Table 1.
The table includes the final recommendations consisting of 63 statements divided into six different topics.
| Statement | Expert Agreement first round | Second round reformulation | Expert Agreement Second round | Agreement within editors | Included in final recomendations | |
|---|---|---|---|---|---|---|
| Behavioral indicators | ||||||
| 1 | Acquired and developmental pedophilia are two widely different disorders/distinct entities | 92.3% | 82.6% | YES | ||
| 2 | Acquired pedophilia occurs “de novo”, i.e., in individuals who have never manifested pedophilic interests or urges before, determining a behavioral fracture. | 92.3% | 82.6% | YES | ||
| 3 | Unlike developmental pedophiles, acquired pedophiles behave in most cases with an impulse dis-control. | 92.3% | 78.3% | YES | ||
| 4 | The impulse dis-control typical of individuals suffering from acquired pedophilia might manifest as lack of premeditation, un-planned actions and absence of masking the sexual abuse. | 84.6% | 78.3% | YES | ||
| 5 | The impulse dis-control typical of individuals suffering from acquired pedophilia might have an impact on the physical places where abuses take place, as acquired pedophiles are likely to act in open or crowded spaces, where they can easily be seen. | 61.6% | Not included within the second round | 60.9% | NO | |
| 6 | The presence of premeditation is an important behavioral indicator that discriminates between an acquired and a developmental pedophile, especially when premeditation manifests in grooming behaviors. | 69.3% | The presence of premeditation is an important behavioral indicator that discriminates between an acquired and a developmental pedophile (acquired pedophiles do not premeditate) | 77% | 78.3% | YES |
| Acquired pedophilia do not manifest grooming behaviors | 84.6% | 78.3% | YES | |||
| While premeditation is always present in developmental pedophilia, acquired pedophiles might act without premeditating the sexual assaults | 84.6% | 78.3% | YES | |||
| 7 | Unlike individuals with developmental pedophilia, individuals with acquired pedophilia do not manifest a predatory behavior (i.e., active search for victims) but they are guided by occasional events. | 77% | 78.3% | YES | ||
| 8 | Unlike individuals with developmental pedophilia, individuals with acquired pedophilia show a lack of rumination (i.e., obsession, constant thought about their victims, etc.). | 61.6% | Individual with developmental pedophilia usually show rumination (i.e., obsession, constant thought about their victims, etc.) | 69.3% | n/a | NO |
| Individuals with acquired pedophilia usually do not show rumination (i.e., obsession, constant thought about their victims, etc.) | 77% | 60.9% | NO | |||
| 9 | Acquired pedophilia can be characterized by the non-selective choice of the sexual partner, OR it can be associated with general hypersexuality. | 84.6% | 87% | YES | ||
| 10 | Unlike individuals with developmental pedophilia, individuals with acquired pedophilia do not usually show aggressive behavior during their abuses (physical violence other than the sexual one, coercion). | 69.3% | Not included in the second round | 47.8% | NO | |
| 11 | Unlike developmental pedophiles, acquired pedophiles behave in most cases with an insufficient moral judgment, which prevents them from understanding the wrongness of their action | 53.9% | Individuals with developmental pedophilia have spared moral judgement: i.e., they are aware of the wrongness of their action | 61.6% | n/a | NO |
| Individuals with acquired pedophilia might have impaired moral judgement | 84.6% | 87% | YES | |||
| In the cases where moral judgement is impaired, individuals might not be aware of the wrongness of their actions | 84.6% | 87% | YES | |||
| 12 | The insufficient moral judgment typical of individuals suffering from acquired pedophilia might manifest as spontaneous confession or lack of sense of guilt, as they do not understand the moral and legal implications of their actions. | 69.3% | The insufficient moral judgement that might be present in individuals suffering from acquired pedophilia might manifest as spontaneous confession or lack of sense of guilt | 84.6% | 78.3% | YES |
| In the cases where moral judgement is impaired, individuals with acquired pedophilia do not understand the legal and moral disvalue of their actions | 84.6% | 87% | YES | |||
| 13 | The impulse dis-control and the moral judgement deficits might be dissociated in acquired pedophilia: acquired pedophiles might act only as a consequence of an irresistible impulse although they are aware of the moral, social and legal disvalue of their acts OR they are only unable to understand that their behavior is morally, socially and legally wrong. | 92.3% | 82.7% | YES | ||
| 14 | As acquired pedophilia occurs as a symptom of a neurological insult, it does not share with developmental pedophilia the psychological risk factors, as for instance having been abused during infancy or high comorbidity with other psychiatric disorders. | 77% | 78.3% | YES | ||
| 15 | While developmental pedophilia is usually present since adolescence, the age of the onset of acquired pedophilia is usually delayed due to its acquired origin. | 100% | 91.4% | YES | ||
| 16 | To evaluate the presence of acquired pedophilia, additional behavioral indicators or abnormalities, indicative of impulse dis-control or of impaired moral judgment, might be present in individual’s daily life habits and outside the modus operandi. | 92.3% | 87% | YES | ||
| 17 | A detailed anamnesis should be carried out in order to understand whether or not additional behavioral indicators (not legally relevant and present in the individual’s daily life) are present or not. | 92.3% | 100% | YES | ||
| 18 | Unlike developmental pedophiles, acquired pedophiles are likely to present concomitant focal cognitive alterations, as a consequence of the brain disorder that also causes acquired pedophilia. | 92.3% | 91.3% | YES | ||
| 19 | Unlike developmental pedophiles, acquired pedophiles are likely to present concomitant neurological symptoms and signs indicative of brain sufferance. | 100% | 87% | YES | ||
| 20 | Acquired pedophilia is a multifactorial phenomenon and for this reason a psychological tool should be developed to capture the subjective experience of acquired pedophilia. | 84.6% | 87% | YES | ||
| Neuroscientific investigation | ||||||
| 21 | If acquired pedophilia is suspected, an in-depth neuro-scientific investigation is warranted to further explore this condition | 100% | 95.7% | YES | ||
| 22 | Acquired pedophilia cannot be the sole symptoms of an underlying brain insult, but additional behavioral alteration, neurological symptoms, etc., should be present as well. | 92.3% | 91.4% | YES | ||
| 23 | Most of the neuro-scientific evidence (i.e., brain scans, neurologic symptoms) cannot be malingered. | 92.3% | 78.3% | YES | ||
| 24 | Including a NEUROPSYCHOLOGICAL EXAMINATION within the neuro-scientific investigation, it can be helpful to discriminate between developmental and acquired pedophilia as individuals with acquired pedophilia might present neuropsychological deficits consistent with the underlying neurologic disorder. | 100% | 100% | YES | ||
| 25 | Neuropsychological tests measuring the ability to control impulses (such as the go/no go task, etc.) can be useful to investigate whether the impulse control component is spared or impaired. If the impulse component is impaired even in a neutral task, acquired origin of pedophilia might be suspected. | 92.3% | 82.7% | YES | ||
| 26 | Neuropsychological tests measuring moral judgement (such as the ability to discriminate right from wrong, to identify a normal behavior, to evaluate the severity of a behavioral violation, etc.) can be useful to investigate whether the moral component is spared or impaired. If the moral component is impaired, even in a neutral task, acquired origin of pedophilia might be suspected. | 69.3% | Neuropsychological tests measuring moral judgement (such as the ability to discriminate right from wrong, to identify a normal behavior, to evaluate the severity of a behavioral violation, etc.) can be useful to investigate whether the moral component is spared or impaired | 92.3% | 78.3% | YES |
| If the moral component is impaired, even in tasks that do not investigate sexual behaviors, acquired origin of pedophilia might be suspected | 92.3% | 78.3% | YES | |||
| 27 | Neuropsychological impairment can potentially be malingered. Thus, particular attention should be paid to this. Neuropsychological tests accounting for malingering of impulse discontrol and impairment in moral judgement should be developed and used. | 92.3% | 82.6% | YES | ||
| 28 | Including PSYCHIATRIC ASSESSMENT within the neuro-scientific investigation it can be helpful to discriminate between developmental and acquired pedophilia as acquired pedophiles are not expected to show high comorbidities with other psychiatric disorders (in particular with personality disorders), differently from developmental pedophiles. | 69.3% | Including PSYCHIATRIC ASSESSMENT within the neuro-scientific investigation it can be helpful to discriminate between developmental and acquired pedophilia | 84.6% | 78.3% | YES |
| 29 | Including a NEUROLOGICAL ASSESSMENT within the neuro-scientific investigation it can be helpful to discriminate between developmental and acquired pedophilia, as acquired pedophilia might be associated with signs and symptoms typical of the underlying neurological disorder. | 100% | 95.7% | YES | ||
| 30 | Neurologic signs of frontal lobe dysfunction can be a key characteristic of acquired pedophilia. | 92.3% | 87% | YES | ||
| 31 | Including NEUROIMAGING within the neuro-scientific investigation it can be helpful to discriminate between developmental and acquired pedophilia as acquired pedophilia should be originated by a neurological disorder usually visible at brain scan (unless in its very early stage). | 100% | 91.4% | YES | ||
| 32 | Brain imaging should be coupled with behavioral diagnosis in order to make the diagnosis of acquired pedophilia as reliable as possible. | 100% | 100% | YES | ||
| 33 | Brain insult leading to acquired pedophilia should be clearly evident. In other words, subtle brain abnormalities emerging only after a statistical analysis of the brain scans (for instance using Voxel Based Morphometry, etc.) could not be used as evidence supporting the presence of acquired pedophilia. Indeed, psychiatric disorders (i.e., developmental pedophilia) might be characterized by subtle abnormalities as well. | 61.6% | After explanation | 84.6% | 87% | YES |
| 34 | The brain pathology associated with the behavioral variant of fronto-temporal dementia (bvFTD) might not be clearly evident in the early stage of the disorder, making bvFTD an exception to the previous statement. However, the fast progression of the disorder and the possibility to support its diagnosis using alternative brain imaging methods (i.e., PET) can help in the diagnostic differentiation. | 92.3% | 78.3% | YES | ||
| 35 | Including PSYCHOPHYSIOLOGICAL INVESTIGATIONS, like heart rate, startle reflex and skin conductance, within the neuro-scientific examination can be helpful to determine the presence of acquired pedophilia as these techniques can be helpful to exclude psychopathic traits | 23.1% | Not included in the second round | 30.4% | NO | |
| 36 | Hormonal or biological analysis might support the possible presence of acquired pedophilia. Genetic investigations (PRGN & TAU) reveal neurobiological risk factors of acquired pedophilia. | 61.6% | Not included in the second round | 21.8% | NO | |
| 37 | The IMPLICIT ASSOCIATION TEST (a behavioral test based on the compatibility effect and the analysis of reaction times) could help to support the late onset of pedophilic urges. | 61.6% | After explanation | 69.2% | 56.5% | NO |
| 38 | Questionnaires investigating sexual behaviors should be provided to clinicians working with at risk populations (for example to all patients with specific neurologic disorders like dementias, Hungtington’s disorder, Parkinson’s disorder etc.) to further explore the possible insurgence of pedophilic tendencies in these patients. | 84.6% | 78.3% | YES | ||
| Neurological condition | ||||||
| 39 | Acquired pedophilia emerge as a symptom of brain disorder. Despite acquired pedophilia has been described following brain tumor, traumatic injuries, surgical lesions, encephalitis, multiple sclerosis, dementias, etc, theoretically, pedophilia can occur as a symptom of any brain disorder. | 61.6% | Acquired pedophilia emerge as a symptom of brain disorder. Despite acquired pedophilia has been described following brain tumor, traumatic injuries, surgical lesions, encephalitis, multiple sclerosis, dementias, etc., theoretically, acquired pedophilia can potentially occur as a symptom of a large variety of neurological disorder with different etiology | 92.3% | 91.4% | YES |
| 40 | Regardless the specific etiology of the underlying neurological insult, it is of the utmost importance to determine a strong temporal link between the onset of the neurological insult and the insurgence of the pedophilic tendencies. | 84.6% | 87% | YES | ||
| 41 | The brain network involved in pedophilia is still unknown and needs to be further investigated. Of note, the relevance of connections/ disconnections to the frontal lobe should be specifically assessed. | 84.6% | 95.7% | YES | ||
| 42 | Despite the brain network involved in acquired pedophilia is still unknown, any lesion affecting hypothalamus can potentially cause acquired pedophilia, as some nuclei of the hypothalamus are relevant for sexual orientation. | 53.9% | Despite the brain network involved in acquired pedophilia is still unknown, lesions affecting the hypothalamus can potentially contribute to the insurgence (or: can potentially influence the insurgence) of acquired pedophilia, as some nuclei of the hypothalamus are relevant for sexual orientation. | 92.3% | 87% | YES |
| 43 | Despite the brain network involved in acquired pedophilia is still unknown, any lesion affecting the limbic system can potentially cause acquired pedophilia, as the limbic system is relevant for sexual behaviors and emotions. | 69.3% | Despite the brain network involved in acquired pedophilia is still unknown, lesions affecting the limbic system can potentially contribute to the insurgence (or: can potentially influence the insurgence) of acquired pedophilia, as the limbic system is relevant for sexual behaviors and emotions | 100% | 87% | YES |
| 44 | Despite the brain network involved in pedophilia is still unknown, any lesion affecting orbitofrontal cortex can potentially cause acquired pedophilia, as the orbitofrontal cortex is relevant for impulse control. | 84.6% | 82.6% | YES | ||
| 45 | Despite the brain network involved in pedophilia is still unknown, any lesion affecting ventro-medial and/or dorso lateral prefrontal cortex can potentially cause acquired pedophilia, as these brain regions are relevant for moral judgement. | 77% | 78.3% | YES | ||
| 46 | Besides disorders with specific etiology, acquired pedophilia can also emerge due to biochemical imbalance (e.g., addiction to dopaminergic drugs to treat Parkinson’s disease). | 77% | 78.3% | YES | ||
| 47 | Deep brain stimulation for movement disorders may result in hyper-sexuality, impulse control disorders and disinhibition, which may increase the risk of pedophilic behavior. | 61.6% | Deep brain stimulation for movement disorders may result in hyper-sexuality, impulse control disorders OR disinhibition, which may increase the risk of pedophilic behavior | 69.2% | 43.5% | NO |
| 48 | Epidemiological studies are needed to be able to better evaluate the prevalence and incidence of acquired pedophilia. | 92.3% | 91.3% | YES | ||
| 49 | To date, pedophilia and other paraphilias are the only psychiatric disorders within the DSM 5 that do not include the diagnostic criteria: «the symptoms are not attributable to the physiological effects of a substance or another medical conditions». As acquired pedophilia is a clear entity, we suggest this criterion should be added to pedophilia within the next DSM edition. | 92.3% | 82.6% | YES | ||
| Consequences of misdiagnosis | ||||||
| 50 | It is important to differentiate developmental from acquired pedophilia as the two require different treatments and/or rehabilitation trajectories. | 100% | 95.7% | YES | ||
| 51 | It is important to correctly differentiate between individuals with acquired versus developmental pedophilia, because acquired pedophiles often need medical treatment to both treat the underlying neurological disease and to arrest the pedophilic tendency. | 100% | 87% | YES | ||
| 52 | The misdiagnosis of acquired pedophilia might have dramatic consequences for the sexual offender as acquired pedophilia often has a treatable etiology. Thus, a misdiagnosis has an impact on the defendant’s health (and possibly on his life). | 100% | 95.7% | YES | ||
| 53 | As acquired pedophilia often origins from a treatable underlying disorder and a “restitutio ad integrum” has been described following treatment of the underlying neurological condition, a correct diagnosis might help in preventing further sexual offenses/recidivism. | 100% | 82.6% | YES | ||
| 54 | The consequences of the misdiagnosis of acquired pedophilia are potentially severe for the defendant’s family, that is suffocated by social stigma. The right diagnosis might help relatives to have a rational explanation of their relative’s behavior. Indeed, from the psychological point of view it is very different to consider a relative as a sexual predator or, on the contrary, as a patient with a neurological disorder producing involuntary inappropriate behavior. | 100% | 95.7% | YES | ||
| 55 | The misdiagnosis of acquired pedophilia might potentially have ethical consequences, as it is an ethical concern to put in jail someone who has a life-threatening condition impacting on his behavior and who would benefit more from medical treatment. In these cases, the offenders should be in any case closely monitored to avoid re-offending. | 100% | 95.7% | YES | ||
| 56 | The misdiagnosis of acquired pedophilia might potentially have ethical consequences, as it would be unethical to impose an inappropriate legal solution based on a retributive penalty instead of a rehabilitative option. | 92.3% | 100% | YES | ||
| 57 | Attention should be paid to the risk of stigmatization of both developmental and acquired pedophilia. As there are pedophiles who never committed sexual crimes and who are actively asking for help, their stigmatization should be avoided as it will not help in preventing crimes. | 92.3% | 87% | YES | ||
| Legal consequences | ||||||
| 58 | A case-by-case approach is the most appropriate when establishing the legal consequences of acquired pedophilia. | 84.6% | 91.4% | YES | ||
| 59 | The legal consequences on insanity should be different between developmental and acquired pedophilia. | 84.6% | 78.3% | YES | ||
| 60 | While defendants with developmental pedophilia are to be considered criminally liable, defendants presenting with acquired pedophilia can be considered not guilty by reason of insanity. | 61.6% | Defendants with developmental pedophilia are to be considered criminally liable | 92.3% | 95.7% | YES |
| Defendants presenting with acquired pedophilia can be considered not guilty by reason of insanity | 77% | 87% | YES | |||
| It is relevant to assess insanity in individual with acquired pedophilia | 92.3% | 87% | YES | |||
| 61 | When acquired pedophilia is suspected, the presence of an underlying neurological condition is not per se enough to lead to insanity, but the impact of the neurological condition on relevant behaviors (i.e., moral reasoning and impulse control) should be carefully assessed. | 84.6% | 100% | YES | ||
| 62 | Acquired pedophiles should be assigned to a non-reclusive condition, however they should be treated in places where their social danger is neutralized until recovery. | 100% | 91.4% | YES | ||
| 63 | Acquired pedophiles should not be condemned to jail, as jail restriction is inadequate as they need to be treated rather than/before being punished. | 84.6% | 95.7% | YES | ||
| 64 | Alternative structures to jail (hospices or something else) may be evaluated for acquired pedophiles. | 92.3% | 87% | YES | ||
| 65 | Determining whether the individual suffering from acquired pedophilia had pre-morbid sexual interests towards children but never acted them, is a scientifically interesting question. However, it is not legally important, as individuals should be judged from their behaviors. | 84.6% | 78.3% | YES | ||
| Issues and future perspectives | ||||||
| 66 | There is definitively a prejudice within the scientific community on this topic. | 84.6% | 78.3% | YES | ||
| 67 | The existing prejudice on this topic will be very hard to overcome. Indeed, providing an explanation is considered equivalent to providing a justification. | 77% | 78.3% | YES | ||
| 68 | The only way to diminish the prejudice on this topic is to publish and disseminate the results of research, to provide a better explanation of how the brain disorders can lead to acquired pedophilia, which are the associated behavioral indicators, and how can sexual offense be prevented in these patients. | 84.6% | 82.6% | YES | ||
| 69 | The only way to overcome prejudice is to keep people informed with the latest scientific results: acquired pedophiles, despite they have committed a crime, are patients that need medical treatment. | 100% | 82.6% | YES | ||
| 70 | It will be useful to include the perspective of victims in any paper concerning criminal justice responses to acquired and developmental pedophilia. Too often, the perspective of victims is not addressed. Victims often have a need to understand why an individual has committed a particular crime. | 84.6% | 69.6% | NO | ||
| 71 | Neuropsychology teaches us that every cognitive component might be selectively damaged. Sexual behavior is a complex function that requires the integrity of many cognitive components (gender recognition, age estimation, moral reasoning, theory of mind, impulse control, to name a few) in order to be carried out. It is thus unreasonable to believe that sexual behavior, being the result of many complex cognitive tasks, could not be affected by neurological damage. | 100% | 91.4% | YES | ||
| 72 | Further studies should try to better estimate the prevalence and incidence of acquired pedophilia, by systematically surveying a consecutive series of individuals charged or convicted with pedophilic activities in a defined region (e.g., country or state). | 100% | 91.4% | YES | ||
n/a not applicable.