Robert L. Spitzer, M.D., and Jerome C. Wakefield, D.S.W., Ph.D.,
New York
State Psychiatric Institute,
1051 Riverside Drive, New York, New York
10032-2695;
Institute for Health, Health Care Policy, and Aging Research, Rutgers,
The State University of New Jersey,
New Brunswick, New Jersey
(e-mail:
rls8@ columbia.edu )
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In the context of recent efforts to normalize pedophilia, Green asks "Is pedophilia a mental disorder?" Remarkably, he never defines either term but clearly answers the question with a resounding "No."
We will use the term pedophilia the way that we believe most clinicians and researchers use it, i.e., to refer to
a sustained pattern of recurrent intense sexual attraction to prepubertal children.
We ask:
The essence of both the intuitive and professional concept of mental or physical disorder is that some mechanism, process, or structure inside the organism is not working properly, i.e., it is failing to adequately perform its biologically "designed" (naturally selected) function.
In addition, the failure of function (dysfunction) causes significant harm to the individual or others.
For example, a heart disorder occurs when the heart's function of circulating blood is impaired. Depressive disorders involve the failure of unknown but inferred brain mechanisms to perform their function of regulating affects. Both of these (and most) dysfunctions cause harm.
This definition of mental disorder is elaborated and defended in Wakefield's "harmful dysfunction" analysis of the concept of both physical and mental disorder
(Spitzer \& Wakefield, 1999; Wakefield, 1992a, 1992b, 1999)
and is implicit in the definition of mental disorder in the DSM-IV (American Psychiatric Association, 2000).
One does not need knowledge of evolutionary theory to recognize that the function of sexual attraction is to facilitate selection of fertile mates and behavior that leads to reproduction. Individuals with this function not
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working properly are less likely to reproduce and pass on their genes to their progeny than individuals whose sexual attraction function is working properly.
Consequently, strong, enduring sexual attraction to very young children (i.e., several years prepubescent) is prima facie a puzzle that needs to be explained.
there is nothing to be explained. He apparently regards all forms of pedophilia as normal variants of sexual development. He never even considers the possibility that certain forms of pedophilia could be due to a dysfunction of attraction mechanisms or, perhaps, a dysfunction of inhibitory mechanisms that block adult-child sexual attraction.
that a pattern of exclusive or highly preferential adult-child attraction, where adult-adult attraction is impaired, is prima facie evidence of a dysfunction in at least some, if not all cases. Other possible explanations for such atypical behavior -- cultural encouragement or other kinds of learned or opportunistic behavior -- may be plausible for some but certainly not for all of cases of pedophilia.
It must be granted that because we know little about the nature of sexual attraction mechanisms, inferences of dysfunction are fallible; however, in some cases, such as early-onset exclusive pedophilic attraction, the inference of the existence of some failure of sexual attraction mechanisms cannot be avoided. Other cases, such as males who are sexually attracted to close-to-adolescent girls, might be more plausibly explained in terms of normal learning and the use of a normal capacity for pleasure.
One might wonder whether this analysis of pedophilia as a disorder necessarily implies that homosexuality is likewise a disorder. A similar argument can be made that at least in some cases it represents a dysfunction in some sexual attraction mechanism; however, one could also argue that, as Green himself suggests, unlike the case of pedophilia in which harm is assumed (see Schmidt, 2002), homosexuality does not necessarily involve harm to self or others and thus cannot be classified as a disorder.
equates pedophilia with any adult-child sexual contact or capacity for arousal and thus ignores the critical distinction between dysfunction and non-dysfunction. He makes no distinction, for example, between
 | cultural practices that involve approved transient adult-child sexual behavior (which one would expect not to necessarily involve dysfunction) and |
| sexual attraction to children that seem to be internally motivated and highly resistant to change despite harsh negative societal sanctions against adult-child sexual behavior. |
What Green has demonstrated with his cross-cultural examples is that many adults have the potential capacity to engage in sexual behavior with children and that some cultures make use of this capacity. Green asks why adult-child sexual contact that is part of socially sanctioned cultural or religious practices is not a disorder.
The answer is simply that in such cases there is no implied dysfunction of sexual attraction.
Green notes that a significant number of people in the general population (e.g., college students, military personnel) either report some sexual interest in children or respond physiologically with arousal to pictures of children; however, he presents no evidence that any of these people have a persistent pattern of intense sexual arousal to children-the hallmark of pedophilia.
Green presents evidence that pedophiles, as compared to various control groups, have no more personality disturbance or other psychopathology. This may well be the case, but it is irrelevant to the disorder status of pedophilia. Many physical and mental disorders involve focal dysfunctions of a particular mechanism and have no other associated pathology.
Green ends his paper by asserting that if pedophilia is a disorder, then it is common in many cultures and in the past.
pedophilia as a mental disorder, as defined here and as clinicians use the diagnosis, is certainly not common. Furthermore, whether a condition is common or rare has little bearing on whether it is a normal variant or a disorder (e.g., gingivitis is relatively common, blue eyes are relatively rare).
on balance, and admitting that we do not yet understand the mechanisms of sexual attraction, the dysfunction explanation remains more compelling than alternative explanations for at least some forms of pedophilia.
Assuming that pedophilic attraction is harmful
(either frustrating if not acted on, or potentially harmful to the child if acted on),
some forms of pedophilia are best conceptualized as a mental disorder.