INTRODUCTION

Pedophilia is evaluated under the headline of pedophilic disorders in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders 5thEdition). According to DSM-5 diagnostic criteria, pedophilic disorder is defined as recurrent, intense sexually arousing thoughts (fantasies), sexual urges, or behaviors involving sexual activity with a prepubescent child or children over a period of at least 6 months. Besides, it is required that the individual should behave in compliance with his sexual urges, or his sexual urges or thoughts should cause marked distress or interpersonal problems. According to DSM-5 diagnostic criteria, pedophilic disorder diagnosis can be made if the individual is at least 16 years old and he should be at least five years older than children with whom he has sexual activities (1). In DSM-5, the term “disorder” was added at the end of paraphilias to clearly define the border with atypical sexual interests, which might not be considered as diseases. Although there was no change in diagnostic criteria of DSM-5 when compared with DSM-IV-TR, it was named as “pedophilic disorder”.

It is generally reported that individuals who have pedophilic disorder start to get sexually interested in children during their adolescence; but there are also data indicating that it may be developed at the adulthood (2). As they perform their activities secretly, and do not apply for treatment, it is not possible to determine prevalence of pedophilic disorder (2). Majority of pedophilia cases are males (3). It has been shown that they generally do not use force during their activities, on the contrary, they start first with innocent touches, and progress to many methods such as inappropriate touches, show nude pictures, and pornography (4,5).

To diagnose pedophilic disorder, it is required to evaluate whether the condition has occurred as a result of psychiatric disease such as mania, or under effect of a substance which may affect the individual’s judgement (2). If there is an action which seems to be related to an existent or accompanying psychiatric disorder or substance abuse, then previous sexual preferences, fantasies, and actions of that individual should be considered (2).

On the other hand, incest is a sexual activity or assault between family members or close relatives which is forbidden socially and culturally (6,7). As it is the case in other sexual attitude and behaviors directed to children, incest is also one of the sexual assault types for children. Incest is a sexual assault which is observed in all populations, and forbidden, and condemned. It is generally observed between own or step-father and children or between siblings. It may be observed between grandfather and grandchild, uncle and female or male nephew in decreasing order (8). Incest has made up 20-25% of overt children sexual assaults (9,10). Prevalence of incest is not known definitely, because similar to pedophilia, it is a blamed and forbidden relationship.

Emphasizing characteristics and differences of pedophilic disorders and defining types of pedophilic disorders are important for clinicians. Concomitance of pedophilic disorder and incest is an important detail which is commonly underestimated. This issue should be considered especially during examination. As it is a significant picture both for medical and population aspects, questioning about incest and gathering information carefully about this issue carry a specific value. Generally these cases apply for psychiatric examination as a result of law cases. In this case presentation, 6-years’ follow-up of an individual with pedophilic disorder, who has applied for psychiatric examination with his wife after a familial crisis is summarized. This case report is important to remind clinical significance of concomitance of pedophilic disorder and incest, and also to show that long-term remission may be possible in these cases.

CASE

The written consent form was provided from the patient to publish this case report. A 50 years old male patient who was graduated from the high school, and self-employed applied to our outpatient clinic with his wife. His wife was crying loudly. The patient was standing up with his down, and depressed condition, rubbing his hands and crying. When his wife left the room, he was relaxed and communicated with us.

He told that he did not know how to tell what he had lived; he was from a conservative and traditional family, and his present family had also the same characteristics. He was a shopkeeper in a small town in Anatolia, and what he had lived, should not be known by anybody, or else he could not live. He told that he was forced to apply after the latest events by his wife. He told that he touched his daughter physically, but his wife understood him wrongly. Actually he would like to love his daughter and his daughter was pleased with that. When he was asked non-judgmental questions to understand the real condition, he told that he did these involuntarily, and he was interested in children. He also told that he was sexually aroused when he thought of them, he had fantasies about them, and he approached children under the cover of affection without drawing attention. He mentioned that his interest for children started since he was an adolescent, the gender of children (boy or girl) was not important. He told that his affectionate behavior was never further than caressing and touching. He explained that his interest in children was deviated so that his daughter was involved in it. His daughter was 13 years old, and behaved very close to his father. He told that he and his wife shared their bed with their daughter in some nights. He mentioned that his daughter loved him very much, and could not live without his father, and she always wanted to sit in his leap. He told that he liked this, and he caressed his daughter, but never had gone any further, but he kissed his daughter’s lips in the last event, and she told it to her mother. Therefore, he told that a crises arose in their house, and they applied hurriedly to us.

He told shyly that when he was a child (aged around 9-10 years) two people in their neighborhood whom he called “big brother” called him to their houses separately at different times, and they had him sat down in their leaps, and touched his body as if they were performing a massage, and kissed his neck, but they did nothing further. He mentioned that his sexual interest was always towards children after adolescence. He mentioned that he was sometimes stimulated by touching small children (without gender difference), and he masturbated sometimes thinking about them. He was married when he was young, but his desire never ended.

In the psychiatric examination, he was showing his age, and answered the questions appropriately and aimed at the target. The place, person, and time orientations were normal. His mood was depressive, and his affect was elevated in anxiety and sadness. His thought context was dominated by themes related to how they would overcome the event they had experienced. No delusion or hallucination was diagnosed. His expressed concerned state was noteworthy.

In the wife’s interview, she told that she observed no suspicious behavior of her husband before, but he was very much interested in children, and loved them by touching, but she did not think of anything inappropriate about it. She told that when their relatives visited them her husband especially wanted to stay at home, and had time with children, and recently he was closely interested in their daughter. She also told that her daughter came to her and told frankly that her father caressed and kissed her lips. She told that they could not tell this to anybody, and they applied us for an emergent help.

After the examination, both the patient and his wife were informed. Legal condition and possible process were told them. Hemogram, routine biochemical tests (including Hepatitis B, C, syphilis, anti-HIV, serum testosterone levels), and substance screening was performed in the blood and urine. Additionally, cranial imaging (cranial magnetic resonance imaging examination) studies and EEG recording were performed. All values were within normal limits, and there was no detected sign.

In the differential diagnosis, no mental retardation was suspected as he seemed to be at normal intelligence level. As no substance was detected in the blood and urine, conditions which might result due to any substance effect were ruled out. In the detailed personal history, no symptoms indicating clinical characteristics of hypomania or mania were determined. No clinical picture which might develop after an obsessive thought and compulsive behavior was detected, and obsessive-compulsive disorder was also ruled out. Any organic underlying cause was ruled out by cranial imaging and EEG recording. Under the light of all data, according to diagnostic criteria of DSM-5, he was diagnosed with pedophilic disorder.

He was referred to behavioral psychotherapy, and citalopram 20mg/day and valproate 750mg/day were started, to benefit from mood-stabilizing and reducing/inhibiting impulsive behavior effects. He started the therapy once a week. The patient and his wife were evaluated weekly. He mentioned that he benefitted from the therapy, and he could suppress his interest for children, and also he felt powerful because his wife was backing him up during this process. His wife confirmed the same information. They asked that they wondered whether therapy and drug treatment would continue these positive effects in the long-term. In the control 1 month later, his wife told that there was no new problem, and the patient told that he paid special care so as not to be alone with his daughter or other children; although his sexual urges were arisen, he could hold himself back, thinking about legal issues, and how much his wife would be sorry. The case has been examined for about 6 years with regular intervals (1-3 months). The familial crisis they had experienced did not recur. Sometimes his wife attended the individualized therapy. He attended therapy regularly for about 2 years (once a week in the first months, supportive, cognitive behavioral therapy in every 2-3 months in later periods). He told that his interest for children continued, but he did not reflect this behavior, and his daughter was grown up. His wife told that she was aware of this interest of him, and they could solve the problems together, and also she trusted him. The patient who is satisfied with his treatment, is continuing his drugs regularly.

DISCUSSION

It is known that fantasies of pedophilia cases are not unfamiliar with ego and disturbing. Therefore, they rarely apply to psychiatry outpatient clinics for treatment, and they are more often seen in clinic due to legal cases of sexual assaults to children (11). The present case applied to psychiatry outpatient clinic due to the experienced familial crisis by enforcement of his wife.

Activities rarely appear as impulsive sexual activities in sexual assaults to children. Majority of actions are previously planned. It was also indicated by many scientific studies that majority of pedophilia cases knew previously the children they abused, and they used this familiarity to get close to the victim as well as to prepare a scene to abuse (12). Our case preferred to stay at home when his relatives or neighbors visited them, and he was getting close to children by playing with them.

Defense mechanisms of pedophilia cases may be examined under five headlines. These are denial (“Is it wrong to hug the child?” etc.), underestimation (“it happened only once” etc.), rationalism (“I am a person who likes male children, not a sexually perverted person etc.), fabrication (“I am using this for the research project” etc.), and attacking (“attacking to a child, police, doctor etc.”) (13). Our patient used similar defense mechanisms and told that he liked to play with children, and he enjoyed this, but he had no malevolence.

It is possible to observe that incest concept has been covered under the headline of pedophilia. They are usually explained as nested clinical conditions. In definition of pedophilic disorder in DSM-5, it was mentioned about this in an incest limited item with pedophilia, so concomitance of incest was also emphasized. In the present case pedophilia was accompanying incest, but not limited to incest. Moreover, DSM-5 emphasized that these characteristics of pedophilic disorder should also be mentioned, if single tendency type (interested only in children) or non-single tendency type; sexually interested in males, sexually interested in females, and sexually interested in both genders, were present (1). The presented case belonged to a single tendency type, and sexually interested in both genders group.

Paraphilic behaviors may also be observed temporal lobe epilepsy, post-encephalitic neuropsychiatric disorders, septal lesions, multiple sclerosis, and secondary to tumors in various regions of brain (14). In previous studies, paraphilic behaviors due to brain diseases and late-onset paraphilic behaviors were shown. In one of the reports, two patients who had hypometabolism in temporal lobe were diagnosed by positron emission tomography. Frontotemporal dementia, was diagnosed in one patient, whereas bilateral hippocampal sclerosis was diagnosed in the second patient (15). No pathology was determined in cranial imaging, physical and neurological examinations in our patient, so organicity was ruled out. Some conditions which are believed to increase risk of pedophilic disorder development are summarized as prenatal androgen exposure, traumatic experiences during childhood (including sexual abuse), cranial trauma occurred before 13 years of age, low intelligent coefficient levels, decreased prefrontal and temporal inhibition, decreased volume in amygdala and hypothalamus (16). Traumatic experiences in childhood (sexual abuse) might be evaluated as the existent risk factor in our patient. It was reported the best treatment response could be obtained by close serious follow-up, psychotherapy, and drug treatment (17). Hormonal agents such as antiandrogens, estrogen, medroxyprogesterone acetate, cyproterone acetate, and gonadotropin analogues may be used in the drug treatment. However, their efficacies are less than their side effects (14). In a couple of recent studies, it has been reported that selective serotonin reuptake inhibitors (SSRI) (sertraline, fluoxetine, and fluvoxamine) have been successful in treatment (18-21). In recent years, it has been reported that cognitive behavioral treatment methods have been promising options to decrease frequency of actions in treatment of pedophilic cases. It has been reported that SSRIs decrease sexual ruminations and sexual desire which were increased by internal and external stresses (22). It is also known that mood stabilizers are effective in preventing impulsive behaviors.

In Turkey, the most important obstacle against jurisdiction and punishment of pedophilic individuals is that they remain confidential as long as they are confronted with life events which cause legal problems. Therefore, repetition of pedophilic behavior cannot be prevented most of the time. Sexual urge, closeness, and satisfaction may sometimes be evaluated as an innocent affection performance, getting well with children and being interested in children. Even it may be disregarded many times if relatively a more serious condition, such as incest, is observed. Although it is known that it is not appropriate for social population rules, some cases may be even unaware that this is a disorder. It is obvious that prevention and development of programs about this issue are the most effective way to eliminate sexual abuse in all nested conditions. Therefore, it has a special importance in education of both children and parents.

Conflict of Interest: Author declared no conflict of interest.

Financial Disclosure: Author declared no financial support.

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