Pedophilia, which literally means "love of children," is a complicated and distressing disorder encompassing both psychiatric and forensic spheres. It is a paraphilic syndrome characterizing individuals who experience recurrent and intense erotic fantasies, urges, or behaviors involving a prepubescent (13 years of age or younger) child. To meet DSM-IV-TR criteria, the individual has either acted upon such urges, or the urges cause significant distress or interpersonal difficulty. Also, to be diagnosed with pedophilia, an individual must be at least 16 years of age and at least 5 years older than the victim. Excluded from this category are older adolescents who are involved sexually with 12- or 13-year-olds. Specifiers denote whether the individual is sexually attracted to males, females, or both; whether the behavior is limited to incestual relationships; and whether the attraction to children is exclusive or non-exclusive. These specifiers are best viewed as descriptive as opposed to reflecting discreet categories (10).

Sexual behaviors with children, unfortunately, are not uncommon. In a general population survey, 12% of men and 17% of women reported that as a child they were sexually touched by an adult (60). The perpetrators of this behavior were often parents or other caretakers. Not all child abuse is motivated by a preferred attraction to younger individuals. Some individuals sexually abuse children in an opportunistic manner, when intoxicated, or secondary to dementia or mental retardation. Still others are indiscriminate in their partner choice due to excessive drive and loss of impulse control. These individuals may have sex with any available or exploitable person, regardless of age, but are not motivated by a nonnormative age attraction.

Therefore, it is critical for clinicians to note that not all child sexual offenses are pedophilic. The essential feature of pedophilia is a primary erotic attachment to children, not criminal-mindedness. Many individuals with pedophilia suffer from fantasies and urges but never engage sexually with a child. Many pedophilic individuals describe romantic love and affection for the children to whom they are also sexually attracted and may fantasize about being in a committed, loving relationship with the child. As abhorrent as this may be to others, an individual with pedophilia is also a sex offender only if he engages in the illegal act of sexual behavior with a child. In and of itself, pedophilia is an unfortunate psychosexual affliction, but not criminal. Most individuals with pedophilia would be grateful to experience more normative sexual attractions.

Approximately 90% of sexual abuse offenses with children are perpetrated by males (61). Consistent with that figure, it appears that individuals with pedophilia are predominantly but not exclusively male (62).

Behavioral manifestations of pedophilia vary widely. Some individuals endorse primary erotic fantasies of children but never act upon such urges, including by the use of pornography. Others limit their behavior to viewing child pornography. For some, use of child pornography appears to fuel the underlying pedophilic urges and increases the risk of escalation from urge to action. However, while clinical observation suggests such as association, only objective research will clarify the correlation, if there is one at all, between exposure to pornography and behavioral manifestation of any paraphilia.

The growth of the Internet and electronic access to child pornography has led to recent legal quagmires regarding exploitation of real vs. virtual children. Possession of child pornography, including in a downloaded format on one's personal computer, is a criminal felony. However, a recent supreme court decision reversed some aspects of the Child Pornography Prevention Act by ruling that there is no evidence that computer-generated images of children are linked to harm to real children and that regulation of such images is an infringement of protected free speech (63). Similarly, in a recent case involving a patient of one of the authors, in the course of soliciting sex with a supposed minor via the Internet, the individual was entrapped by a federal agent posing as the minor. The charges were later dismissed on grounds of their being no real victim and that prosecution could not be justified on the basis of a "virtual" victim.

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