SPECIAL COMMUNICATION

Pedophilia
Peter J. Fagan, PhD
Thomas N. Wise, MD This article addresses the risk factors associated with the psychiatric disor-
der pedophilia, its treatment, and treatment outcomes. It addresses physi-
Chester W. Schmidt, Jr, MD
cian responsibilities associated with case identification of victims and pos-
Fred S. Berlin, MD, PhD sible roles in the medical management of pedophilia. The essential feature
of pedophilia is that an individual is sexually attracted exclusively or in part

T
HE PURPOSE OF THIS ARTICLE IS to prepubescent children. While pedophilia may be limited to fantasies and
to increase health care profes-
impulses, pedophilic behaviors are the primary concern of both the mental
sionals’ understanding of pe-
dophilia, a psychiatric disor- health and criminal justice systems. Remote risk factors for development of
der affecting a portion of the individuals pedophilia often include the individual having been sexually abused as a
who sexually abuse children. It ad- child. Proximate risk factors for its behavioral expression are prevalence of
dresses risk factors associated with the comorbid psychiatric disorders and substance abuse disorders. Current treat-
disorder, treatment, treatment out- ment goals focus on stopping the behavior and achieving long-term behav-
comes, physician responsibilities asso- ioral control in the community. Common treatment methods are cognitive-
ciated with case identification, and rec- behavioral, group therapy, and, when appropriate, medications such as
ommendations for criminal and medical
androgen-lowering agents that can act as sexual appetite suppressants. Meta-
systems collaboration.
Pedophilia is a diagnosis applicable analyses have established that treatment is more effective than nontreat-
to only a portion of individuals who ment in preventing recidivism of sexual offenders in general, a finding that
sexually abuse children. Information has a high probability of application to individuals with pedophilia. Pedo-
has been drawn from published re- philia is a chronic psychiatric disorder, but it is treatable in terms of devel-
search about pedophilia and child oping strategies for preventing behavioral expression. Ultimately, reducing
sexual abuse in general to present the the prevalence of pedophilic behavior requires further collaboration be-
current state of knowledge. Despite a tween the criminal justice system and the health care communities.
sizeable body of published, peer-
JAMA. 2002;288:2458-2465 www.jama.com
reviewed articles about topics such as
child sexual abuse, child molestation,
and sexual offenders, data and our contained meta-analyses, or written by child sexual abuse is a major public
knowledge base about pedophilia have recognized experts on the topic of pe- health problem. In a general popula-
significant limitations. dophilia. Several of the latter have writ- tion study of sexual behaviors in the
ten books or chapters in texts that al- United States, 12% of men and 17% of
METHODS lowed the search to be extended with women in the study reported being sexu-
A MEDLINE search conducted in June the assistance of further bibliographic ally touched by an older person when
2002 using the Medical Subject Head- resources. Staff members at the Na- they were children.2 Governmental agen-
ing (MeSH) pedophilia identified a total tional Clearinghouse on Child Abuse cies working largely from criminal
of 447 articles from 1965 to the pres- and Neglect Information (www.calib records and child protective services
ent. A second search using the MeSH .com/nccanch) provided helpful assis- agencies data have provided further es-
term child molestation yielded 137 ci- tance in obtaining data.
tations. These articles were examined Author Affiliations: Department of Psychiatry and Be-
SCOPE OF THE PROBLEM havioral Sciences, The Johns Hopkins University School
for relevance to the prevalence, expres- of Medicine, Lutherville, Md.
sion, and treatment of pedophilia. Spe- Since the initial research on the epide- Corresponding Author and Reprints: Peter J. Fagan,
PhD, Sexual Behaviors Consultation Unit, 10751 Falls
cial attention was given to those ar- miology of child sexual abuse by Finkel- Rd, Greenspring Station, Suite 300, Lutherville, MD
ticles that were reviews of the literature, hor,1 it has been generally accepted that 21093 (e-mail: pfagan@jhmi.edu).

2458 JAMA, November 20, 2002—Vol 288, No. 19 (Reprinted) ©2002 American Medical Association. All rights reserved.
 PEDOPHILIA

timation of the magnitude of the prob-

lem. The Third National Incidence Study Box. Diagnostic Criteria for Pedophilia
of Child Abuse and Neglect (NIS-3), A. Over a period of at least 6 months, recurrent, intense sexually arousing fanta-
which addressed only those cases in- sies, sexual urges or behaviors involving sexual activity with a prepubescent
volving parents, parent substitutes, child or children (generally age 13 years or younger).
adults, or nonparental teenagers in a B. The person has acted on these sexual urges, or the sexual urges or fantasies
caretaking relationship with the child, cause marked distress or interpersonal difficulty.
estimated that the number of sexually C. The person is at least age 16 years and at least 5 years older than the child or
children in Criterion A.
abused children rose 125% from 133600
Note: Do not include an individual in late adolescence involved in an ongoing
reported cases in 1986 to 300 200 in sexual relationship with a 12- or 13-year-old.
1993.3 The report concluded that chil-
Specify if:
dren are consistently vulnerable to
Sexually attracted to males
sexual abuse from the age of 3 years on, Sexually attracted to females
girls were sexually abused 3 times more Sexually attracted to both
often than boys, children from the low-
Specify if:
est-income families were 18 times more Limited to incest
likely to be sexually abused, and there
Specify type:
were no racial differences in maltreat-
Exclusive type (attracted only to children)
ment incidence.3 Nonexclusive type
The NIS-3 reported that natural par-
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
ents accounted for 29%, other parents Fourth Edition, Text Revision.6 Copyright 2000 American Psychiatric Association.
for 25%, and others in a caretaking role
for 46% of the offenders. In addition,
a sexually abused child was most likely
to sustain a serious injury or impair- Such data can provide only some ap- pedophilia erotica—which literally
ment when a birth parent was the per- proximation of the prevalence of pedo- means the erotic love of children.7 The
petrator. Approximately 89% of the philia in a population for 2 reasons. First, ruminations of Humbert Humbert in
children were abused by a male, com- a pedophilic disorder may be present in Vladimir Nabokov’s Lolita give a
pared to 12% abused by a female.3 a person who does not act on the fan- graphic picture of the erotic mental life
Additional incidence data about both tasies and impulses. Second, not all child of a man attracted to a 12-year-old girl.8
custodial and noncustodial sexual abuse sexual crime is the product of a pedo- The term “ephebophilia” (or “hebo-
have been provided from findings from philic disorder. This caveat notwith- philia”) has occasionally been used to
the Federal Bureau of Investigation’s standing, these data and the general con- denote an inordinately high sexual at-
National Incident-Based Reporting Sys- clusions of similar reports leave little traction to postpubescent adoles-
tem.4 Based on reports from 12 states doubt that sexual crimes against chil- cents. What persons with pedophilia or
from 1991 to 1996, 67% of sexual as- dren, and by inference pedophilia, are ephebophilia share in common is an at-
saults handled by law enforcement both a major public health problem as traction to children who are legal mi-
agencies involved juvenile victims, of well as a criminal justice problem.5 nors. This rational distinction is often
whom 1 of every 7 was younger than 6 not mirrored in the erotic mental life
years and a third of whom were younger PEDOPHILIA: of the pedophilic individual, again us-
than 12 years. Eighty-three percent of A PSYCHIATRIC DISORDER ing as an example Humbert Humbert,
the younger than 12 years cohort was Pedophilia should be distinguished from who was attracted to “girl children”
female. Adults were the offenders in other terms that may be applied to be- aged 9 to 14 years.
60% of the sexual assaults on children havior involving sex with minors but are Terms such as “child sexual abuse,”
younger than 12 years, and 5 of every not equivalent constructs. The essen- “incest,” “child molestation,” and “ped-
6 assaults occurred in a residence. tial feature of pedophilia is that an indi- erasty” are not equivalent to pedo-
Nearly all the offenders were male vidual is sexually attracted either exclu- philia. Terms that denote sex with mi-
(96%), although female offenders were sively, or in part, toward prepubescent nors are criminal actions; pedophilia is
most common in assaults on victims children. It is operationally categorized the sexual attraction to children and is
younger than 6 years. Strangers ac- in the Diagnostic and Statistical Manual a psychiatric disorder. Not all who sexu-
counted for less than 5% of the offend- of Mental Disorders, Fourth Edition, Text ally abuse minors are pedophilic. For
ers, while except for the younger than Revision (DSM-IV-TR) of the American example, some who sexually abuse chil-
6 years group, acquaintances were 53% Psychiatric Association (BOX).6 dren may opportunistically select mi-
and family members were 42% of the The word pedophilia comes from a nors simply because they are avail-
offenders.4 term coined by Krafft-Ebing— able. Sex with a minor is not, ipso facto,
©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, November 20, 2002—Vol 288, No. 19 2459
PEDOPHILIA

a determination of pedophilia. Also, not der,” or as the manifestation of a dis- psychological integrity.12,21 Children do
all individuals who fulfill the diagnos- torted “love map.” These feelings may not have the ability to give consent to the
tic criteria for pedophilia actually abuse further obscure perception of the chil- sexual relationship. The sexual behav-
children. Possessing such fantasies and dren’s reaction of fear, anxiety, and, in ior is a violation of the child’s sense of
being distressed by them is sufficient some cases, pain to the sexual abuse. security and control of personal bound-
to meet diagnostic criteria. An indi- Thus, when confronted by the legal sys- aries in a (usually) trusted relationship.
vidual with pedophilia is not a sexual tem, many pedophilic offenders ini- The consequent secrecy about the be-
offender unless he or she commits a le- tially respond with excuses rife with haviors further erodes trust with the adult
gally proscribed act. cognitive distortions such as, “The child world that should be serving as a pro-
We were unable to find any pub- wanted it. She was the initiator. She was tective and nurturing environment.
lished reports indicating the preva- not harmed.” Others will be relieved
lence of pedophilia among those who that they have finally been appre- Typologies of Pedophilia
were either arrested for or convicted of hended and harbor the hope that with It is not known why some adults and
child sexual abuse or the prevalence of treatment and control by the legal sys- older adolescents are sexually at-
pedophilia in the general population. tem, the behaviors will cease. tracted to prepubescent children. Lack-
Research inventories on psychiatric dis- Researchers in a child sex offender ing this knowledge, clinicians and re-
orders or sexual behaviors in the gen- program based in Seattle, Wash, have searchers have used typologies to gain
eral population have not inquired about provided a qualitative study of the at- a greater understanding of the causal
pedophilic fantasies or behaviors.2,9 We titudes and modus operandi of men or correlational phenomena involved in
suspect that researchers had concerns who have sexually abused children.13 pedophilia. Thus, dichotomous types
about the validity of the data they would The men reported being attracted to a such as familial vs nonfamilial offend-
obtain, the participant reactions lead- friendly, open, vulnerable child who ers, touching vs nontouching, seduc-
ing to dropping from the interview, and would be easily persuaded and would tive vs aggressive are appealing at first
the need to report the pedophilic par- remain silent after the sexual abuse. The glance. But the dichotomies should not
ticipants to civil authorities if behav- initial social contact with the child in- obscure the variety and complexity of
iors were admitted. volved some nonsexual enticements the expression of pedophilic behav-
such as purchases or flattery. Sexual iors.22 At this point, the typologies and
Behaviors Associated conversation generally followed. A categories should be considered con-
With Pedophilia gradual progression from nonsexual junctive and suggestive of group dif-
While the psychiatric disorder may be touch to sexual touch happened with ferences, not mutually exclusive cat-
limited to fantasies and impulses, the the purposeful desensitization of the egories. Individuals who have been
pedophilic behaviors are the primary child to the purpose of the touch. A apprehended for incest may also have
concern of mental health and criminal sleeping child was often the victim of sexually abused children outside their
justice systems. Based on the assump- the touching. Following the sexual con- families. The current standard typolo-
tion that pedophilic behaviors are simi- tact, the offender would use his adult gies are the specifications suggested by
lar to those reported for child moles- authority to isolate the child and the the DSM-IV-TR, which in an effort to
tation, we can expect that the offending “shared” behavior from family or peers. be descriptive without implying etiol-
individual usually begins pedophilic be- Physical threats were rare, but threats ogy, has 3 specifications for pedo-
haviors in the middle to late teen years, to the child’s sense of psychological se- philia: (1) sex of the children toward
while others may act on the attraction curity were common.13 whom they are sexually attracted (male,
in middle adulthood.10 Typically, fon- Sexual abuse is a risk factor for sub- female, both); (2) range of attraction
dling and genital exposure are per- sequent psychological morbidity. (incest only); and (3) age of the indi-
formed, while oral, anal, or vaginal in- Higher morbidity occurs in adoles- viduals toward whom they are sexu-
tercourse are less frequent progressions cence and adulthood. In adolescence, ally attracted (exclusively to children
of pedophilic behavior.11 It is less com- behavioral problems, substance abuse, or to children and adults) (Box). Even
mon to assault (rape) or abduct the and suicidal ideation are associated with these specifications should be seen as
child, although such cases have been reported sexual abuse.16-18 Further, men descriptors rather than mutually ex-
given notoriety in the media.12 While and women who were abused during clusive categories.
some persons with pedophilia view chil- childhood are at higher risk for mood,
dren as objects solely for sexual grati- anxiety, and substance abuse disor- Etiological and Precipitant
fication, many pedophilic individuals ders as well as suicide attempts.19,20 Risk Factors
report they feel affection toward chil- Even when there are no subsequent Another strategy to better understand
dren.13 This has been described fur- physical or emotional sequelae, how- etiologic issues in pedophilia is to iden-
ther by Freund et al14 and Money,15 who ever, pedophilic behavior is an infringe- tify risk factors—both remote and pre-
view pedophilia as a “courtship disor- ment on the child’s right to physical and cipitant.22 Risk factors in the early life his-
2460 JAMA, November 20, 2002—Vol 288, No. 19 (Reprinted) ©2002 American Medical Association. All rights reserved.
 PEDOPHILIA

tory that may have been pathogenic for ence of a 93.3% lifetime and 75.5% cur- diate attention and refer the child to an
pedophilia can differ from those risk fac- rent psychiatric comorbid disorder, agency or group that specializes in the
tors that maintain continuance in the most of these being depression and treatment of children who have been
present. One of the most frequently cited anxiety disorders. Sixty percent had a sexually abused.37
remote risk factors for pedophilic be- lifetime substance abuse history, 51% All physicians who have children as
haviors is the individual’s own personal of the total group having alcohol as their patients should be familiar with “Guide-
experience of being a victim of sexual drug of choice. Sixty percent of the men lines for the evaluation of sexual abuse
abuse.23,24 Other researchers have cited met the criteria for a personality dis- of children.”38 Those who are involved
an inadequate attachment style that is order, the chief among them being ob- more intensively in the forensic aspect
rooted in a dysfunctional family as a re- sessive-compulsive (25%), antisocial of the evaluation should be aware that
mote risk factor.25 (22.5%), narcissistic (20%), and avoid- the general guidelines for evidence col-
Elevated plasma epinephrine and nor- ant (20%). These data indicate a high lection in cases of acute sexual assault
epinephrine levels, and reduced corti- prevalence of personality disorder rela- are not well suited for prepubertal vic-
sol responses to meta-chlorophenylpi- tive to the population and counter the tims.39 Further guidance regarding the
perazine challenges have been identified belief that pedophilic behaviors are sim- evaluation of children for sexual abuse
in pedophilic cohorts.26,27 The investi- ply an expression of antisocial or nar- is beyond the scope of this article and
gators hypothesized that there is in- cissistic personality disorders. As noted is available elsewhere.40
creased sympathetic activity and re- by Raymond et al,33 77.5% of the men Mandated Reporting. Statutes that
duced serotonergic activity present in the did not meet criteria for antisocial per- mandate clinicians to report sus-
pedophilic samples. However, the in- sonality disorder, and 80% did not meet pected child sexual abuse to criminal
vestigators could not rule out the pos- the narcissistic personality criteria. justice authorities can sometimes de-
sibility that their pedophilic sample had ter individuals with pedophilia from
a high comorbidity of anxiety disorder, RESPONSIBILITIES seeking treatment even though they
and as a consequence could not be cer- OF PHYSICIANS have not been identified or appre-
tain whether the documented results Victims of Sexual Abuse. Early iden- hended and may want help.41 How-
were specific to pedophilia or an arti- tification of the victims of sexual abuse ever, physicians have an administra-
fact attributable to the presence of anxi- is essential. The physician in office prac- tive responsibility when faced with
ety disorder. Other developmental28,29 tice may encounter child sexual abuse actual or suspected child abuse. In most
and organic30 phenomena have been de- in the course of a routine physical ex- jurisdictions, all health care profession-
scribed in pedophilic individuals. amination or parents may request an als must report suspected child sexual
Gaffney and Berlin31 documented a evaluation for confirmed or suspected abuse to civil authorities. Mandatory re-
marked elevation in the release of lu- sexual abuse of their child. Children porting laws vary from jurisdiction to
teinizing hormone to the intravenous who have been sexually abused may dis- jurisdiction in scope and application.
infusion of luteinizing hormone- play depression and aggressive behav- The standard of care is that physicians
releasing hormone within a group of pe- iors, have an increased frequency of understand and conform to the report-
dophilic patients when compared with anxiety disorders, and have problems ing laws of the jurisdictions in which
nonpedophilic patients. A report of 2 with age-appropriate sex roles and they practice. In cases where the phy-
older men with temporal lobe disease sexual functioning.34,35 However, such sicians are uncertain about reporting a
and the emergence of late life pedo- behaviors, as well as persistent and un- case, they should consult with col-
philia led the authors to suggest that a explained somatic complaints, are not leagues in local child abuse agencies
dementing illness may lead to sexual dis- specific to a sexual abuse etiology. The or the jurisdiction’s child protection
inhibition of previously behaviorally optimal strategy is to provide a trust- agency.
controlled pedophilic vulnerabilities.32 ing environment for the child and, if
Precipitating factors that may lead to there is reason to suspect abuse, evalu- THE SPECTRUM OF
the expression of the behavior are af- ate the child accordingly. PEDOPHILIC DESIRES
fective illness, psychosocial stress in- Symptoms such as genital or rectal AND ACTS: IMPLICATIONS
volving loss of relationship, or status pain, injury to genitals or rectum, sexu- FOR TREATMENT
and alcohol abuse. When any of these ally transmitted disease, and pathologi- Pedophilic individuals are heterog-
factors concur with a situation in which cal anatomy of the hymen are more de- eneous with regard to character, tem-
the individual with pedophilia has ac- finitive signs of possible sexual abuse.36 perament, and manner of expressing
cess to children, the tragic stage is set These warrant further evaluation re- their sexuality.21,42,43 Clinicians might
for pedophilic behaviors. High rates of garding their causes. When there is little see patients with pedophilia who have
psychiatric comorbidity have been doubt that sexual abuse did occur, the interacted sexually with children, who
found among pedophilic sex offend- clinician should screen for medical and have only looked at sexualized pic-
ers. Raymond et al33 reported the pres- emotional problems requiring imme- tures of children, or who have not in
©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, November 20, 2002—Vol 288, No. 19 2461
PEDOPHILIA

any way acted on their urges but seek namic theories suggest pedophilia is the androgenic (sex drive–lowering) medi-
treatment because of distress and shame manifestation of underlying conflicts cations. The group process allows for
about having such feelings. For these that developed during a maladaptive therapeutic confrontation of denial and
reasons, clinicians must develop indi- childhood.47 According to this view, the self-deception. Through therapeutic
vidualized formulations and treat- condition could be “cured” through the confrontation, an individual can be
ment plans for each patient, even development of insights about those helped to appreciate the true ramifica-
though certain generalized principles conflicts. It was this theory that led tions of his actions. The sequence of
are applied to treating the disorder. many to believe that a person with pe- events that has led to any past sexual
Some men become aroused by look- dophilia who had been “cured” could misconduct is identified, and the pa-
ing at sexual images of children but be returned to an environment with tient is taught about the changes in life-
never seek out such relationships.44 Even minimal or no risk of further pedo- style needed to achieve control of the
that sort of voyeuristic pedophilic be- philic behaviors. Behavior therapists behaviors. The therapy also provides
havior can pose a threat to the indi- have attempted to recondition the emotional support, while encourag-
vidual and warrant treatment, because sexual orientations of persons with pe- ing the development of a social sup-
it is a criminal felony to possess and view dophilia.48-50 The goal is to decondi- port network. Brief periods of inpa-
images of real children. A recent United tion sexual arousal toward children, tient hospitalization may be required as
States Supreme Court decision re- while reconditioning erotic feelings to- a precaution during periods of height-
moved criminal sanctions for viewing ward adults. In considering such an ap- ened stress or risk. Any comorbid con-
sexualized images of children, if such im- proach, it is important to appreciate that ditions, such as alcoholism and affec-
ages have been computer generated (so- even if pedophilic desires had been tive illness, also must be treated.
called virtual reality).45 learned, the learning involved may have For those with pedophilia who are ei-
been imprinting, a type of “stamping ther on parole or probation, clinicians
Rationale for Treatment in,” rather than classic conditioning.51 must work collaboratively with the
During psychosexual development, no In the case of imprinting, that which has criminal justice system. Electronic sur-
one decides whether to be attracted to been learned cannot ordinarily be de- veillance and polygraph testing can be
women, men, girls, or boys. Rather, in- conditioned or unlearned. If one heeds used when indicated, and noncompli-
dividuals discover the types of persons the American Psychiatric Associa- ance with treatment should not be tol-
they are sexually attracted to, ie, their tion’s advisory against attempts to re- erated. At the same time, every effort
sexual orientation. When the powerful condition sexual orientation, then treat- should be made to maintain a good pa-
biological force that constitutes sexual ment efforts, especially with the tient-physician relationship.
drive becomes misdirected toward chil- individual attracted exclusively to chil-
dren, it recurrently craves satiation.42 dren, will be aimed more at control- Treating Volitional Impairment
Thus, by fantasy or by behaviors, indi- ling the behaviors rather than recon- in Pedophilia
viduals with pedophilia discover their ditioning the drive toward adults.52 Medications that can act as sexual ap-
sexual attraction toward children. Al- Since the late 1980s, pedophilia has petite suppressants have proven to be
though the person with pedophilia is not generally not been considered curable helpful in augmenting volitional con-
at fault for having this psychiatric dis- in the sense that the individual would trol of pedophilic attractions.54-61 In
order, he or she has the responsibility no longer be sexually attracted to chil- most species that have been studied, in-
for controlling its expression. dren. As Fuller wrote, “The aim of treat- cluding humans, a significant decline
The moral argument that an indi- ment [for pedophilia] is to stop abuse in testosterone level is ordinarily asso-
vidual should be capable of exercising of children, to prevent its recurrence, ciated with a marked decrease in sexual
consistent self-control does not mean and to help the patient control his de- drive and in the frequency of sexually
that he can actually do so. Recently, the viant behavior, impulses and preoccu- motivated behaviors.62 In the past, tes-
United States Supreme Court, in reaf- pations.”53 Currently, pedophilia is con- tosterone could only be reduced via sur-
firming the involuntary civil commit- sidered a chronic disorder. Therefore, gical castration. Though less vigorous
ment of some persons with pedo- treatment should focus on stopping the than today’s standards, early studies that
philia, suggested that it is just such an behavior and achieving long-term be- investigated reducing testosterone in
impairment in volitional capabilities havioral change in the community. sex offenders, including those with pe-
that, in part, constitutes justification for dophilia, generally confirmed that do-
forced confinement and treatment of The Cognitive and Social ing so could result in long-term low
some pedophilic individuals.46 Components of Treatment rates of criminal recidivism.62-65
One method commonly used for treat- The testosterone-lowering medica-
Earlier Treatment Methods ing pedophilia is outpatient group tions currently used in the United States
Historically, several types of treat- therapy, which is sometimes com- are Depo-Provera (medroxyprogester-
ment had been proposed. Psychody- bined with the administration of anti- one acetate) or Depo-Lupron (leupro-
2462 JAMA, November 20, 2002—Vol 288, No. 19 (Reprinted) ©2002 American Medical Association. All rights reserved.
 PEDOPHILIA

lide acetate). 66 A recent study re- dophilia.71 Finally, double-blind studies eral, not on pedophiles in particular. It
ported that triptorelin is also effective.67 involving placebo treatments are diffi- also did not review medical and drug
Although these drugs suppress the in- cult for ethical reasons. treatment programs. From a practical
tensity of libidinal drive, they gener- On average, 10% to 17% of offend- standpoint, what seems clear in recent
ally allow erectile function, thereby ers commit another offense after 4 to years is that the majority of persons who
making intercourse with an age- 5 years when untreated.72,73 This rela- have undergone therapy for sexual of-
appropriate partner possible. Persons tively low recidivism baseline makes fenses have not reoffended. A hopeful
receiving testosterone-lowering medi- establishing treatment effectiveness a indicator that this conclusion applies
cations should be maintained on a treat- statistical and clinical challenge. Mea- to persons with pedophilia is sug-
ment protocol that includes a com- surements of treatment efficacy vary gested by a study in which the sexual
plete physical examination with from decrease of sexual arousal to erotic recidivism rate (based on criminal
appropriate laboratory testing yearly. stimuli as measured by penile plethys- charge) was 7.4% over an average 5.12
In addition to the testosterone- mography to no subsequent arrest.74 years.81 Those who had been fully co-
lowering medications, some clinical re- Much controversy exists about the re- operative with treatment, as opposed to
searchers have prescribed selective sero- liability and validity of penile plethys- those discharged for treatment non-
tonin reuptake inhibitors in an effort mography assessment, and arrest data compliance, had an even lower recidi-
to treat pedophilia. The mechanism of are likely to underreport actual inci- vism rate of 2.9%.
action hypothesized is that these drugs dence of pedophilic behaviors.75,76 Fi-
increase levels of serotonin, thereby nally, great variability exists between the Recent Legislation and
lowering sexual drive.68 protocols of treatment programs and the Its Relationship to Treatment
The primary goal of sex drive– length of follow-up time for possible re- Four types of legislation have been in-
lowering medications in pedophilia is cidivism. troduced in recent years pertaining to
to enhance the capacity to exercise ap- Clearly, early treatment efforts of- individuals with pedophilia who have
propriate self-control. These medica- ten have been unsuccessful. A large been criminally convicted.82 Such stat-
tions should not be denied to persons meta-analysis on treatment efficacy of utes have mandated registration, com-
who fear losing control or who appear regimens for sexual offenders in gen- munity notification, civil commit-
to be at risk of failing a more conser- eral documented some successes, but ment, or the involuntary imposition of
vative treatment approach.69 Incarcer- a number of failures as well.77 Many of either “surgical or chemical castra-
ated persons with the disorder may also the programs reported were in the tion.” Recently, legislators in Alabama
benefit from such care to the extent that 1960s and 1970s and would not meet have introduced a bill calling for the ex-
they can be relieved of intrusive pedo- practice standards today.73 ecution of certain repeat child molest-
philic sexual preoccupations and urges. Four recent reviews and meta- ers (House Bill 209).83
analyses of recidivism of sexual offend- Registration statutes require indi-
Results of Treatment ers in general, not pedophiles specif- viduals with pedophilia who have been
Media presentations that ignore treat- ically, suggest a positive effect of convicted of a sexual offense to pro-
ment successes have often left the pub- treatment. Alexander78 found lower re- vide certain information to local crimi-
lic with a false impression regarding cidivism rates, defined as rearrest, nal justice authorities. Doing so would
treatment efficacy.70 At the same time, among treated (14.4%) as contrasted seem to have few, if any, mental health
there are also legitimate challenges in with nontreated (25.8%) child molest- implications. Community notification
assessing the treatment efficacy for pe- ers. Two other reviews79,80 reported a statutes require public disclosure of the
dophilia. The vast majority of recidi- significant treatment effect for cogni- fact that a given individual is a regis-
vism and treatment effectiveness stud- tive behavioral treatments, and one79 tered sex offender. To the extent that
ies do not limit their participants to found a similar effect for medical treat- doing so may make it difficult to find
those with pedophilia, but rather de- ments for sexual offenders in gen- housing, employment, and public ac-
scribe participants according to the be- eral. 80 A meta-analysis published ceptance, such statutes may make treat-
havior (eg, child abuse) or by relation- in 2002 included 43 studies of the ment success more problematic. 84
ship to the victims (eg, incest vs psychological (largely cognitive- Though potentially helpful in its in-
extrafamilial). Many studies have used behavioral) treatment for sex offend- tended purpose of warning communi-
diverse terms such as “sexual offend- ers.73 The findings were that sexual of- ties, there have also been instances in
ers,” “sexual predators,” or “child mo- fense recidivism was significantly lower which this has inadvertently caused dis-
lesters,” none of which have any diag- for the treatment groups (12.3%) than tress to an innocent child whose par-
nostic specificity. This blurring of the untreated comparison groups ent was a sex offender.84
inclusion criteria in studies further com- (16.8%) over an average 46-month fol- Civil commitment statutes, which are
promises any attempt to look specifi- low-up period. This meta-analysis was now in force in 14 states, involve the
cally at the treatment outcome for pe- conducted on sexual offenders in gen- continued involuntary detention of cer-
©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, November 20, 2002—Vol 288, No. 19 2463
PEDOPHILIA

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