Pedophilic disorder is characterized by the presence of intense sexual fantasies and urges of sexual activity with prepubertal children (Hooley et al., 2017). According to the DSM-5 criteria for the diagnosis of pedophilic disorders, even in the absence of sexual interaction with children, the experience of overwhelming interpersonal distress from recurrent fantasies with prepubertal children enough to warrant a diagnosis with pedophilic disorder. In some instances, sexual preoccupation is confined to prepubescent children. However, some pedophilic individuals may also have fantasies and urge regarding adults (Hooley et al., 440).
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Some pedophilic individuals may be able to restrict their sexual preoccupation with children to their fantasies. Other groups may act on their desires and engage in sexual activity with children. However, it is essential to distinguish between individuals who commit such offense as a result of the influence of pedophilic preferences and others who exhibit no such inclination. No evidence suggests that pedophilic disorder can be cured. Most interventions involve increasing voluntary control over sexual arousal, reducing sex drive, and teaching self-management skills to the individual so they can avoid eventually acting on their impulses.
According to Cohen & Galynker (2002), pedophilic behavior predominantly occurs in males with a sexual inclination towards girls between the ages of eight and eleven years old. The incidence of pedophilic disorder is higher among homosexual male than heterosexual males with homosexual pedophiles having more victims than heterosexual pedophiles. It is difficult .to investigate the prevalence of pedophilic disorder due to the absence of epidemiological survey and data and the inaccuracy of self-report data. However, some studies suggest that the incidence may be between 3 and 5 percent in the general population if sexual preference and fantasies are taken into account (Seto, 2009).
The etiology of pedophilia has been a contentious issue in the psychiatric community. Numerous studies have postulated diverse variables such as familial history, childhood abuse, neglect, and sexual victimization, sibling order and configuration, history of substance use and personality traits that could predispose individuals to prefer using children for sexual gratification. Marshall & Marshall (2010), found that most individuals with pedophilic disorders are often lonely, display difficulty with intimacy as well as forming and maintaining attachment bonds with other adults. Issues such as slow self-esteem, maternal rejection, problems with intimacy, and sensitivity to rejection were prevalent in individuals with pedophilia (Marshall & Marshall, 2010). Despite the utility of these findings in understanding the behavior of most pedophiles, they do not provide specific psychological causative agents for pedophilia.
From a classical psychodynamic point of view, pedophilia is viewed as a consequence of unresolved oedipal conflicts. From an object-relation theory point of view, pedophilic disorders result from distorted self-object representations. While from a social learning theory perspective, perpetual sexual victimization during childhood results in future pedophilic psychopathology. Neurological abnormalities such as subtle brain damage during formative years, brain structural disparities, and impaired cognitive functioning could also be implicated pedophilic behavior (Blanchard et al., 2002). Some studies have proposed the presence of several neuroamine hormone irregularities in pedophiliacs as predictors of pedophilic disorders (Maes, 2001). According to Maes, pedophiles often present with decreased activity at critical presynaptic receptor sites, reduced activity and post-synaptic sites, increased levels of cortisol and prolactin. The impact of these subtle variations in hormone regulation on downstream behavior is yet to be elucidated. Thus, unlike with other psychopathologies, the direct psychological cause of pedophilic behavior is still to be discovered. Some critics have argued that sexual orientation is not a choice. As with homosexuality, individuals with pedophilia are involuntarily attracted to a particular identifiable group and display biologically predetermined behavior.
Diagnosis of pedophilic disorders current practices, issues and perspectives
The most established method of measuring pedophilic preferences in male adults is penile plethysmography (PPG) (Seto, 2009). Sexual preference is determined by measuring the intensity of penile arousal in response to various categories of sexual stimuli. For instance, individuals may be subjected to sexual stimuli involving prepubescent, pubescent, or adult females and males. A wire band that responds to changes in penile girth is then fitted around the base of their penis. The alternative volumetric method measures air output as a result of an erection and employs the use of a glass tube fitted around the penis. It is expected that once the individual is exposed to several categories of stimuli, at least one of the categories should trigger arousal and allow determination of sexual preference. To cope with faking responses, researchers could use a viewing time paradigm to assess the length of time a subject spends viewing different categories of stimuli. It is assumed that subjects will view arousing stimuli for more extended periods. Clinical diagnosis of pedophilic disorders involves detecting a combination of recurrent arousing fantasies involving prepubescent children aged 13 or younger; who are at least five years younger than the individual, evidence of acting on such fantasies and psychological distress from recurrence of such fantasies (Hooley et al., 441).
Despite the relative credibility of plethysmography as a predictor of sexual preference, it provides minimal diagnostic utility in a clinical setting (Marshall & Fernandez, 2003). For instance, if a subject fails to respond to sexual stimuli in the prepubertal category but has already committed one or several pedophilic acts, then does the presence of offending behavior delimit the value of the test, or should the possibility of psychopathology be pressed due to the presence of offending acts. It is accurate to posit that individuals with pedophilia will respond to prepubertal stimuli, and are more likely to commit pedophilic acts. However, committing pedophilic acts is not necessarily accompanied by pedophilia. Yet, according to the DSM-5 criteria committing a pedophilic act should warrant the diagnosis of pedophilia. In the scenario presented above, DSM criteria may be used to press for the possibility of psychopathology even when none is present.
Treatment for Pedophilia
From a neurological perspective, pedophilia correlates to prenatal developmental factors such as cognitive functioning, non-right handedness, and structural volume disparities Thus, the presence of a pedophilic disorder is unlikely to be altered through interventions delivered in adulthood (Cantor et al., 2008). Typical treatment for pedophilia patients aims at reducing sexual arousal and equipping the individual with cognitive and behavioral capabilities to manage urges and arousal that limit the possibility of pedophilic offending. These goals can be achieved through a variety of techniques including; behavioral treatments, cognitive behavioral therapy, drug treatments, and surgical castration. Due to the absence of randomized control trial data that examines the efficacy of treatment, no one treatment has been proven to be completely effective. Treatment programs may often employ a combination of treatment techniques. For instance, androgen deprivation medication can be combined with cognitive-behavioral therapy techniques (Hooley et al. 445). This approach ensures that while the patient learns impulse control, sexual arousal (which could trigger offending behavior) is minimized.
Behavioral treatments teach individuals how to control sexual arousal. For instance, through olfactory aversive conditioning techniques individual suffering from pedophilia can learn how to suppress arousal patterns by repeatedly associating noxious stimuli such as an unpleasant smell with prepubescent sexual stimuli. Alternative behavioral treatments include covert sensitization, in which the patient imagines aversive events while viewing pedophilic sexual stimulus (Hooley et al., 445). Behavioral techniques can also reduce the distress often associated with recurrent sexual urges by increasing voluntary control over sexual arousal to prepubescent sexual stimuli. However, changes in sexual arousal patterns may not be permanent even with the addition of booster sessions (Seto, 399).
Cognitive-behavioral therapy techniques teach the individual how to recognize ingrained attitudes, beliefs, and behaviors that may factor in risky situations and increase the likelihood of pedophilic offending (Seto, 399). Once the individual understands these factors, then he/she can anticipate his/her behavior in potentially risky situations and respond appropriately. Therapists often rely heavily on the relapse prevention approach to treat pedophilic offenders and sexual offenders in general (Seto, 399).This approach gives the individual the ability to identify situations that pose a high risk for reoffending, identify lapses in judgment and behavior that could potentially lead to a relapse and respond effectively, adopt strategies that keep the offender away from children and develop coping strategies that limit the potential risk of encounters with children that cannot be avoided.
Medical treatments focus on reducing sexual arousal by targeting hormonal neurotransmitters that influence sexual drive, arousal, and sexual behavior. A variety of drugs can, therefore, be used to treat pedophilia including antiandrogens, cyproterone acetate, medroxyprogesterone acetate (Seto, 400). Antiandrogens reduce the frequency and intensity of sex drive by reducing the effects of androgens such as testosterone. Cyproterone acetate blocks testosterone uptake while medroxyprogesterone acetate reduces circulating levels of testosterone (Seto, 400). Although drugs like cyproterone acetate have been proven to produce desired treatment, they bring about adverse side effects such as osteoporosis, weight gain, gynecomastia, and liver damage (Seto, 400). Furthermore, in the absence of legal pressure for compliance, most individuals often discontinue drug usage, which undermines the effectiveness of medical treatment techniques (Seto, 400).
Complete removal of the testes through surgical castration eliminates androgen production almost entirely and provides a more permanent alternative to medical treatment (Seto, 401). While physical castration still remains controversial in the United States, several sex offenders have undergone the procedure in Germany, Netherlands, and parts of Europe. Studies of surgical treatments in these countries show promise for a reduction in deviant behavior with lower rates of relapse compared to other treatments. (Hooley et al., 445)
Pedophiles typically present with deviant sexual fantasies and arousal patterns indicative of a preoccupation with sexual activity with children. The neurological perspective argues that pedophilia result from an interaction non-right handedness, disparities in brain structure land impaired cognitive functioning. Diagnostic procedure for pedophilia involves the application of DSM-5 criteria or plethysmography techniques, while treatment may include behavioral interventions, cognitive behavioral therapy, drug treatments, or surgical castration. Research in pedophilia diagnosis and management is still in its early stages. As such, there is little agreement within the psychiatric community regarding etiology, epidemiology, diagnostic criteria, and treatment best practices.