Pedophilia: Definition, classifications, criminological and neurobiological profiles, and clinical treatments. A complete review

However, there are exceptions to this strictly clinical rule and they concern environmental factors and circumstances. This diagnosis is excluded if the two subjects are both minors (provided they have reached puberty or are peers with absence or reduced presence of drives sexually attributable to libidinal energy [4]) or the sexual bond is secondary to a bond of affection between the two subjects who are fully aware of the intrapersonal and interpersonal implications of their behavior, and provided that they are sexually mature, even if the culture of origin admits as functional the relationship between older and younger subjects beyond the limits indicated by western cultures [2].


Introduction, defi nition, classifi cation and diagnostics aspects
Pedophilia is a form of paraphilia recognized and classifi ed in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, V ed.) and other psychodiagnostic manuals [1]. It is a paraphilic disorder which meets certain criteria [2,3]. a) recurring sexual fantasies, impulses, or behaviors involving one or more prepubertal children (usually ≤ 13 years) that have been present for ≥ 6 months; b) the person is driven by the impulses, has diffi culty resisting the impulses, or is altered by the impulses and fantasies; c) the person is ≥ 16 years old and at least ≥ 5 years older than the child-targeted by the fantasies or behavior.
However, there are exceptions to this strictly clinical rule and they concern environmental factors and circumstances.
This diagnosis is excluded if the two subjects are both minors (provided they have reached puberty or are peers with absence or reduced presence of drives sexually attributable to libidinal energy [4]) or the sexual bond is secondary to a bond of affection between the two subjects who are fully aware of the intrapersonal and interpersonal implications of their behavior, and provided that they are sexually mature, even if the culture of origin admits as functional the relationship between older and younger subjects beyond the limits indicated by western cultures [2].
Epistemological data underline a greater prevalence of pedophilia among the male sex over the female sex, but the data appear to be underestimated, especially about female pedophilia where they generally prefer young male children, who tend to be younger than male pedophiles' victims. Female pedophiles often have been victims of abuse and mistreatment in childhoods and tend to have other disorders, such as depression, substance abuse, and frequent personality disorders. They also have diffi culties in intimate relationships with peers, have low self-esteem, poor anger management skills, are afraid of being abandoned, and show emotional diffi culties such as limited empathy, and act together with men (in these cases, in general, more than one child is involved) [2,5]. Recent research [8][9][10], has helped to defi ne two distinct profi les: those who limit themselves to the possession and exchange of child pornography and those who, in addition to holding these materials, try to involve children and adolescents directly in sexual acts. Within this second profi le, the presence of two subgroups have been identifi ed: a) Fantasy-driven: motivated to involve teenagers in virtual sex without requesting a direct meeting; b) Contact-driven: motivated to engage in sexual relations with teenagers outside the Internet.
Generally, however, there are 2 types of pedophiles: the sadistic pedophiles and the playful pedophiles. The sadistic pedophile experiences maximum pleasure by brutalizing his victim. This occurs both through psychological violence (humiliation) and through physical violence. The playful pedophile tends to play with children and rarely traumatizes them. The game has the dual purpose of winning the trust of a) exclusive when the patient is attracted only to children; b) non-exclusive, if the pedophile experiences attraction and sexual drive for subjects over the age considered to be pathological; c) differentiated, when the adult is attracted exclusively to one sex (male or female); d) undifferentiated when the adult is attracted indiscriminately to both sexes (male and female); e) preferential when the adult is attracted to both sexes but has a higher prevalence to one; f) incestuous when the adult experiences attraction and drive exclusively or mainly for a minor linked by a family relationship (children, brothers, sisters, grandchildren, or cousins).
For the diagnosis of this mental disorder, it is not necessary to wait for the sexual interest to materialize in the sexual act with the minor [2].
Registry age plays a fundamental role in identifying this morbid condition. The central parameter for the diagnosis of pedophilic disorder is sexual attraction for subjects aged 13 or under. Therefore, the victims are not yet developed from a maturational and sexual point of view, even if from a legal point of view, this age limit is slightly higher than an age of consent (for example, in the UK the age of consent to perform sexual acts is 16 years, while in Italy it is 14 years). For the pedophilic form, it is necessary to distinguish pederasty (ephebophilia towards males, nymphophilia towards females), i.e. sexual attraction towards subjects of adolescent age, between 14 and 17 years old. Socially more tolerated and less serious, this attraction focuses on subjects who have completed or are completing the phase of sexual development and maturity [2].
Another important distinction lies in the difference between a pedophile and a child molester, as too often, especially in the common sense and in journalistic jargon, outside the psychiatric sphere, these two terms are confused or scrambled.
The pedophile is the one who presents a marked and signifi cant pathological deviation of the libido towards children but who does not carry out violent acts (i.e. objective behavior).
However, there are hypotheses in which the pedophile is also an active molester (and in this case, it is not uncommon to fi nd a comorbidity with antisocial, borderline, or histrionic personality disorders), but other hypotheses exist where the molester is not necessarily a pedophile [6].
The places of interest where the victim can be identifi ed and chosen is always linked to family or public activities such as schools or youth meeting centers. In recent years, the Internet has become another place (albeit non-physical) where potential victims may be found, thanks to social networks and online messaging. In criminological and judicial practice [5], with the child, proposed as part of the game itself [5].

Psychological profi les
The term pedophilia derives from the Greek pais = child and fi lìa = love, and means love for children. From a behavioral point of view, this interest can manifest itself in multiple ways, from simply looking at children to adopting strongly sexualized behaviors, which may include: stripping, stroking, or touching the child or masturbating in his presence, or by subjecting the child to oral, anal, or vaginal intercourse by penetrating the child with the penis, fi ngers, or other objects. A distinctive feature of this pathology is its ego-syntonic character.
It is conduct that does not cause discomfort to the subject, but gives him pleasure [11]. For this reason, the pedophile is not aware of having an illness, does not present feelings of guilt towards the victims, and frequently presents a series of errors of thought that lead him to justify his actions and to consider the victim as consenting. On the other hand, those who are aware of their condition have a pedophile tendency, which has not yet fully evolved into the actual disorder [2].
In dynamic psychology, the classical psychoanalytic thesis maintains that the pedophilic act is linked to fi xations and regressions towards forms of infantile sexuality. We stress the importance of drive theory, but also of relational aspects in the genesis of pedophile behavior. The explanatory factor hypothesized consists of halted psychosexual development due to early trauma or having lived one's sexuality in a restrictive environment, or pedophilia could be the result of sexual confl icts reached without the contribution of the imagination, probably due to a failure of consciousness caused by a pathology [4]. In any case, the approach of S. Freud [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] who considered pedophilia as a perversion, taken up more recently by Kernberg, is based on the castration anxiety that hinders the pervert from achieving adult sexuality and makes him regress to a partial drive (anal, oral, .). The fear of facing an adult woman makes him fall back towards a less powerful and therefore, less anxiety-provoking subject, with whom he can avoid penetration, or if he faces it, it occurs from a position of strength [32]. Freud stated that childhood traumas, in general, are incurable and leave wounds that no longer heal and that provoke in adults with a history of abuse in their childhoods, a multiplicity of phenomena affecting the emotional, relational, social, and behavioral spheres of varying depths [4].
Recent psychoanalytic approaches distinguish between pedophilic behavior, pedophilic fantasy, and pedophilic obsession (which must have sexual activity with a child in order not to suffer from intolerable and anguished anxiety).
The bases of this theory are, however, exclusively derived from clinical observations and in any case, explain very little about why pedophilia is chosen by some individuals as a defense mechanism instead of other possible defensive mechanisms [4]. Failure to resolve the oedipal crisis through identifi cation with the father-assailant (for boys) or mother-aggressor (for girls), causes an improper identifi cation with the parent of the opposite sex or an improper choice of the object for libidinal catharsis [12]. To appease their castration anxieties, paraphilics are forced to constantly examine their own or others' genitals. Also, the decisive factor that prevents orgasm through conventional genital intercourse is castration anxiety.
Perversions, therefore, perform the function of denying castration [13]. Many people suffering from paraphilias have separated and incompletely identifi ed from their intrapsychic representations of the mother. The result is that they feel that their identities as separate people are constantly being threatened by a merger or incorporation by internal or external objects. Sexual expression may be the only area in which they manage to assert their independence. Another aspect of the relief experienced by paraphilic patients after they have implemented their sexual desires is their feeling of triumph over the mother who controls them from within [12]. Pedophiles especially need to dominate and control their victims, to make up for their feelings of helplessness during the Oedipal crisis. Some theorists believe that the choice of a child as an object of love by pedophiles is narcissistic. According to the classical view [13], pedophilia does represent a narcissistic object choice, since the pedophile sees the child as a mirror image of himself as a child. Narcissism results from the oedipal fi xation, where the pedophile identifi es with his mother and sees himself in the child. Pedophiles are also considered to be weak and helpless individuals because their choice of children as sexual objects pose less resistance or create less anxiety than adult partners, thereby allowing pedophiles to avoid castration anxiety [14]. In clinical practice, many pedophiles are found to suffer from a narcissistic character pathology, including psychopathic variants of narcissistic personality disorder. Finally, another author believes that the origins of pedophile tendencies should be sought in the very fi rst mother-child interactions, as the mother's narcissistic needs for self-love could be excessively transmitted to the child due to the mother's need to be idealized by the son. This would have the effect of substantially delaying the child's separation-detection process [15].
Still on the dynamic trend, Jungian psychology has not made great contributions to the study of pedophilia, except for a group of analysts (including Gordon) who argue that to understand pedophilia it is essential to consider its non- pathological version. In practice, normal pedophilia consists of the adult-child interaction, but at the same time is mediated and altered by the characteristics of childhood. In pedophilia, there could be a tendency to retain an idealized desire for the purity and innocence of childhood [4].
Some psychotherapists [4,67] who treat perpetrators of sexual abuse against children seem to adhere to the theory that pedophilia is caused by the fact that the sexual perpetrators were themselves abused in childhood. Garland and Dougher thus coined the term abuse abuser theory, which is strongly criticized for the lack of representative samples due to the heterogeneity of the abusers, the absence of adequate control groups, and insuffi cient statistical evaluations. However, the theory still appears interesting and has not yet been denied.
In essence, the crimes of the adult aggressor can be in part a repetition and a refl ection of a sexual assault that he suffered as a child. Pedophilia is then a distorted attempt to give an outlet to early unresolved sexual trauma. This theory was originally In a study aimed at researching the degree of parental identifi cation, for example, subjects defi ned as pedophiles had a low degree of identifi cation towards their parents compared to a control group represented by college students or compared to a group of subjects defi ned as criminals. These fi ndings support the notion that sex offenders are different from other offenders in their perception of parental identifi cation. Failure to identify can play an important role in the development of a psychosexual disorder [33].
The psychiatric psychodiagnostic instead hypothesize the existence of: a) Primary pedophilia which involves, to a certain extent, an integration of the pedophile ego and a consequent stability of its personality; b) Secondary pedophilia, resulting from other serious psychopathologies such as schizophrenia, some organic psychoses, and other conditions in which the personality disintegrates, causing a series of perverse behaviors.
On this line of thought, pedophilia takes on the appearance of a paraphilia composed of two very distinct aspects, aggression, which has as its purpose the imposition of suffering and is aimed at neutralizing threats to the mental and physical survival of the perverted individual, and annihilation, as intimate relationships with others, generally viewed as normal, are viewed as perilous or destructive by perverts, since in such situations they feel completely under the control of the other person. The emotional focus of the pedophile's relationship with others is on himself. An important question that remains open is how can a pedophile commit acts that the whole of society, including criminals, strongly and unequivocally condemns. The explanation that Glasser offers underlines the fact that the company's regulatory standards do not become an integral part of the pedophile's personality due to the strong repulsion he feels for his parents and other authoritarian fi gures who mistreated him during childhood. In pedophile activities, what is pursued is precisely the protest against them. Nonetheless, there is a struggle between the individual's internal psychological needs and the pressures of society, which results in the characteristic self-deception of the pedophile [34,35].
The cognitive model claims that pedophiles seek any means to justify their actions and use, for example, pornography as a source of reassurance. In it, pedophiles see other adults doing the things that they do or would like to do and this creates an aura of normality around the abuse that can loosen their inhibitions, and constitute the fi rst step of an escalation that can result in the most foul acts. In this perspective, the idea that pornography serves as a relief valve, useful for diverting sexual energy away from the material fulfi llment of abuse, is rejected. Pedophilia is considered by cognitivism to be like an addictive behavior, as is the case with alcohol and drug use, and therefore it cannot be contained and fought by offering material that instead feeds it. Among the characteristics of the cognitive style of pedophiles, there is the minimization of abuse. In fact, in their stories, the abuse is defi ned as something consensual and in a certain sense desired by the child himself. Pedophiles often defend themselves, citing as an excuse for their behavior, unemployment, or a family bankruptcy. These are nothing more than defensive rationalizations, which act as fragile justifi cations. Some authors have hypothesized the presence of cognitive distortions but they cannot be considered as a specifi c etiological factor, as abusers distort perceptions in terms advantageous to themselves and only secondarily report their deviant desire to have sex with the minor. This is the indicative precursor, not a distorted perception. As a result, distorted interpretations of children's behavior can lead to inappropriate beliefs, while it is more diffi cult for beliefs to produce the perceptions themselves [5]. serotonergic turnover, which are related to impulse control and aggressivity-ostility, behaviours that are associated with paedophilia [56,57].
In the course of visual stimulation with images of naked children, increased brain response in areas known to be generally involved in the development of sexual stimuli (in particular, insula and cingulate gyrus) has been observed. The cerebral response of pedophiles in front of naked children is similar to that of adults in front of images of naked adults [39].
Conversely, in the course of visual stimulation with images of naked adults, a reduced activation is observed in areas of the brain that usually activate in non-pedophile subjects, since it would refl ect in the brain the lack of sexual interest in adults [40].
Furthermore, the left hemisphere of criminals' brains tend to be smaller than that of normal subjects. Pedophiles, in particular, differ from normal subjects and rapists in the particularity of having the left hemisphere smaller than the right one [2,41].
Also, although there is no defi nitive evidence on the involvement of hormone profi les about pedophilia, some results indicate an increase in prolactin, cortisol, testosterone, and androsterone. In any case, there is a great deal of caution in presenting these results since the altered hormone levels could also be due to the stressful events suffered by the subjects [42].
Recently, genetic studies have shown that the cause of an adult's diverted attraction towards children could be the result of the defect of a growth factor (progranulin) involved in numerous physiological, but also pathological processes. This defect is the consequence of a progranulin genetic mutation [43].

Treatments and therapies
The most correct clinical treatment appears to be the integrated one between pharmacological profi les (usually antiandrogens, anxiolytics, and serotonin reuptake inhibitors) and cognitive-behavioral, strategic, or group psychotherapy Studies have shown that pedophiles can share many psychiatric characteristics beyond deviant sexual desire, including high rates of affective disorder disorders, substance use disorders, impulse control disorders, other paraphilias, as well as cluster personality disorders B and A. Among the etiological causes, the childhood history of sexual abuse and the underlying neurobiology of deviant sexual arousal certainly emerge, with a reduction in erotic differentiation [44].
Neuroimaging studies show a heterogeneous picture and do not allow defi nitive conclusions on the neurobiological mechanisms underlying pedophilic preferences and behavior.
However, the three theories outlined above, the altered network transformation related to sexual arousal remain factors to be investigated for future studies. Ultimately, success could be achieved with further investigation on a subject that still carries a considerable burden of social stigma, but which promises to offer an improvement not only for patients but also for society in general.
In the multifactorial model, therefore, a different and articulated number of levels is suggested which, in whole or part, play to favor a better evaluation in the holistic approach of the pathology, according to a progression of scale that passes from the simple pedophile inclination to a real pedophile tendency, to evolve into the typical pathological condition, as to attribute the etiopathogenesis of pedophilia to a single class of events, either intrapsychic or external. It is necessary to take into consideration a multiplicity of factors because there does not seem to be a single typology of pedophiles.