Pedophilic disorder is characterized by recurrent, intense sexually arousing fantasies, urges, or behaviors involving sexual activity with prepubescent children (generally ≤ 13 years); based on clinical criteria, it is diagnosed only when the patient is ≥ 16 years and ≥ 5 years older than the child who is the target of the fantasies or behaviors.
Pedophilia is a form of paraphilia that causes harm to others and is thus considered a paraphilic disorder. Multiple studies suggest that there are both structural and functional differences in the brains of pedophiles compared to those of controls, in both cortical and subcortical areas (eg, limbic system, frontostriatal region) (1).
Sexual offenses against children constitute a significant proportion of reported criminal sexual acts. For older adolescents (ie, 17 to 18 years old), ongoing sexual interest or involvement with a 12- or 13-year-old may not meet the clinical criteria for a disorder, as Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria stipulate that the offender must be over 16 years of age and the individual who has been engaged in sexual activity must be at least 5 years younger than the offender. However, legal criteria may be different from psychiatric criteria. For example, sexual activity between a 19-year-old and a 16-year-old may be a crime but not a pedophilic disorder, depending on the jurisdiction. Diagnostic age guidelines from Western classification systems, including DSM-5-TR, may not apply to all cultures. Many cultures accept sexual activity, marriage, and childbearing at younger ages and accept much greater age differences between sex partners. In a systematic review of nonoffenders, sexual attraction to minors is reported to be present in 2 to 24% of men worldwide (2).
Most pedophiles are male. The prevalence is unknown but is estimated to be up to 3% of the adult male population and substantially lower in women (3). Attraction may be to children or adolescents of 1 or more than 1 gender. However, pedophiles are known to prefer opposite-sex to same-sex children in a 2:1 ratio (4). In most cases, the adult is known to the child, and may be a family member, stepparent, or a person with authority (eg, a teacher, clergy, a coach). Looking at children undressed and fondling their genitals seems more prevalent than intercourse for nonincestuous cases of pedophilia (5).
Pedophiles may be attracted only to children (exclusive form) or also adults (nonexclusive form); some are attracted only to children who are related to them (incest).
Predatory pedophiles, many of whom have antisocial personality disorder, may use force and threaten to physically harm the child or the child’s pets if the abuse is disclosed. When both antisocial personality disorder and pedophilia are simultaneously present, treatments have been shown to be of limited value compared to those with pedophilia alone as measured by increased dropout rates from treatment and increased recidivism rates for individuals with both conditions (5, 6).
The course of pedophilia is chronic, and perpetrators often have or develop substance use disorders or dependence and depression. Pervasive family dysfunction, a personal history of sexual abuse, and marital conflict are common. Other comorbid disorders include attention-deficit/hyperactivity disorder, anxiety disorders, and posttraumatic stress disorder.
General references
1. Kirk-Provencher KT, Rebecca J Nelson-Aguiar RJ, Spillane NS. Neuroanatomical differences among sexual offenders: A targeted review with limitations and implications for future directions. Violence Gend. 7(3):86-97, 2020. doi: 10.1089/vio.2019.0051
2. Savoie V, Quayle E, Flynn E. Prevalence and correlates of individuals with sexual interest in children: A systematic review. Child Abuse Negl. 2021;115:105005. doi:10.1016/j.chiabu.2021.105005
3. Seto MC, Kingston DA, Bourget D. Assessment of the paraphilias. Psychiatr Clin North Am. 37(2):149-161 2014. doi: 10.1016/j.psc.2014.03.001
4. Freund K, Watson RJ. The proportions of heterosexual and homosexual pedophiles among sex offenders against children: An exploratory study. J Sex Marital Ther. 18(1):34-43, 1992. doi: 10.1080/00926239208404356
5. Hall RC, Hall RCW. A profile of pedophilia: Definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues. Mayo Clin Proc. 82(4):457-471, 2007. doi: 10.4065/82.4.457
6. Cohen LJ, Galynker II. Clinical features of pedophilia and implications for treatment. J Psychiatr Pract. 8(5):276-289, 2002. DOI: 10.1097/00131746-200209000-00004
Diagnosis of Pedophilic Disorder
Psychiatric assessment
Extensive use of child pornography is a reliable marker of sexual attraction to children and may sometimes be the only indicator of the disorder. However, the use or possession of child pornography by itself does not meet criteria for pedophilic disorder, although it is typically illegal.
If a patient denies sexual attraction to children but circumstances suggest otherwise, certain diagnostic tools (typically in the context of legal involvement) can help confirm such attraction. Tools include penile plethysmography (men), vaginal photoplethysmography (women), and viewing time of standardized erotic materials; however, the possession of such material, even for diagnostic purposes, may be illegal in certain jurisdictions.
Clinical criteria for diagnosis of pedophilic disorder from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) include the following (1):
Recurrent, intense sexually arousing fantasies, urges, or behaviors involving a prepubescent child or children (usually ≤ 13 years) have been present for ≥ 6 months.
The person has acted on the urges or is greatly distressed or impaired by the urges and fantasies. The experience of distress about these urges or behaviors is not a requirement for the diagnosis, as many with this condition deny any distress or impairment.
The person is ≥ 16 years and ≥ 5 years older than the child who is the target of the fantasies or behaviors (but excluding an older adolescent who is in an ongoing relationship with a 12- or 13-year-old).
When making the diagnosis, the clinician must specify whether
The patient has an exclusive attraction to prepubescent children (exclusive type) or attraction to both children and adults (nonexclusive type).
The patient is sexually attracted to males, females, or both.
The behaviors/urges/fantasies are limited to incest.
Identifying a patient as a potential pedophile sometimes poses an ethical crisis for clinicians. However, clinicians have a responsibility to protect the community of children. If clinicians have reasonable suspicion of child sexual or physical abuse, the law requires that it be reported to authorities. Clinicians should know the reporting requirements in their state, as these can vary (2).
Diagnosis references
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022:792-796.
2. Child Welfare Information Gateway. State Statutes Search. Accessed August 25, 2025.
Treatment of Pedophilic Disorder
Individual and/or group psychotherapy
Treatment of comorbid disorders
Pharmacologic therapy (eg, antiandrogens, selective serotonin reuptake inhibitors [SSRIs])
Although there are few randomized trials of treatments for pedophilia, long-term individual or group psychotherapy, particularly cognitive-behavioral therapy, is usually necessary. This approach may be especially effective when integrated into a multimodal treatment plan that includes social skills training, treatment of comorbid physical and psychiatric disorders, and pharmacologic therapy involving androgen deprivation (1).
The treatment of pedophilia has been suspected to be less effective when court ordered, although many adjudicated sex offenders have benefited from treatments, such as group psychotherapy along with antiandrogens (2). Some clinics that have treated self-referred and court-ordered patients have accumulated long-term follow-up studies using phallometric monitoring. They have reported substantial improvements with treatment over the long term with low recidivism rates (3).
Some pedophiles who are committed to treatment and monitoring can refrain from pedophilic activity and be reintegrated into society. Such results tend to be more likely when no other psychiatric disorders, particularly personality disorders, are present.
Medications
Depot medroxyprogesterone acetateDepot medroxyprogesterone acetate
Sometimes gonadotropin-releasing hormone (GnRH) agonists
Cognitive-behavioral therapy
Medications are most effective when used as part of a multimodal treatment program that involves cognitive-behavioral therapy.
By blocking pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), medroxyprogesterone reduces By blocking pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), medroxyprogesterone reducestestosterone production and thus reduces libido. Cyproterone acetate, which blocks testosterone receptors, is used in Europe. Serum testosterone should be monitored and maintained in the normal female range in male patients. Treatment is usually long-term because pedophilic fantasies usually recur weeks to months after treatment is stopped. Liver tests should be done, and blood pressure, bone mineral density, and complete blood count should be monitored as required.
GnRH agonists (eg, leuprolide, goserelin), which reduce pituitary production of LH and FSH and thus reduce GnRH agonists (eg, leuprolide, goserelin), which reduce pituitary production of LH and FSH and thus reducetestosterone production, are also an option and require less frequent IM injections (at 1- to 6-month intervals) than medroxyprogesterone (production, are also an option and require less frequent IM injections (at 1- to 6-month intervals) than medroxyprogesterone (4). The onset of therapeutic action is reported to be 2 weeks after the initial injection. However, the cost is usually considerably higher.
The usefulness of antiandrogens in female pedophiles is less well established.
In addition to antiandrogens, limited unblinded data suggest that SSRIs may be useful (4). One unreplicated study demonstrated some efficacy for benperidol (5).
Treatment references
1. Castro Rodrigues J, Vieira M, da Silva BF, Ribeiro LM. What’s new on the treatment of pedophilia and hebephilia?. Eur Psychiatry. 2023;66(Suppl 1):S1098. Published 2023 Jul 19. doi:10.1192/j.eurpsy.2023.2333
2. von Franqué F, Briken P. Mandated or Voluntary Treatment of Men Who Committed Child Sexual Abuse: Is There a Difference?. Front Psychiatry. 2021;12:708210. Published 2021 Sep 30. doi:10.3389/fpsyt.2021.708210
3. Federoff JP. Pedophilia: Interventions that work. Psychiatric Times. 33(7): 2016.
4. Hall RCW, Hall RCW. A profile of pedophilia: Definition, characteristics of offenders, recidivism, treatment outcomes, and forensic issues. Mayo Clin Proc. 82(4):457-471, 2007. doi: 10.4065/82.4.457
5. Tennent G, Bancroft J, Cass J. The control of deviant sexual behavior by drugs: a double-blind controlled study of benperidol, chlorpromazine, and placebo. The control of deviant sexual behavior by drugs: a double-blind controlled study of benperidol, chlorpromazine, and placebo.Arch Sex Behav. 1974;3:261–71
