There is no cure, so the focus is on protecting children.

Pedophilia, the sexual attraction to children who have not yet reached puberty, remains a vexing challenge for clinicians and public officials. Classified as a paraphilia, an abnormal sexual behavior, researchers have found no effective treatment. Like other sexual orientations, pedophilia is unlikely to change. The goal of treatment, therefore, is to prevent someone from acting on pedophile urges — either by decreasing sexual arousal around children or increasing the ability to manage that arousal. But neither is as effective for reducing harm as preventing access to children, or providing close supervision.

The understanding of pedophilia has evolved over time, so each successive edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has defined this disorder in a slightly different way. The current edition, DSM-IV, categorizes pedophilia as a disorder only if the sexual fantasies or urges involve prepubescent children (defined as 13 or younger), if they last at least six months, if the individual has acted on them, or if they cause marked distress (including legal problems). The DSM-IV also specifies that a person be at least 16 years old and at least five years older than the prepubescent child.

The draft version of DSM-V, now undergoing review, proposes several changes to the diagnosis of pedophilia. One is to expand the definition of this disorder to include hebephilia, an attraction to children who are going through puberty. The hybrid category, pedohebephilia, would consist of the pedophilic type (attracted to prepubescent children, generally younger than 11), the hebephilic type (attracted to pubescent children, usually ages 11 through 14), and the pedohebephilic type (attracted to both). In another significant change, the draft suggests that the use of pornography depicting prepubescent or pubescent children for six months or longer should be considered a symptom of pedohebephilia.

Key points Pedophilia is a sexual orientation and unlikely to change. Treatment aims to enable someone to resist acting on his sexual urges.

No intervention is likely to work on its own; outcomes may be better when the patient is motivated and treatment combines psychotherapy and medication.

Parents should be aware that in most sexual abuse cases involving children, the perpetrator is someone the child knows.

Limitations of research

One challenge in the scientific literature is that most of the studies on pedophilia have involved men convicted of crimes against children, and experts estimate that only one in 20 cases of child sexual abuse is reported. It remains unclear how prevalent pedophilia is in the general population. Research on convicts may not apply to people with pedophilic tendencies who live without detection in the community or suffer silently while controlling their impulses.

Researchers also do not agree about what proportion of child sex abusers are pedophiles. Other types of offenders include sexually curious or abusive adolescents who molest younger children, hypersexual adults who opportunistically target children, and people who act impulsively (rather than in response to erotic attachment) under the influence of alcohol or drugs. Moreover, about half of all child sexual abuse victims are 12 to 17 years old (postpubescent), so their assailants don't meet the strict definition of pedophilia.

There is more agreement on other issues. Nearly all people with pedophilic tendencies are male. Studies of child molesters have reported that only 1% to 6% of perpetrators are female. Co-occurring disorders, such as personality disorders or mood disorders, are common in people with pedophilic tendencies. And about 50% to 70% of people with pedophilic tendencies are also diagnosed with another paraphilia, such as exhibitionism, voyeurism, or sadism.

Consensus now exists that pedophilia is a distinct sexual orientation, not something that develops in someone who is homosexual or heterosexual. Some people with pedophilic urges are also attracted to adults, and may act only on the latter urges. Because people with pedophilic urges tend to be attracted to children of a particular gender, they are sometimes described in the literature as heterosexual, homosexual, or bisexual pedophiles. Roughly 9% to 40% of pedophiles are homosexual in their orientation toward children — but that is not the same as saying they are homosexual. Homosexual adults are no more likely than heterosexuals to abuse children.

Several reports have concluded that most people with pedophilic tendencies eventually act on their sexual urges in some way. Typically this involves exposing themselves to children, watching naked children, masturbating in front of children, or touching children's genitals. Oral, anal, or vaginal penetration is less common.

Fears about predatory behavior are valid. Most pedophiles who act on their impulses do so by manipulating children and gradually desensitizing them to inappropriate behavior. Then they escalate it. Pedophiles are able to do this because in most cases they already know the children or have access to them. In about 60% to 70% of child sexual abuse cases involving pedophiles, the perpetrator is a relative, neighbor, family friend, teacher, coach, clergyman, or someone else in regular contact with the child. Strangers are less likely to sexually abuse children — although they are more likely to commit violent assaults when they do.

Estimates of recidivism vary because studies define this term in different ways. One review found recidivism rates of 10% to 50% among pedophiles previously convicted of sexual abuse, although this could include anything from an arrest for any offense to reconviction on a crime against a child. One long-term study of previously convicted pedophiles (with an average follow-up of 25 years) found that one-fourth of heterosexual pedophiles and one-half of homosexual or bisexual pedophiles went on to commit another sexual offense against children.

When confronted about sexual abuse, convicted pedophiles often rationalize their actions, such as insisting that a victimized child acted seductively or enjoyed the encounter. These rationalizations may reflect an inability to empathize with the child, which could be part of a co-occurring antisocial or narcissistic personality disorder.

Some researchers fear that the growth of Internet communities for people with pedophilic tendencies may encourage users to act on their sexual urges and share information about how to elude detection. But other commentators note that these online communities actually make it easier for law enforcement officials to lure and entrap potential offenders before they commit a sexual crime.

Management options

Treatment is effective only if a patient with pedophilia is motivated and committed to controlling his behavior — attributes that are difficult for mental health professionals to assess. Outcomes are better when treatment combines psychotherapy and medication.

Psychotherapy. Most psychotherapies used to treat pedophilia incorporate the principles and techniques of cognitive behavioral therapy. The focus of therapy is to enable the patient to recognize and overcome rationalizations about his behavior. In addition, therapy may involve empathy training and techniques in sexual impulse control.

The most common type of cognitive behavioral therapy used with sex offenders, known as relapse prevention, is based on addiction treatment. Relapse prevention is intended to help the patient anticipate situations that increase the risk of sexually abusing or assaulting a child, and to find ways to avoid or more productively respond to them. Reviews that have included uncontrolled and nonrandomized studies concluded that relapse prevention programs reduced recidivism. Only one randomized controlled trial has evaluated how effective a relapse prevention program was, however, and it included sex offenders who had assaulted adults as well as those who hurt children. After an average of eight years, there was no significant difference in recidivism between sex offenders who underwent relapse prevention therapy and controls who did not undergo treatment.

Aversive conditioning, a behavioral method directed at associating a pedophilic fantasy or desire with an unpleasant sensation such as nausea, an electric shock, or a bad smell, was once popular. Although a review concluded that aversive conditioning might increase someone's ability to control sexual attraction to children in the short term, there is no evidence that this approach is effective over time.

Drug treatment. Drugs that suppress production of the male hormone testosterone are used to reduce the frequency or intensity of sexual desire. Although physical castration is another option, testosterone suppression offers advantages such as the need for follow-up visits (which aids in monitoring behavior). It may take three to 10 months for testosterone suppression to reduce sexual desire.

Investigators were once optimistic about the potential of selective serotonin reuptake inhibitors (SSRIs) in treating pedophilia. But only case reports and open-label trials find that SSRIs are helpful; this has not been demonstrated in randomized, placebo-controlled trials. However, SSRIs may be a useful adjunct to other treatments, because they not only subdue sexual ruminations and urges but also help with impulse control.

Preventing child sexual abuse

State programs such as Megan's Law and the Adam Walsh Act seek to limit where convicted sex crime offenders may live and work. Meanwhile, school- and community-based educational programs offer advice about how to identify situations that may endanger children, how to recognize behaviors such as inappropriate touching that may desensitize children so that they are more easily victimized, and how children can protect themselves.

Unfortunately, little evidence exists about how effective these efforts are. Most studies that have evaluated the efficacy of educational programs have examined specific components, such as whether young children understand the concepts being taught, rather than long-term outcomes. Only two observational studies have examined whether these educational programs actually prevent childhood sexual abuse; one concluded that it did, while the other found no benefit.

Other public education programs, such as "Stop It Now" (www.stopitnow.org), target bystanders — people who suspect that a child is being sexually abused, but may not know how best to intervene. The preliminary research suggests that such programs may help.

In an effort to better understand pedophilia and find ways to intervene before sexual crimes occur, researchers are now trying to broaden study populations to include people who voluntarily seek treatment in response to community outreach rather than a court order. One example of this is Prevention Project Dunkelfeld, based at the University of Berlin. The word "dunkelfeld" is German for "dark field," and refers to the fact that most people with pedophilic tendencies remain invisible in the community because they have not been charged with or convicted of crimes. The project deliberately used nonjudgmental language in media advertisements to recruit participants. (One example: "You are not guilty because of your sexual desire, but you are responsible for your sexual behavior. There is help.") So far, the project's preliminary reports offer no guidance for clinicians.

There is some encouraging news. Sexual crimes against U.S. children, as recorded by law enforcement agencies, declined 53% between 1992 and 2006. A review identified four possible explanations for the decline: economic growth, increased numbers of police and child protection workers, greater efforts to identify and prosecute child sex offenders of all types, and increased treatment of aggressive behavior.

It is unclear whether these factors are reducing activity by people with pedophilia, because the original data and the review are not limited to individuals with the disorder. Until we know more, parents and others who want to protect children from pedophiles are best advised to watch for the subtle stalking behaviors that may precede physical contact — and to remember that most sex offenders of any type approach children they know.

Blanchard R. "The DSM Diagnostic Criteria for Pedophilia," Archives of Sexual Behavior (April 2010): Vol. 39, No. 2, pp. 304–16.

Hall RC. "A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues," Mayo Clinic Proceedings (April 2007): Vol. 82, No. 4, pp. 457–71.

Seto MC. "Pedophilia," Annual Review of Clinical Psychology (2009): Vol. 5, pp. 391–407.

For more references, please see www.health.harvard.edu/mentalextra.

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