INVITED COMMENTARY
Toward a Neurodevelopmental Understanding of Pedophilia
Rachel L. Fazio, PsyD
Pedophilia has long been a topic that draws morbid fascination
and strong disdain. Throughout the modern history of pedo-
philia, investigators have pointed toward environmental
underpinnings of this behavior, primarily reiterating the “abused-
abuser” hypothesis, which speculates that being sexually abused
as a child predisposes the abused child to develop into a sexual
abuser as an adult. Although this theory might have some rele-
vance to childhood sexual abuse—the overt behavior—it has less
relation to pedophilia itself—the internally experienced sexual
preference for prepubescent children. In other words, any given
individual could be a perpetrator of childhood sexual abuse but
not a pedophile, and there are definitive pedophiles who have not
molested any children (see Seto1 for a brief discussion of the
abused-abuser hypothesis and estimated prevalence of pedophilia
among those who perpetrate childhood sexual abuse).
Some diagnostic schemas capture this definition of pedophilia
more accurately than others. For example, the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition2 casts some-
what too wide of a net by including internally perceived expe-
riences and overt behaviors interchangeably as the primary
diagnostic criteria. Although those diagnostic criteria would be
accurate if the individual admitted to such preferences, whether
or not engaging in corollary behavior, an individual also could be
diagnosed as a pedophile based on repeated behavior alone.
Although the purpose of this is presumably to allow clinicians to
identify the behavior as a diagnosable problem, and perhaps even
offer some predictive utility in certain situations, repeated
behavior alone is only a mark of someone committing childhood
sexual abuse, which might or might not be accompanied by true
pedophilic preference. For the present discussion, the Interna-
tional Classification of Diseases, 10th Revision’s3 definition of
pedophilia—which refers to sexual preference for prepubertal or
early pubertal children—is the one most applicable, which can be
best established through collateral data such as penile plethys-
mography with validated classification properties.4
As medical knowledge—and particularly neuroscience—has
advanced, there is burgeoning evidence that pedophilia has a
biological origin in terms of neurodevelopmental insults. In-
dividuals with pedophilic preference tend to have what could
loosely be deemed as a number of neurologic soft signs, namely
Received December 13, 2017. Accepted April 8, 2018.
Private Practice, Little Rock, AR, USA
Copyright ª 2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2018.04.631
J Sex Med 2018;-:1e3
very mild, often inconsequential features that are associated with
atypical neurodevelopment. An extreme example of this would
be the stereotypical facial features of a developmental disorder
such as fetal alcohol syndrome or a genetic disorder such as
Down syndrome. These facial features are often harmless but are
strongly associated with the underlying disorder.
These atypical neurodevelopmental features were studied
extensively at the Centre for Addiction and Mental Health (Tor-
onto, Ontario, Canada). These early publications showed that
pedophiles had lower IQ,5 higher prevalence of childhood trau-
matic brain injury,6 atypical neuropsychological functioning,7 and
other features relative to those with a teleiophilic sexual preference
(attraction to adults). The studies also showed a tendency for those
with pedophilia to have a higher rate of noneright-handedness
than those with teleiophilia, suggesting a link between pedophilia
and other neurodevelopmental disorders, because autism spec-
trum disorders in particular have been linked with atypical later-
alization.8 Research from the same laboratory suggested that
pedophiles have shorter self-reported height than individuals with
typical sexual preferences.9,10 All this research points to a very early
developmental origin for pedophilia, because handedness can
begin as early as the 10th week of prenatal development and
typically solidifies in childhood,11 and shorter height has been
linked to various conditions of neurodevelopmental origin,
perhaps most notably schizophrenia.12
These early findings have recently been solidified. In an
expansion of the earlier studies, the classification of handedness
was more finely dissected from “non-right-handed” to left-
handed, ambiguously handed, or right-handed and showed a
distinct pattern of pedophiles demonstrating higher rates of
left-handedness, and those with hebephilia (those with sexual
preference for pubescent children, typically 11 14 years old)
demonstrating higher rates of ambiguous handedness than those
with teleiophilia.11 Similarly, using measured height rather than
self-reported height, another recent study indicated pedophiles
are substantially shorter than teleiophiles and specifically
demonstrated shorter leg length, which is a marker of prenatal
stress.12 Harkening back to the facial anomalies seen in other
disorders, research on the prevalence of minor physical anomalies
in those with pedophilic preference indicated a higher rate of
craniofacial—but not peripheral—anomalies.13 This is an even
more pronounced rate of anomalies than seen in schizophrenia
and other disorders of recognized neurodevelopmental origin.
Neuroimaging data concerning pedophilia are still evolving.
Early studies analyzing magnetic resonance imaging data indi-
cated decreased white matter generally, but perhaps specifically in
1
2 Fazio
2 particular fasciculi.14,15 More sensitive diffusion tensor imaging
confirmed the earlier findings involving white matter abnor-
malities, but not the findings of other studies that suggested
differences in the gray matter.16 Other studies have not found
differences when using diffusion tensor imaging, but as the
investigators of this literature point out, the methodologic dif-
ferences between studies and small samples add considerable
confusion to the issue.17
Investigators originally reporting gray matter differences in
those with pedophilia have since concluded that most of these
differences were associated with the propensity to commit of-
fenses rather than to pedophilia itself.18 It appears that the
pattern of gray matter differences between pedophiles and non-
pedophiles, sexual offenders and non-sexual offenders, and the
various combinations of these variables is quite complicated.
Recent research has demonstrated gray matter anomalies that
were not seen in earlier studies and remain to be validated,
whereas the extant relations have been refined and apparently
apply only to particular subsets of the populations of interest.
Specifically, it is now suggested that volume discrepancies in the
right temporal pole might exist between offending pedophiles
and healthy controls, whereas the previously identified volume
discrepancy in the right amygdala might be an artifact of sexual
preference differences between offending pedophiles (samples of
which tend to skew toward boys as victims) and healthy controls
(largely heterosexual).18 The nuance of this study illustrates how
far neuroimaging research has come in recent years and how far it
has yet to go, because the study did not include a sample of
sexually offending teleiophiles as a control and thus failed to
control for the possible influence of non-consensual sexual
behaviors more generally.
Most of the extant research on pedophilia might seem largely
obtuse; it is important to keep in mind the difficulties of con-
ducting research in this field. Very few individuals openly admit
to pedophilic sexual preference owing to social stigma and po-
tential consequences of such, even if they have never committed
an offense and have an active intent and desire to keep from
offending. Prevention Project Dunkelfeld (which evolved into
Prevention Network “Kein Täter Werden” [Don’t Offend]),
started in Berlin in 2005, is unique in that it is a first-of-its-kind
nationwide effort aimed to prevent child sexual abuse through
targeting individuals with pedophilic sexual preference and
providing them with anonymous therapeutic intervention such
as psychotherapy and potentially even libido-suppressing medi-
cations; they have had more than 8,500 individuals reach out to
them since their inception,19 although fewer entered treatment.
Currently, there is no North American equivalent of the Pre-
vention Project Dunkelfeld.20 As such, sample sizes remain a
limiting factor, and many participants are those who have been
identified as possibly having pedophilic preference owing to
legally problematic sexual behaviors, which could introduce
unknown bias into the samples. Indeed, some research
comparing offending and non-offending pedophiles is beginning
to emerge with discrepant findings among the various groups,21
which casts additional confusion on results of older studies,
whose participants were generally not categorized in such a
fashion, but rather purely on the diagnosis of pedophilia.
In summary, we are slowly moving toward a neuro-
developmental and potentially epigenetic explanation of pedo-
philic sexual preference. There is growing evidence that a
propensity toward pedophilic sexual preference begins prenatally,
with early neurodevelopmental abnormalities resulting from
different prenatal events, which then can be further shaped by
experiences in childhood development. This is not unlike
developmental theories of schizophrenia that combine genetic
propensity with in utero events, such as those associated with
season of birth and exposure to influenza viruses and later trig-
gered by environmental stressors. Future research directions on
the biological origin of pedophilia currently being pursued
include additional neuroimaging research and examination of
season of birth to elucidate further possible neurodevelopmental
stressors. Although there is no known cure for pedophilia—and
indeed, there are no currently published data clearly demon-
strating the effectiveness of even Prevention Project Dunkelfeld,
which arguably might be among the most promising prevention
efforts—perhaps the classification of pedophilia as one of the end
points on a spectrum of neurodevelopmental abnormalities will
help facilitate preventative efforts in early prenatal care, adequate
social services for children and mothers, and treatment efforts for
adults struggling with this attraction.
ACKNOWLEDGMENTS
I thank James M. Cantor for a review of a previous version of
this commentary.
Corresponding Author: Rachel L. Fazio, PsyD, 400 W Capitol
Avenue, Suite 1700, Little Rock, AR 72201, USA. Tel: 501-
301-4643; E-mail: rlfazio@gmail.com
Conflicts of Interest: The author reports no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Rachel L. Fazio
(b) Acquisition of Data
Not applicable
(c) Analysis and Interpretation of Data
Not applicable
Category 2
(a) Drafting the Article
Rachel L. Fazio
(b) Revising It for Intellectual Content
Rachel L. Fazio
J Sex Med 2018;-:1e3
Neurodevelopmental Understanding of Pedophilia
Category 3
(a) Final Approval of the Completed Article
Rachel L. Fazio
REFERENCES
1. Seto MC. Pedophilia and sexual offenses against children. Ann
Rev Sex Res 2004;15:321-361.
2. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 5th ed. Arlington, VA: American
Psychiatric Publications; 2013.
3. World Health Organization. The ICD-10 classification of mental
and behavioural disorders: clinical descriptions and diagnostic
guidelines. Geneva: World Health Organization; 1992.
4. McPhail IV, Hermann CA, Fernane S, et al. Validity in phallo-
metric testing for sexual interests in children: a meta-analytic
review. Assessment https://doi.org/10.1177/1073191117706139.
E-pub ahead of print.
5. Blanchard R, Kolla NJ, Cantor JM, et al. IQ, handedness, and
pedophilia in adult male patients stratified by referral source.
Sex Abuse 2007;19:285-309.
6. Blanchard R, Kuban ME, Klassen P, et al. Self-reported head
injuries before and after age 13 in pedophilic and nonpedophilic
men referred for clinical assessment. Arch Sex Behav 2003;
32:573-581.
7. Cantor JM, Blanchard R, Christensen BK, et al. Intelligence,
memory, and handedness in pedophilia. Neuropsychology
2004;18:3-14.
8. Cantor JM, Klassen PE, Dickey R, et al. Handedness in
pedophilia and hebephilia. Arch Sex Behav 2005 Aug 28;
34:447-459.
9. Cantor JM, Kuban ME, Blak T, et al. Physical height in pedo-
philic and hebephilic sexual offenders. Sex Abuse treatment
2007;19:395-407.
10. McPhail IV, Cantor JM. Pedophilia, height, and the magnitude
of the association: a research note. Deviant Behav 2015;
36:288-292.
J Sex Med 2018;-:1e3
3
11. Fazio RL, Lykins AD, Cantor JM. Elevated rates of atypical
handedness in paedophilia: theory and implications. Laterality
2014;19:690-704.
12. Fazio RL, Dyshniku F, Lykins AD, et al. Leg length versus torso
length in pedophilia: further evidence of atypical physical
development early in life. Sex Abuse 2017;29:500-514.
13. Dyshniku F, Murray ME, Fazio RL, et al. Minor physical
anomalies as a window into the prenatal origins of pedophilia.
Arch Sex Behav 2015;44:2151-2159.
14. Cantor JM, Kabani N, Christensen BK, et al. Cerebral white
matter deficiencies in pedophilic men. J Psychiatr Res 2008;
42:167-183.
15. Cantor JM, Blanchard R. White matter volumes in pedo-
philes, hebephiles, and teleiophiles. Arch Sex Behav 2012;
41:749-752.
16. Cantor JM, Lafaille S, Soh DW, et al. Diffusion tensor imaging
of pedophilia. Arch Sex Behav 2015;44:2161-2172.
17. Gerwinn H, Pohl A, Granert O, et al. The (in)consistency of
changes in brain macrostructure in male paedophiles: a com-
bined T1-weighted and diffusion tensor imaging study.
J Psychiatr Res 2015;68:246-253.
18. Schiffer B, Amelung T, Pohl A, et al. Gray matter anomalies in
pedophiles with and without a history of child sexual offend-
ing. Transl Psychiatry 2017;7:e1129.
19. Almost 8.500 people asked for help. Available at: https://
www.dont-offend.org/story/around-8-500-people-asked-for-
help.html; Accessed 2017.
20. Beier KM, Ahlers CJ, Goecker D, et al. Can pedophiles be
reached for primary prevention of child sexual abuse? First
results of the Berlin Prevention Project Dunkelfeld (PPD).
J Forensic Psychiatry Psychol 2009;20:851-867.
21. Kärgel C, Massau C, Weiß S, et al. Evidence for superior
neurobiological and behavioral inhibitory control abilities in
non-offending as compared to offending pedophiles. Hum
Brain Mapp 2017;38:1092-1104.