Pedophilia

==Diagnosis==

===DSM and ICD-11===
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) states, "The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who freely disclose this paraphilia and to individuals who deny any sexual attraction to prepubertal children (generally age 13 years or younger), despite substantial objective evidence to the contrary."<ref name="DSM-5-TR"/> The manual outlines specific criteria for use in the diagnosis of this disorder. These include the presence of sexually arousing fantasies, behaviors or urges that involve some kind of sexual activity with a prepubescent child (with the diagnostic criteria for the disorder extending the cut-off point for prepubescence to age 13) for six months or more, or that the subject has acted on these urges or is distressed as a result of having these feelings. The criteria also indicate that the subject should be 16 or older and that the child or children they fantasize about are at least five years younger than them, though ongoing sexual relationships between a 12- to 13-year-old and a late adolescent are advised to be excluded. A diagnosis is further specified by the sex of the children the person is attracted to, if the impulses or acts are limited to [[incest]], and if the attraction is "exclusive" or "nonexclusive".<ref name="DSM-5-TR"/>

The [[ICD-11]] defines pedophilic disorder as a "sustained, focused, and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—involving pre-pubertal children."<ref name=ICD-11/> It also states that for a diagnosis of pedophilic disorder, "the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. This diagnosis does not apply to sexual behaviours among pre- or post-pubertal children with peers who are close in age."<ref name=ICD-11/>

Several terms have been used to distinguish "true pedophiles" from non-pedophilic and non-exclusive offenders, or to distinguish among types of offenders on a continuum according to strength and exclusivity of pedophilic interest, and motivation for the offense (see [[Child sexual abuse#Offenders|child sexual offender types]]). Exclusive pedophiles are sometimes referred to as ''true pedophiles.'' They are sexually attracted to prepubescent children, and only prepubescent children. Showing no erotic interest in adults, they can only become sexually aroused while fantasizing about or being in the presence of prepubescent children, or both.<ref name=psychiatrictimes.com/> Non-exclusive offenders—or "non-exclusive pedophiles"—may at times be referred to as ''non-pedophilic'' offenders, but the two terms are not always synonymous. Non-exclusive offenders are sexually attracted to both children and adults, and can be sexually aroused by both, though a sexual preference for one over the other in this case may also exist. If the attraction is a sexual preference for prepubescent children, such offenders are considered pedophiles in the same vein as exclusive offenders.<ref name=psychiatrictimes.com/>

Neither the DSM nor the ICD-11 diagnostic criteria require actual sexual activity with a prepubescent youth. The diagnosis can therefore be made based on the presence of fantasies or sexual urges even if they have never been acted upon. On the other hand, a person who acts upon these urges yet experiences no distress about their fantasies or urges can also qualify for the diagnosis. ''Acting'' on sexual urges is not limited to overt sex acts for purposes of this diagnosis, and can sometimes include [[indecent exposure]], [[voyeurism|voyeuristic]] or [[frotteurism|frotteuristic]] behaviors.<ref name="DSM-5-TR"/> The ICD-11 also considers planning or seeking to engage in these behaviors, as well as the use of [[child pornography]], to be evidence of the diagnosis.<ref name=ICD-11/> However the DSM-5-TR, in a change from the prior edition, excludes the use of child pornography alone as meeting the criteria for "acting on sexual urges."<ref name="DSM-5-TR"/> This change is controversial due to being made for legal reasons rather than scientific. According to forensic psychologist [[Michael C. Seto]], who was part of the DSM-5-TR workgroup, the removal of child pornography use alone was to avoid diagnosing criminal defendants convicted of child pornography offenses, but no in-person offenses, with pedophilic disorder, as this could potentially lead to such defendants being committed to mental institutions under [[sexually violent predator laws]]. Seto, who has published several research studies on pedophilia and its relationship with child pornography, objected to this reasoning by the APA, as it would only apply to a tiny minority of commitments, as well as deny help-seeking pedophiles access to clinical care due to not having an official diagnosis for insurance purposes.<ref name=Seto2022>{{cite journal |vauthors=Seto MC |title=Clinical and Conceptual Problems With Pedophilic Disorder in the DSM-5-TR |journal=Arch Sex Behav |volume=51 |issue=4 |pages=1833–1837 |date=May 2022 |pmid=35471678 |doi=10.1007/s10508-022-02336-1 |s2cid=248389557 |url=}}</ref>

In practice, the patient's behaviors need to be considered in-context with an element of clinical judgment before a diagnosis is made. Likewise, when the patient is in late adolescence, the age difference is not specified in hard numbers and instead requires careful consideration of the situation.<ref name=DSMmedem>[http://www.medem.com/MedLB/article_detaillb.cfm?article_ID=ZZZUZRUZGLC&sub_cat=355 ''Pedophilia''] {{webarchive | url = https://web.archive.org/web/20060508052445/http://www.medem.com/MedLB/article_detaillb.cfm?article_ID=ZZZUZRUZGLC&sub_cat=355 | date = 2006-05-08 }} DSM at the Medem Online Medical Library</ref>

===Debate regarding criteria===
There was discussion on the DSM-IV-TR being overinclusive and underinclusive. Its criterion A concerns sexual fantasies or sexual urges regarding prepubescent children, and its criterion B concerns acting on those urges or the urges causing marked distress or interpersonal difficulty. Several researchers discussed whether or not a "contented pedophile"—an individual who fantasizes about having sex with a child and masturbates to these fantasies, but does not commit child sexual abuse, and who does not feel subjectively distressed afterward—met the DSM-IV-TR criteria for pedophilia since this person did not meet criterion B.<ref name=SetoReview/><ref>{{cite journal | vauthors = O'Donohue W, Regev LG, Hagstrom A | title = Problems with the DSM-IV diagnosis of pedophilia | journal = Sex Abuse | volume = 12 | issue = 2 | pages = 95–105 | year = 2000 | pmid = 10872239 | doi = 10.1023/A:1009586023326 | s2cid = 195287902 }}</ref><ref name="greenpedo">{{cite journal | author = Green R | year = 2002 | title = Is pedophilia a mental disorder? | url = http://www2.hu-berlin.de/sexology/BIB/pedophilia.htm | journal = [[Archives of Sexual Behavior]] | volume = 31 | issue = 6 | pages = 467–471 | doi = 10.1023/a:1020699013309 | pmid = 12462476 | s2cid = 7774415 | url-status = dead | archive-url = https://web.archive.org/web/20101012005114/http://www2.hu-berlin.de/sexology/BIB/pedophilia.htm | archive-date = 2010-10-12 }}</ref><ref name=DiagnosticCompare>{{cite journal | vauthors = Moulden HM, Firestone P, Kingston D, Bradford J | year = 2009 | title = Recidivism in pedophiles: an investigation using different diagnostic methods | journal = Journal of Forensic Psychiatry & Psychology | volume = 20 | issue = 5 | pages = 680–701 | doi=10.1080/14789940903174055 | s2cid = 144622835 }}</ref> Criticism also concerned someone who met criterion B, but did not meet criterion A. A large-scale survey about usage of different classification systems showed that the DSM classification is only rarely used. As an explanation, it was suggested that the underinclusiveness, as well as a lack of validity, reliability and clarity might have led to the rejection of the DSM classification.<ref name="feelgood">{{cite journal | vauthors = Feelgood S, Hoyer J | year = 2008 | title = Child molester or paedophile? Sociolegal versus psychopathological classification of sexual offenders against children | journal = Journal of Sexual Aggression | volume = 14 | issue = 1 | pages = 33–43 | doi=10.1080/13552600802133860 | s2cid = 145471750 }}</ref>

[[Ray Blanchard]], an [[Canadians of American origin|American-Canadian]] [[Sexology|sexologist]] known for his research studies on pedophilia, addressed (in his literature review for the DSM-5) the objections to the overinclusiveness and under underinclusiveness of the DSM-IV-TR, and proposed a general solution applicable to all paraphilias. This meant namely a distinction between ''paraphilia'' and ''paraphilic disorder''. The latter term is proposed to identify the diagnosable mental disorder which meets Criterion A and B, whereas an individual who does not meet Criterion B can be ascertained but ''not'' diagnosed as having a paraphilia.<ref name="pmid19757012">{{cite journal | author = Blanchard R | title = The DSM diagnostic criteria for pedophilia | url = https://archive.org/details/sim_archives-of-sexual-behavior_2010-04_39_2/page/304 | journal = Arch Sex Behav | volume = 39 | issue = 2 | pages = 304–16 | date = April 2010 | pmid = 19757012 | doi = 10.1007/s10508-009-9536-0 | s2cid = 20213586 }}</ref> Blanchard and a number of his colleagues also proposed that hebephilia become a diagnosable mental disorder under the DSM-5 to resolve the physical development overlap between pedophilia and hebephilia by combining the categories under ''pedophilic disorder'', but with specifiers on which age range (or both) is the primary interest.<ref name="dsm5.org"/><ref name=Blanchard>{{cite journal | vauthors = Blanchard R, Lykins AD, Wherrett D, Kuban ME, Cantor JM, Blak T, Dickey R, Klassen PE | title = Pedophilia, Hebephilia, and the DSM-V | journal = Archives of Sexual Behavior | volume = 38 | issue = 3 | pages = 335–350 | year = 2009 | pmid = 18686026 | doi = 10.1007/s10508-008-9399-9 | s2cid = 14957904 }}</ref> The proposal for hebephilia was rejected by the American Psychiatric Association,<ref name=prnsdhebephilia>{{cite magazine | url = http://www.psychologytoday.com/blog/witness/201212/psychiatry-rejects-novel-sexual-disorder-hebephilia | title = Psychiatry Rejects Novel Sexual Disorder "Hebephilia" | author = Karen Franklin | date = 2 December 2012 | magazine = Psychology Today | location = USA | access-date = 7 December 2012 }}</ref> but the distinction between ''paraphilia'' and ''paraphilic disorder'' was implemented.<ref name="dsm5.org Fact Sheet">{{cite web | title = Paraphilic Disorders | year = 2013 | access-date = July 8, 2013 | publisher = [[American Psychiatric Association|American Psychiatric Publishing]] | url = http://www.dsm5.org/Documents/Paraphilic%20Disorders%20Fact%20Sheet.pdf | url-status = dead | archive-url = https://web.archive.org/web/20160724010712/https://www.dsm5.org/Documents/Paraphilic%20Disorders%20Fact%20Sheet.pdf | archive-date = July 24, 2016 }}</ref>

The American Psychiatric Association stated that "[i]n the case of pedophilic disorder, the notable detail is what wasn't revised in the new manual. Although proposals were discussed throughout the DSM-5 development process, diagnostic criteria ultimately remained the same as in DSM-IV TR" and that "[o]nly the disorder name will be changed from pedophilia to pedophilic disorder to maintain consistency with the chapter's other listings."<ref name="dsm5.org Fact Sheet"/> If hebephilia had been accepted as a DSM-5 diagnosable disorder, it would have been similar to the ICD-10 definition of pedophilia that already includes early pubescents,<ref name=SetoReview/> and would have raised the minimum age required for a person to be able to be diagnosed with pedophilia from 16 years to 18 years (with the individual needing to be at least 5 years older than the minor).<ref name="dsm5.org"/>

O'Donohue, however, suggests that the diagnostic criteria for pedophilia be simplified to the attraction to children alone if ascertained by self-report, laboratory findings, or past behavior. He states that any sexual attraction to children is pathological and that distress is irrelevant, noting "this sexual attraction has the potential to cause significant harm to others and is also not in the best interests of the individual."<ref>{{cite journal | author = O'Donohue W | title = A critique of the proposed DSM-V diagnosis of pedophilia | url = https://archive.org/details/sim_archives-of-sexual-behavior_2010-06_39_3/page/587 | journal = Arch Sex Behav | volume = 39 | issue = 3 | pages = 587–90 | date = Jun 2010 | pmid = 20204487 | doi = 10.1007/s10508-010-9604-5 | s2cid = 30900698 }}</ref> Also arguing for behavioral criteria in defining pedophilia, Howard E. Barbaree and [[Michael C. Seto]] disagreed with the American Psychiatric Association's approach in 1997 and instead recommended the use of actions as the sole criterion for the diagnosis of pedophilia, as a means of [[taxonomy (biology)|taxonomic]] simplification.<ref name="barbaree-seto">Barbaree, H. E., and Seto, M. C. (1997). Pedophilia: Assessment and Treatment. ''Sexual Deviance: Theory, Assessment, and Treatment''. 175–193.</ref>