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The (in)consistency of changes in brain macrostructure in male paedophiles:

A combined T1-weighted and diffusion tensor imaging study

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 Journal of Psychiatric Research 68 (2015) 246e253

Contents lists available at ScienceDirect

Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/psychires

The (in)consistency of changes in brain macrostructure in male

paedophiles: A combined T1-weighted and diffusion tensor imaging
study
Hannah Gerwinn a, *, 1, Alexander Pohl a, 1, Oliver Granert a, Thilo van Eimeren a, 2,
Stephan Wolff b, Olav Jansen b, Günther Deuschl a, Christian Huchzermeier c,
Aglaja Stirn c, Hartwig Roman Siebner d, e, Jorge Ponseti c
a
Department of Neurology, Kiel University, Medical School, Arnold-Heller-Str. 3, 24105, Kiel, Germany
b
Department of Radiology and Neuroradiology, Kiel University, Medical School, Arnold-Heller-Str. 3, 24105, Kiel, Germany
c
Institute of Sexual Medicine and Forensic Psychiatry and Psychotherapy, Centre for Integrative Psychiatry Kiel, Niemannsweg 147, 24105, Kiel, Germany
d
Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Kettegaard All
e 30, 2650, Hvidovre, Denmark
e
Department of Neurology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen, Denmark

a r t i c l e i n f o a b s t r a c t

Article history: Thus far, four studies have used magnetic resonance imaging (MRI) to test for differences in brain
Received 11 February 2015 structure between paedophilic (i.e. sexually attracted to pre-pubescent children) and teleiophilic (i.e.
Received in revised form sexually attracted to adults) men, revealing divergent results. To re-examine this issue, we acquired high
1 July 2015
resolution structural T1-weighted and diffusion MRI scans of the brain in 24 paedophilic and 32 tele-
Accepted 1 July 2015
iophilic men. We performed voxel-based morphometry (VBM) of the T1-weighted images and tract-
based spatial statistics (TBSS) of the diffusion tensor imaging data to search for grey and white matter
Keywords:
differences between groups. In contrast to previous studies, less than half of the individuals in our
Paedophilia
Brain structure
paedophilic group had a record of sexual offences against children, as subjects were partially recruited
MRI from two outpatient facilities of a child sexual abuse prevention project for self-acknowledged paedo-
DTI philes. After adjustment for multiple comparisons and controlling for important confounding factors, we
VBM did not find any significant grey or white matter differences between the paedophilic and teleiophilic
Sexual orientation subjects. Together with the inconsistencies in the literature, these results argue against consistent
structural differences at the macroanatomical scale between paedophiles and teleiophiles.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction motivated research into the aetiology of sexual attraction to pre-

Although the prevalence of child sexual abuse is declining
somewhat, it is still estimated that 6.7% of children in the United
States are being abused sexually (Finkelhor et al., 2010). As child
sexual abuse leads to high tangible and intangible costs (Miller
et al., 1996), it is a matter of great public concern. Approximately
half of first-time child sex offenders are paedophilic men, i.e. men
who experience intense and sustained sexual attraction to prepu-
bescent children (Blanchard et al., 2001; Seto, 2007). This has
* Corresponding author.
E-mail address: gerwinn@sexmed.uni-kiel.de (H. Gerwinn).
1
Both authors contributed equally to this work.
2 €ln University,
Present address: Department of Neurology and Psychiatry, Ko
€ln, Germany.
Medical School, Kerpener Str. 62, 50937, Ko
pubescent children. Some findings indicate a neuro-
developmental contribution to paedophilia as it has been associ-
ated with an increased likelihood of left-handedness, a lower
intelligence quotient (IQ), a higher incidence of head injuries in
childhood and deficits in executive functioning (Blanchard et al.,
2002, 2007, 2003; Cantor et al., 2004; Schiffer and Vonlaufen,
2011). This has prompted four research groups to use structural
magnetic resonance imaging (sMRI) of the brain to pinpoint
regional changes in the macrostructure of paedophiles (Cantor
et al., 2008; Poeppl et al., 2013; Schiffer et al., 2007; Schiltz et al.,
2007). However, these studies have fallen short to reveal a consis-
tent pattern of morphological brain anomalies in paedophiles.
While each study reported regional reductions in grey or white
matter, these changes were found in different brain areas with little
overlap among studies (see Table 1). Schiffer et al. (2007)

http://dx.doi.org/10.1016/j.jpsychires.2015.07.002
0022-3956/© 2015 Elsevier Ltd. All rights reserved.
Table 1
Summary of structural MRI studies (adapted from Mohnke et al., 2014).
Reference Sample
Schiltz et al., 2007 15 inpatient paedophilic CSO,
exclusivity unknown; 6 offending
against F only, 3 offending against M
only, 6 offending against M and F
15 teleiophilic community controls;
sexual gender orientation unknown
Schiffer et al., 2007 18 inpatient exclusively paedophilic
CSO; 9 excl. attracted to boys, 9 excl.
attracted to girls
24 teleiophilic community controls; 12
excl. or predominantly homosexual, 12
excl. or predominantly heterosexual
Cantor et al., 2008 44 outpatient paedo- and hebephilic
CSO, exclusivity unknown; 31.8%
offending against M, 90.9% offending
against F
53 outpatient teleiophilic NSO; sexual
gender orientation unknown
Poeppl et al., 2013 9 inpatient paedophilic CSO, exclusivity
unknown; 7 homosexual, 6 offending
against M only, 2 offending against F
only, 1 offending against M and F
11 teleiophilic inpatient NSO;
0 homosexual
Our study 24 paedophilic outpatient CSO and NO,
7 non-exclusive; 13 homosexual, 11
heterosexual
32 teleiophilic community controls; 14
homosexual, 18 heterosexual
Annotations: MRI magnetic resonance imaging, DTI diffusion tensor imaging, CSO child sex offender, NSO non-sex offender, NO non-offender, VBM voxel-based morphometry, MM manual morphometry, TBSS tract-based spatial
statistics, ROI region of interest, L/R left/right, GM grey matter, WM white matter, CSF cerebrospinal fluid, FWE family-wise error, FDR false discovery rate, M male children, F female children.
a
Considered a potential confounding variable because experimental and control groups (significantly) differed in this variable, but it was not included as a covariate.
b
Considered a potential confounding variable because information on group differences is missing.
Method Main findings Significance Potential confounds
VBM þ MM GM reductions in paedophiles: p < 0.05 corrected for multiple sexual orientationb
amygdala R, hypothalamus L/R, comparisons within predefined ROIs offending behavioura
innominate substance L/R, bed nucleus incarceration-related stressa
striae terminalis L/R, septal region R intelligenceb
WM: not analysed
CSF: enlargement of the anterior
quarter of the right temporal horn in
paedophiles
VBM GM reductions in paedophiles: p < 0.05 FDR corrected for whole brain offending behavioura
separate regression analyses for cerebellum R*, inferior frontal gyrus *
regions which survived FWE incarceration-related stressa
clinical and personality measures, L*/R, cingulate gyrus L/R, posterior correction (p < 0.05) for the whole brain psychiatric disordersa
neuropsychological parameters and cingulate gyrus L, precuneus L/R, years of educationa
length of stay in a forensic hospital parahippocampal gyrus L/R*, middle
temporal gyrus R, putamen L/R
obsessiveness negatively correlated
H. Gerwinn et al. / Journal of Psychiatric Research 68 (2015) 246e253
with bilateral putamen volume and
volume in the left posterior lobe of the
cerebellum
obsessiveness and depression
negatively correlated with medio- and
orbitofrontal volume
WM/CSF: no differences
VBM GM: no differences p < 0.05 FDR corrected for whole brain sexual orientationb
WM reductions in paedo-/hebephiles: whole brain volumeb
temporal lobe L/R parietal lobe R corpus
callosum
CSF: no differences
VBM GM reduction in paedophiles: p < 0.05 FWE corrected after small sexual orientationa
amygdala R volume correction whole brain volumeb
WM/CSF: not analysed
VBM þ TBSS GM reductions in homophilic p < 0.05 FWE corrected for whole brain psychiatric disordersb
teleiophiles compared to homophilic
paedophiles: inferior parietal lobe R
WM: no differences
CSF: not analysed
247
248 H. Gerwinn et al. / Journal of Psychiatric Research 68 (2015) 246e253
performed whole-brain voxel-based morphometry (VBM) to
compare paedophiles and controls. In their study, paedophilia was
associated with a decrease in grey matter density in several brain
regions after false discovery rate correction for multiple compari-
sons, including clusters in the cerebellum, orbitofrontal and tem-
poral cortex. The authors argue that paedophilia might be
conceptualized as an obsessive-compulsive spectrum disorder as
these disorders were shown to be associated with abnormalities in
similar brain areas. Schiltz et al. (2007) predefined regions of in-
terest (ROIs) and found regional reductions in grey matter in the
right amygdala, hypothalamus (bilateral), substantia innominata
(bilateral), right septal regions and bed nucleus striae terminalis
(bilateral). They hypothesize that structural deficits in the right
amygdala might interfere with sexual development in puberty.
According to the authors this could obstruct the devalorisation of
pre-existing sexual interest in children and result in a paedophilic
preference combined with an adult sex drive. Poeppl et al. (2013)
used whole-brain VBM and performed small volume correction
(SVC) for those regions that had been identified in Schiffer et al.'s
(2007) and Schiltz et al.'s (2007) studies, and were able to repli-
cate a reduction in grey matter volume in the right amygdala. The
authors thereby take their finding as a proof of the hypothesis
outlined by Schiltz et al. (2007). Cantor et al. (2008) analysed
structural brain scans in a sample of 44 paedophiles and hebephiles
and 53 controls. Their sample was three to five times larger than
the samples of the other sMRI studies, ranging between a full
sample size of 20 and 42 participants. This study found no differ-
ences in regional grey matter in the paedophilic and hebephilic (i.e.
sexually attracted to pubescent children) subjects. However, they
observed decreased white matter volumes in the bilateral temporal
and right parietal lobes as well as in the corpus callosum of pae-
dophiles and hebephiles compared to teleiophiles. According to
Cantor et al. (2008) their findings implicate that paedophilia results
from a partial disconnection of brain areas crucial for recognising
sexual stimuli. In summary, there is one replicated structural MRI
finding: an amygdala volume reduction in paedophilic men (cf.
Mohnke et al., 2014).
The otherwise divergent results can at least partially be attrib-
uted to methodological differences and limitations. In three out of
the four sMRI studies, the experimental and comparison groups
varied with respect to one or more of the following variables:
sexual gender orientation, IQ, years of education, comorbidity,
offending behaviour and incarceration-related stress. Furthermore,
there were differences with respect to the non-paedophilic groups,
which in some cases consisted of non-sexual offenders and in other
cases of community controls. Concerning the reported white mat-
ter differences, it remains uncertain whether this finding can be
replicated with the diffusion tensor imaging (DTI) technique, which
provides more advanced features for white matter than VBM
methods with T1-weighted images. Taken together, the mostly
heterogeneous findings regarding regional changes in brain struc-
ture and the methodological issues give rise to questions con-
cerning the existence of paedophilia-related changes in brain
morphology which can be detected with the current sMRI resolu-
tion of approximately 1 or 2 mm.
These considerations motivated this sMRI study in which we
have tried to overcome some limitations of previous studies. We
included the second largest e maybe even the largest e outpatient
sample of paedophilic men that has been studied so far. Although
Cantor et al. (2008) had about twice as much paedophilic men at
their disposal, it is unclear how many of these 44 men were pae-
dophilic (and not hebephilic) and how many of them had a history
of offences against children. As Cantor et al. (2008) state that the
primary source of referrals to their outpatient facility is parole and
probation officers, one can assume that it must have been the
majority. In contrast to this, approximately half of the men of our
experimental group were recruited from the prevention project
“Dunkelfeld”, which offers anonymous treatment for self-identified
paedophiles who are not under actual judiciary supervision (Beier
et al., 2009). We recruited a control group matched for sexual
gender orientation, handedness, age and IQ. We conducted whole-
brain analyses based on our high-resolution T1-weighted structural
and diffusion MRI data. The only brain region for which we had an a
priori assumption was the right amygdala, where two out of the
four previous studies have reported reduced grey matter in pae-
dophiles as compared to teleiophiles.
2. Materials and methods
2.1. Participants
We scanned 24 male paedophiles from two outpatient facilities.
Thirteen of these participants were part of the prevention project
“Dunkelfeld” (Beier et al., 2009). The remaining 11 paedophiles
were treated in our outpatient department. Ten paedophiles had
been sentenced earlier in life (mostly for possessing child
pornography), with three having served a prison sentence. Twelve
paedophiles had a history of hands-on offences against children.
Participants and recruitment procedure are described in detail
elsewhere (Ponseti et al., 2012).
We assessed paedophilia using a semi-structured interview and,
if necessary, phallometric testing and/or forensic records. Eleven
paedophiles were heterosexual (HePe), 13 were homosexual (HoPe)
and seven were of the nonexclusive type (sometimes sexually
attracted to adults). As a control group of teleiophile men, we
recruited 18 gynephilic (HeTe) and 14 androphilic (HoTe) volun-
teers not significantly different from the paedophilic group in terms
of sexual gender orientation (Chi2 ¼ 0.596, p ¼ 0.440), handedness
(measured by the 10-item version of the Edinburgh Handedness
Inventory (Oldfield, 1971); F3,50 ¼ 0.826; p ¼ 0.486), age
(F3,52 ¼ 1.807; p ¼ 0.157 e although our HoPe group had a greater
variance in age than all other groups: F1,54 ¼ 10.351; p ¼ 0.002), and
IQ (F3,52 ¼ 1.247; p ¼ 0.302). The groups differed significantly in
their average level of education (F3,50 ¼ 3.435, p ¼ 0.024), with
teleiophiles possessing higher educational qualifications than
paedophiles (T27.626 ¼ 2.815, p ¼ 0.009). All participants provided
written informed consent before participating in the study. The
local ethics committee of the Medical Faculty of Christian-Albrechts
University approved this study.
2.2. MRI image acquisition
High resolution structural T1-weighted and diffusion-weighted
MRI scans of the brain were obtained using a 3T scanner (Philips
Achiva) immediately after completion of a functional MRI session
(Ponseti et al., 2012). T1-weighted images were acquired using a
magnetization-prepared rapid acquisition gradient echo (MPRAGE)
with an echo time (TE) of 3.8 ms, repetition time (TR) of 8.3 ms and
a flip angle of 8 . The T1-weighted image had a 1  1  1 mm3
isotropic resolution, covering the whole brain. Brain volume con-
sisted of 160 slices with a 240  240 mm matrix and a slice
thickness of 1 mm without inter-slice gap.
Diffusion-weighted images were obtained for 32 directions us-
ing a b-value of 1000 and an echo planar imaging (EPI) sequence
with a TE of 59 ms and TR of 8950 ms. A single volume consisted of
60 slices without gap. A single slice had a 224  224 mm matrix,
resulting in a 2  2  2 mm3 isotropic resolution. The maximum
gradient strength was 40 mT/m and maximum slew rate was
200 mT/m/ms. Parallel imaging was performed using a SENSE
factor of 2 (NSA ¼ 1).
 H. Gerwinn et al. / Journal of Psychiatric Research 68 (2015) 246e253
During image acquisition, the participants were comfortably
placed, and their heads were fixated within the head coil with
special cushions and gussets.
2.3. Data analysis
The data were analysed using statistical parametric mapping
(SPM) software (SPM 8; http://www.fil.ion.ucl.ac.uk/spm), SPSS 20
(IBM, Armonk, New York) and the FMRIB Software Library (FSL)
from the Oxford Centre for Functional Magnet Resonance Imaging
of the Brain (version 4.1, http://fsl.fmrib.ox.ac.uk/fsl/fslwiki/FDT;
Jenkinson et al., 2012). In the first step we segmented the high
resolution structural T1-weighted images into grey matter, white
matter and cerebrospinal fluid (CSF) using the New Segment option
of SPM 8. For the VBM (Ashburner and Friston, 2000) analysis of the
grey matter, we used the Dartel toolbox (Ashburner, 2007) as
implemented in SPM 8 to spatially normalize the images into the
Montreal Neurological Institute (MNI) space. We then performed
voxel-wise statistics using participants' total brain volume, age and
educational level as covariates. We applied the family-wise error
correction (FWE) method as implemented in SPM to correct for
multiple non-independent comparisons. FWE correction was per-
formed at the cluster level, applying a cluster-defining primary
(Woo et al., 2014) threshold of p < 0.001 (uncorrected). An FWE-
corrected p-value of p < 0.05 at the cluster level was considered
significant. The right amygdala was the only structure found to be
altered in paedophiles in more than one of the previous sMRI
studies (Poeppl et al., 2013; Schiltz et al., 2007). Therefore, we
defined this region as an ROI. Using the same procedure as
described by Poeppl et al. (2013), we drew a sphere with a 16 mm
radius around the averaged coordinates (MNI coordinates: 29, 3,
13) of the two highest peaks within the amygdala reported by
Schiltz et al. (2007). For these voxels, FWE correction only consid-
ered all voxels within the ROI (i.e. SVC).
The diffusion-weighted images were analysed based on a
diffusion tensor model, using the FSL diffusion toolbox, as distrib-
uted in the Debian software repository (https://packages.debian.
org/de/wheezy/fsl-4.1). In a first step, all diffusion images and the
b0 images without a diffusion gradient of each subject were
merged and corrected for eddy currents using the FSL “eddy_-
correct” tool. Maps of fractional anisotropy (FA), axial diffusivity
(AD), radial diffusivity (RD) and mean diffusivity (MD) were then
calculated using the FSL “dtifit” command. The program fitted a
tensor model to the raw diffusion data in each voxel within a mask
calculated by the FSL brain extraction tool (bet2). All subjects' FA
maps were then aligned within a common normalized coordinate
space using the linear registration tool (flirt e Linear Image
Registration Tool). For voxel-wise analysis of group differences, we
used the FSL randomize tool including participants' total brain
volume, age and educational level as covariates (using threshold-
free cluster enhancement in its version for 3D data [TFCE-3D;
Smith and Nichols, 2009] based on 5000 permutations and FWE
correction at an alpha level of 5%). Because VBM-style analysis of FA
maps can be problematic (Smith et al., 2006), in a second step, we
also used tract-based spatial statistics (TBSS; Smith et al., 2006) to
test for differences between the groups. Therefore a mean FA image
was created and thinned to create a mean FA skeleton. This skeleton
represents the main fibres of all tracts common to our sample. The
subjects' aligned FA maps were then projected onto this skeleton
and the resulting data were used to perform voxel-wise statistics on
this skeleton using the FSL randomize tool, again including par-
ticipants' total brain volume, age and educational level as covariates
(using TFCE-2D based on 5000 permutations and FWE correction at
an alpha level of 5%).
249
3. Results
3.1. Voxel-based morphometry
VBM analysis revealed no significant differences in cerebral grey
or white matter between paedophiles and teleiophiles after FWE
correction. This was also the case when comparing heterosexual
and homosexual teleiophiles and paedophiles separately (i.e.
comparing the HeTe group with the HePe group and the HoTe
group with the HoPe group). The only exception was a cluster in the
right inferior parietal lobe close to the intraparietal sulcus, where
the HoTe group showed a significant reduction in regional grey
matter volume compared to the HoPe group (PFWEcorr ¼ 0.045; 910
contiguous voxels). The peak difference was located in the angular
gyrus (T ¼ 4.96; x ¼ 38, y ¼ 52, z ¼ 52). Other regional peaks were
located on the supramarginal gyrus (T ¼ 4.68; x ¼ 47, y ¼ 37,
z ¼ 49) and in the Brodmann area 40 (T ¼ 4.41; x ¼ 44, y ¼ 45,
z ¼ 54). Apart from this significant cluster level result, we found no
significant peak differences in voxel volumes of grey or white
matter when comparing teleiophiles with paedophiles (neither in
the whole samples nor in the subsamples of hetero and homo-
sexual subjects; all p > 0.74).
Given that two previous studies reported a grey matter change
in paedophiles (Poeppl et al., 2013; Schiltz et al., 2007), we defined
the right amygdala as an ROI. However, we did not find any sig-
nificant differences between our paedophile and teleiophile par-
ticipants, regardless of their sexual gender orientation, after SVC.
3.2. Diffusion tensor imaging
Voxel-wise analysis of the FA and MD maps revealed no sig-
nificant differences between paedophilic and teleiophilic partici-
pants. This was the case for the comparison of the entire groups
(teleiophiles vs. paedophiles; all corrected p-values p > 0.35 for FA
and p > 0.25 for MD), as well as the sub-groups (HoTe vs. HoPe and
HeTe vs. HePe; all corrected p-values p > 0.80 for FA and p > 0.10 for
MD). TBSS analysis of the white matter skeletons did not change
these results, neither for the comparison of the entire groups nor
for the comparison of the sub-groups (all corrected p-values
p > 0.17 for regional FA values and p > 0.12 for regional MD values).
4. Discussion
Apart from the right inferior parietal lobe, there were no
consistent differences in brain structure between our paedophilic
and teleiophilic groups. While our analysis revealed a relative in-
crease in regional grey matter in homophilic paedophiles compared
to homophilic teleiophiles in some parts of the right inferior pari-
etal lobe, no such differences were reported in three previous
studies (Poeppl et al., 2013; Schiffer et al., 2007; Schiltz et al., 2007;
for an overview of sMRI studies regarding differences between
paedophiles and teleiophiles see Table 1). Schiffer et al. (2007)
found rather the opposite pattern, reporting a decrease in
regional grey matter in teleiophile subjects in the left and the right
precuneus, which is part of the parietal lobe, but these reductions
in grey matter were located further left and were more dorsocaudal
than ours. Schiffer et al. (2007) did not control for years of educa-
tion, although their paedophilic subjects on average had signifi-
cantly fewer years of education than those in their teleiophilic
group. However, a recent study by Arenaza-Urquijo et al. (2013)
confirmed a positive relationship between years of education and
grey matter volume: a higher level of education was associated
with higher grey matter volumes in several parts of the brain.
Therefore, the conflicting results obtained from Schiffer et al.'s
(2007) study and ours might at least in part be explained by the
250 H. Gerwinn et al. / Journal of Psychiatric Research 68 (2015) 246e253
fact that we did control for differences in the length of education.
When we did not control for the level of education, but only for
brain volume and age, the significant cluster in which paedophiles
had more grey matter than teleiophiles disappeared.
Furthermore, we also adopted a different strategy for the
recruitment of participants. We compared a group of paedophilic
patients from two outpatient facilities with a teleiophilic control
group of healthy participants from the community, whereas
Schiffer et al. (2007) compared paedophilic sexual offenders from
two high security forensic facilities with healthy community con-
trols. Thus, it is possible that parts of the conflicting results from
these two studies are due to differences other than sexual age
orientation, which existed between the experimental and control
groups in Schiffer et al. (2007) study but not in ours. For example,
incarceration-related stress comes to mind as stress has been found
to be linked to neuroanatomic changes (cf. McEwen, 2001). In
addition, the paedophilic group in the Schiffer et al. (2007) study
had a whole range of current and lifetime psychiatric disorders,
whereas a personal or family history of psychiatric illness was one
of the exclusion criteria for the control group. This may also have
contributed to regional differences in grey matter density because
all of the reported psychiatric disorders are associated with volu-
metric brain alterations relative to healthy controls (cf. Damsa et al.,
2009; Harrison, 2002; Job et al., 2003; Pujol et al., 2004; Raine et al.,
2003; Wilke et al., 2001). Schiffer et al. (2007) state that the
“clinical measures were part of the [paedophile behaviour] disor-
der” (p. 757) and that they therefore did not include them as
covariates in their main group analysis. However, their separate
regression analyses revealed negative correlations of depression
and obsessiveness with most of the frontostriatal alterations they
found, so the specificity of the reported structural brain alterations
for paedophilic preferences remains unclear in at least those parts
of the brain.
Schiltz et al. (2007) also used paedophilic offenders from high
security forensic hospitals for their study and compared them to
healthy community controls, but excluded individuals with psy-
chiatric diseases from their experimental group (see Table 1). They
used predefined ROIs and found differences in the right amygdala
and corresponding structures such as the hypothalamus and the
bed nucleus striae terminalis, as well as an enlargement of the
temporal horn. We were not able to confirm these findings in our
study. Schiltz et al. (2007) reported that the structural differences
were correlated with offence types: individuals with a lower
amygdala volume committed more stereotypical, clandestine pae-
dophilic offences, whereas offenders with less affected amygdala
volume committed more diverse sexual offences. It is therefore
conceivable that the reduced amygdala volume reported by Schiltz
et al. (2007) may be associated with paedophilic offences rather
than paedophilic sexual orientation per se. Indeed, Mohnke et al.
(2014) proposed that the differences in amygdala volume be-
tween paedophilic and teleiophilic groups found in previous
studies (Poeppl et al., 2013; Schiltz et al., 2007) might in fact be
related to personality features such as aggression or empathy def-
icits that are unrelated to sexual age orientation. They conclude that
if the amygdala volume alterations in paedophiles are really linked
to the sexual age orientation of these men, it should be possible to
replicate these findings in a non-offending population of paedo-
philes. Here we failed to replicate this finding in a mixed sample of
offending and non-offending paedophiles, more than half of whom
had not committed any hands-on offences. This lends further
support to the notion that the structural changes in the amygdala
might not be related to sexual age orientation per se.
Poeppl et al. (2013) chose a different study design, comparing
paedophile offenders from high security forensic facilities to non-
sexual offenders from the same institutions. This may have
circumvented some of the above-mentioned problems associated
with the studies by Schiffer et al. (2007) and Schiltz et al. (2007).
Poeppl et al. (2013) nevertheless found trend differences in regional
grey matter for the right amygdala, but only after SVC. Beyond that,
they found significant correlations between lower victim age and
grey matter loss in the orbitofrontal cortex (OFC) and the bilateral
angular gyrus, and between higher scores in the screening scale for
paedophilic interest (SSPI; Seto et al., 2004) and left-sided grey
matter loss in the transition zone between the insula and parietal
operculum, as well as in the left dorsolateral prefrontal cortex
(DLPFC). It is worth mentioning that Poeppl et al. (2013) did not find
any significant grey matter differences in the DLPFC or OFC be-
tween the paedophile offenders and the non-sexual offenders.
Thus, a better explanation for the findings reported by (Schiffer
et al., 2007) might also lie in paedophilic offending behaviour
(and corresponding factors) than in a paedophilic orientation per
se. Poeppl et al. (2013) state that the DLPFC is associated with im-
pulse inhibition. Individuals with less grey matter in this area might
therefore experience more difficulties inhibiting their sexual urges.
Along these lines, one might speculate that the paedophile of-
fenders in the Schiffer et al. (2007) or Schiltz et al. (2007) studies
might also have been unable to exhibit the inhibitory control
needed to suppress their sexual urges, or that they lacked empathy
for their victims or had problems regulating aggression (Mohnke
et al., 2014). All these factors have been posited to facilitate the
probability of committing sexual offences against minors (Gery
et al., 2009; Mohnke et al., 2014) and might cause an individual
to be placed in a forensic hospital. A present resting state study also
indicates that differences between groups could be better
explained by offending behaviour than by sexual age orientation
(Kargel et al., 2015). Thus, there might be a systematic bias in at
least three of the four brain imaging studies that have searched for
structural brain differences so far, as they only included paedophile
offenders from high security forensic facilities in their experimental
group (Poeppl et al., 2013; Schiffer et al., 2007; Schiltz et al., 2007).
At least it gives rise to questions in terms of whether the results
reported in these studies do also apply to paedophiles in general e
a concern corroborated by this study which included a far less se-
lective sample than previous studies.
Finally, Cantor et al. (2008) reported pronounced white matter
differences e without observing any differences in grey matter e
between paedo-/hebephiles and teleiophiles. The authors did not
include any covariates (except a measure for alcoholism, which did
not change their results) in their analyses because their study
groups did not differ significantly in terms of age, IQ, handedness or
education. Cantor et al. (2008) used the largest study group so far
and their failure to find any grey matter differences between
paedo-/hebephiles and teleiophiles raises doubts concerning the
grey matter findings of the other structural brain studies in pae-
dophiles (Poeppl et al., 2013; Schiffer et al., 2007; Schiltz et al.,
2007). The white matter differences they found were located in
the corpus callosum and bilaterally in the temporal and parietal
lobes. A reanalysis of this data by Cantor and Blanchard (2012), in
which they reassigned subjects to separate paedophilic and hebe-
philic groups and analysed the white matter volumes in the bilat-
eral temporal and parietal lobes only, revealed no differences
between the paedophilic and the hebephilic groups, but rather
between the hebephilic and the teleiophilic groups. Cantor et al.
(2008) recommended verifying their results using the DTI tech-
nique, which is more sensitive with regard to white matter differ-
ences than volumetric analyses (Assaf and Pasternak, 2008; Santillo
et al., 2013). Using the DTI technique and controlling for age, total
brain volume and education, we were unable to replicate the
findings reported by Cantor et al. (2008). We were also not able to
replicate the finding using VBM analysis. It is possible that the
 H. Gerwinn et al. / Journal of Psychiatric Research 68 (2015) 246e253
conflicting results found by Cantor et al.'s (2008) and our studies
are based on the use of different comparison groups. Cantor et al.
(2008) used non-sexual offenders whereas we used healthy com-
munity controls as a reference.
While one could argue that non-sexual offenders are a valid
comparison group for convicted paedophilic child sex offenders (in
holding a “general factor of delinquency” equal), we might question
this view because sexual deviancy does not seem to be related to
general delinquency (Hanson and Morton-Bourgon, 2005). We
rather conceptualize paedophilia as a sexual orientation (Seto,
2012) which involves an increased risk of illegal behaviour
because of legal restrictions against childeadult sexual contact
(Hanson and Bussiere, 1998) and not because of a general weakness
in following the rules of society. Whereas paedophiles who have
been able to refrain from child sex abuse for their entire lives might
represent an (albeit desirable but) untypically highly self-
controlled sample, convicted paedophiles on the other hand
might suffer from inhibitory deficits or from incarceration-related
stress. We therefore reasoned that the best perspective on the
paedophilic brain might be afforded by comparing a mixed sample
of paedophiles with and without a history of child sex abuse to a
group of community controls. Yet, we were unable to find any white
matter differences between paedophiles and teleiophiles, not even
when using the sensitive DTI technique.
To rule out the possibility that our null finding (that paedophiles
do not exhibit reduced grey or white matter) was merely based on
insufficient power, we calculated a power analysis using GPower
3.1 (Erdfelder et al., 1996) for one-tailed t-tests. Based on previous
studies we could expect an effect size d of at least 0.44 for white
matter (Cantor et al., 2008) and of at least 1.08 for grey matter
(Poeppl et al., 2013; Schiffer et al., 2007; Schiltz et al., 2007). We
calculated the minimal required number of participants to detect
an effect of d  1.08 or d  0.44 with a power of 90% (alpha ¼ 0.05).
To detect an effect of this magnitude with a power of 90%, one
would need at least 32 respectively 182 participants (and for a
power of 80%, 24 respectively 132). As we included 56 participants
in our study, these results argue against structural differences be-
tween paedophiles and teleiophiles in regard to grey matter. With
regard to white matter, no definite conclusions can be drawn,
because studies with 56 participants would yield a significant
result (p < 0.05) in only about 49% of all cases (for d ¼ 0.44).
Nevertheless, the actual p-value can also be informative (O'Keefe,
2007). The minimum p-value observed in our VBM analysis was
0.74, the minimum effect size reported in earlier studies was
d ¼ 0.44. Using these values in a power analysis for N ¼ 56, reduces
the beta error to 0.012. This means that under the assumption that
the alternative hypothesis (d  0.44) is true, values as extreme (or
extremer) as those observed in our study, occur with a probability
of less than 2%. This indicates that our null finding is probably not
only due to insufficient power. Indeed these results do not mean
that there are no structural differences between paedophiles and
teleiophiles at all. They only suggest that potential differences are
probably smaller than the effect sizes derived from previous studies
indicate (Hoenig and Heisey, 2001; Levine and Ensom, 2001;
O'Keefe, 2007). As this is the first study using DTI on a sample of
paedophilic and teleiophilic subjects, we could not calculate a
minimum effective sample size prior to our DTI analysis and post
hoc power analyses do not provide further information (Hoenig
and Heisey, 2001). Therefore, we cannot draw any definite
conclusion, if there are any white matter differences between
paedophiles and teleiophiles which are detectable with the DTI
technique. Further studies are needed to clarify this issue.
Yet, we do not want to decry the results of previous studies. It
just admittedly seems very likely to us, that the sexual age orien-
tation of the participants in previous studies was not the only factor
251
causing the observed brain alterations. Other factors like offending
behaviour (and associated factors like for example impulsivity and
anti-sociality) might have substantially biased previous findings.
Furthermore, only the Schiffer et al. (2007) and our study evidently
controlled for sexual gender orientation. Schiltz et al. (2007) and
Cantor et al. (2008) do not state the sexual gender orientation of
their control group and only indicate the gender of the victims of
their paedophilic subjects, but not the actual sexual gender orien-
tation. And although Poeppl et al. (2013) explicitly state that they
included seven primarily homosexual subjects in their paedophilic
group, but none in their control group, they don't indicate the
sexual gender orientation of the rest of their subjects neither (cf.
Table 1). So, one can only speculate that the design in at least the
Poeppl et al. (2013) study was not balanced with respect to sexual
gender orientation, but that by far more homosexual subjects were
included in the paedophilic than in the teleiophilic group. Although
studies relating to grey matter differences between teleiophilic
heterosexual and homosexual men up till now revealed rather
controversial results (Abe et al., 2014; Ponseti et al., 2007), at least
one study found significantly smaller volumes in the (postmortem)
interstitial nucleus 3 of the anterior hypothalamus of homosexual
as compared to heterosexual men (LeVay, 1991) e a region not that
far away from the ROIs in which Schiltz et al. (2007) found reduced
hypothalamic volume in their paedophilic group. We would
therefore argue that the meaningfulness of future studies designed
to establish proof of grey matter variations in paedophiles also
depends on the degree to which authors manage to isolate the
effect of sexual age from the effect of sexual gender orientation.
In summary, given the inconsistencies among studies, it is
currently not possible to pinpoint a macrostructural brain “pa-
thology” related to paedophilia. Furthermore, our findings raise the
question of whether there are any brain structural differences be-
tween paedophiles and teleiophiles at all if one succeeds in
isolating the effects of the sexual age orientation of these men. This
contrasts with studies which have demonstrated structural brain
differences in relation to sexual gender orientation in males (Allen
and Gorski, 1992; LeVay, 1991), females (Ponseti et al., 2007) and
transsexuals (Rametti et al., 2011). In the light of these findings, it
appears possible that there are also subtle brain alterations related
to paedophilia. The sample used in our study was large in com-
parison to most of the previous studies in this realm, but perhaps
larger cohorts are required to identify subtle alterations in regional
brain structure. Alternatively, these structural changes might be too
small to be traceable with the current standard MRI resolution of
1e2 mm. In this case, a neurostructural delineation of sexual age
preferences would depend on a further improvement in MRI
techniques.
Author contribution
Hannah Gerwinn and Alexander Pohl have contributed equally
to this work. They were involved in data analysis and prepared and
wrote the manuscript (mainly the introduction, the results and the
discussion section).
Jorge Ponseti was involved in the study design, data collection,
and the planning and revision of the manuscript.
Oliver Granert was involved in data analysis and wrote parts of
the material and methods section of the manuscript.
Thilo van Eimeren was involved in study design and the plan-
ning and revision of the manuscript (mainly the material and
methods and the results section).
Stephan Wolff was involved in study design, data collection and
wrote parts of the material and methods section of the manuscript.
Olav Jansen was involved in study design and the revision of the
manuscript.
252 H. Gerwinn et al. / Journal of Psychiatric Research 68 (2015) 246e253
Günther Deuschl was involved in study design and the revision
of the manuscript.
Christian Huchzermeier was involved in the revision of the
manuscript.
Aglaja Stirn was involved in the revision of the manuscript.
Hartwig Roman Siebner was involved in study design, data
analysis and the writing and revision of the manuscript.
All authors have approved the final article.
Funding sources
The funding sources named in the acknowledgement section
had no involvement in study design; in the collection, analysis and
interpretation of data; in the writing of the report; or in the deci-
sion to submit the article for publication.
Conflicts of interest
H.R.S. has received honoraria as a speaker from Lundbeck A/S,
Valby, Denmark, Biogen Idec, Denmark A/S, Genzyme, Denmark
and MerckSerono, Denmark, honoraria as an editor from Elsevier
Publishers, Amsterdam, the Netherlands and Springer Publishing,
Stuttgart, Germany, and travel support from MagVenture,
Denmark. The other authors declare that they have no conflicts of
interest.
G.D. has received lecture fees from UCB, Medtronic and Desitin
and has been serving as a consultant for Medtronic, Sapiens, Boston
Scientific and Britannica. He received royalties from Thieme pub-
lishers. He is a government employee and he receives through his
institution funding for his research from the German Research
Council, the German Ministry of Education and Health and
Medtronic.
Acknowledgements
MRI measurement was performed in the MRI unit sponsored by
the Federal Ministry of Education and Research. A Federal Ministry
of Education and Research grant to NeMUP-Nord (grant no.
01KR1205D) sponsored the research conducted by J.P., H.G. and A.P.
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