Pedophilia: causes, symptoms, diagnosis, treatment

Pedophilia is manifested by the preferred choice of prepubescent children for sexual activity. Pedophilia often leads to imprisonment; medical treatment should include pharmacotherapy and psychotherapy.

Sexual offences against children constitute a significant proportion of reported criminal sexual acts. The age of a person with pedophilia is considered to be 16 years or older, with an age difference of 5 years or more between the offender and the child. The age of the child is usually under 13. For older adolescents with pedophilia, there is no established age distinction; it depends on clinical and judicial judgment.

Most pedophiles are male. Pedophiles prefer children of the opposite sex to children of the same sex at a ratio of 2:1. In most cases, the adult knows the child and may be a family member, stepparent, or authority figure. Looking and touching seem to be more common than genital contact. Homosexual men usually have less intimate knowledge of the child. Some pedophiles are attracted only to children; some pedophiles may also be attracted to adults.

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Incest

Some pedophiles limit their sexual activity to their own children or close relatives.

Incest is the crime of coitus (vaginal sex) between a man and a woman who is related to him in the first degree, with the man's knowledge of what he is doing. Since coitus is required for the crime to be classified as incest, only 1% of sexual crimes against children fall into this category. Most often, they are classified as indecency with a child or indecent assault. However, the possibility that vaginal sex with children within the family may be underreported, as the perpetrator may choose to plead guilty to a lesser charge in order to avoid being charged with a more serious crime. In the absence of other forensic evidence, this may be a child's allegation against the defendant's allegation. Although most incest convictions involve father-daughter incest, the most common sexual relationship is between siblings. In 65% of incest cases, girls aged 10-15 are involved (13). In recent years, cases of sexual abuse by mothers against their young sons have been increasingly recognized. 20% of such victims are under 4 years of age, and 70% are between 4 and 10 years of age. The most common form of behavior on the part of the woman is fondling the child's genitals and oral sex. The least common is vaginal sex, as is also the case with intra-familial sexual abuse by the man. However, this behavior also needs to be considered in context and should take its place among the phenomena studied. In 1993, only 12 women were imprisoned for sexual crimes in the United Kingdom.

The number of registered cases of incest fell from 444 in 1986 to 183 in 1997. Criminal statistics do not keep track of the age of victims of sexual crimes, with the exception of the category of gross indecency with a child (1,259 in 1977) and unlawful sexual intercourse with a girl under 13 and under 16 (148 and 1,112, respectively, in 1997). Based on the research conducted, specialists from the Ministry of Internal Affairs came to the conclusion that the level of sexual crimes against children is much higher than previously thought.

Previously, a distinction was made between intrafamilial criminals and criminals from outside the family. However, since it was found that 20 to 33% of "intrafamilial" sexual criminals show sexual arousal at the sight of children, which indicates pedophilic attraction, this distinction is no longer considered valid. More than 80% of persons who have committed sexual crimes against children are either their relatives (13%) or known to them (68%). A third of these criminals are teenagers.

The UK Home Office commissioned an evaluation of the effectiveness of community-based treatment programmes for sex offenders, the Sexual Offender Treatment Evaluation Project (STEP). It was found that almost 90% of the offenders studied had committed crimes against children. Overall, the researchers described this group as "isolated, lonely individuals who lack self-confidence, are usually unable to defend their own interests, and who are also unable to cope with their own negative emotions, as well as unable to assess the emotional distress of the victims of their criminal behaviour." They compared family offenders and outside offenders. One difference was found between the two groups - the level of emotional congruence with children. A more detailed description follows below. The researchers did not classify the offenders by their relationship with the victim; they found it more reliable to divide all persons who had committed sexual offences against children into groups with a high and low degree of deviance. The following characteristics were identified in the high deviance group:

1. They committed crimes both within and outside the family.
2. They committed crimes against boys and against girls.
3. Among them, the likelihood of having committed sexual crimes in the past is twice as high.
4. They were characterized by a high risk of reconviction according to the Thornton Scale.
5. They are more likely than others to have been victims of abuse as children.

Pedophiles, many of whom have antisocial personality disorder, may use force or threats of physical violence against a child or their pets if the abuse is revealed. Pedophilia is chronic, and perpetrators often develop substance abuse or dependence, depression, and family conflict. Many cases of child abuse occur in the context of substance abuse or serious family problems.

Identification of a pedophile often poses an ethical problem for the physician. The physician must try to protect the patient's privacy, but at the same time must protect children. The physician must be aware of the legal requirements regarding such reports.

Treatment of pedophilia

Long-term individual or group psychotherapy is usually necessary and may be particularly useful as part of a multimodal treatment that includes social skills training, treatment of comorbid physical and mental disorders (eg, epilepsy, attention deficit disorder, depression), and medication. Treatment is less effective when administered by court order, although many convicted sex offenders benefit from treatments such as group psychotherapy and antiandrogens.

In the United States, intramuscular medroxyprogesterone is the drug of choice; in Europe, cyproterone is used. The usual dose is 200 mg medroxyprogesterone intramuscularly 2 to 3 times a week for 2 weeks, then 200 mg 1 to 2 times a week for 4 weeks, then 200 mg every 2 to 4 weeks. Blood testosterone levels should be monitored and maintained within normal female limits (<62 ng/dL). Treatment is usually long-term, since deviant fantasies often return weeks to months after stopping treatment. Gonadotropin-releasing hormone preparations (eg, leiprolide, gosarelin) are also used intramuscularly. The effectiveness of antiandrogens in female pedophiles is poorly established. In addition to antiandrogens, SSRIs (eg, high-dose fluoxetine 60-80 mg once daily or fluvoxamine 200-300 mg once daily) may be helpful. The drugs are most effective when used as part of a multimodal treatment program.