Pedophilia: Clinical Features, Etiology and Treatment

Abstract

There is a growing recognition that child sexual abuse is a critical public health problem. Child sexual abusement is not a medical diagnosis and is not necessarily a term synonymous with pedophilia. According to DSM-IV, a pedophile is an individual who fantasizes about, is sexually aroused by, or experiences sexual urges toward prepubescent children (generally

Keywords

• Pedophilia, Paraphilia, Child, Sexual Abuse, Etiology, Treatment

Pedofili: Klinik Özellikleri, Nedenleri ve Tedavisi

Öz

Son yıllarda çocukların cinsel istismarının çok önemli bir halk sağlığı sorunu olduğu kabul edilmektedir. Çocuklara cinsel istismarda bulunmak tıbbi bir tanı olmadığı, her çocuğa cinsel istismarda bulunan kişinin de pedofilik olmadığı bilinmektedir. Pedofili en az 6 aylık bir süre boyunca, kişide ergenlik dönemine girmemiş bir çocukla ya da çocuklarla cinsel etkinlikte bulunmayla ilgili yoğun, cinsel yönden uyarıcı fantezilerinin, cinsel dürtülerinin ya da davranışlarının yineleyici biçimde ortaya çıkması olarak tanımlanmıştır. Genellikle eylemlerini gizli yaptıkları ve tedavi için başvurmadıkları için pedofili olgularının yaygınlığını belirlemek mümkün olamamaktadır. Diğer cinsel saldırı yapan gruplarla karşılaştırıldığında pedofilik bireylerin daha büyük yaş grubunda oldukları, eylemlerin yapıldığı ortalama yaşların ise 40-70 yaş arası olduğu gösterilmiştir. Pedofili bireylerin büyük çoğunluğu erkeklerdir. Çocuğun cinsel istismarı sözel istismar, cinsel organlarını gösterme, çocukları soyma ve seyretme, cinsel ilişkiye veya mastürbasyona tanık etme, cinsel organını sürtme, bedenine cinsel amaçla dokunma, okşama, müstehcen yayınlara konu etme, oral seks, ağza, vajinaya ve/veya anüse penetrasyon gibi çok çeşitli şekillerde ortaya çıkabilmektedir. Pedofili olgularının eylemlerinde genellikle zor kullanmadığı, aksine önce masum dokunma sonra uygunsuz dokunma, açık resimler gösterme, porno izletme gibi birçok fizik manipülasyon ve desensitizasyon uyguladıkları gösterilmiştir. Bu bireyler için internet ortamı bilgi edinme, mağduru belirleme ve ilişki kurma, fantezi geliştirme, diğer sapkınlığı olan kişilerle bağlantı kurma gibi birçok istek ve ihtiyaçlarını karşılamak için bir araç olmaya başlamıştır. Pedofili bireylerin eylemlerinin nadir olarak impulsif bir cinsel eylem olarak ortaya çıktığı, büyük çoğunluğunun önceden planlandığı gösterilmiştir. Pedofilik bireylerin aile içinde ve dışında sosyal teması sınırlı, içe kapanık, eşi ya da ailesiyle sıcak ilişki kuramayan psikopatik, psikoseksüel ve sosyal açıdan immatür kişilik özelliklerine sahip olduğu belirtilmektedir. Pedofilik eğilimin ortaya çıkmasında gelişimsel, ailesel ve çevresel faktörler ve bu faktörlerin etkileşimi gibi birçok faktörün etkili olduğu anlaşılmaktadır. Uzun süreli psikoterapi, farmakolojik tedavi sonrasında cinsel arzu ve istekte azalma saptanmasına karşın bu bireylerin çocuğa cinsel yönelimlerinde bir farklılık tespit edilmediği için günümüzde pedofilik bireylerin tedavisinde hedef çocuklara cinsel yönelimi değiştirmek olmayıp, yeniden eylemde bulunma oranlarını azaltmaya yöneliktir. Kimyasal kastrasyon adı verilen erkeklerde libidoya etkisi olan testesteron düzeyini düşürmek, bu yolla cinsel eylem sıklığını azaltmak konusu son yıllarda önem kazanmıştır. Tedavide sıkı adli ve klinik izlem ve raporlama, kimyasal ve cerrahi kastrasyon, psikoterapi ve psikofarmakolojik ilaçların kombine olarak kullanımı en büyük yararı sağlamaktadır.Cinsel istismarı ortadan kaldırmanın en etkin

Anahtar Kelimeler

• Pedofili, Parafili, Çocuk, Cinsel İstismar, Etyoloji, Tedavi

References

1. Lee J, Jackson H, Pattison P, Ward T. Developmental risk factors for sexual offending. Child Abuse Negl 2002; 26:73–92.
2. Craissati J, McClurg G. The challenge project: Perpetrators of child sexual abuse in South East London. Child Abuse Negl 1996; 20:1067–1077.
3. Çeçen AR. Çocuk cinsel istismarı: Sıklığı, etkileri ve okul temelli önleme yolları. Ulusla- rarası İnsan Bilimleri Dergisi, 2007;4:1-17.
4. İşeri E. Cinsel istismar. In Çocuk ve Ergen Psikiyatrisi Temel Kitabı (Eds FÇ Çetin, B Pehlivantürk, F Ünal, R Uslu, E İşeri, T Türkbay, A Coşkun, S Miral, N Motavallı): 470- 477. Ankara, Hekimler Yayın Birliği, 2008.
5. Snyder HN. Sexual Assault of Young Children as Reported to Law Enforcement: Victim, Incident, and Offender Characteristics. Washington, DC, USA, US Department of Justice, Bureau of Justice Statistics, 2000.
6. Amerikan Psikiyatri Birliği. Psikiyatride Hastalıkların Tanımlanması ve Sınıflandırılması Elkitabı, Yeniden Gözden Geçirilmiş 4. Baskı (DSM-IV-TR) (E.Köroğlu, Çev.). Ankara, Hekimler Yayın Birliği, 2001.
7. Freund K, Scher H, Chan S, Ben-Aron M. Experimental analysis of pedophilia. Behav Res Ther 1982; 20:105−112.
8. Abel GG, Harlow N. The Stop Child Molestation Book. Philadelphia, USA, Xlibris, 2001.

9. Blanchard R, Christensen BK, Strong SM, Cantor JM, Kuban ME, Klassen P et al. Retrospective selfreports of childhood accidents causing unconsciousness in phallometrically diagnosed pedophiles. Arch Sex Behav 2002; 31:511-526.
10. Raymond NC, Coleman E, Ohlerking F, Christenson GA, Miner M. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry 1999; 156:786–788.
11. Aktepe E. Çocukluk çağı cinsel istismarı. Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry 2009; 1:95-119.
12. Taner Y, Gökler B. Çocuk istismar ve ihmali: Psikiyatrik yönleri. Hacettepe Tıp Dergisi 2004; 35:82-86.
13. McConaghy N. Paedophilia: a review of the evidence. Aust NZJ Psychiatry 1998; 32:252-265.
14. Bagley C, Wood M, Young L. Victim to abuser: mental health and behavioral sequels of child sexual abuse in a community survey of young adult males. Child Abuse Negl 1994; 18:683-697.
15. Akduman GG, Ruban C, Akduman B, Korkusuz I. Çocuk ve cinsel istismar. Adli Psiki- yatri Dergisi 2005; 3:9–14.
16. Ceylan A, Tuncer O, Melek M, Akgün C, Gülmehmet F, Erden O. Van bölgesindeki çocuklarda cinsel istismar. Van Tıp Dergisi 2009; 16:131-134.
17. Vandiver DM, Kercher G. Offender and victim characteristics of registered female sexual offenders in Texas: A proposed typology of female sexual offenders. Sex Abuse 2004; 16:121-137.
18. Fagan PJ, Wise TN, Schmidt CW, Berlin FS. Pedophilia. JAMA 2002; 288:2458-2465.
19. Abel GG, Becker JV, Mittelman M, Cunningham-Rathner J, Rouleau JL, Murphy WD. Self-reported sex crimes of nonincarcerated paraphiliacs. J Interpers Violence. 1987;2:3-25.
20. Lanning KV. Child Molesters: A Behavioral Analysis. 4th ed. Alexandria, Va, National Center for Missing & Exploited Children, 2001.
21. Cohen LJ, Galynker II. Clinical features of pedophilia and implications for treatment. J Psychiatr Pract 2002; 8:276-289.
22. Hall RC, Hall RC. A profile of pedophilia: Definition, characteristics of offenders, recidivism, treatment outcomes, and forensic ıssues. Mayo Clin Proc 2007; 82:457- 471.
23. Danni K, Hampe GD. An analysis of predictors of child sex offender types using presentence investigation reports. Int J Offender Ther Comp Criminol 2000; 44:490- 504.
24. Murray JB. Psychological profile of pedophiles and child molesters. J Psychol 2000; 134:211-224.
25. Dickey R, Nussbaum D, Chevolleau K, Davidson H. Age as a differential characteristic of rapists, pedophiles, and sexual sadists. J Sex Marital Ther 2002; 28:211-218.
26. Green A. Child sexual abuse and incest. In Child and Adolescent Psychiatry. A Comprehensive Textbook, 2nd ed (Ed M Lewis): 1041-1048. Baltimore, MA, Williams&Wilkins, 1996.
27. Blanchard R, Barbaree HE, Bogaert AF, Dickey R, Klassen P, Kuban ME et al. Fraternal birth order and sexual orientation in pedophiles. Arch Sex Behav 2000; 29:463-478.
28. Greenberg DM, Bradford J, Curry S. Infantophilia—a new subcategory of pedophilia? a preliminary study. Bull Am Acad Psychiatry Law 1995; 23:63- 71.
29. Bogaerts S, Declercq F, Vanheule S, Palmans V. Interpersonal factors and personality disorders as discriminators between intra-familial and extra-familial child molesters. Int J Offender Ther Comp Criminol 2005; 49:48−62.
30. Akbaş S, Turla A, Karabekiroğlu K, Senses A, Karakurt MN, Taşdemir GN ve ark. Cinsel istismara uğramış çocuklar. Adli Bilimler Dergisi 2009; 8:24-32.
31. Avcı A, Tahiroğlu AY. Cinsel İstismar. In Çocuk ve Ergen Ruh Sağlığı ve Hastalıkları (Eds A Aysev, YI Taner): 721-736. İstanbul, Golden Print, 2007.
32. Tardif M, Van Gijseghem H. Do pedophiles have a weaker identity structure compared with nonsexual offenders? Child Abuse Negl 2001; 25:1381–1394.
33. Cohen LJ, Gans SW, McGeoch PG, Poznansky O, Itskovich Y, Murphy S et al. Impulsive personality traits in male pedophiles versus healthy controls: Is pedophilia an impulsive-aggressive disorder? Compr Psychiatry 2002; 43:127-134.
34. Gacono CB, Meloy JR, Bridges MR. A Rorschach comparison of psychopaths, sexual homicide perpetrators, and nonviolent pedophiles: where angels fear to tread. J Clin Psychol 2000; 56:757-777.
35. Curnoe S, Langevin R. Personality and deviant sexual fantasies: an examination of the MMPIs of sex offenders. J Clin Psychol 2002; 58:803-815
36. Whitaker DJ, Le B, Hanson RK, Baker CK, McMahon PM, Ryan G et al. Risk factors for the perpetration of child sexual abuse: A review and meta-analysis. Child Abuse Negl 2008; 32:529–548.
37. Hall GCN, Hirschman R. Sexual aggression against children: A conceptual perspective of etiology. Crim Justice Behav 1992; 19:8–23.
38. Ward T, Seigert RJ. Toward a comprehensive theory of child sexual abuse: A theory knitting perspective. Psychol Crime Law 2002; 8:319–351.
39. Marshall WL. Diagnostic issues, multiple paraphilias, and comorbid disorders in sexual offenders: Their incidence and treatment. Aggress Violent Behav 2007; 12:16– 35.
40. Ryan G. The relevance of early life experience in the treatment of sexually abusive youth. Irish J Psychol 1998; 19:32–48.
41. Tost H, Vollmert C, Brassen S, Schmitt A, Dressing H, Braus DF. Pedophilia: neuropsychological evidence encouraging a brain network perspective. Med Hypotheses 2004; 63:528–531.
42. Miller WB, Pasta DJ, MacMurray J, Chiu C, Wu H, Comings DE. Dopamine receptor genes are associated with age at first sexual intercourse. J Biosoc Sci 1999; 31:43–54.
43. Comings DE. Role of genetic factors in human sexual behavior based on studies of Tourette syndrome and ADHD probands and their relatives. Am J Med Genet 1994; 54:227–241.
44. Cantor JM, Kuban ME, Blak T, Klassen PE, Dickey R, Blanchard R. Grade failure and special education placement in sexual offenders’ educational histories. Arch Sex Behav 2006; 35:743-751.
45. Schiffer B, Peschel T, Paul T, Gizewski E, Forsting M, Leygraf N et al. Structural brain abnormalities in the frontostriatal system and cerebellum in pedophilia. J Psychiatr Res 2007; 41:753–762.
46. Stein DJ. Neurobiology of the obsessive–compulsive spectrum disorders. Biol Psychiatry 2000; 47:296–304.
47. Castle DJ, Phillips KA. Obsessive–compulsive spectrum of disorders: A defensible construct? Austr NZJ Psychiatry 2006; 40:114–120.
48. Bradford JM. The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias and compulsive sexual behaviour. Can J Psychiatry 2001; 46:26–34.
49. Alexander GE, Crutcher MD. Functional architecture of basal ganglia circuits: neural substrates of parallel processing. Trends Neurosci 1990; 13:266–271.
50. Alexander GE, Crutcher MD, DeLong MR. Basal ganglia-thalamocortical circuits: parallel substrates for motor, oculomotor, ‘‘prefrontal’’ and ‘‘limbic’’ functions. Prog Brain Res 1990; 85:119–146.
51. Mega MS, Cummings JL. Frontal subcortical circuits: anatomy and function. In The Frontal Lobes and Neuropsychiatric Illness (Eds SP Salloway, PF Malloy, JD Duffy): 15- 33. Washington, American Psychiatric Publishing, 2001.
52. Pujol J, Soriano-Mas C, Alonso P, Cardoner N, Menchen JM, Deus J et al. Mapping structural brain alterations in obsessive–compulsive disorder. Arch Gen Psychiatry 2004; 61:720–730.
53. Valente Jr AA, Miguel EC, Castro CC, Amaro Jr E, Duran FL, Buchpiguel CA, et al. Regional gray matter abnormalities in obsessive- compulsive disorder: A voxel based morphometry study. Biol Psychiatry 2005; 58:479–487.
54. Szeszko PR, Ardekani BA, Ashtari M, Malhotra AK, Robinson DG, Bilder RM, et al. White matter abnormalities in obsessive–compulsive disorder: A diffusion tensor imaging study. Arch Gen Psychiatry 2005; 62:782–90.
55. Liberzon I, Martis B. Neuroimaging studies of emotional responses in PTSD. Ann N Y Acad Sci 2006; 1071:87-109.
56. Rauch SL, Shin LM, Phelps EA. Neurocircuitry models of posttraumatic stres disorder and extinction: human neuroimaging research—past, present, and future. Biol Psychiatry 2006; 60:376-382.
57. Maes M, De Vos N, Van Hunsel F, Van West D, Westenberg H, Cosyns P et al. Pedophilia is accompanied by increased plasma concentrations of catecholamines, in particular epinephrine. Psychiatry Res 2001; 103:43-49.
58. Maes M, van West D, De Vos N, Westenberg H, Van Hunsel F, Hendriks D et al. Lower baseline plasma cortisol and prolactin together with increased body temperature and higher mCPP-induced cortisol responses in men with pedophilia. Neuropsychopharmacology 2001; 24:37-46.
59. Blanchard R, Watson MS, Choy A, Dickey R, Klassen P, Kuban M et al. Pedophiles: mental retardation, maternal age, and sexual orientation. Arch Sex Behav 1999; 28:111-127.
60. Cohen LJ, McGeoch PG, Gans SW, Nikiforov K, Cullen K, Galynker II. Childhood sexual history of 20 male pedophiles vs. 24 male healthy control subjects. J Nerv Ment Dis 2002; 190:757-766.
61. Proeve M, Reilly E. Personal and offending characteristics of child sexual offenders who have been sexually abused. Psychıatry Psychol Law 2007; 14:251–259.
62. Salter D, McMillan D, Richards M, Talbot T, Hodges J, Bentovim A et al. Development of sexually abusive behaviour in sexually victimised males: A longitudinal study. Lancet 2003; 361:471–476.
63. Kavoussi RJ, Kaplan M, Becker JV. Psychiatric diagnoses in adolescent sex offenders. J Am Acad Child Adolesc Psychiatry 1988; 27:241–243.
64. Berner W, Berger P, Guitierrez K, Jordan B, Berker K. The role of personality disorders in the treatment of sex offenders. J Offender Rehabil 1992; 11:159–169.
65. Seto MC, Cantor JM, Blanchard R. Child pornography offenses are a valid diagnostic indicator of pedophilia. J Abnorm Psychol 2006;115:610-615.
66. Quayle E, Taylor M. Model of problematic Internet use in people with a sexual interest in children. Cyberpsychol Behav 2003; 6:93-106.
67. Durkin KF, Bryant CD: “Log on to sex”: some notes on the carnal computer and erotic cyberspace as an emerging research frontier. Deviant Behav 1995; 16:179–200.
68. McGrath MG, Casey E. Forensic psychiatry and the internet: Practical perspectives on sexual predators and obsessional harassers in cyberspace. J Am Acad Psychiatry Law 2002; 30:81–94.
69. Meloy JR. Stalking (obsessional following): a review of some preliminary studies. Agress Violent Behav 1996; 1:147–162.
70. Cooper A, Scherer CR, Boies SC, Gordon BL. Sexuality on the internet: From sexual exploration to pathological expression. Profess Psychol 1999; 30:154–164.
71. Johnson S. Psychological force in sexual abuse: Implications for recovery. In The Sex Offender: New Insights, Innovations and Legal Developments Vol 2 (Eds BK Schwartz , HR Cellini): 17-1-11. Kingston, NJ, Civic Research Institute, 1997.
72. Casey E. Cyberpatterns: criminal behavior on the internet. In Criminal Profiling: An Introduction to Behavioral Evidence Analysis (Ed B Turvey): 299-327. London, Academic Press, 1999.
73. Saleh FM, Berlin FS. Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders. J Child Sex Abus 2003; 12:233-253.
74. Quinsey VL, Harris GT, Rice ME, Lalumière ML. Assessing treatment efficacy in outcome studies of sex offenders. J Interpers Violence 1993; 8:512-523.
75. Berlin FS. Sex offender treatment and legislation. J Am Acad Psychiatry Law 2003; 31:510–513.
76. Schober JM, Kuhn PJ, Kovacs PG, Earle JH, Byrne PM, Fries RA. Leuprolide acetate suppresses pedophilic urges and arousability. Arch Sex Behav 2005;34:691-705.
77. McGrath RJ, Cumming GF, Livingston JA, Hoke SE. Outcome of a treatment program for adult sex offenders. From prison to community. J Interpers Violence 2003; 18: 3- 17.
78. McGrath RJ, Hoke SE, Vojtisek JE. Cognitive-behavioral treatment of sex offenders. A treatment comparison and long-term follow- up study. Crim Justice Behav 1998; 25:203-225.
79. McGuire, J. Integrating findings from research reviews. In Offender Rehabilitation And Treatment: Effective Programmes and Policies to Reduce Re-Offending (Ed J McGuire): 3-38. Chichester, UK, Wiley, 2002.
80. Zonana H, Abel G, Bradford J. Pharmacological treatment of sex offenders, In Dangerous Sex Offenders: A Task Force Report of the American Psychiatric Association: 103-127. Washington DC, American Psychiatric Association, 1999.
81. Guay DRP. Drug treatment of paraphilic and nonparaphilic sexual disorders. Clin Ther 2009; 31:1-31.
82. Stone TH, Winslade WJ, Klugman CM. Sex offenders, sentencing laws and pharmaceutical treatment: a prescription for failure. Behav Sci Law. 2000; 18:83-110.
83. Chow EW, Choy AL. Clinical characteristics and treatment response to SSRI in a female pedophile. Arch Sex Behav 2002; 31:211-215.
84. Fong TW, De La Garza R II, Newton TF. A case report of topiramate in the treatment of nonparaphilic sexual addiction. J Clin Psychopharmacol 2005; 25:512-514.
85. Bradford JM. The paraphillas, obsessive compulsive spectrum disorder, and the treatment of sexually deviant behavior. Psychiatr Q 1999; 70:209-219.
86. Hughes JR. Review of medical reports on pedophilia. Clm Pediatr 2007; 46:667-682.
87. Schmucker M, Lösel F. Does sexual offender treatment work? A systematic review of outcome evaluations. Psicothema 2008; 20:10-19.
88. Meyer WJ, Cole C, Emory, E. Depo provera treatment for sex offending behavior: An evaluation of outcome. Bull Am Acad Psychiatry Law 1992; 20:249-259.
89. Scott L, MD, Holmberg T. Castration of Sex Offenders: Prisoners’ Rights Versus Public Safety. J Am Acad Psychiatry Law 2003;31:502–9
90. Bradford JMW, Pawlak A. A double-blind placebo crossover study of cyproterone acetate in the treatment of the paraphilias. Arch Sex Behav 1993; 22:383–402.
91. Yalın A, Kerimoğlu E, Erman H. Okul öncesi çocuklarda cinsel istismarı önleme prog- ramı: ana babaların tutum, görüş ve davranışlarının taranması. Çocuk ve Gençlik Ruh Sağlığı Dergisi 1995; 2:19-27.