**Magnetic Resonance Techniques in Study of Sexual Stimuli Processing in Paedophilia**

Juan Antonio Becerra-García

*Department of Psychology, University of Jaén, Spain* 

### **1. Introduction**

The sexual aggression of children is a major public health and criminological issue and a paedophilic crime causes considerable public concern. Paraphilias are deviant sexual behaviors that have common clinical features: sexual fantasies leading to sexual urges and, ultimately, to the deviant sexual behavior. In these group of disorders is include the paedophilia (American Psychiatric Association [APA], 2000). Paedophilia is defined as a psychiatric disorder characterized by intense sexually arousing urges and behaviours focused on the sexual activity with a prepubescent child (APA, 2000; Fagan et al., 2002). The ICD-10 defines paedophilia as a sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age (World Health Organization [WHO], 2010).

The Diagnostic and Statistical Manual of Mental Disorders, define a paedophile as an individual who fantasizes about, is sexually aroused by, or experiences sexual urges toward prepubescent children (generally <13 years) for a period of at least 6 months. Paedophiles are either severely distressed by these sexual urges, experience interpersonal difficulties because of them, or act on them (diagnostic criteria, according to the DSM-IV-TR, are shown in Table 1), usually come to medical or legal attention by committing an act against a child because most do not find their sexual fantasies distressing or ego-dystonic enough to voluntarily seek treatment. The clinical diagnosis of paedophilia is based on a specific act, it usually is not solely the result of intoxication or caused by another state or condition (APA, 2000).

Paedophiles are subdivided into several classifications. One of the first classifications divided to the paedophiles in two groups, group "exclusively" attracted to children (exclusive paedophile) or attracted to adults as well as children (nonexclusive paedophile group) (APA, 2000). Other categorization of paedophiles is based in if they are attracted to only male children (homosexual paedophilia), female children (heterosexual paedophilia), or children from both sexes (bisexual paedophilia).

The course of paedophilia is usually long term and has yet no cure. The onset of paedophilia usually occurs during adolescence. Occasional paedophiles begin their activities during middle age but this late onset is uncommon. The frequency of behavior associated with paedophilia varies with psychosocial stress . As the paedophile's stress levels increase, the frequency of his or her acting out generally rises also. Various treatments are available. The medical treatments (medications anti-androgens, luteinizing hormone-releasing hormone agonists, female hormones, antidepressant ) and psychological treatments (aversive

Magnetic Resonance Techniques in Study of Sexual Stimuli Processing in Paedophilia 75

& Barbaree, 2005; Stone et al., 2000) The term hebophilia or hebephilia is generic term to describe sexual interest in either male or female pubescent children ((Blanchard & Barbaree, 2005; Blanchard et al., 2000; Danni & Hampe, 2000; Stone et al., 2000). The hebophiles tend to be more interested in having reciprocal sexual affairs or relationships with children, are more opportunistic when engaging in sexual acts, have better social functioning, and have a better posttreatment prognosis than paedophiles (Danni & Hampe, 2000; Stone et al., 2000). Other subclassification of paedophilia known as infantophilia, which describes individuals interested in children younger than 5 years (Greenberg et al., 1995). These distinctions are important in understanding current research about paraphilias, selection criteria for studies of sexual behavior and for future diagnosis criteria of paedophilia or pedohebephilic disorders (table 2 shown the future diagnosis criterias of this disorder, where are included

A. Over a period of at least six months, one or both of the following, as manifested by

1. The person has clinically significant distress or impairment in important areas of

2. The person has sought sexual stimulation, on separate occasions, from either of the

3. Repeated use of , and greater arousal from, pornography depicting prepubescent or pubescent children than from pornography depicting physically mature persons, for a

C. The person is at least age 18 years and at least five years older than the children in

Pedophilic type: sexually attracted to prepubescent children (generally younger than 11). Hebephilic type: sexually attracted to pubescent children (generally age 11 through 14).

In remission (no distress, impairment, or recurring behavior and in an uncontrolled

1. Recurrent and intense sexual arousal from prepubescent or pubescent children. 2. Equal or greater arousal from such children than from physically mature individuals.

criteria of paedophilia and hebephilia).

B. One or more of the following signs or symptoms:

a. Two or more different children, if both are prepubescent. b. Three or more different children, if one or more are pubescent.

functioning from sexual attraction to children.

Pedohebephilic type: sexually attracted to both.

environment): state duration of remission in months: \_\_\_\_.

Table 2. Futures DSM-V criteria for the diagnosis of Pedohebephilic Disorder (Recommendation of American Psychiatric Association for to rename Paedophilia to

fantasies, urges, or behaviors:

period of six months or longer.

Criterion A or Criterion B.

Sexually attracted to males. Sexually attracted to females. Sexually attracted to both.

In a controlled environment.

Pedohebephilic Disorder; APA, 2011).

following:

Specify type:

Specify type:

Specify if:

behavior therapy and cognitive-behavioral therapy) are aimed at reducing or preventing the expression of paedophilic behavior and to reducing the prevalence of child sexual abuse (Drapeau et al., 2005; Rosler & Witztum, 2000; Schober et al., 2005). The prognosis of successfully ending paedophilic habits among persons who practice paedophilia is not favorable. Paedophiles have a high rate of recidivism; that is, they tend to repeat their acts often over time. Paedophiles offer rationalizations or excuses that enable them to avoid assuming responsibility for their actions. They may blame the children for being too attractive or sexually provocative. They may also maintain that they are "teaching" the child about "the facts of life" or "love". This cognitive distortions made that paedophile behavior is maintained (Mihailides et al., 2004; Ward et al., 1997).

Paedophiles may engage in a wide range of sexual acts with children. These activities range from exposing themselves to children (exhibitionism), undressing a child, looking at naked children (voyeurism), or masturbating in the presence of children to more intrusive physical contact, such as rubbing their genitalia against a child (frotteurism), fondling a child, engaging in oral sex, or penetration of the mouth, anus, and/or vagina (APA, 2000; Cohen & Galinker, 2002).

A. Over a period of at least six months, recurrent and highly arousing sexual fantasies, sexual urges or behaviors that involve sexual activity with prepubertal children or children somewhat older (generally 13 years old or under).

B. The fantasies, the sexual urges or the behaviors produce clinically significant unease or deterioration on the social or professional level or in other important areas of the activity of the individual.

C. The person is at least 16 years old and is at least five years older than the child or children referred to in criterion A.

Note: Individuals in the final stages of adolescence who have contact with 12 or 13-yearolds should not be included.

Specify whether: There is sexual attraction to males. There is sexual attraction to females. There is sexual attraction to both sexes.

Specify whether: The type is exclusive (attraction only to children). The type is not exclusive.

Table 1. DSM-IV-TR criteria for the diagnosis of paedophilia.

In relation to sex preference of the victims, the ratio of girls to boys is 11:1 among (male) paedophiles in contrast to 20:1 among (male) adults committing sex crimes like rape. The homosexual attraction is greater in paedophiles than in other adults involved with sexual crimes with nearly a 2:1 difference (Freund & Watson, 1992). With respect to the choice of children as the object of sexual desire, the distinction has been made between paedophiles and hebephiles, depending on the age of the children. Individuals who engage in sexual activities with pubescent teenagers under the legal age of consent (ages 13-16 years) are known as hebophiles (attracted to females) or ephebophiles (attracted to males) (Blanchard & Barbaree, 2005; Stone et al., 2000) The term hebophilia or hebephilia is generic term to describe sexual interest in either male or female pubescent children ((Blanchard & Barbaree, 2005; Blanchard et al., 2000; Danni & Hampe, 2000; Stone et al., 2000). The hebophiles tend to be more interested in having reciprocal sexual affairs or relationships with children, are more opportunistic when engaging in sexual acts, have better social functioning, and have a better posttreatment prognosis than paedophiles (Danni & Hampe, 2000; Stone et al., 2000). Other subclassification of paedophilia known as infantophilia, which describes individuals interested in children younger than 5 years (Greenberg et al., 1995). These distinctions are important in understanding current research about paraphilias, selection criteria for studies of sexual behavior and for future diagnosis criteria of paedophilia or pedohebephilic disorders (table 2 shown the future diagnosis criterias of this disorder, where are included criteria of paedophilia and hebephilia).

A. Over a period of at least six months, one or both of the following, as manifested by fantasies, urges, or behaviors:

1. Recurrent and intense sexual arousal from prepubescent or pubescent children.

2. Equal or greater arousal from such children than from physically mature individuals.

B. One or more of the following signs or symptoms:

1. The person has clinically significant distress or impairment in important areas of functioning from sexual attraction to children.

2. The person has sought sexual stimulation, on separate occasions, from either of the following:

a. Two or more different children, if both are prepubescent.

b. Three or more different children, if one or more are pubescent.

3. Repeated use of , and greater arousal from, pornography depicting prepubescent or pubescent children than from pornography depicting physically mature persons, for a period of six months or longer.

C. The person is at least age 18 years and at least five years older than the children in Criterion A or Criterion B.

Specify type:

74 Neuroimaging for Clinicians – Combining Research and Practice

behavior therapy and cognitive-behavioral therapy) are aimed at reducing or preventing the expression of paedophilic behavior and to reducing the prevalence of child sexual abuse (Drapeau et al., 2005; Rosler & Witztum, 2000; Schober et al., 2005). The prognosis of successfully ending paedophilic habits among persons who practice paedophilia is not favorable. Paedophiles have a high rate of recidivism; that is, they tend to repeat their acts often over time. Paedophiles offer rationalizations or excuses that enable them to avoid assuming responsibility for their actions. They may blame the children for being too attractive or sexually provocative. They may also maintain that they are "teaching" the child about "the facts of life" or "love". This cognitive distortions made that paedophile behavior is

Paedophiles may engage in a wide range of sexual acts with children. These activities range from exposing themselves to children (exhibitionism), undressing a child, looking at naked children (voyeurism), or masturbating in the presence of children to more intrusive physical contact, such as rubbing their genitalia against a child (frotteurism), fondling a child, engaging in oral sex, or penetration of the mouth, anus, and/or vagina (APA, 2000; Cohen &

A. Over a period of at least six months, recurrent and highly arousing sexual fantasies, sexual urges or behaviors that involve sexual activity with prepubertal children or

B. The fantasies, the sexual urges or the behaviors produce clinically significant unease or deterioration on the social or professional level or in other important areas of the activity

C. The person is at least 16 years old and is at least five years older than the child or

Note: Individuals in the final stages of adolescence who have contact with 12 or 13-year-

In relation to sex preference of the victims, the ratio of girls to boys is 11:1 among (male) paedophiles in contrast to 20:1 among (male) adults committing sex crimes like rape. The homosexual attraction is greater in paedophiles than in other adults involved with sexual crimes with nearly a 2:1 difference (Freund & Watson, 1992). With respect to the choice of children as the object of sexual desire, the distinction has been made between paedophiles and hebephiles, depending on the age of the children. Individuals who engage in sexual activities with pubescent teenagers under the legal age of consent (ages 13-16 years) are known as hebophiles (attracted to females) or ephebophiles (attracted to males) (Blanchard

maintained (Mihailides et al., 2004; Ward et al., 1997).

children somewhat older (generally 13 years old or under).

Galinker, 2002).

of the individual.

Specify whether:

Specify whether:

The type is not exclusive.

children referred to in criterion A.

There is sexual attraction to males. There is sexual attraction to females. There is sexual attraction to both sexes.

The type is exclusive (attraction only to children).

Table 1. DSM-IV-TR criteria for the diagnosis of paedophilia.

olds should not be included.

Pedophilic type: sexually attracted to prepubescent children (generally younger than 11). Hebephilic type: sexually attracted to pubescent children (generally age 11 through 14). Pedohebephilic type: sexually attracted to both.

Specify type: Sexually attracted to males. Sexually attracted to females. Sexually attracted to both.

Specify if:

In remission (no distress, impairment, or recurring behavior and in an uncontrolled environment): state duration of remission in months: \_\_\_\_. In a controlled environment.

Table 2. Futures DSM-V criteria for the diagnosis of Pedohebephilic Disorder (Recommendation of American Psychiatric Association for to rename Paedophilia to Pedohebephilic Disorder; APA, 2011).

Magnetic Resonance Techniques in Study of Sexual Stimuli Processing in Paedophilia 77

Hamann et al., 2004; Holstege et al., 2003; Karama et al., 2002; Mouras et al., 2003; Redoute et al., 2000).In summary, that the cortical and subcortical structures are implicated in the

Currently the available data concerning the links between brain anomalies and deviant sexuality, between them the paedophilia has been obtained by means of four main

1. Neuropsychiatry, the study of acquired psychiatric disorders following brain

4. Functional neuroimaging of sexual offenders compared with nonsexual offenders and

Of this four approaches, especially the neuroimaging studies have a great potential to identify relevant brain networks and affected structures and for to estimate the brain activation and functioning during the processing of visual information in paedophilia. Previous studies with computed tomography find that the child molesters have less dense skulls and lower cerebral blood flow values (Hendricks et al., 1988). Recent studies show that the functional response patterns of the brain to sexual stimuli contain sufficient information to predict individual sexual orientation with high accuracy, and suggest that the neuroimaging techniques could be a good methods for the diagnosis of the paraphilic disorders, for example paedophilia (Ponseti et al., 2009). Though the neuroimaging studies are very small and very recent in this disorder and the application of these technologies in paedophilia has lagged behind in comparison with others psychopathologies. For what little is known about brain function in paedophilia, the structures involved in sexual behaviour and in the sex stimuli processing in this disorder. For this reason, from a neurological perspective, the aims of this review are to summarize the findings from structural and functional magnetic resonance studies in paedophilia realized up to the date and to present a summary of how is the neurological activation during sex images processing in people

The search of works was performed in different databases. The databases used were Pubmed, PsycINFO, Scopus and Cochrane. There has been no restriction in the years to search or on the type of document sought. The terms used for search were: "pedophilia" and "paedophilia" searched in conjunction with the terms "brain" and "neuroimaging". The

1. Works in which they studied people with diagnosis of paedophilia, according to the

2. Works in which they studied the structure or function of the brain in paedophilia by neuroimaging techniques, specifically by structural and functional Magnetic Resonance Image. This criterion allowed to reject works that used other types of techniques that

regulation of sexual arousal and in the processing of visual sexual stimuli.

**2. Selection methods of magnetic resonance studies** 

search terms were limited to title, abstract and keywords.

were not specifically neuroimaging techniques.

approaches:

damage.

with this disorder.

**2.2 Inclusion criteria** 

**2.1 Methods of literature review** 

diagnostic criteria of the DSM.

2. Structural neuroimaging.

the general population.

3. Neuropsychological assessments.

In the field of personality, individuals with this disorder generally experience feelings of inferiority, isolation or loneliness, low self-esteem, internal dysphoria, and emotional immaturity. They have difficulty with mature age-appropriate interpersonal interactions, particularly because of their reduced assertiveness, elevated levels of passive-aggressivity, and increased anger or hostility (Egan et al., 2005; Huprich et al., 2004; Vandiver, 2006; Vandiver & Kercher, 2004). Finally, has been found other differences between paedophilia and control groups. This differences shown that paedophiles presented: a lower intelligence (an area of controversy), a slight increase in the prominence of left-handed individuals, impaired cognitive abilities, neuroendocrine differences, and brain abnormalities, particularly frontocortical irregularities and/or differences (Blanchard & Barbaree, 2005; Bogaert, 2001; Cantor et al., 2005; Tost et al., 2004).

#### **1.2 Neuroanatomic theories in paedophilia: brief description**

The role of neurological factors and neuropsychological functioning are being integrated in theories of sexual offending (Ward & Beech, 2006). In this disorder, from a neuropsychiatric and neuropsychological perspective, different neuroanatomic theories exist that involve to different cerebral regions in paedophilia.


#### **1.3 Justification and objective**

Human sexual arousal is a multidimensional experience comprising physiological and psychological processes. Is known that in normal sexual functioning the frontal and temporal cortices are involved in the modulation of drive, initiation, and sexual activation, subcortical structures including the hippocampus, the amygdala, the septal complex and the hypothalamus are implicated in the modulation of sexual behaviours and genital responses. Modern imaging techniques allow the in vivo observation of brain activation correlated with sensory or cognitive processing and emotional states (Krueger et al., 2005**)** Today the neuroimaging studies in normal sexual functioning confirmed the involvement of inferior temporal cortex, the orbitofrontal cortex, the inferior and superior parietal lobules, the cingulate cortex, the anterior cingulated cortex, the insula, and the hypothalamus in the processing of visual sexual stimuli (Arnow et al., 2002; Bocher et al., 2001; Ferrettiet al., 2005; Hamann et al., 2004; Holstege et al., 2003; Karama et al., 2002; Mouras et al., 2003; Redoute et al., 2000).In summary, that the cortical and subcortical structures are implicated in the regulation of sexual arousal and in the processing of visual sexual stimuli.

Currently the available data concerning the links between brain anomalies and deviant sexuality, between them the paedophilia has been obtained by means of four main approaches:


76 Neuroimaging for Clinicians – Combining Research and Practice

In the field of personality, individuals with this disorder generally experience feelings of inferiority, isolation or loneliness, low self-esteem, internal dysphoria, and emotional immaturity. They have difficulty with mature age-appropriate interpersonal interactions, particularly because of their reduced assertiveness, elevated levels of passive-aggressivity, and increased anger or hostility (Egan et al., 2005; Huprich et al., 2004; Vandiver, 2006; Vandiver & Kercher, 2004). Finally, has been found other differences between paedophilia and control groups. This differences shown that paedophiles presented: a lower intelligence (an area of controversy), a slight increase in the prominence of left-handed individuals, impaired cognitive abilities, neuroendocrine differences, and brain abnormalities, particularly frontocortical irregularities and/or differences (Blanchard & Barbaree, 2005;

The role of neurological factors and neuropsychological functioning are being integrated in theories of sexual offending (Ward & Beech, 2006). In this disorder, from a neuropsychiatric and neuropsychological perspective, different neuroanatomic theories exist that involve to

a. On one hand, the Frontal-Dysexecutive Theories associate sexual offending with dysfunction of frontal cortex and behavioural disinhibition. Proponents of this theory cite studies that show that heterogeneous groups of sexual offenders perform poorly on tests that assess executive functioning, tests as for example: Verbal Fluency, Digit Span, Tower of London, Porteus Mazes, Stroop, Trail-Making, and Wisconsin Card Sort (Dolan et al., 2002; Kelly et al., 2002; Stone & Thompson, 2001; Valliant et al., 2000). b. Other group is of the Temporal-Limbic Theories that implicate in the regulation of sexual behaviour to temporal lobe structures or give a role to these structures in behavioural disinhibition. The theorists of this point of view cite the associations between temporal lobe epilepsy and paraphilia and between temporal lobe lesions and the hypersexuality exhibited in Kluver-Bucy Syndrome (Hucker et al., 1986; Lilly et al.,

c. These two previous approximations have joined in the Dual Dysfunction Theories, in which is defends that the paedophilic men suffer from dysfunction both in temporal regions (causing sexual urges) and in frontal regions (causing behavioural disinhibition)

Human sexual arousal is a multidimensional experience comprising physiological and psychological processes. Is known that in normal sexual functioning the frontal and temporal cortices are involved in the modulation of drive, initiation, and sexual activation, subcortical structures including the hippocampus, the amygdala, the septal complex and the hypothalamus are implicated in the modulation of sexual behaviours and genital responses. Modern imaging techniques allow the in vivo observation of brain activation correlated with sensory or cognitive processing and emotional states (Krueger et al., 2005**)** Today the neuroimaging studies in normal sexual functioning confirmed the involvement of inferior temporal cortex, the orbitofrontal cortex, the inferior and superior parietal lobules, the cingulate cortex, the anterior cingulated cortex, the insula, and the hypothalamus in the processing of visual sexual stimuli (Arnow et al., 2002; Bocher et al., 2001; Ferrettiet al., 2005;

Bogaert, 2001; Cantor et al., 2005; Tost et al., 2004).

different cerebral regions in paedophilia.

1983; Mendez et al., 2000).

(Cohen et al., 2002).

**1.3 Justification and objective** 

**1.2 Neuroanatomic theories in paedophilia: brief description** 


Of this four approaches, especially the neuroimaging studies have a great potential to identify relevant brain networks and affected structures and for to estimate the brain activation and functioning during the processing of visual information in paedophilia. Previous studies with computed tomography find that the child molesters have less dense skulls and lower cerebral blood flow values (Hendricks et al., 1988). Recent studies show that the functional response patterns of the brain to sexual stimuli contain sufficient information to predict individual sexual orientation with high accuracy, and suggest that the neuroimaging techniques could be a good methods for the diagnosis of the paraphilic disorders, for example paedophilia (Ponseti et al., 2009). Though the neuroimaging studies are very small and very recent in this disorder and the application of these technologies in paedophilia has lagged behind in comparison with others psychopathologies. For what little is known about brain function in paedophilia, the structures involved in sexual behaviour and in the sex stimuli processing in this disorder. For this reason, from a neurological perspective, the aims of this review are to summarize the findings from structural and functional magnetic resonance studies in paedophilia realized up to the date and to present a summary of how is the neurological activation during sex images processing in people with this disorder.
