play a role in deviant attractions. diagnosis dsm and icd-11 the diagnostic and statistical manual of mental disorders, fifth edition, text revision (dsm-5-tr) states, "the diagnostic criteria for pedophilic disorder are intended to apply both to individuals who freely disclose this paraphilia and to individuals who deny any sexual attraction to prepubertal children (generally age 13 years or younger), despite substantial objective evidence to the contrary." the manual outlines specific criteria for use in the diagnosis of this disorder. these include the presence of sexually arousing fantasies, behaviors or urges that involve some kind of sexual activity with a prepubescent child (with the diagnostic criteria for the disorder extending the cut-off point for prepubescence to age 13) for six months or more, or that the subject has acted on these urges or is distressed as a result of having these feelings. the criteria also indicate that the subject should be 16 or older and that the child or children they fantasize about are at least five years younger than them, though ongoing sexual relationships between a 12- to 13-year-old and a late adolescent are advised to be excluded. a diagnosis is further specified by the sex of the children the person is attracted to, if the impulses or acts are limited to incest, and if the attraction is "exclusive" or "nonexclusive". the icd-11 defines pedophilic disorder as a "sustained, focused, and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—involving pre-pubertal children." it also states that for a diagnosis of pedophilic disorder, "the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. this diagnosis does not apply to sexual behaviours among pre- or post-pubertal children with peers who are close in age." several terms have been used to distinguish "true pedophiles" from non-pedophilic and non-exclusive offenders, or to distinguish among types of offenders on a continuum according to strength and exclusivity of pedophilic interest, and motivation for the offense (see child sexual offender types). exclusive pedophiles are sometimes referred to as true pedophiles. they are sexually attracted to prepubescent children, and only prepubescent children. showing no erotic interest in adults, they can only become sexually aroused while fantasizing about or being in the presence of prepubescent children, or both. non-exclusive offenders—or "non-exclusive pedophiles"—may at times be referred to as non-pedophilic offenders, but the two terms are not always synonymous. non-exclusive offenders are sexually attracted to both children and adults, and can be sexually aroused by both, though a sexual preference for one over the other in this case may also exist. if the attraction is a sexual preference for prepubescent children, such offenders are considered pedophiles in the same vein as exclusive offenders. neither the dsm nor the icd-11 diagnostic criteria require actual sexual activity with a prepubescent youth. the diagnosis can therefore be made based on the presence of fantasies or sexual urges even if they have never been acted upon. on the other hand, a person who acts upon these urges yet experiences no distress about their fantasies or urges can also qualify for the diagnosis. acting on sexual urges is not limited to overt sex acts for purposes of this diagnosis, and can sometimes include indecent exposure, voyeuristic or frotteuristic behaviors. the icd-11 also considers planning or seeking to engage in these behaviors, as well as the use of child pornography, to be evidence of the diagnosis. however the dsm-5-tr, in a change from the prior edition, excludes the use of child pornography alone as meeting the criteria for "acting on sexual urges." this change is controversial due to being made for legal reasons rather than scientific. according to forensic psychologist michael c. seto, who was part of the dsm-5-tr workgroup, the removal of child pornography use alone was to avoid diagnosing criminal defendants convicted of child pornography offenses, but no in-person offenses, with pedophilic disorder, as this could potentially lead to such defendants being committed to mental institutions under sexually violent predator laws. seto, who has published several research studies on pedophilia and its relationship with child pornography, objected to this reasoning by the apa, as it would only apply to a tiny minority of commitments, as well as deny help-seeking pedophiles access to clinical care due to not having an official diagnosis for insurance purposes. in practice, the patient's behaviors need to be considered in-context with an element of clinical judgment before a diagnosis is made. likewise, when the patient is in late adolescence, the age difference is not specified in hard numbers and instead requires careful consideration of the situation. debate regarding criteria there was discussion on the dsm-iv-tr being overinclusive and underinclusive. its criterion a concerns sexual fantasies or sexual urges regarding prepubescent children, and its criterion b concerns acting on those urges or the urges causing marked distress or interpersonal difficulty. several researchers discussed whether or not a "contented pedophile"—an individual who fantasizes about having sex with a child and masturbates to these fantasies, but does not commit child sexual abuse, and who does not feel subjectively distressed afterward—met the dsm-iv-tr criteria for pedophilia since this person did not meet criterion b. criticism also concerned someone who met criterion b, but did not meet criterion a. a large-scale survey about usage of different classification systems showed that the dsm classification is only rarely used. as an explanation, it was suggested that the underinclusiveness, as well as a lack of validity, reliability and clarity might have led to the rejection of the dsm classification. ray blanchard, an american-canadian sexologist known for his research studies on pedophilia, addressed (in his literature review for the dsm-5) the objections to the overinclusiveness and under underinclusiveness of the dsm-iv-tr, and proposed a general solution applicable to all paraphilias. this meant namely a distinction between paraphilia and paraphilic disorder. the latter term is proposed to identify the diagnosable mental disorder which meets criterion a and b, whereas an individual who does not meet criterion b can be ascertained but not diagnosed as having a paraphilia. blanchard and a number of his colleagues also proposed that hebephilia become a diagnosable mental disorder under the dsm-5 to resolve the physical development overlap between pedophilia and hebephilia by combining the categories under pedophilic disorder, but with specifiers on which age range (or both) is the primary interest. the proposal for hebephilia was rejected by the american psychiatric association, but the distinction between paraphilia and paraphilic disorder was implemented. the american psychiatric association stated that "n the case of pedophilic disorder, the notable detail is what wasn't revised in the new manual. although proposals were discussed throughout the dsm-5 development process, diagnostic criteria ultimately remained the same as in dsm-iv tr" and that "nly the disorder name will be changed from pedophilia to pedophilic disorder to maintain consistency with the chapter's other listings." if hebephilia had been accepted as a dsm-5 diagnosable disorder, it would have been similar to the icd-10 definition of pedophilia that already includes early pubescents, and would have raised the minimum age required for a person to be able to be diagnosed with pedophilia from 16 years to 18 years (with the individual needing to be at least 5 years older than the minor). o'donohue, however, suggests that the diagnostic criteria for pedophilia be simplified to the attraction to children alone if ascertained by self-report, laboratory findings, or past behavior. he states that any sexual attraction to children is pathological and that distress is irrelevant, noting "this sexual attraction has the potential to cause significant harm to others and is also not in the best interests of the individual." also arguing for behavioral criteria in defining pedophilia, howard e. barbaree and michael c. seto disagreed with the american psychiatric association's approach in 1997 and instead recommended the use of actions as the sole criterion for the diagnosis of pedophilia, as a means of taxonomic simplification. treatment general there is no evidence that pedophilia can be cured. instead, most therapies focus on helping pedophiles refrain from acting on their desires. some therapies do attempt to cure pedophilia, but there are no studies showing that they result in a long-term change in sexual preference. michael seto suggests that attempts to cure pedophilia in adulthood are unlikely to succeed because its development is influenced by prenatal factors. pedophilia appears to be difficult to alter but pedophiles can be helped to control their behavior, and future research could develop a method of prevention. there are several common limitations to studies of treatment effectiveness. most categorize their participants by behavior rather than erotic age preference, which makes it difficult to know the specific treatment outcome for pedophiles. many do not select their treatment and control groups randomly. offenders who refuse or quit treatment are at higher risk of offending, so excluding them from the treated group, while not excluding those who would have refused or quit from the control group, can bias the treated group in favor of those with lower recidivism. the effectiveness of treatment for non-offending pedophiles has not been studied. cognitive behavioral therapy cognitive behavioral therapy (cbt) aims to reduce attitudes, beliefs, and behaviors that may increase the likelihood of sexual offenses against children. its content varies widely between therapists, but a typical program might involve training in self-control, social competence and empathy, and use cognitive restructuring to change views on sex with children. the most common form of this therapy is relapse prevention, where the patient is taught to identify and respond to potentially risky situations based on principles used for treating addictions. the evidence for cognitive behavioral therapy is mixed. a 2012 cochrane review of randomized trials found that cbt had no effect on risk of reoffending for contact sex offenders. meta-analyses in 2002 and 2005, which included both randomized and non-randomized studies, concluded that cbt reduced recidivism. there is debate over whether non-randomized studies should be considered informative. more research is needed. behavioral interventions behavioral treatments target sexual arousal to children, using satiation and aversion techniques to suppress sexual arousal to children and covert sensitization (or masturbatory reconditioning) to increase sexual arousal to adults. behavioral treatments appear to have an effect on sexual arousal patterns during phallometric testing, but it is not known whether the effect represents changes in sexual interests or changes in the ability to control genital arousal during testing, nor whether the effect persists in the long term. for sex offenders with mental disabilities, applied behavior analysis has been used. sex drive reduction pharmacological interventions are used to lower the sex drive in general, which can ease the management of pedophilic feelings, but does not change sexual preference. antiandrogens work by interfering with the activity of testosterone. cyproterone acetate (androcur) and medroxyprogesterone acetate (depo-provera) are the most commonly used. the efficacy of antiandrogens has some support, but few high-quality studies exist. cyproterone acetate has the strongest evidence for reducing sexual arousal, while findings on medroxyprogesterone acetate have been mixed. gonadotropin-releasing hormone analogues such as leuprorelin (lupron), which last longer and have fewer side-effects, are also used to reduce libido, as are selective serotonin reuptake inhibitors. the evidence for these alternatives is more limited and mostly based on open trials and case studies. all of these treatments, commonly referred to as "chemical castration", are often used in conjunction with cognitive behavioral therapy. according to the association for the treatment of sexual abusers, when treating child molesters, "anti-androgen treatment should be coupled with appropriate monitoring and counseling within a comprehensive treatment plan." these drugs may have side-effects, such as weight gain, breast development, liver damage and osteoporosis. historically, surgical castration was used to lower sex drive by reducing testosterone. the emergence of pharmacological methods of adjusting testosterone has made it largely obsolete, because they are similarly effective and less invasive. it is still occasionally performed in germany, the czech republic, switzerland, and a few u.s. states. non-randomized studies have reported that surgical castration reduces recidivism in contact sex offenders. the association for the treatment of sexual abusers opposes surgical castration and the council of europe works to bring the practice to an end in eastern european countries where it is still applied through the courts. epidemiology pedophilia and child molestation the prevalence of pedophilia in the general population is not known, but