confined against their will because they are dangerous to themselves (e.g., they are suicidal).
A final forensic issue is that the federal government passed a sex offender registration law (this often applies to a wide range of sexual offenders—child abusers, rapists, and even exhibitionists and voyeurs). This was spurred by a 1989 abduction of an 11-year-old boy in Minnesota. In 1994 a federal law was passed mandating all sexual offenders to register with their local law enforcement agencies so that their location could be known. In 1996 President Clinton signed what is commonly known as “Megan's Law,” which required all states to disseminate this registry information to the public. In 2006 the law as also modified by the so-called Adam Walsh Sex Offender Registration and Notification Act, which also created a national registry for classifying sex offenders based on their type of offense for which they were convicted. All 50 states are also mandated to have websites so that the public can become informed about who is a sex offender and where they are living. The overall goals of this law is to both (1) enable law enforcement to track past offenders, and (2) help the public protect itself by allowing potential victims to understand where a past offender lives or works. Currently it is estimated that there are more than 600,000 registered sex offenders in the United States (ATSA, 2010). These laws are controversial and have been criticized for the following three reasons: (1) There is little research showing that these laws actually produce the intended outcomes, for example, they actually reduce future victimization; (2) they may violate the privacy of these convicted individuals, which may be a constitutional violation of rights; and (3) there are some data to suggest that these offenders and even their families receive problematic consequences due to these laws, such as job loss, threats, or property damage.