Mayo Clin Proc. ��� April 2007 82(4):457-471 ��� www.mayoclinicproceedings.com 457 PROFILE OF For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. For personal use. Mass reproduce only with permission from Mayo Clinic Proceedin g s. SPECIAL ARTICLEPEDOPHILIA From the Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Hospital, Baltimore, Md (R.C.W.H.) and Psychiatry, Lake Mary, Fla (R.C.W.H.). Individual reprints of this article are not available. Address correspondence to Richard C. W. Hall, MD, PA, 2500 W Lake Mary Blvd, Suite 219, Lake Mary, FL 32746 (e-mail: dr.rcwh@att.net). �� 2007 Mayo Foundation for Medical Education and Research A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues RYAN C. W. HALL, MD, AND RICHARD C. W. HALL, MD, PA Pedophilia has become a topic of increased interest, awareness, and concern for both the medical community and the public at large. Increased media exposure, new sexual offender disclosure laws, Web sites that list the names and addresses of convicted sexual offenders, politicians taking a ���get tough��� stance on sexual offenders, and increased investigations of sexual acts with children have increased public awareness about pedophilia. Be- cause of this increased awareness, it is important for physicians to understand pedophilia, its rate of occurrence, and the charac- teristics of pedophiles and sexually abused children. In this ar- ticle, we address research that defines the various types and categories of pedophilia, review available federal data on child molestation and pornography, and briefly discuss the theories on what makes an individual develop a sexual orientation toward children. This article also examines how researchers determine if someone is a pedophile, potential treatments for pedophiles and sexually abused children, the risk of additional sexual offenses, the effect of mandatory reporting laws on both physicians and pedophiles, and limitations of the current pedophilic literature. Mayo Clin Proc. 2007 82(4):457-471 AASI = Abel Assessment for Sexual Interest NIBRS = National Incident- Based Reporting System OCD = obsessive-compulsive disorder SSRI = selective serotonin reuptake inhibitor Nationalof concerns about pedophilia have grown be- cause recent high-profile child abuse and murder cases and congressional sex scandals. Recent media atten- tion by television shows such as To Catch a Predator has fueled fears about children���s vulnerability to sexual offend- ers. Such attention has exposed a side of pedophilia that many did not want to acknowledge existed. A pedophile is no longer seen as the isolated ���dirty old man��� in a raincoat preying on unsuspecting children at the local theaters or the rare flawed priest abusing an altar boy. To Catch a Preda- tor has exposed pedophiles as our friends, neighbors, and, with the recent allegations from the House of Representa- tives that a US congressman engaged in ���cybersex��� and possibly physical sex with underage congressional pages, even political representatives. As a result of this increasing attention to sexual abuse of children, many Americans, both inside and outside the medical community, are trying to define pedophilia, the characteristics of offenders, the frequency and course of pedophilia, and the treatments for both offenders and abused children. WHAT IS PEDOPHILIA? Pedophilia is a clinical diagnosis usually made by a psy- chiatrist or psychologist. It is not a criminal or legal term, such as forcible sexual offense, which is a legal term often used in criminal statistics.1,2 The Federal Bureau of Investigation���s National Incident-Based Reporting Sys- tem���s (NIBRS) definition of forcible sexual offenses in- cludes any sexual act directed against another person forc- ibly and/or against that person���s will or not forcibly or against the person���s will in which the injured party is incapable of giving consent.2 By diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, a pedophile is an individual who fantasizes about, is sexually aroused by, or experiences sexual urges toward prepubescent children (generally 13 years) for a period of at least 6 months. Pedophiles are either severely distressed by these sexual urges, experience interpersonal difficulties because of them, or act on them.3 Pedophiles usually come to medical or legal attention by committing an act against a child because most do not find their sexual fantasies distressing or ego-dystonic enough to voluntarily seek treatment.3 Generally, the individual must be at least 16 years of age and at least 5 years older than the juvenile of interest to meet criteria for pedophilia. In cases that involve adolescent of- fenders, factors such as emotional and sexual maturity may be taken into account before a diagnosis of pedophilia is made.3 Pedophiles usually report that their attraction to children begins around the time of their puberty or adoles- cence, but this sexual attraction to children can also de- velop later in life.3-9 If the clinical diagnosis of pedophilia is based on a specific act, it usually is not solely the result of intoxication or caused by another state or condition that may affect judgment, such as mania.3,10-12 These cases are distinguished from pedophilia by the act being contrary to the individual���s usual sexual behaviors and fantasies.3,10-12 Some studies have found that as many as 50% to 60% of pedophiles also have a substance abuse or dependence

Mayo Clin Proc. ��� April 2007 82(4):457-471 ��� www.mayoclinicproceedings.com 458 PROFILE OF PEDOPHILIA For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. For personal use. Mass reproduce only with permission from Mayo Clinic Proceedin g s. diagnosis, but what is important is that their attraction to children is present in both the sober and the intoxicated state.12,13 The course of pedophilia is usually long term.3,5,9,14,15 In a study that examined the relationship between age and types of sexual crimes, Dickey et al14 found that up to 44% of pedophiles in their sample of 168 sex offenders were in the older adult age range (age, 40-70 years). When com- pared with rapists and sexual sadists, pedophiles comprise 60% of all older offenders, indicating that pedophiles of- fend in their later years at a greater rate than other sexual offenders.14 Technically, individuals who engage in sexual activities with pubescent teenagers under the legal age of consent (ages 13-16 years) are known as hebophiles (attracted to females) or ephebophiles (attracted to males).15-17 The term hebophilia (also spelled as hebephilia) is becoming a ge- neric term to describe sexual interest in either male or female pubescent children.16-19 Distinctions noted in the literature between hebophiles and pedophiles are that hebophiles tend to be more interested in having reciprocal sexual affairs or relationships with children, are more op- portunistic when engaging in sexual acts, have better social functioning, and have a better posttreatment prognosis than pedophiles.17,18 The term teleiophile applies to an adult who prefers physically mature partners.16,19 There is also a sub- classification of pedophilia known as infantophilia, which describes individuals interested in children younger than 5 years.20 These distinctions are important in understanding current research about paraphilias, selection criteria for studies of sexual behavior, and tests that gauge sexual interest (eg, plethysmography). Pedophiles may engage in a wide range of sexual acts with children. These activities range from exposing them- selves to children (exhibitionism), undressing a child, look- ing at naked children (voyeurism), or masturbating in the presence of children to more intrusive physical contact, such as rubbing their genitalia against a child (frotteurism), fondling a child, engaging in oral sex, or penetration of the mouth, anus, and/or vagina.3,5,7,9 Generally, pedophiles do not use force to have children engage in these activities but instead rely on various forms of psychic manipulation and desensitization (eg, progression from innocuous touching to inappropriate touching, showing pornography to chil- dren).1,5,17,21 When confronted about engaging in such ac- tivities, pedophiles commonly justify and minimize their actions by stating that the acts ���had educational value,��� that the child derived pleasure from the acts or attention, or that the child was provocative and encouraged the acts in some way.1,3,9,22-24 A US Department of Justice manual for law enforcement officers identifies 5 common psychological defense patterns in pedophiles: (1) denial (eg, ���Is it wrong to give a child a hug?���), (2) minimization (���It only hap- pened once���), (3) justification (eg, ���I am a boy lover, not a child molester���), (4) fabrication (activities were research for a scholarly project), and (5) attack (character attacks on child, prosecutors, or police, as well as potential for physi- cal violence).1 Fifty percent to 70% of pedophiles can be diagnosed as having another paraphilia, such as frotteurism, exhibition- ism, voyeurism, or sadism.7,12,25 Pedophiles are approxi- mately 2.5 times more likely to engage in physical contact with a child than simply voyeuristic or exhibitionistic ac- tivities.7 Typically, pedophiles engage in fondling and genital manipulation more than intercourse, with the ex- ceptions occurring in cases of incest, of pedophiles with a preference for older children or adolescents, and when children are physically coerced.5-7 Child molestation is not a medical diagnosis and is not necessarily a term synonymous with pedophilia.5,7,15,17,26 A child molester is loosely defined as any individual who touches a child to obtain sexual gratification with the speci- fier that the offender is at least 4 to 5 years older than the child.15,26 The age qualifier is added to eliminate develop- mentally normal childhood sex play (eg, two 8-year-olds ���playing doctor���).26 By this definition, a 13-year-old who touches an 8-year-old would be considered a child molester but would not meet criteria to be a pedophile. The NIBRS data on juvenile sexual assaults found that 40% of assaults against children younger than 12 years were committed by juveniles, with the most frequent age of the offenders being 14 years old.2 Data from the study by Abel and Harlow15 showed that 40% of child molesters, who were later diag- nosed as having pedophilia, had molested a child by the time they were 15 years old. An estimated 88% of child molesters and 95% of molestations (one person, multiple acts) are committed by individuals who now or in the future will also meet criteria for pedophilia.9,15 Pedophilic child molesters on average commit 10 times more sexual acts against children than nonpedophilic child molesters.15 In general, most individuals who engage in pedophilia or paraphilias are male.2-7,9,10 There was a time when it was believed that females could not be pedophiles because of their lack of long-term sexual urges unless they had a primary psychotic disorder.4,22 When women were studied for sexually inappropriate behavior directed toward chil- dren, these behaviors were classified as ���sexual abuse��� or ���molestation��� but not pedophilia.6,7,27 From federal data on sexual crimes, females were reported to be the ���molester��� in 6% of all juvenile cases.2 The study by Abel and Harlow of 4007 ���child molesters��� found 1% to be female, but the authors believed this number was low because of the sys- tematic underreporting of women for molestation.15,27 One reason why acts of pedophilia committed by women are

Mayo Clin Proc. ��� April 2007 82(4):457-471 ��� www.mayoclinicproceedings.com 459 PROFILE OF PEDOPHILIA For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. For personal use. Mass reproduce only with permission from Mayo Clinic Proceedin g s. underreported is that many acts are not recognized because they occur during the course of regular ���nurturing or care- giving activities,��� such as when bathing and dressing chil- dren.22,27 Another reason is that when adult women engage in sexual acts with adolescent boys, others do not perceive this activity as abuse but rather a fortunate rite of passage.27 The law sees it otherwise. Pedophilic women tend to be young (22-33 years old) have poor coping skills may meet criteria for the presence of a psychiatric disorder, particularly depression or sub- stance abuse and frequently also meet criteria for being personality disordered (antisocial, borderline, narcissistic, dependent)27 (Table 1). In incidents in which women are identified as being involved in sexually inappropriate acts with children, there is an increased chance of a male pedo- phile being involved as well.7 When a male co-offender is involved, usually more than 1 child is involved. Molested children tend to be both male and female and are more likely to be related to the offender. In these cases, the female offender is also likely to have committed a non- sexual offense and a sexual offense.28 Cases that involve a male codefendant rightfully or wrongfully often do not result in the woman being charged.27 Unless specifically stated, the rest of this article deals with male pedophiles because most studies are based on male offenders. CATEGORIES OF PEDOPHILES Pedophiles are subdivided into several classifications. One of the first distinctions made when classifying pedophiles is to determine whether they are ���exclusively��� attracted to children (exclusive pedophile) or attracted to adults as well as children (nonexclusive pedophile). In a study by Abel and Harlow15 of 2429 adult male pedophiles, only 7% identified themselves as exclusively sexually attracted to children, which confirms the general view that most pedophiles are part of the nonexclusive group. Pedophiles are usually attracted to a particular age range and/or sex of child. Research categorizes male pedophiles by whether they are attracted to only male children (homo- sexual pedophilia), female children (heterosexual pedo- philia), or children from both sexes (bisexual pedo- philia).3,6,10,29 The percentage of homosexual pedophiles ranges from 9% to 40%, which is approximately 4 to 20 times higher than the rate of adult men attracted to other adult men (using a prevalence rate of adult homosexuality of 2%-4%).5,7,10,19,29,30 This finding does not imply that ho- mosexuals are more likely to molest children, just that a larger percentage of pedophiles are homosexual or bisexual in orientation to children.19 Individuals attracted to females usually prefer children between the ages of 8 and 10 years.3,5,31 Individuals attracted to males usually prefer slightly older boys between the ages of 10 and 13 years.3,5 Heterosexual pedophiles, in self-report studies, have on average abused 5.2 children and committed an average of 34 sexual acts vs homosexual pedophiles who have on average abused 10.7 children and committed an average of 52 acts.15 Bisexual offenders have on average abused 27.3 children and committed more than 120 acts.15 A study by Abel et al32 of 377 nonincarcerated, non���incest-related pedophiles, whose legal situations had been resolved and who were surveyed using an anonymous self-report ques- tionnaire, found that heterosexual pedophiles on average reported abusing 19.8 children and committing 23.2 acts, whereas homosexual pedophiles had abused 150.2 children and committed 281.7 acts. These studies confirm law en- forcement reports about the serial nature of the crime, the large number of children abused by each pedophile, and the underreporting of assaults.1 Studies that used self-reports and polygraphs show that pedophiles currently in treat- ment underreport their current interest in children and past behaviors.33,34 Another common pedophilic specifier is whether the abused children are limited to family members (ie, incest).6 Federal data show that 27% of all sexual offenders as- saulted family members. Fifty percent of offenses commit- ted against children younger than 6 years were committed by a family member, as were 42% of acts committed against children 6 to 11 years old and 24% against children 12 to 17 years old.2 The study by Abel and Harlow15 found that 68% of ���child molesters��� had molested a family mem- ber 30% had molested a stepchild, a foster child, or an adopted child 19% had molested 1 or more of their bio- TABLE 1. Proposed Classes and Groupings of Female Sex Offenders4,22,27,28 Class Description Experimenter Usually a young female adult (adolescent to early 20s) who molests out of curiosity (classic example is the babysitter) Male Willing participant not coerced by male partner to accompanied engage in molestation of children Male coerced Usually a passive female involved with an abusive male many times abuses own children Nurturers or Female adult who has caregiving responsibilities for caregivers younger children (feeding, dressing, babysitting, day care) and molests children under the justification of carrying out these duties Psychologically Offender with some form of psychosis, currently disturbed considered rare Teacher or lover Female adult usually in some position of authority, who sees sex as a consensual relationship and not as abuse of a child Traditional Individual who molests children with the purpose offender of obtaining sexual gratification, follows a similar pattern as male offenders