From Perversion to Pathology: A Historical Perspective on Pedophilia

Arda ALTAY/Adobe Stock

Sexually problematic behaviors permeated society long before their recognition as medical or psychiatric disorders. Descriptions of voyeurism, bestiality, and exhibitionism are even found in the Bible.¹ The societal perception of sexual acts as “deviant” was commonly based on factors like the degree of consent involved, the potential for harm or distress, or societal distaste for certain sexual behaviors.² Over time, perception about such sexual behaviors has evolved considerably. In ancient Greek society, sexual relationships between adult men and adolescent boys were commonplace and seen as a form of mentoring.³ In contrast homosexuality and masturbation, while once considered aberrant expressions of sexuality, have since become normalized in most modern societies.⁴ Other expressions of sexual deviance, such as pedophilia, continue to be regarded as socially unacceptable, yet have undergone significant evolution in their conceptualization from perversion to pathology.

Initial conceptualizations of sexual deviance as perversions arose from the publication of Psychopathia Sexualis in 1886 by German psychiatrist Richard von Krafft Ebbing.⁵ Specifically, Krafft Ebbing classified any sexual activity not directly relating to procreation, including pedophilia, as a perversion of the sex drive.⁵ He believed that perversions stemmed from inherited flaws that disrupted the balance between sexual impulses and self-control.⁴ This view was supported by others in the field, including Sigmund Freud, who classified perversions as “aberrations according to the sexual aim” and “aberrations according to the sexual object,” characterizing pedophilia within the latter group.^4,6 Freud himself developed a range of theories about deviant sexuality, including the belief that perversions stemmed from developmental disturbances in the integration of “component drives,”to the idea that all sexual perversions could be understood as defenses against castration anxiety.^5,7

Literature from the early to mid-20th century cites various psychodynamic explanations behind pedophilia. Kurland reviewed a range of theories, from the idea that trauma during weaning an infant creates hostility towards the mother that is later displaced onto young girls, to the notion that prolonged mother-infant relationships contribute to deviant sexual development.^8-10 Sexual deviation as a perversion was also reflected in early versions of the DSM. The DSM-I characterized sexual deviations as “Sociopathic Personality Disturbances” under the Personality Disorder category. Sociopathic personality disturbances applied to individuals who were “ill primarily in terms of society and of conformity with the prevailing cultural milieu.”¹¹The DSM-II listed sexual deviations under the heading of “Personality Disorders and Certain Non-Psychotic Mental Disorders,” which included personality disorders, sexual deviations, alcoholism, and drug dependence.¹² The DSM-II considered “pedophilia” a sexual deviation but, like the DSM-I, did not further define the diagnostic criteria or associated features, including prognosis or longitudinal course. It recognized, however, that “even though many find their practices distasteful, [individuals with sexual deviation] remain unable to substitute normal sexual behavior for them.”¹² Given the prevailing theories and conceptualization of pedophilia, the primary focus of treatment at this time was psychoanalytic.¹³ During the 20th century, homosexuality and pedophilia were also often conflated, in part due to studies suggesting that both were associated with similar factors—such as being the youngest male sibling or having early sexual experiences in childhood or adolescence.^14,15 This perception was reinforced by historical associations, media portrayals, and efforts by political and religious groups to categorize both homosexuality and pedophilia as forms of “sexual immorality.”^16,17

During the later part of the 20th century, sexual deviations began to be viewed through the framework of psychiatric pathology. The DSM-III reflected this evolution and altogether replaced the term “sexual deviations” with “paraphilias,” which it categorized into a new diagnostic class called “Psychosexual Disorders.” In an editorial piece, Robert Spitzer, MD, contributor and chairperson of the DSM-III Task Force on Nomenclature and Statistics, indicated that paraphilias were included as mental disorders because even if an individual was not distressed by a paraphilia, it still caused impairment in an important area of functioning, namely, sexual functioning.¹⁸ Based on this logic, the DSM-III defined paraphilias as nonnormative arousal-activity patterns that could “interfere with the capacity for reciprocal affectionate sexual activity.”¹⁹ The DSM-III was the first to establish diagnostic criteria for pedophilia, defining it as “the act or fantasy of engaging in sexual activity with prepubertal children” and specifying that if the individual was an adult, the prepubertal child must be at least 10 years younger.¹⁹ It also provided guidance about the chronicity and prognosis of pedophilia.¹⁹

The next versions of the DSM varied in their consideration of the degree of “distress,” “impairment,” and “behaviors” needed to meet the criteria for pedophilia, which reflected ongoing discussion about balancing a medicalized approach to paraphilias while still allowing for the possibility of criminality without mental disorder. For example, the DSM-III-R in 1987 characterized pedophilia as a paraphilia within the class of “Sexual Disorders” and included 2 criteria: Criterion A, which required the presence of recurrent sexual urges or fantasies about sexual activity with prepubescent children, and Criterion B, which included the statement, “The person has acted on these urges, or is markedly distressed by them.”²⁰ However, the next version, the DSM-IV in 1994, omitted the first part of Criterion B and instead stated that “recurrent sexual fantasies, urges, or behaviors” (Criterion A) must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning’’ (Criterion B) to meet the full criteria for pedophilia.²¹ Although this change was meant to distinguish paraphilias from the nonpathological uses of sexual fantasies or behaviors for sexual excitement and from criminality, this was criticized by individuals who believed that this change meant that pedophilia was not considered a “mental disorder” unless it caused distress.^4,21,22 As a result, the DSM-IV-TR, published in 2000, reverted to the DSM-III-R definition for Criterion B. However, authors continued to caution the inherent danger in defining paraphilias by behavior alone, as it “blurs the distinction between mental disorder and ordinary criminality.”²²

Recent editions of the DSM have more clearly distinguished between nonpathological sexual arousal, mental disorders, and criminality associated with pedophilia. The DSM-5 was the first to differentiate between a paraphilia—defined as a persistent, intense, and atypical pattern of sexual arousal—and a paraphilic disorder.²³ Specifically, a paraphilic disorder (eg, pedophilic disorder) was defined as a paraphilia that causes distress or impairment to an individual or whose satisfaction entails harm to oneself or others. Accordingly, it clarified that individuals could have a pedophilic sexual interest without meeting the criteria for pedophilic disorder—for example, if they do not experience guilt, shame, or anxiety about their impulses, are not functionally impaired by them, and have never acted on them.²³ The DSM-5-TR preserved this definition.According to the DSM-5-TR, the diagnostic criteria for pedophilic disorder include: (A) recurrent, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child for at least 6 months; (B) the individual has either acted on these urges, or experiences marked distress or interpersonal difficulty as a result; and (C) the individual is at least 16 years old and at least 5 years older than the prepubescent child.²⁴ The DSM-5-TR also describes diagnostic and associated features, such as child pornography use, self-reported interests in children, or a history of multiple child victims and boy victims, to differentiate between child offenders with or without pedophilic disorder.²⁴

Treatments for pedophilia have evolved alongside changes in its classification and medicalization. Since the late 19th century, sexual deviance has been viewed as a medical problem. In light of this, surgical treatments such as castration also originated in the 19th century.²⁵ By the 20th century, surgical castration was used both in the United States and Europe for individuals who committed sexual offenses.²⁵ In the 1940s, biological treatments included oral estrogens, though these were largely replaced in the 1960s with testosterone-lowering medications, such as Depo Provera (injection of medroxyprogesterone).¹³ More recently, luteinizing hormone-releasing agonists were introduced to reduce testosterone levels successfully in individuals with paraphilic disorders including pedophilic disorder.¹³ Both surgical and biological treatments have been effective in decreasing sexual offender recidivism.¹³

While psychoanalytic therapy initially dominated as the treatment for sexual deviance, its questionable effectiveness led to the emergence of behavioral interventions beginning in the 1960s. Behavioral approaches were based on the idea that deviant sexual preferences, which motivated deviant behavior, were learned behaviors; thus, the treatment goal was based on reducing the deviant sexual response through negative and positive reinforcement.^26,27 A common method was aversion therapy, which paired noxious stimuli (eg, nausea-inducing injections, electrical shock) with either images related to the deviant behavior (Pavlovian conditioning) or the enactment of the deviant behavior (operant forms of punishment).²⁷ Classical conditioning techniques, such as those that paired unconditioned stimuli (pictures of young girls) with neutral stimuli (pictures of mature women), were also described.²⁸ Aversion therapy was the most common type of therapy for pedophilia during the 1960s and 1970s, and while it showed early success in reorienting pedophilic behavior,later studies revealed that it did not produce permanent changes in sexual behavior.^27,28

In the 1970s, cognitive behavioral therapy began to have a significant influence on clinical practice.²⁹ By the 1980s, the standard treatment approach to paraphilias, including pedophilia, had evolved to target sexual interests, associated attitudes, distorted beliefs, lack of empathy, and inadequate coping.³⁰ The focus of treatment shifted from external aversive methods (eg, electric shock) to self-regulatory methods.³¹ This approach aligned with the broader multifactorial model of sex offender treatment proposed by Abel et al which emphasized 5 main treatment components: correcting cognitive distortions, providing sex education, promoting social skills, decreasing deviant arousal (including with the use of medication), and increasing non-deviant arousal.³² By the late 1980s and throughout the 1990s, this approach was adopted by several large treatment programs that integrated relapse prevention into cognitive behavioral therapy programs for sex offenders, and this model continues to play a prominent role in treatment today.^13,29 Today, studies generally show that sex offenders with pedophilic disorder who receive treatment are less likely to reoffend compared to those who do not receive treatment.^33,34

Although treatment approaches to pedophilic disorder have evolved over time, psychiatrists have traditionally played a central role in treatment due to their expertise in pharmacology, psychotherapy, risk assessment, and navigation of ethical and legal complexities.³⁵ The role of psychiatrists in the management of pedophilic disorder should serve as a reminder that the disorder is a medical condition. The societal and political climate has, over time, challenged this concept, resulting in barriers to the research and treatment of pedophilic disorder. Unfortunately, today there remains a scarcity of psychiatrists with expertise and experience working with this population. It is important for psychiatrists to recognize pedophilic disorder as a pathological condition, both to combat societal misperceptions and stereotypes as well as establish a consensus that the disorder does and should remain in the DSM. Most importantly, psychiatrists can serve a pivotal role in decreasing child sexual abuse by treating pedophilic disorder, a risk factor for sexual offending.

Dr Kulkarni is an attending psychiatrist at Bridgewater State Hospital.

Dr Sorrentino is a clinical assistant professor at Harvard Medical School.

References

1. Aggrawal A. References to the paraphilias and sexual crimes in the Bible. J Forensic Leg Med. 2009;16(3):109-114.

2. Hensley C, Tewksbury R, eds. Sexual Deviance: A Reader. Lynne Rienner; 2003.

3. Laios K, Moschos MM, Koukaki E, et al. Homosexuality according to ancient Greek physicians. Psychiatriki. 2017;28(1):60-66.

4. De Block A, Adriaens PR. Pathologizing sexual deviance: a history. J Sex Res. 2013;50(3-4):276-298.

5. Oosterhuis H. Sexual modernity in the works of Richard von Krafft-Ebing and Albert Moll. Med Hist. 2012;56(2):133-155.

6. Ellenberger H. The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. Basic Books; 1970.

7. Metzl JM. Voyeur nation? Changing definitions of voyeurism, 1950–2004. Harvard Review of Psychiatry. 2004;12(2):127-131.

8. Kurland ML. Pedophilia erotica. J Nerv Ment Dis. 1960;131:394-403.

9. Cassity J. Psychological considerations of pedophilia. Psych Rev. 1927;14:189-199.

10. Hadley E. Comments on pedophilia. Med Record. 1926;124:157-162.

11. Diagnostic and Statistical Manual of Mental Disorders. First edition. American Psychiatric Association; 1952:38.

12. Diagnostic and Statistical Manual of Mental Disorders. Second edition. American Psychiatric Association; 1968:44.

13. Thibaut F, Cosyns P, Fedoroff JP, et al. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry. 2020;21(6):412-490.

14. Hughes JR. Review of medical reports on pedophilia. Clin Pediatr (Phila). 2007;46(8):667-682.

15. James WH. The cause(s) of the fraternal birth order effect in male homosexuality. J Biosoc Sci. 2004;36(1):51-59, 61-62.

16. Angelides S. The emergence of the paedophile in the late twentieth century. Aus Hist Studies. 2005;36(126):272-295.

17. Santos MEM, Sá-Silva JR. Medical science and pedophilia: knowledge, discourses, and representations of pedophilia in medical books from 1910 to 1990 in a Brazilian public library. Child Youth Serv Rev. 2024;160:107577.

18. Spitzer RL. The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. Am J Psychiatry. 1981;138(2):210-215.

19. Diagnostic and Statistical Manual of Mental Disorders. Third edition. American Psychiatric Association; 1980:261-272.

20. Diagnostic and Statistical Manual of Mental Disorders. Third edition revised. American Psychiatric Association; 1987:282-290.

21. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. American Psychiatric Association; 1994:525-529.

22. First MB, Frances A. Issues for DSM-V: unintended consequences of small changes: the case of paraphilias. Am J Psychiatry. 2008;165(10):1240-1241.

23. Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. American Psychiatric Association; 2013:685-700.

24. Diagnostic and Statistical Manual of Mental Disorders. Fifth edition, text revision. American Psychiatric Association; 2022:793-796.

25. Gordon H. The treatment of paraphilias: an historical perspective. Crim Behav Men Health. 2008;18(2):79-87.

26. Marshall WL, Barbaree HE. The long-term evaluation of a behavioral treatment program for child molesters. Behav Res Ther. 1988;26(6):499-511.

27. Laws DR, Marshall WL. A brief history of behavioral and cognitive behavioral approaches to sexual offenders: part 1 early developments. Sex Abuse. 2003;15(2):75-92.

28. Kelly RJ. Behavioral re-orientation of pedophiliacs: can it be done? Clin Psych Rev. 1982;2:387-408.

29. Marshall WL, Laws DR. A brief history of behavioral and cognitive behavioral approaches to sexual offender treatment: part 2 the modern era. Sex Abuse. 2003;15(2):93-120.

30. Marshall WL, Marshall LE. Psychological treatment of the paraphilias: a review and an appraisal of effectiveness. Curr Psychiatry Rep. 2015;17(6):47.

31. Marks IM. Review of behavioral psychotherapy, II: sexual disorders. Am J Psychiatry. 1981;138(6):750-756.

32. Abel GG, Becker JV, Skinner LJ. Behavioral Approaches to Treatment of the Violent Sex Offender. In: Clinical Treatment of the Violent Person. National Institute of Mental Health; 1985:100-123.

33. Marshall, WL. Are pedophiles treatable? Evidence from North American studies. J Sex Mental Health. 2008;6(1):39-43.

34. Landgren V, Malki K, Bottai M, Arver S, Rahm C. Effect of gonadotropin-releasing hormone antagonist on risk of committing child sexual abuse in men with pedophilic disorder: a randomized clinical trial. JAMA Psychiatry. 2020;77(9):897-905.

35. Glaser B. Psychiatry and paedophilia: a major public health issue. Aust N Z J Psychiatry. 1998;32(2):162-167.